HCMC_P_049062 - Hennepin County Medical Center

Dear Readers:
This issue of Approaches in Critical Care is focused on the art and science of
resuscitation. Perhaps no area of medicine has received more scientific, public, or
media attention. For at least the last 2 decades, the drama of severe illness and
injury and the tension-provoking attempts to intervene with catastrophe have fueled
countless TV and film dramas, news specials, documentaries and stories in print.
Concurrently, the science and art of resuscitation has also been observed by a
wide audience of medical and non-medical people. While the viewing and reading
audiences who follow a medical story appreciate the fabulous outcomes often
achieved, they may have come to expect nothing less. It is very unlikely that the
nature of resuscitation, and the miracle it often represents, is fully appreciated
or understood.
While those involved in a successful resuscitation may ultimately be viewed as
heroes, only those who are actually present and fully understand what is
happening, realize that this outcome is very hard won. Rarely are the nitty-gritty
details, procedural misadventures or difficulties, or the complexity of bedside
decision-making in resuscitation described. In this issue we present four case
reports of severely ill or injured persons and the blow-by-blow descriptions of the
steps, procedures, technologies and management decisions involved.
Regardless of eventual patient outcome, a well disciplined, thoughtful and cutting
edge resuscitation effort is impressive. I felt my anxiety rising as I read these cases,
and tried to will a happy and quick resolution into being. I marveled at the amazing
technologies that enhanced the likelihood of favorable outcome for these patients.
The evolution of medicine is thrilling to witness, as we all have or will do, during the
course of our careers. Bringing scientific discoveries to the bedside equips us to
achieve even more from our efforts to improve patient care. While we cannot
become complacent in our quest to find ever more successful methods and tools
for resuscitation, it is also important to remain appreciative of the tremendous
human effort and perseverance it takes to save a life.
Sincerely,
Michelle H. Biros, MD, MS
Approaches in Critical Care Editor-in-Chief
Department of Emergency Medicine
Hennepin County Medical Center
®
Every Life Matters

Contents Volume 9 | Approaches in Critical Care | January 2013
Approaches in Critical Care
Editor-in-Chief
Michelle Biros, MD, MS
Managing Editor
Mary Bensman
Graphic Designer
Karen Olson
Public Relations Director
Tom Hayes
Printer
Sexton Printing
Photographers and
Image Sources
Raoul Benavides
Karen Olson
HCMC History Museum
HCMC Department of
Emergency Medicine
Images from the History
of Medicine (IHM)
Canadian Medical
Association Journal
Clinical Reviewers
Joseph Clinton, MD
2 Case Reports
Resuscitated Cardiac Arrest after a Prolonged Down-time: Advances in Care
Steve Smith, MD and Brian Mahoney, MD
6 Management of a Difficult Airway Using Newer Airway Adjuncts
Emily Ragaini, MD
8 A Memorable Case of Hypothermia
Ernie Ruiz, MD
9 The Deadly Duo of Smoke Inhalation: Carbon Monoxide and Hydrogen Cyanide
Ben Orozco, MD
12 The Use of ED Bedside Ultrasound to Direct the Management of a Life-threatening
Complication of a Routine Procedure
Brian Driver, MD
13 EMS Perspectives
Pre-hospital Cardiac Resuscitation: Yesterday, Today and Tomorrow
Robert Ball, BA, EMT-P
16 Calendar of Events
18 News Notes
Events Calendar Editor
Susan Altmann
To submit an article
Contact the managing editor at approaches@hcmed.org. The editors reserve the right to reject the editorial
or scientific materials for publication in Approaches in Critical Care. The views expressed in this journal do
not necessarily represent those of Hennepin County Medical Center, or its staff members.
Copyright
Copyright 2013, Hennepin County Medical Center. Approaches in Critical Care is published twice per year by
Hennepin County Medical Center, 701 Park Avenue, Minneapolis, Minnesota 55415.
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To subscribe, send an email to approaches@hcmed.org with your name and full mailing address.
Approaches in Critical Care | January 2013 | 1

Case Reports
Resuscitation: Four Case Reports
“...the medical
community
did not widely
recognize and
promote
artificial
respiration
combined
with chest
compressions
as a key part of
resuscitation
following
cardiac arrest
until the middle
of the 20th
century.”
The effectiveness of cardiopulmonary
resuscitation, (CPR) is often seen in
movies and television as a highly effective
way to save the life of someone who is not
breathing. In fact, a 1996 study published
in the New England Journal of Medicine
showed that the CPR success rate in TV
shows was 75% for immediate circulation,
and 67% survival to discharge. 1 This gives
the general public an unrealistic expectation
of a successful outcome when, on average,
the actual survival rates for a patient who
gets CPR after a cardiac arrest is 5-10
percent. Where CPR is followed by
defibrillation, within three to five minutes of
VF cardiac arrest, survival rates rise to
about 30 percent. 2
The case reports in this issue are more in
line with the reality of how lives are saved
in our emergency departments. In addition,
the history and improving technology of
pre-hospital resuscitation is also detailed in
the Emergency Medical Perspectives
feature that follows the case studies.
Amazing stuff when you consider that the
medical community did not widely recognize
and promote artificial respiration combined
with chest compressions as a key part of
resuscitation following cardiac arrest until
the middle of the 20th century.
The “ABC’s of Resuscitation” was written
by Peter Safar in 1957 and CPR was first
promoted as a technique for the public to
learn in the 1970s. Ernie Ruiz, MD, a
founding member of Emergency Services
at HCMC, considers this one of the most
significant advances in resuscitation during
his tenure as a resuscitation surgeon and
emergency physician.
“These techniques were applied to all
forms of resuscitation in the 1960s. In my
opinion, we should also look to advancements
in fiber optic instrumentation that enabled
quicker and safer airway management and
advances in pre-hospital care and emergency
care coordination in urban and rural areas.
In addition, there have been advances in
medical imaging, CT, MRI and transvascular
techniques that are used to
discover and repair conditions such as
coronary occlusions and cerebral aneurysms.
Not to mention, the digital age in general.”
The cases that follow are examples.
References
1. (Diem, S.j.; Diem, Susan J MD; Lantos, John D
MD; Tulsky, James A MD (1996-06-13).
“Cardiopulmonary Resuscitation on Television-
Miracles and Misinformation”)
2. Cardiopulmonary Resuscitation Statistics
(http://www.americanheart.org)
Resuscitated Cardiac Arrest after
a Prolonged Down-time: Advances
in Care
Steve Smith, MD and Brian Mahoney, MD
Department of Emergency Medicine
Hennepin County Medical Center
Abstract
Cardiac arrest remains a major cause of
mortality in the US. However, new
advances in out-of-hospital, emergency
department, and intensive care have
provided hope for improved outcomes.
Here we describe a case of a patient who
benefited from new technologies that were
applied to all aspects of his acute care.
Case Report
An athletic male in his 40s was biking on a
trail when bystanders witnessed him go
down but, reportedly, without significant
trauma. They found him unresponsive and
without a pulse. They started chest
compressions and called 911. First
responders and paramedics were dispatched
at T = 1 minute. The subsequent events are
as follows:
T = 5 minutes: Minneapolis Fire
Department (MPD, first responders)
arrived. They continued CPR, placed a
King airway, with the ResQPod ® (Inspiratory
Threshold Device [ITD]) applied between
King and Valve-Mask. Respirations were
delivered at 10 per minute, as guided by
the flashing light on the ITD. An automatic
2 | Approaches in Critical Care | January 2013

Case Reports
external defibrillator (AED) was applied, which
advised “shock.” They delivered one shock and
continuous chest compressions were resumed.
T = 9 minutes: EMS (paramedics) arrived and found
the patient in full arrest, the King airway working and
MPD performing manual chest compressions.
T = 10 minutes: The LUCAS device was placed and
automated chest compressions were begun.
T = 13 minutes: The patient’s rhythm was checked
and found to be ventricular fibrillation. Biphasic
defibrillation at 150 Joules was administered and
LUCAS compressions were continued.
T = 14 minutes: IV access was obtained while chest
compressions continued.
T = 15 minutes: Epinephrine 1 mg IV was given.
T = 16 minutes: Defibrillation at 180 Joules was
performed and CPR resumed.
T = 20 minutes: Defibrillation was repeated at 180
Joules and CPR resumed.
T = 24 minutes: Defibrillation at 200 Joules was
performed and CPR resumed.
T = 25 minutes: A second dose of Epinephrine 1 mg
IV was given.
T = 27 minutes: Defibrillation at 200 Joules was
performed with conversion of VF to sinus tachycardia.
Thus, the patient had at least 27 minutes without a
perfusing rhythm. He was then transported.
T = 31 minutes: He arrived at the emergency
department at Hennepin County Medical Center.
Figure One. The ED ECG showing an ST- segment elevation
Myocardial infarction
The emergency department ECG (Figure One) was
recorded at T = 35 minutes and showed massive ST
elevation in the anterior leads. The catheterization lab
was activated at T = 36 minutes (5 minutes after
patient arrival in the emergency department). The
King airway was removed and the patient was
orotracheally intubated. As the patient was no longer
in arrest, the ITD was removed. At this point, his
pulse was 120 bpm and BP 130/80. On further
examination, his pupils were noted to be equal and
reactive to light, but the patient was completely
comatose with no response to pain. A chest X-ray
showed mild pulmonary edema. An emergency
department bedside ultrasound showed the expected
anterior wall motion abnormality and moderately
decreased left ventricular function, consistent with
acute anterior STEMI. The potassium was 4.5 mEq/L
and the total CO2 was 12 mEq/L; thus, there was
only mild acidosis.
While waiting for the cath team, therapeutic
hypothermia was begun. A Thermistor Foley was
placed for temperature monitoring and feedback to
the temperature control device, which in this case
was to be the Arctic Sun external cooling system.
The patient was given 10 mg vecuronium to prevent
shivering. A propofol 40 mg bolus and drip were
started in case sedation was necessary, after which
the patient became mildly hypotensive to 88 systolic;
propofol was discontinued and lorazepam 4 mg was
given instead. To help prevent recurrent ventricular
fibrillation, 2 g of magnesium was given, as well as a
lidocaine load (100 mg IV bolus, then another 50 mg
5 minutes later, then an additional 50 mg 5 minutes
after the second dose, for a total of 200 mg) and a
lidocaine drip at 3 mg/minute was begun. Amiodarone
was intentionally avoided due to its beta blocking
properties; patients with large anterior MI are at high
risk of cardiogenic shock, especially when there is
tachycardia. The patient received an IV load of
heparin (5000 U), a rectal ASA, and 600 mg of
clopidogrel (Plavix ® ) through an orogastric tube.
Eptifibatide and Heparin boluses and drips were
administered. The Arctic Sun cooling pads were
applied and cooling was initiated, with a goal
temperature of 33.5 degrees Celsius.
At T = 69 minutes, the patient left the emergency
department for the cath lab.
At T = 73 minutes, the patient arrived in the cath lab.
At T = 83 minutes, angiography of the left coronary
system identified the culprit lesion in the mid left
anterior descending coronary artery (LAD).
At T = 87 minutes, the wire crossed the occlusion in
the mid-LAD and flow was restored, for a door-toballoon
time of 56 minutes.
Thrombus in the LAD was suctioned out. Ostial
stenosis of the first diagonal artery was angioplastied
Approaches in Critical Care | January 2013 | 3

Case Reports
Figure Two. The cardiac monitor strip showing a wide complex
tachycardia, likely AIVR
Figure Three. The Inspiratory
Threshold Device
Figure Four. The ResQPump ®
and stents were placed at each lesion. Following
PCI, an intra-aortic balloon pump was placed due to
cardiogenic shock with elevated left ventricular enddiastolic
pressure and resulting pulmonary edema.
(This has since been shown to be ineffective in
cardiogenic shock in STEMI.) 1
The patient developed an intermittent wide complex
rhythm which at first was interpreted as ventricular
tachycardia (VT) (Figure Two). He was started briefly
on amiodarone and it was subsequently stopped
when the rhythm was reassessed. The diagnosis of
VT was not certain because of a relatively slow heart
rate. Instead, an accelerated idioventricular rhythm
(AIVR) was considered. AIVR is differentiated from
ventricular tachycardia by the heart rate: AIVR is < 120
bpm, while ventricular tachycardia is almost always >
120 bpm. AIVR is a common reperfusion dysrhythmia
and is good evidence of reperfusion of STEMI (in
other words, a good sign). It does not require any
treatment unless associated with hypotension.
By 24 hours, the balloon pump could be removed.
Serial troponin I peaked at 13.7 ng/ml, which is far
lower than expected for a STEMI of this size and
suggests that total occlusion time was brief. Initial
transthoracic echocardiogram on day 2 showed an
ejection fraction (EF) of 15-20% (normal, 65-70%);
with septal and apical wall motion abnormalities
(WMA). Thus, as is usual, the myocardium was
“stunned,” though not all infarcted. The EF greatly
improved by 2 days later, when a repeated
echocardiogram revealed an EF 35% and
corresponding improvement in WMA.
At 48 hours, the patient had completed the
hypothermia protocol without complication and was
extubated, at which time he was following simple
commands but had anterograde amnesia. By 72
hours, his neurological status had greatly improved;
anterograde amnesia was resolving but there was no
memory of events. He recovered fully and was
discharged on prasugrel, aspirin, lisinopril, carvedilol,
atorvastatin, and eplerenone. After cardiac
rehabilitation, his ejection fraction returned to normal
and he was again able to bike 50 miles at a time. He
has had no further symptoms.
Discussion
More information on Compression Decompression
CPR, the Inspiratory Threshold Device, and the
LUCAS device is available at http://www.naph.org/
Homepage-Sections/Explore/Innovations/Heart-
Health/Hennepin-County-Medical-Center.aspx.
In January 2011, investigators, including several from
HCMC, published the results of a randomized trial
comparing compression-decompression CPR to
standard CPR in out-of-hospital cardiac arrest, and
found that 74 (9%) of 840 patients survived to 1 year
in the intervention group compared with 48 (6%) of
813 controls (p=0·03), with equivalent cognitive skills,
disability ratings, and emotional-psychological status
in both groups. 2 In the compression-decompression
group, first responders used both the ITD (ResQPod ® ),
(Figure Three) and a specially designed compressiondecompression
device called the ResQPump ®
(Figure Four). The ResQPump ® has a suction cup
that attaches to the chest, and when pulled up
forcefully, may create 30 pounds of negative
pressure in the chest, augmenting the pumping
action of the chest. The ITD is placed on the
endotracheal tube and has a valve that stays closed
for a fraction of a second, preventing that negative
pressure from drawing air down the endotracheal
tube, ensuring that there will be negative pressure to
draw blood into the chest and into the heart, for
further pumping out to the body with each
compression. The two together, then, increased
survival with good neurologic outcome (Modified
Rankin Score of 3 or less) by 50%.
The LUCAS device (Figure Five) combines
mechanical compression that is uniform and does not
fatigue with suction for decompression, but with less
suction. It provides 2 inches of chest compression at
4 | Approaches in Critical Care | January 2013

Case Reports
Figure Five.
The LUCAS device
several pounds of negative force. Newer software
automatically adjusts the plunger to ensure good
contact with the sternum. It is unlike human CPR,
which degrades due to fatigue or distraction, and is
often done at a rate too slow or too fast for optimal
blood flow, does not allow for full chest wall recoil as
the provider tends to lean on the chest, and must be
stopped during administration of shocks. It has been
shown to improve blood flow in experimental models
and anecdotal reports in humans. We have found in
some cases that it creates exceptional blood
pressure in ED cardiac arrest patients, as measured
by arterial line; and it is more likely than manual
chest compression to keep the brain perfused (and
therefore alive) in prolonged arrest. The LUCAS
device also allows safe transport of the patient with
ongoing CPR, thus making it possible to go to the
cath lab with ongoing CPR.
Therapeutic Hypothermia
In 2002, 2 randomized studies in the New England
Journal of Medicine compared therapeutic cooling for
24 hours to standard care. 3, 4 These trials, and
evidence from dog studies, form the basis of this now
standard therapy for comatose survivors of cardiac
arrest. In these studies, patients who were
resuscitated from pulseless ventricular fibrillation
(VF) or tachycardia (VT) were randomized within 3
hours, and those who underwent hypothermia were
sedated, chemically paralyzed, and externally cooled
to a target temperature of 32 to 34 degrees Celsius,
where they were kept for 24 hours before rewarming.
Only 8% of cardiac arrest patients met eligibility
criteria. The primary endpoint was good neurologic
outcome at 6 months, which, when combining the 2
studies, was achieved in the hypothermia group in
54% vs. 37%. Mortality was 43% vs. 58%. Adverse
events were not different between the groups.
Based on this, the International Liaison Committee
on Resuscitation advised use of therapeutic
hypothermia, to 32-34 degrees for 12 to 24 hours, for
unconscious adult patients with return of spontaneous
circulation after out-of-hospital ventricular fibrillation
arrest. 5 Therapeutic hypothermia requires intubation
and paralysis and very intensive monitoring for
electrolyte shifts and dysrhythmias.
Conclusion
Since 2003, we at Hennepin County Medical Center
have cooled comatose survivors of cardiac arrest.
We have decided to broaden the indications for the
therapy beyond those with VF or VT to those patients
who have been resuscitated from asystole, pulseless
electrical activity (PEA) and respiratory etiologies of
cardiac arrest, as long as they have return of
spontaneous circulation within 60 minutes of arrest.
From January 2008 through December 2011,
Hennepin had 129 patients resuscitated after cardiac
arrests who were eligible for and underwent
therapeutic hypothermia: 86 had VF or VT, and 43
had PEA or asystole. Of the 129, 61 (47%) survived
with good neurologic outcome; 6 of these had PEA or
asystole as the initial rhythm. In total, 57 (44%) died,
35 of whom had asystole or PEA. There were 11
survivors, but with poor neurologic outcomes; 2 of
these had asystole or PEA. The 56 of 86 (65%) with
a shockable rhythm survived with good neurologic
outcome. Most of these were before the use of the
LUCAS device.
This case and our survival statistics illustrate the
rapid advancements occurring in the management of
patients with cardiac arrest. Combining new therapies,
such as those described in this case report, has the
potential to improve survival even more.
References
1. Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon
support for myocardial infarction with cardiogenic shock. N Engl J
Med 2012; 367(14):1287-96.
2. Aufderheide TP, Frascone RJ, Wayne MA, et al. Standard
cardiopulmonary resuscitation versus active compressiondecompression
cardiopulmonary resuscitation with augmentation
of negative intrathoracic pressure for out-of-hospital cardiac arrest:
a randomised trial. Lancet 2011;377(9762):301-11.
3. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose
survivors of out-of-hospital cardiac arrest with induced
hypothermia. N Engl J Med 2002; 346(8):557-63.
4. The_Hypothermia_after_Cardiac_Arrest_Study_Group. Mild
therapeutic hypothermia to improve the neurologic outcome after
cardiac arrest. N Engl J Med 2002; 346(8):549-56.
5. Nolan JP, Morley PT, Hoek TL, Hickey RW. Therapeutic
hypothermia after cardiac arrest. An advisory statement by the
Advancement Life support Task Force of the International Liaison
committee on Resuscitation. Resuscitation 2003;57(3):231-5.
Approaches in Critical Care | January 2013 | 5

Case Reports
Management of a Difficult Airway Using
Newer Airway Adjuncts
Emily Ragaini, MD
Departments of Emergency Medicine
Hennepin County Medical Center
Abstract
Angioedema is a well documented side effect of
angiotensin converter enzyme (ACE) inhibitors.
Cases of severe angioedema can present challenges
in acute airway management. We describe the use of
several airway adjuncts in the management of a case
of severe angioedema in a morbidly obese patient.
Case Report
A 37-year-old morbidly obese female with a history of
hypertension was at home when she began to notice
swelling of her tongue. Initially, the swelling was
minimal, but over the next 2 hours progressed until
her tongue filled her mouth and it was difficult for her
to speak. A family member called 911 and paramedics
were dispatched. They gave her 50 mg IV Benadryl
en route to the hospital. She did not realize she was
on a combination antihypertensive pill containing
amlodipine and benazepril.
At T = 0 minutes, the patient arrived in the
emergency department at Hennepin County Medical
Center. On initial examination, the patient was
observed to be breathing through her nose. Her
tongue was swollen and firm and filled the
oropharynx. The submental area was also swollen
and protruding over her lower teeth. She was mildly
tachypnic and sitting upright on cart. There was
firmness of her submandibular area. She had no
stridor or wheezing. Her emergency department
management proceeded as follows:
T = 4 minutes: She was given IV solumedrol, IV
Zantac, IM epinephrine without improvement. Given
the rapidly progressing tongue swelling, we
recommended intubation and the patient was in
agreement with this.
T = 27 minutes: An initial attempt at fiberoptic
guided nasotracheal intubation was made after IV
ketamine was given for sedation. Despite multiple
doses of sedation, the patient remained very agitated
and unable to be intubated.
T = 49 minutes: She was given IV etomidate and
blind nasotracheal intubation was attempted. However,
she remained too agitated and nearly threw herself
off the cart during the final attempt. She was
repositioned on the cart while being bagged. It was
noted on the cardiac monitor that she had a run of
bigeminy, then a short run of ventricular tachycardia.
T = 56 minutes: A crichothyrotomy tray was opened
at the bedside. Rapid sequence intubation was
attempted after the patient was given IV etomidate
and succinylcholine. This attempt used the C-MAC
videolaryngoscope with a Macintosh size 4 blade.
However, because of the massive tongue swelling,
we were not able to pass a blade deep enough to
visualize the vocal cords. Her oxygen saturation
dropped into the 80%s on pulse oximetry (POX).
An intubating laryngeal mask airway (ILMA) was
placed and bag-value ventilation restored her to a
POX of 100%.
“Angioedema is a well documented side
effect of angiotensin converter enzyme
(ACE) inhibitors. Cases of severe
angioedema can present challenges in
acute airway management.”.”
T = 61 minutes: An attempt to pass an endotracheal
tube (ETT) was made through the ILMA but was not
successful. The ETT was therefore removed. At that
time, her POX was noted to be 83%.
T = 64 minutes: The patient was noted to be
bradycardic with heart rate in the 40s. She was given
0.5 mg IV atropine with a good response in heart rate.
T = 69 minutes: An ETT was passed through ILMA.
She was then easily bagged. However, her POX
dropped into the 70%s, with a nadir of 68%. Fiberoptic
scope confirmed that the ETT was in the trachea, but
appeared to be sitting low. The ETT pulled back.
T = 78 minutes: A CXR showed the ETT to be
positioned about 1 cm above the carina. It was pulled
back 2 cm. Given her low POX, a bedside ultrasound
was performed to rule out pneumothorax; this
showed sliding lung signs present bilaterally.
Etomidate was given for sedation and a propofol
infusion started.
T = 97 minutes: Her SpO2 improved to only 89%
despite adequate bagging and 100% FiO2. The
decision was made to remove the ILMA from around
ETT. During the attempt to remove ILMA using the
stabilizer rod, the ETT pilot balloon tubing became
caught and snapped, causing the ETT cuff to deflate,
and the ETT became dislodged.
T = 99 minutes: At this point, the patient’s neck was
re-prepped for possible crichothyrotomy and the
ILMA was replaced.
T = 107 minutes: An ETT was passed through ILMA
and the ILMA was removed with ETT in place.
T = 116 minutes: A CXR confirmed good placement
of the ETT.
6 | Approaches in Critical Care | January 2013

Case Reports
Figure One. The C-MAC videolaryngoscope. The camera is fixed
in the handle, with the lens within the blade. Images are projected
onto a video screen that allows others besides the intubator to
view the anatomy during the intubation procedure. Its usefulness
is demonstrated in a case of difficult boogie placement, seen at
http://www.hqmeded.com/video/40879557
invaginated scolex is clearly seen inside of the cystic cavity.
T = 124 minutes: She began to cough against the
vent and was, therefore, paralyzed with vecuronium.
An ABG revealed a mild acidosis with a pH of 7.19.
Her EKG showed sinus tachycardia with lateral
t wave inversions, concerning for demand ischemia.
T = 164 minutes: The patient was taken to CT
scanner for a CT of the neck with IV contrast to rule
out Ludwig’s angina. Her CT showed a massively
swollen tongue filling the airway and protruding from
the mouth, with significant narrowing of the airway.
There was only mild swelling of the sublingual and
submandibular areas, suggesting that angioedema
was more likely the cause of swelling than a soft
tissue abscess.
T = 184 minutes: She was transferred to the MICU
with a secure airway.
The patient’s benazepril was discontinued. Serial
troponins were followed, given her abnormal ECG
post -intubation and the witnessed episodes of
bigeminy and ventricular tachycardia during
intubation attempts. Her troponin peaked at 0.193
ng/mL. Transthoracic echocardiogram showed a
normal left ventricular ejection fraction, but she was
noted to have an area of hypokinesis in the mid
portion of the intraventricular septum, concerning for
atypical stress cardiomyopathy.
On hospital day 2, the patient had significant
improvement in her tongue swelling. Given her
extremely difficult intubation in the emergency
department, she was extubated over an exchange
catheter with anesthesia at the bedside. She
tolerated extubation well. She was transferred to the
medicine floor and discharged the next day. She was
instructed to discard her amlodipine- benazepril
combination pills at home, and given a new
prescription for amlodipine alone. She was advised to
avoid ACE inhibitors and an allergy alert was placed
in her chart.
Discussion
Two important airway adjuncts were used in the
management of this difficult airway. The C-MAC
videolaryngoscope (Figure One) uses a modified
Macintosh laryngoscope blade with an integrated
video camera, which is directed toward the blade tip.
More details of its functions and an example of its
usefulness are illustrated in a video that shows
difficulty passing a boogie. See http://www.hqmeded.
com/video/40879557. The video screen image allows
the attending physician to visualize the airway as the
resident is intubating (see video). It also allows for
recording of the intubation to facilitate image review
and teaching opportunities. Studies have demonstrated
a greater proportion of successful intubations and a
greater percentage of Cormack-Lehane grade I or II
views when compared with direct laryngoscopy.
Figure Two. The intubating laryngeal mask airway (ILMA). The
procedure for its placement can be viewed at http://www.hqmeded.
com/video/13164204.
The ILMA (Figure Two) is a supraglottic airway device
that is useful for difficult airway management. The
Approaches in Critical Care | January 2013 | 7

Case Reports
laryngeal mask airway (LMA) was developed in the
1980s and initially used in the operating room as an
alternative to bag-valve-mask (BVM) ventilation. It
has become a popular airway adjunct in the
emergency setting for the management of difficult
airways. The intubating LMA (ILMA) was developed
in the late 1990s and allows an endotracheal tube to
be passed through the LMA.
Placement of the ILMA is a simple, single operator
procedure: (http://www.hqmeded.com/video/
13164204). The ILMA cuff is checked for leaks. The
cuff is then deflated against a flat surface. A water
soluble lubricant should be applied to the posterior
surface of the mask. The ILMA is inserted, while
holding the handle, into the oropharynx against the
hard palate, with the mask opening toward the
tongue. It is advanced until resistance is met, and the
cuff then inflated. The handle can be held like a
skillet, and lifted toward the ceiling, to insure an
adequate seal of the mask. The BVM is directly
attached to the ILMA. Either an ETT or the Fastrach
Silicone Tube (FTST, a tube specially designed for
intubation through the ILMA) can be used. At
Hennepin, a standard ETT is often used. Placement
of this is facilitated by inserting the tube with the
curvature opposite of how it is held during standard
intubation. A stabilizer rod is used to maintain the
ETT in position, while the ILMA is deflated and
removed from around the ETT. McGill forceps can
also be used to stabilize the ETT in the oropharynx
as the ILMA is removed.
As illustrated in this case report, the ILMA is an
easily placed airway adjunct that can be used in the
management of difficult airway in the emergency
department. An important learning point from this
case is ensuring that the stabilizer rod is removed
temporarily to allow passage of the pilot balloon for
the ETT. On the first attempt at removal of the ILMA
around the ETT, this was not done, and ultimately
resulted in dislodgement of the ETT. On the subsequent
attempt, this was performed and the ILMA was
removed from around the ETT without difficulty.
Overall, the use of the ILMA was instrumental in
avoiding a surgical airway in this patient.
A Memorable Case of Hypothermia
by Ernie Ruiz, MD
Ernie Ruiz, MD
Founding member of
Emergency Services
Hennepin County Medical Center
A young woman was found by police laying on the
sidewalk of a Minneapolis city street on a very cold
morning in midwinter in 1975-1976. She was cold
and appeared dead. The city's morgue vehicle was
summoned. While awaiting the van, the woman took
a breath. The ambulance was summoned and the
patient was delivered to the Hennepin Emergency
Department. She was without a pulse as she was
transferred to the resuscitation cart. An ECG monitor
showed ventricular fibrillation. While the patient was
being prepared for resuscitation, I called Dr. John
Haglin, Head of Cardiovascular Surgery (CVP),
because during my surgery training he and I
discussed the possibility of using a heart lung
machine to warm very cold patients. Dr. Haglin
agreed that this patient was a good candidate. He
called Dr. Per Wickstrom, who was his Chief
Resident on CVP, and the patient was moved to the
operating room. On the heart lung machine, the
patient warmed to normal temperature in just a few
minutes. She was able to go home in a few days.
She was normal again.
This was the first time that this method of re-warming
was used and reported. It quickly became the world
standard for severe hypothermia resuscitation. This
was a world's first for Hennepin.
8 | Approaches in Critical Care | January 2013

Case Reports
The Deadly Duo of Smoke Inhalation: Carbon
Monoxide and Hydrogen Cyanide
Ben Orozco, MD and Jon Cole, MD
Departments of Emergency Medicine
Hennepin County Medical Center
Abstract
Persons found down in house fires are subject to
varied mechanisms of injury, making them among the
most critically ill of patients. Patients are subject to
thermal injury at dermal, mucosal, and respiratory
surfaces. The gases produced by combustion pose
thermal and particulate damage to airways, but also
may expose the patient to a hypoxic atmosphere with
carbon monoxide (CO) and hydrogen cyanide gases
(HCN). This case report and review of acute carbon
monoxide and hydrogen cyanide gas poisoning from
structure fires should help clinicians recognize these
similar, but distinctly treated toxicities.
Case Report
A 27-year-old female rescued from an active house
fire was initially unconscious and hypoxic with a
Sp02 in the 40s. Paramedics intubated her on scene
and end tidal C02 was 76mmHg. She was given 5mg
of midazolam for sedation and transported.
Upon arrival to the emergency department, vitals
were SpO2 of 90% on 100% FiO2, pulse 139, and
blood pressure of 180/63 mmHg. The position of the
endotracheal tube was confirmed with auscultation
and an end tidal CO2 waveform. The primary survey
was remarkable for diffuse rhonchi. IV hydration with
Ringer's Lactate solution was begun through large
bore IV access. The burn team was present shortly
after patient arrival. The secondary survey revealed
sluggish 2mm pupils, minimal response to pain,
carbonaceous sputum, and a 9% body surface area
partial thickness burn to the abdomen. Chest X-ray
showed pulmonary infiltrates. The patient was
sedated with propofol and paralyzed. Co-oximetry
gave a markedly elevated carboxyhemoglobin
(COHb) level and labs returned with a measured
COHb of 41%. Arterial pH was 6.8 with a marked
metabolic acidosis. Ventilator settings were
advanced, and hydroxocobalamin (Cyanokit ® ) was
started for presumed cyanide poisoning with 12.5g
of sodium thiosulfate to follow. Of note, the serum
lactate later resulted at 18mmol/L.
Arterial and central lines were placed and
myringotomies performed. The patient was
transferred to the hyperbaric oxygen (HBO) chamber
where she was treated with a 90 minute 2.4
atmosphere dive by a hyperbaracist. At admission to
the burn unit, the patient was able to follow commands
with each extremity and open her eyes to voice. Her
SpO2 was 90% on 60% FIO2 and her HR 98 bpm,
and BP 179/103. Her serum lactate had fallen to
3.8mmol/L and pH had improved to 7.3 with serum
bicarbonate of 24. Over the next two days, her
pulmonary status worsened. She had bronchoscopy
with lavage and advanced ventilator management
with pulmonology consultation. She had a tracheostomy
placed on hospital day three. Her hospital course
was complicated by pneumonia, and underlying
asthma. Eventually antibiotics, vasopressors, and the
ventilator were weaned and withdrawn. She received
daily wound care, physical and occupational therapy,
and was discharged neurologically intact without
a tracheostomy.
Discussion
Carbon Monoxide Poisoning
Carbon monoxide (CO) is produced in fires as result
of incomplete combustion and is colorless and
odorless. CO levels within structure fires routinely
exceed the immediately-dangerous-to-life-and-health
(IDLH) standard of 1200 parts per million, as set by
the US National Institute for Occupational Safety and
Health (NIOSH). Once inhaled, CO binds hemoglobin
with 250 times the potency of oxygen, creating
carboxyhemoglobin (COHb), which shifts the
hemoglobin desaturation curve to the left, impairing
both oxygen content and delivery. CO also binds
skeletal and cardiac myoglobin. Other significant
mechanisms include protein oxidation, lipid
peroxidation, neutrophil adhesion, vasodilation, and
inhibition of cytochrome oxidase. CO persists with a
half-life of approximately 250-300 minutes while
breathing room air.
Based on these mechanisms, patients may
experience profound tissue hypoxia despite normal
ambient oxygen. Symptoms depend on the level of
exposure and functional status of the patient, but
symptoms such as nausea, vomiting, and headache
typify exposures with COHb levels of 15-20%. Severe
toxicity may produce syncope, seizures, myocardial
ischemia, cerebral infarction, and death. Such
patients may present with chest pain, arrhythmia,
positive biomarkers, shortness of breath, confusion,
focal neurologic signs, or be comatose. COHb levels
over 40% are generally associated with severe
toxicity. Neurologic symptoms may be permanent.
All victims of structure fires are at risk of CO
poisoning. Routine pulse oximetry may be falsely
Approaches in Critical Care | January 2013 | 9

Case Reports
elevated and the skin may look pink. Screening
should begin with co-oximetry, when available.
Measured COHb should be performed in all cases
where there is significant exposure or clinical symptoms.
Cardiac monitoring and a 12 lead electrocardiogram
(ECG) are mandatory in patients with chest pain,
shortness of breath, comorbidities, or significant
COHb levels. In addition to resuscitation and airway
management, the mainstay of treatment for CO
poisoning is oxygen. Also, 100% oxygen should be
delivered via a tight fitting, non-rebreather mask or
endotracheal tube as soon as possible, reducing the
half-life of COHb from 300 minutes on room air to
approximately 60 minutes. Myocardial depression
and vasodilation may cause hypotension, needing
treatment with fluids, vasopressors, and/or inotropes.
should be placed on clinical findings suggesting
severe toxicity rather than simple CO levels. The
following indications for HBO are generally used by
the Minnesota Poison Control Center and the Center
for Hyperbaric Medicine at Hennepin County Medical
Center which is open for emergencies 24/7.
Indications for Hyperbaric Oxygen:
1. History of loss of consciousness
2. Serious toxicity including lethargy, confusion,
seizures, focal neurologic deficit, ischemic chest
pain, new dysrhythmia, ECG changes, hypotension
3. COHb levels > 25% plus cardiovascular disease,
cerebrovascular disease, age > 60years, < 2
years, hemoglobin < 10, or exposure > 24hours
4. COHb > 40%
5. Pregnancy with COHb > 20% or signs of fetal
distress
6. Symptoms refractory to normobaric oxygen
Figure One. The patient was transferred to the hyperbaric oxygen
(HBO) chamber where she was treated with a 90 minute 2.4
atmosphere dive by a hyperbaracist.
Hyperbaric oxygen (HBO) therapy remains the
optimum treatment for the elimination of CO from
the human body and should be performed whenever
available in cases of significant poisoning. The halflife
of CO is reduced to a mere 20 minutes at 2.5
atmospheres of 100% oxygen. The best published
data suggests that HBO reduces cognitive sequelae
of CO poisoning from 46% in the untreated group to
24% in the group treated with HBO. Though practice
will vary by institution, immediate consultation with a
HBO facility is indicated when significant carbon
monoxide poisoning occurs (Figure One). Importance
Hydrogen Cyanide Gas Poisoning
Hydrogen cyanide gas (HCN) is produced during the
combustion of a variety of natural and synthetic
fibers. HCN toxicity is often overlooked in fires as
patients’ symptoms may be attributed to CO. HCN
was detected in 59% of decedents of structure fires,
and 50% of survivors in a recent Polish study. Once
inhaled, HCN distributes to tissues affecting metabolic
enzymes; most importantly, it binds cytochrome
oxidase and halts cellular respiration. Effects vary,
depending on concentration, duration of exposure,
and patient factors; nonetheless, HCN is considered
among the fastest poisons and may rapidly produce
syncope, seizures, and cardiovascular collapse. While
confusion, lethargy, hypertension, and tachycardia
may occur, coma, bradycardia, and hypotension
consistently precede death. It is eliminated with a
variable half-life of 1 hour to > 2 days.
Diagnosis relies on a timely clinical assessment
rather than analytics. Like CO toxicity, HCN toxicity
may result in normal pulse oximetry, and pink skin
despite severe toxicity; moreover, venous oxygen
saturations may be elevated. COHb levels poorly
predict HCN toxicity, but serum lactate > 8mmol/L in
fire victims predicts cyanide levels > 1.0μg/ml with
94% sensitivity and 70% specificity. Hydroxocobalamin
has emerged as the antidote of choice. It has been
safely administered pre-hospital in France since the
10 | Approaches in Critical Care | January 2013

Case Reports
Figure Two: Photographs showing bright red discoloration of the patient's skin (A) and urine (B) after treatment with hydroxocobalamin for
cyanide poisoning. Cescon D W , Juurlink D N. CMAJ 2009; 180:251-251. Used with permission.
invaginated scolex is clearly seen inside of the cystic cavity.
1980s and was FDA approved in the US in 2006.
Hydroxocobalamin is given 5g IV and may be
repeated. It rapidly binds and detoxifies circulating
cyanide anions to form cyanocobalamin (vitamin
B12). Adverse reactions are limited to transient
reddening of the skin and bodily fluids (Figure Two),
minor allergy, transient hypertension, and temporary
interference with colorimetric laboratory tests. Since
routine serum HCN levels are lacking, administration
is empiric.
Suspect and treat HCN toxicity in patients with:
1. Suspected smoke inhalation (carbonaceous
sputum, enclosed fire, etc.)
2. Altered mental status
3. Cardiovascular instability (especially systolic
blood pressure < 90mmHg in adults)
4. Initial serum lactate > 8.0mmol/L
Given the rapid mechanism of action of both HCN
and the antidote, there should be no delay in
antidotal treatment of unstable patients without
laboratory values. After administration of
hydroxocobalamin, clinicians may consider treatment
with sodium thiosulfate (STS) through a separate
line. STS in conjunction with endogenous rhodanase
detoxifies HCN to thiocyanate. STS is a constituent
of the older cyanide antidote kit, which also included
amyl, butyl, and sodium nitrite. The nitrites induce
methemoglobinemia and should be avoided in
patients suffering from concomitant CO toxicity.
should now readily identify that her profound
alteration of mental status, inhalational injury, and
high lactate as nearly diagnostic of cyanide toxicity.
Both conditions warrant immediate treatment. Our
patient was fortunate to have received timely
therapies, including emergency department
resuscitation, airway management, hydroxocobalamin,
sodium thiosulfate, and hyperbaric oxygen. Her
ultimate full recovery would not have been possible
without the continued thorough inpatient treatment
from a multidisciplinary care team in the burn unit.
References
Baud, F. J., S. W. Borron, B. Megarbane, H. Trout, F. Lapostolle,
E. Vicaut, M. Debray, and C. Bismuth. Value of Lactic Acidosis in
the Assessment of the Severity of Acute Cyanide Poisoning. Crit
Care Med 30, No. 9. Sep 2002: 2044-50.
Cone, D. C., D. MacMillan, V. Parwani, and C. Van Gelder. Threats
to Life in Residential Structure Fires. Prehosp Emerg Care 12, No.
3. Jul-Sep 2008: 297-301.
Grabowska, T., R. Skowronek, J. Nowicka, and H. Sybirska.
Prevalence of Hydrogen Cyanide and Carboxyhaemoglobin in
Victims of Smoke Inhalation During Enclosed-Space Fires: A
Combined Toxicological Risk. Clin Toxicol (Phila) 50, No. 8. Sep
2012: 759-63.
Nelson, Lewis, and Lewis R. Goldfrank. Goldfrank's Toxicologic
Emergencies. 9th ed. New York: McGraw-Hill Medical, 2011.
O'Brien, D. J., D. W. Walsh, C. M. Terriff, and A. H. Hall. Empiric
Management of Cyanide Toxicity Associated with Smoke Inhalation.
[In Eng]. Prehosp Disaster Med 26, No. 5. Oct 2011: 374-82.
Weaver, L. K., R. O. Hopkins, K. J. Chan, S. Churchill, C. G. Elliott,
T. P. Clemmer, J. F. Orme, Jr., F. O. Thomas, and A. H. Morris.
Hyperbaric Oxygen for Acute Carbon Monoxide Poisoning. N Engl
J Med 347, No. 14. Oct 3 2002: 1057-67.
Conclusion
In our patient, the COHb of 41% is consistent with
severe carbon monoxide toxicity; however, clinicians
Approaches in Critical Care | January 2013 | 11

Case Reports
5
Figure One: ED ultrasound of Morison's pouch, showing free
intraperitoneal fluid
5
Figure Two: ED ultrasound showing free fluid surrounding the bladder
Use of ED Bedside Ultrasound to Direct the
Management of a Life-threatening
Complication of a Routine Procedure
Brian Driver, MD
Departments of Emergency Medicine and Internal Medicine
Hennepin County Medical Center
Abstract
Ultrasound use in the emergency department has
been shown to be time and cost efficient, and in
many cases, life saving. This case describes its use
to direct the management of an unusual complication
of routine colonoscopy.
Case Report
A 65-year-old woman presented to the emergency
department with altered mental status eleven hours
after a routine screening colonoscopy. She was at
home the evening after the procedure and telephoned
her neighbor for help. When he arrived, he found her
collapsed on the kitchen floor and immediately called
911. Emergency medical services emergently
transported her to a stabilization room.
On arrival, she appeared obtunded, pale, and
critically ill. A bedside ultrasound was immediately
performed revealing a large amount of free fluid in
her peritoneal cavity, instantly diagnostic of an intraabdominal
catastrophe (Figures One and Two).
Blood was called for, fluids where hung, and general
surgery was immediately paged to determine the
need for emergency operative intervention.
The differential diagnosis included, most prominently,
hemoperitoneum from an unknown source of bleeding
and viscus perforation with bowel contents spilling into
the abdomen. An upright chest radiograph failed to
show any pneumoperitoneum, making viscus perforation
less likely. The patient’s mental status, blood pressure,
and heart rate all improved with rapid fluid resuscitation.
As she was now hemodynamically stable, a CT of her
abdomen/pelvis was obtained, demonstrating severe
splenic injury with active extravasation of contrast
(Figure Three). She was taken emergently to the
operating room where she was found to have severe
avulsion of her splenic capsule. A splenectomy was
performed, and she was discharged on post-operative
day 7 with an otherwise uncomplicated hospital course.
Discussion
There are more than 14 million colonoscopies per
year in the United States, with a relatively low overall
complication rate of about 5 per 1,000 procedures.
Splenic injury from a colonoscopy is exceedingly
rare, with only approximately 95 case reports in the
English literature. This case is the first documented
report in which bedside ultrasound was utilized to
facilitate rapid diagnosis and treatment.
This particular injury occurs when excessive force
is applied downward at the splenic flexure during
colonoscopy, exerting traction on the splenocolic
ligament and ultimately the splenic capsule, which
then pulls free from the spleen (Figure Four). This
leaves the splenic parenchyma open to the abdomen,
with resultant, and often severe, bleeding. Usually, 75%
of patients with this injury will present within 24 hours
of colonoscopy. However, this diagnosis of colonoscopy.
5
Figure Three: Abdominal Ct scan showing free fluid and active contrast
extravasation at the injury
12 | Approaches in Critical Care | January 2013

EMS Perspectives
5
Figure Four: Excessive
downward force at the splenic
flexure stretches the splenic
ligament and capsule, which
then pulls off from the spleen
cystic cavity.
However, this diagnosis can present as
late as 10 days post-procedure. Almost all
patients present with abdominal pain, but
only variably with back pain, shoulder pain,
and shock.
Treatment options include splenectomy, as
in our case, but also splenic artery embolization
in select institutions and, if the injury is
small, careful observation in an intensive
care unit.
Conclusion
Bedside ultrasound is crucial to making a
rapid diagnosis of hemoperitoneum in
critically ill patients. It can detect as little as
400 mL and 150 mL of fluid in Morison’s
pouch and the pelvis, respectively.
Ultrasound should be utilized in every
critically ill individual who presents with
unexplained hemodynamic instability to rule
out intra-abdominal hemorrhage. In this
case, an intra-abdominal catastrophe was
detected within seconds of arrival, expediting
the patient’s definitive treatment.
References
Ghevariya, V., Kevorkian, N., Asarian, A., Anand, S., &
Krishnaiah, M. (2011). Splenic Injury from Colonoscopy.
Southern Medical Journal, 104(7), 515–520.
Shankar, S., & Rowe, S. (2011). Splenic injury after
colonoscopy: case report and review of literature. The
Ochsner journal, 11(3), 276–281.
Kuenssberg Jehle, Von, D., Stiller, G., & Wagner, D.
(2003). Sensitivity in detecting free intraperitoneal fluid
with the pelvic views of the FAST exam. American
Journal of Emergency Medicine, 21(6), 476–478.
Figure 4 is taken from the Ghevariya article
Pre-hospital Cardiac
Resuscitation: Yesterday,
Today and Tomorrow
by Robert Ball, BA, EMT-P
Hennepin County Medical Center
More than 300,000 people are treated for
Sudden Cardiac Arrest (SCA) by emergency
medical services (EMS) each year 1 . Cardiac
arrest remains one of the areas where prehospital
care can have the largest impact
on patient outcome. It is also an area that
has changed dramatically from the early
days of EMS to today, and will likely
continue to change into the future.
The 1950s and 1960s
The basics of cardiac arrest management
were developed in the late 1950s when
Guy Knickerbocker, William Kouwenhoven,
PhD, and James Jude, MD, realized that
pushing on the chest improved circulation
and external cardiac massage was
possible. This technique remained largely
unchanged until the 1960s, when it was
combined with Dr. Peter Safar’s research
on artificial respiration leading to the birth
of cardio-pulmonary resuscitation (CPR) 2 .
From the 1960s well into the 1990s, CPR
changed little, but EMS changed a great
deal, as progressive communities began
using ambulances that were (or could be)
staffed with a physician for cardiac arrest
calls. In Minneapolis, at Hennepin County
General Hospital (as it was then known), a
donated “infant ambulance” was refitted to
include “mobile coronary unit”.
In a cardiac emergency, this ambulance
was dispatched to the emergency department
to pick up a physician (normally a resident)
and a nurse to provide advanced care (EMS
personnel of this era were lucky to have
EMT training). A “portable” monitor/
defibrillator weighing more 50 pounds also
had to be retrieved with the physician. In
these early days, Hennepin County General
created a Basic Life Support training program
for area ambulance drivers but providing
more than basic CPR still required help
from the hospital.
Approaches in Critical Care | January 2013 | 13

EMS Perspectives
Eugene Nagel, MD demonstrated that non-physicians
could be trained to provide advanced cardiac care in
the field under a combination of standing orders and
consultations with physicians by radio. Dr. Nagel and
Jim Hirschman, MD developed the original telemetry
device to send ECG data to a radio receiver in a
hospital, allowing physicians to hear what the
paramedic on scene had to say about a patient’s
condition while reading the ECG waveform in real
time and directing advanced care.
Meanwhile, the Seattle Fire Department created the
breakthrough Medic-1 program, which combined
community CPR education with advanced life support
by paramedics. Seattle’s early survival rates
of up to 50% were much better than the low singledigit
survival in much of the nation. This program
showed that pre-hospital cardiac resuscitation
required a coordinated approach combining the
efforts of the bystander, the professional rescuer,
and the hospital.
By the later 1970s, a patient living in a major city
who experienced cardiac arrest might receive CPR
from a bystander or from a rescuer, such as a police
officer or firefighter. By then, paramedics could
initiate care at the scene, control the airway, establish
IV access and attach ECG electrodes while calling a
physician for orders. Patients often received
epinephrine, sodium bicarbonate and Isuprel (a strong
beta agonist). Patients in ventricular fibrillation were
often given lidocaine and defibrillated under the radio
direction of a physician, often with the aid of ECG
telemetry. Once initial care was established, the
patient was transported with CPR in progress.
Unfortunately, most patients who required CPR
during transport still did not survive to admission.
The 1980s and 1990s
The ‘80s and ‘90s brought more gradual change, and
the scope of the paramedic’s practice increased in
most communities, allowing for more seamless
resuscitation efforts under standing orders without
continuous calls to a physician for orders. Telemetry
for ECG rhythm analysis fell by the wayside as
paramedic education increased. However, community
involvement in CPR continued in fits and starts.
Attempts to mitigate the lack of bystander action in
cardiac arrest included the Medical Priority Dispatch
System (MPDS), developed by Dr. Jeff Clawson.
MPDS used standard questions to allow the emergency
dispatcher to send the correct emergency resources
to the scene while providing bystander care
instructions to the caller, to assist in childbirth, help
someone who is choking, or administer CPR 5 .
Early defibrillation remained a key factor in resuscitation.
The advent of the Automatic External Defibrillator in
the ‘80s was expected to greatly increase survival
because this device did not require a paramedic to
determine a shockable rhythm. CPR took a back seat
in many training programs, with the idea of “buying a
little time” while waiting for a defibrillator.
By the 90s, many EMS systems had established first
responder programs using local police or nontransporting
fire services to bring an AED to the
patient’s side. These first responders would arrive
and attach the AED and deliver defibrillation.
Advanced life support was performed by paramedics
on scene. Unlike the ‘60s and ‘70s, transportation of
patients in cardiac arrest decreased dramatically.
Patients who had a return of spontaneous circulation
received continued advanced life support and
transport. Those patients who did not have a return
of pulse were often pronounced dead at the scene.
National survival rates still hovered around 20%, so
researchers began to examine why surviving sudden
cardiac arrest was so elusive. Drugs came and went,
often based on anecdote or animal studies. Human
resuscitation research was fraught with ethical
obstacles, such as the lack of informed consent from
a patient in cardiac arrest. These efforts to study
cardiac arrest finally led to the Utstein Template,
which provided specific definitions to help researchers
and providers better understand one another’s
successes and roadblocks 6 . It allowed EMS systems
to report and reflect on their success. Nevertheless,
even in high-performing EMS systems, successful
resuscitation remained less than 30% for patients in
ventricular fibrillation.
Today’s Rapid Access
Today’s more rapid access to basic life support
improves survival in cardiac arrest 7 and CPR for the
lay rescuer has become even easier. Disco has
returned, at least for resuscitation. “Fast and hard”
compressions on the center of the chest, to the beat
of the Bee Gee’s “Stayin’ Alive” and “Call 9-1-1”
simplify what a layperson needs to know to initiate
resuscitation. Pulse checks and rescue breathing
have become a thing of the past for lay rescuers.
Researchers found that Safar was right—exhaled
breaths provide sufficient oxygen to preserve life –
and it is more important to provide circulation
because sufficient oxygen is already in the sudden
cardiac arrest patient. The old approach to “ABC”;
Airway, Breathing and Circulation has been replaced
by “CAB”, where circulation comes first, then airway
and breathing.
14 | Approaches in Critical Care | January 2013

EMS Perspectives
Advanced life support has changed to provide more
direct support to basic care. Interventions can be
performed, but should not be to the detriment of
compressions. Endotracheal intubation, a mainstay in
pre-hospital ALS management of cardiac arrest, has
become a secondary intervention to supraglottic
airways, such as the King airway, in order to reduce
the need to interrupt compressions. Many of the
popular drugs of the late 20th Century have fallen by
the wayside. Aside from epinephrine, few drugs are
routinely given during a cardiac arrest, and when
they are used, it is often based on other findings or
suspected causes. Sodium bicarbonate, once a
standard drug in cardiac arrest, is only given if there
is reason to believe the patient has acidosis, as
opposed to an assumption of acidosis. In many
ambulances, lidocaine is used so infrequently that it
often expires without ever being used.
Best Practices
Now, the Cardiac Arrest Registry to Enhance Survival
(CARES), sponsored by the Centers for Disease
Control, Emory University and the American Heart
Association, allows physicians, epidemiologists and
EMS systems to identify best practices. By reporting
standardized information, key stakeholders can see a
direct comparison of their local survival statistics with
those of the rest of the nation. These changes have
resulted in increased survival rates nationwide. While
a survival rate for the patient in out-of-hospital
ventricular fibrillation of 30% was considered a goal
for many parts of the country in the past it is now the
average performance level. Today, high-performing
systems, such as Hennepin EMS, achieve survival
rates of 50-55% 7 .
Currently, the victim of sudden cardiac arrest is more
likely to receive rapid access to the 9-1-1 system. In
many cases, bystander CPR is accomplished without
the need for instruction by an emergency medical
dispatcher. Public access defibrillators may be
employed, or first responder AEDs will be used.
Automated CPR devices are often deployed early to
ensure continuous quality compressions. In a growing
number of cases, the patient may have a return of
spontaneous circulation before the paramedics even
arrive, or it occurs shortly after the beginning of ALS
interventions. Post-arrest patients are often cooled to
controlled hypothermia to preserve neurologic function
and reduce the insult of the arrest on the central
nervous system. This cooling often begins in the field
with the placement of ice packs. In systems such as
Hennepin’s, the victim of a sudden v-fib arrest is as
likely as not to walk out of the hospital alive.
Looking Ahead
How will the cardiac arrest patient of the future fare?
There are increased opportunities for the pre-hospital
resuscitation, through improved education, improved
communication and improved technology. In
Minnesota, CPR training is mandated for all high
school students graduating on or after 2014. For
those businesses that choose to register their AEDs
through a HeartSafe Community program 8 , EMS
dispatchers can not only provide CPR instruction if
needed, but direct laypeople to the nearest AED.
In the future a text message may be sent to any
registered CPR provider near a scene so that they
can respond and provide trained bystander CPR.
Automated CPR devices may prove to be as easy to
use as an AED and also find their way into the public
realm. As we study the neuroprotective properties of
cooling, we may see specific devices make their way
into the field, such as cooling helmets to allow for
quick cooling of the brain. Descendents of Left
Ventricular Assist Devices (LVADs), currently in use
for those patients in heart failure, could entirely
eliminate cardiac compressions at the paramedic
level, relying instead on a mechanical pump to better
circulate blood.
Conclusion
For centuries, physicians have strived to stop early
death. While death is the ultimate certainty for us all,
sudden death from cardiac arrest may someday
become a relic of the past as we find better and faster
ways to restore circulation and protect the brain.
References
1. American Heart Association. American Heart Association
develops program to increase cardiac arrest survival [Online] April
2012. Available at http://newsroom.heart.org/pr/aha/american-heartassociation-develops-232125.aspx.
Accessed November 29, 2012.
2. Cooper JA, Cooper JD, and Cooper JM. Contemporary Reviews
in Cardiovascular Medicine. Circulation, December 2006. Vol. 114:
2839-2849.
3.C, Staresinic. Send Freedom House! PittMed. February, 2004.
4. National EMS Museum Foundation. 1967: City of Miami Fire
Department Paramedic Program [Online] August 2, 2011. Available
at http://www.emsmuseum.org/virtual-museum/history/articles/
399754-1967-City-of-Miami-Fire-Department-Paramedic-Program.
Accessed November 30, 2012.
5. G, Cady. The Medical Priority Dispatch System–A System and
Product Overview. National Academies of Emergency Dispatch
[Online] 1999. Available at http://www.emergencydispatch.org/
articles/ArticleMPDS(Cady).html. Accessed November 30, 2012.
6. Cummins RO, Chamberlain DA, Abramson NS, Allen N, Baskett
PJ, Becker L, Bossaert L, Delooz HH, Dick WF, and Eisenberg
MS. Recommended Guidelines for Uniform Reporting of Data
From Out-of-Hospital Cardiac Arrest: The Utstein Style.
Circulation, 2, 1991, Vol. 84: 960-975.
7. Steill IG, Wells GA, Field B, et al. Advanced Cardiac Life
Support in Out-of-Hospital Cardiac Arrest, 2004. New Engl J Med.
Vol. 351: 647-656.
8. Cardiac Arrest Registry to Enhance Survival. MyCares Utstein
Survival Report. MyCares.NET [Online] 2011. Available at
https://mycares.net/index.jsp. Accessed: November 29, 2012.
9. Hennepin EMS. Hennepin EMS HeartSafe Community [Online]
2012. Available at http://www.hennepinems.org/projectheartsafe.
Accessed November 28th, 2012.
Approaches in Critical Care | January 2013 | 15

MS
Calendar of Events
2012 Course Dates
Basic, Refresher
& Advanced
w w w . h c m c . o r g / e m s
1-yr Paramedic Program
Begins June 2013
__________________________________________
2-yr AAS Paramedic Degree
Begins September 2013
For course information, please contact Roger
Younker, Course Director@612-873-4907.
__________________________________________
Advanced Cardiac Life Support for Providers (AHA)
February 19 and 20, March 4 and 5, April 16 and 17,
May 14 and 15
__________________________________________
Advanced Cardiac Life Support (ACLS) Provider
Renewal (AHA)
February 28, March 28, April 18, May 13
__________________________________________
Advanced Cardiac Life Support (ACLS)
Heartcode Online Provider Renewal
Call for details & scheduling
__________________________________________
Advanced Cardiac Life Support (ACLS) for
Experienced Providers (AHA)
February 26
__________________________________________
Advanced Cardiac Life Support (ACLS) Instructor
(AHA)
March 26 and 27
__________________________________________
Advanced Cardiac Life Support (ACLS) Instructor
Renewal (AHA)
March 27
__________________________________________
Advanced Pediatric Life Support (APLS)
March 19 and 20
__________________________________________
Advanced Trauma Life Support (ATLS)
January 24 and 25, March 12 and 13, May 2 and 3
__________________________________________
Advanced Trauma Life Support (ATLS) Instructor
April 29 and 30 (tentative)
__________________________________________
Pediatric Advanced Life Support (PALS) for
Providers (AHA)
January 29 and 30, February 14 and 15, April 30 and
May 1, June 24 and 25
__________________________________________
Pediatric Advanced Life Support (PALS) Renewal
(AHA)
February 7, March 7, April 11, May 7, June 27
__________________________________________
Pediatric Advanced Life Support (PALS)
Instructor (AHA)
May 23 and 24
__________________________________________
Pediatric Advanced Life Support (PALS)
Instructor Renewal (AHA)
May 24
__________________________________________
Trauma Nursing Core Course (TNCC)
February 12 and 13, April 9 and 10
__________________________________________
Emergency Nurses Pediatric Course (ENPC)
January 22 and 23
__________________________________________
Basic EKG/ACLS Preparation (EKG I)
March 18
__________________________________________
EKG Interpretation (EKG II)–Basic 12-Lead EKG
February 5, May 7
__________________________________________
16 | Approaches in Critical Care | January 2013

Calendar of Events
EKG Interpretation (EKG III)–12-Lead Beyond
the Basics
May 21
__________________________________________
International Trauma Life Support (ITLS)
Instructor
January 31 and February 1
__________________________________________
Advanced Medical Life Support (AMLS)
February 4 and February 11
February 5 and February 12
__________________________________________
Paramedic Refresher–48 hour National Registry
24 hours classroom/24 hours online
February 9
__________________________________________
Advanced Burn Life Support (ABLS)
February 22, June 11
__________________________________________
Healthcare Provider Cardiopulmonary
Resuscitation (CPR)
March 18, April 15
__________________________________________
Online Healthcare Provider CPR Renewal with
Skills Check-off (Lab hours of MD CPR)
To register, please call 612-873-5681 or email:
ems.ed@hcmed.org
__________________________________________
Cardiopulmonary Resuscitation (CPR) Instructor
April 1
__________________________________________
Cardiopulmonary Resuscitation (CPR) Instructor
Renewal
April 1
__________________________________________
Infant and Child Cardiopulmonary Resuscitation
(CPR)
March 27, May 9
__________________________________________
Emergency Medical Technician (EMT) Basic
Online @ HCMC
January 7-March 20, April 1-June 10
Monday & Wednesday evenings @ HCMC
__________________________________________
Emergency Medical Technician (EMT) Refresher
January 23-25, February 119-21, February 25-27,
March 18-20, (South Metro Training Facility, Edina, MN)
March 16, 23, and 30 (Saturdays @ HCMC)
__________________________________________
First Responder (FR)
April 22-26
__________________________________________
First Responder (FR) Refresher
March 21 and 22
__________________________________________
TEMPO TM (Tactical Emergency Medical Police
Officer Program) EMT Refresher
TBD–Please contact Robert Snyder@612-373-7698
__________________________________________
TEMPO TM First Responder (FR) Refresher
TBD–Please contact Robert Snyder@612-373-7698
__________________________________________
Wilderness First Responder
February 11-17
TBD–Please contact Phil Rach@612-373-7698
To register and for more information, visit
www.hcmc.org/ems.htm or contact Joni
Egan in the medical education department
at Hennepin County Medical Center at
612-873-5681 or email joni.egan@hcmed.org
unless another contact person is provided.
Classes are at Hennepin unless otherwise
indicated. Many courses fill quickly; please
register early to avoid being wait-listed.
3/31/08 10:16 AM Page 5
Emergency Medical Technician (EMT) Basic
April 1-April 26 (South Metro Training Facility, Edina,
MN)
__________________________________________
Emergency Medical Technician (EMT) Refresher
Online @ HCMC
February 2, March 9
16 hours online/8 hours classroom
__________________________________________
Rapid access to Hennepin physicians
for referrals and consults
Services available 24/7
1-800-424-4262
612-873-4262
Approaches in Critical Care | January 2013 | 17

News Notes
News Notes
“The simulation
center’s resources
enable us to
rehearse situations
that we rarely see,
and improve
targeted procedures.
As we acquire new
technologies, we
can test them in
simulation before
we roll them out to
the institution
broadly. This
process enables us
to achieve quality
improvement in a
very controlled,
organized setting.
Additionally, we can
improve patient
satisfaction scores
by working with a
patient in the
simulation center
to do patient and
family counseling
and discussion.
It’s a powerful
tool to coordinate
better care.”
- Danielle Hart, MD,
director of the
Integrated
Simulation
Center
HCMC Opens Interdisciplinary
Simulation and Education Center
In January of 2013, HCMC opened a new
simulation center designed for both student
and hospital training. The $3.5 million
facility offers the most cutting edge
procedural technology in the metro area.
The center is designed with two large
rooms that can simulate an ED stabilization
bay or ICU. The stabilization setting
features a full range of monitoring and
radiology equipment, allowing medical
faculty to simulate a real trauma with the
participation of a multidisciplinary team of
nurses, students, residents, faculty and
pharmacists. Faculty can build exact
scenarios for curriculum, and learners will
be able to practice procedures and
simulate interventions that they may have
to do in real life. The ICU environment will
provide staging for a variety of situations
ranging from a family meeting and
discussion to a simulated code experience.
Sophisticated mannequins can interact with
the learner and can be programmed to
create vitals and findings that simulate
heart or lung exams. Students can perform
surgical procedures on the mannequin in a
18 | Approaches in Critical Care | January 2013
realistic bedside setting. During
simulations, equipment and procedural
techniques will be integrated with order
sets in HCMC’s electronic medical record
system. Learners can work with the
equipment, create a sterile field, practice a
procedure on a mannequin, and enter
orders in the electronic medical record.
A soundproof control room allows those
controlling the simulation to change vitals,
medications, and scenarios in real time.
Observing rooms with mirrored windows
enable faculty to observe and record
everything done during a simulation, so
that practice sessions can be debriefed
with video resources. “Debriefing is the
key,” says Dr. Meghan Walsh, Chief
Medical Education Officer at HCMC. “We
can watch the video, and talk with students
about how they felt and what they could
have done differently. It’s a powerful tool
for learning.”
The value of the simulation center extends
beyond student and resident training. “We
see the center as a vehicle to bring all of
our medical professionals together and
build more continuity across our
multidisciplinary teams,” explains Walsh.

News Notes
“The simulation center’s resources enable us to
rehearse situations that we rarely see, and improve
targeted procedures. As we acquire new technologies,
we can test them in simulation before we roll them
out to the institution broadly. This process enables us
to achieve quality improvement in a very controlled,
organized setting. Additionally, we can improve
patient satisfaction scores by working with a patient
in the simulation center to do patient and family
counseling and discussion. It’s a powerful tool to
coordinate better care.”
The Center’s director is Danielle Hart, MD. She is an
Associate Program Director in HCMC’s Department
of Emergency Medicine and an Assistant Professor
at the University of Minnesota Medical School. Dr.
Hart designed and integrated the simulation program
into the Emergency Medicine Residency Program.
“Simulation will revolutionize medical education at
HCMC. Hands-on learning, such as this, has been
proven to improve both learning and retention in
healthcare providers and trainees, and allows them
not only to practice medical decision-making, but
also teamwork, communication, professionalism and
other skills integral to delivering the best patient care
and safety.”
the chest and abdomen, specifically bladder, small
bowel, kidney, ureter, duodenum, diaphragm, spleen,
pancreas, stomach, cardiac, liver laceration and IVC
injuries. ATOM is a full-day course preceded by selfstudy
and self-efficacy testing that includes didactic,
surgical operative laboratory and post test components.
It is directed at surgical residents in light of reduced
duty hours and practicing trauma surgeons.
HCMC has chosen to become one of the approved
sites as a demonstration of its commitment to trauma
education and collaboration with outside practitioners
to provide better operative outcomes.
Participants will include
• Trauma Fellows and Senior Surgical Residents in
their fourth or fifth year of training external to
HCMC as well HCMC fourth year surgical trainees;
• Practicing surgeons taking call in non-trauma
centers and who are expected to manage
penetrating injuries;
• Practicing surgeons in trauma centers who do
not see a significant number of penetrating
trauma cases and who want to maintain or
improve their trauma operative skills; and
• Military surgeons.
Participating physicians will:
• Find their psychomotor skills for managing
trauma improved
• Be better prepared to identify penetrating trauma
• Be better prepared to develop a treatment plan
• Be better prepared to repair penetrating injuries
ATOM
Advanced Trauma Surgery Course to Be Held
at HCMC
For surgical residents, now held to an 80-hour work
week, ATOM assures them operative trauma
experience, as well as a response to the new
regulatory requirement for simulated skills training of
surgical residents. To the practicing surgeon, ATOM
provides the opportunity to practice solutions to
penetrating trauma. It would be HCMC’s important
contribution that surgeons in both the public and
private sectors be competent and confident in
management of penetrating injuries.
For more information or to register contact
www.hcmc.org/atom
Hennepin County Medical Center is one of only a few
national sites offering the American College of
Surgeons (ACS) Advanced Trauma Operative
(ATOM) course, none other presently in Minnesota.
The purpose of the course is to increase self-efficacy
and surgical competence in the repair of injuries to
Approaches in Critical Care | January 2013 | 19

News Notes
Best of Hennepin 2013 to Challenge Your
Emergency Resuscitation Skills
Three learning opportunities in one weekend
Friday, April 26
• CALS Conference–Rural Emergency Care:
Stepping up to the Challenge
Saturday, April 27
• Advances in Resuscitation: The Crashing Patient
Sunday, April 28
• Hands-On Workshops (Including Ultrasound)
in the New Simulation Center
Best of Hennepin, 2013 will kick off with Keith Lurie,
MD, an expert in Advanced Cardiac Resuscitation
techniques. Participants (in person and online) will
have a front row seat for the action at one of the
country’s best and busiest emergency departments.
Experts will present interactive case studies. YOU
can make the call about what to do next in six reallife
emergency scenarios in person, or online. For
registration and details about this exciting opportunity
visit www.hcmc.org/bestofhennepin.
Upcoming Education Session for EMS
EMS Update – February 20
This free annual conference for EMS will be held at
a new location in 2013, Minneapolis Fire Emergency
Operations Training Facility in Fridley. Highlights
include: Pediatric Head Trauma, Infectious Critters,
Stroke Case Studies, Lessons from EMS Down
Under (Australian EMS), Scene Safety-Active
Shooter, Identifying Drug Use at the Scene and Fiery
Scenarios & Confined Smoke Exposure. Web Cast
option is available. http://ems.hcmed.org to register.
7.1 Contact hours
12th Annual “Trauma: Life in the
ICU, April 11 – Doubletree Hotel,
Minneapolis
This session will feature: Facial
Trauma, Subarachnoid Hemorrhage,
Nutrition in the ICU, Complications
of Abdominal Trauma, Workplace
Moral Distress of Nurses, Hyperbaric
Oxygen, Hospital Acquired Delirium, ECMO and more.
Email Barbara.Gale@hcmed.org (612) 873-7176 for
more information.
Did you train at Hennepin?
We’re looking for you.
20 | Approaches in Critical Care | January 2013
You are an important member of an exclusive group
of physicians who share Hennepin County Medical
Center’s expertise and knowledge with the people of
the Upper Midwest. Hennepin is committed to
continue a learning and sharing relationship with our
alumni and would like to stay in touch.
Please submit your contact information at
www.hcmc.org/alumni/updateform.htm
or to R. Hoppenrath, 701 Park Ave., Mpls, MN 55415

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The cover image depicts a heart and lung from
an anatomical plate published in Anatomie
Generale Des Visceres, thought to have been
printed in Paris in 1752. The artist is Gautier
d’Agoty. He produced a number of large,
colorful anatomical atlases, which were noted
more for their style and sometimes their
shocking appearance than their usefulness
to physicians.
Hennepin County Medical Center is a Level I
Trauma Center and public teaching hospital
repeatedly recognized as one of America’s
best hospitals by U.S. News & World Report.
As one of the largest and oldest hospitals in
Minnesota, with 469 staffed beds and more
than 102,000 emergency services visits per
year at our downtown Minneapolis campus,
we are committed to provide the best possible
care to every patient we serve today; to search
for new ways to improve the care we will
provide tomorrow; to educate health care
providers for the future; and to ensure access
to health care for all.
Approaches in Critical Care | www.hcmc.org