Agonal rhythm/Slow PEA

[u/complacentlate]

What do you do when the chance of ROSC is abysmal, and even if you got it the outcome would be terrible, but they still have a wide complex bradycardic electrical rhythm say in the 20s, and maybe even a little valve flicker on beside echo. Its clearly just the last gasp of an almost dead heart being flogged by rocket fuel epi but I dont want nurses/techs or families to freak out. I'm moving towards giving fewer and fewer doses of epi to avoid this. I usually don't give more than 3 but sometimes EMS has given a few and they usually get at least one on arrival.

I'm talking a 70 year old with comorbidities, with no bystander CPR, who was worked for > 20 mins by EMS, and maybe had one shockable rhythm but mostly was just asystole or sometimes this agonal rhythm. For the sake of this conversation we are talking a situation where we all know where this is going.

I usually just call it anyways, but it always feels a little weird to call something thats not pure asystole.

Or do you work it until asystole everytime.

Edited to add:
Ok thanks for the validation that what I’m doing is normal. I usually aggressively call death pretty early and it seemed like the nurses and techs thought it was it weird I was calling death on PEA and it had me second guessing what I was doing. There’s was also an EMRAP recently that talked about only calling it when you could see on BSUS that the heart had stopped and that’s definitely not how I practice

[u/insertkarma2theleft]

I can't speak from an EM perspective, but we terminate resus on PEA all the time in the field. I'd say ~ half my codes that I call the final rhythm is PEA, usually wide complex and not very fast

[u/OccasionTop2451 → u/insertkarma2theleft]

Same in the ICU. Most of ours are PEA and we have no problem terminating codes prior to asystole.

[u/LunarSoul]

No, I call it. Let them die peacefully. 

[u/DadBods96]

Call it and explain to the room “Occasional agonal beat on bedside ultrasound”. Anyone with experience will understand why you mean, and it opens up an opportunity for anyone without experience to ask what you mean. Then you can point and say “The heart is beating once every x but it’s not enough to move blood, completely normal around time of death, and will cease in the next few minutes”.

Then turn the monitor off, and if family happen to see a few beats at any point before that you tell them “We’ve given a bunch of drugs that are causing electric activity in the heart which can last quite awhile, it’s not pumping though”.

[u/Goldy490 → u/DadBods96]

Yea I’ll usually just announce “that is not a perusing rhythm.” So everyone knows what I’m thinking.

Or just don’t look at the heart. All you need is one good look at the start of the code to rule out tamponade and after that you’re feeling for a palpable pulse. If they have a pulse that can only be weakly seen on US/doppler that’s just pseudo-PEA and should be treated like regular PEA.

If they’ve already gotten multiple pushes of code dose epi there’s nothing on this earth that will make the heart squeeze harder than that, and that degree of squeeze is not compatible with life.

[u/LunarSoul → u/Goldy490]

Yeah I agree, I peruse the POCUS and it there's nothing there or barely any movement, I don't bother looking again. I don't really announce anything to my team about any movement or anything. No point if I've already. Made up mind to call it. 

Also prevents the family or anyone else from prolonged decision making regarding next steps. Saddest thing, I once had a 20-something kid almost kill himself because he thought he killed his mom with palliative extubation. All cause one my colleagues just didn't stop the code, got ROSC eventually and of course the patient was brain dead and died in the ICU.

[u/Hippo-Crates]

It's a pretty easy call.

[u/tenaceseven]

If you're convinced that it's futile, call it. 

Before I call any code I address the room, summarize the case, and ask for input. That's the time to discuss briefly how this rhythm is an agonal rhythm, not compatible with life, prolonged resuscitation with no chance of neuro survival etc. (I once had a tech tell another, newer, tech "you ever cut a head off a snake?" while explaining agonal respirations) 

I can't say I've had family in the room in this situation. I guess I'd have to have the same conversation with them and tell them that they might expect to see activity on the monitors or even some agonal respirations... 

[u/MrPBH]

I agree. I do the same thing. Futile is futile.

I had one were we had worked it for around an hour (plus the 30 minutes EMS had as well) and I called it for futility. The rhythm was PEA and there was ineffective heart activity on POCUS. We never achieved ROSC at any point.

About 15 minutes later, I got called back into the room by the nurse to see the RT bagging the (dead) patient and a tech performing CPR. I asked what happened and was told that they detected a pulse. There was a slow pulse (maybe 10-20 BPM) and the patient was making agonal respirations.

I told them to stop the bagging and compressions. I stood at bedside, fingers on the carotid artery, counting pulses for what felt like ages, but was probably only 8-10 minutes. The heart beats eventually stopped, as did the agonal respirations, and I only left the room then. I felt it was only proper that I'd be the one to stand watch, instead of forcing the nursing staff to do so. Sometimes, you need to be the captain of the ship and do things like that to make everyone feel better.

I think it was the right thing, because there was no chance of neurologically intact survival and the literature is pretty clear that these Lazarus syndrome patients don't survive long term, but it was hard to watch regardless. It was my job to witness because I was the one making the call.

[u/Cautious-Extreme2839]

Jesus, the Americans are not ok.

Who cares about the rhythm? If you're stopping for futility you're stopping for futility. Fin. The end.

Working until asystole is absolutely insane. Where the fuck have you even got that from?

[u/TriceraDoctor → u/Cautious-Extreme2839]

65,000 docs practicing EM in the US and you decide to assume OPs Reddit post is widespread standard of care?

[u/complacentlate → u/Cautious-Extreme2839]

Bro chill. Yikes.

I aggressively call PEA and dont work it til asystole but I don’t know if other people do. I’m always hearing about places that do 40 min codes and feel weird that I usually call it after a few rounds. It seems like everyone else works codes way longer than me.

Just wondering I guess if people have a strategy for talking to the nurses and techs and family especially if family is in the room when you call it.

One time someone left the machine on and the family freaked out about agonal rhythm and it was a whole thing

[u/ItsOfficiallyME]

From a nursing perspective, we all know the right move is a TOR. I have done many codes where a TOR 10-20 mins ago would have also been the right move, and they’re still producing some non-shockable flicker of measurable electricity.

I also think of things like traumatic arrests where the bleeding was totally unmanageable, they’re often still PEA but it’s beyond futile.

[u/nursingintheshadows]

My MDs call it and we turn off the monitors so family can visit. Had a nurse leave the monitor on and family saw a heart beat after time of death once. That was a circus and it wasn’t fun.