It is not everyday that you find something in medicine that could change your practice completely. For me, the last time was for Point-of-Care-Ultrasound. This imaging tool is not just a fancy toy, it has definitely proven itself over and over how it could identify medical conditions early and change the management of my patients. You know how that story ended.

This week though, I might have another Wow moment. It was for an arterial line during a cardiac arrest.

Short story. It was a man in his sixties who collapsed on the ground, found in asystole, received the proper ACLS treatment, then went into ROSC, then we lost the pulse again, he was in PEA. Or so we thought. At some point in this resuscitation, the anesthesiology specialist installed an arterial line on the radial artery. During a pulse check, nobody felt a pulse, but the attending saw something on the arterial line monitor. We have a blood pressure, we have some circulation!!! The BP was rocket low, but something was going on.

Instead of continuing the chest compressions and giving large doses of adrenaline, we just moved to an adrenalin infusion and stopped CPR. The blood pressure improved, he actually ended-up requiring two vasopressors, but we managed to have an ok MAP and the patient went to the ICU.

Game changer?

This was some sort of an illumination for me.

I have always been skeptical of arterial lines in the ER. During my training, we never installed it, they were more an ICU type of things. But here, in Iceland, ICU installs it quite often. Sometimes too often. They consume too much time, people put all their concentration into it and become tunnel vision, it has delayed imaging before, etc. I just didn’t see them as a priority in the first 15 minutes when a critical patient arrived.

But when something like this happens, I have to reconsider my own opinions.

This right case, at my right time

This wow moment arrived at the perfect time. It arrives at a time that people talk about all kind of new stuff for cardiac arrest. For example, the use of POCUS in cardiac arrest. Or, is adrenalin good or bad? Do we just give too much? What about ECMO? We are moving from a cookie-cutter approach of ACLS to a more personalized approach.

I do not consider myself an expert resuscitationist. Most of opinions are made from podcast I listen to or conference I go to. But I believe we can not consider all fruits as apples. There are oranges, bananas and these small yummi blueberries. Same things for cardiac arrest.

There are just so many questions I am asking myself now :

• If there is cardiac activity on POCUS during cardiac arrest, is it PEA or a low flow state?
• How can I differentiate?
• Arterial line vs US doppler of the femoral artery to differentiate?
• Arterial line, yet more thing to consider on top of POCUS, ECMO, …
• Do all cardiac arrest patients need an arterial line or just a subgroup? PEA vs V Fib?
• Are there any “hard” evidence on this? Any improvement of mortality or neurological outcomes or this would again just be a surrogate or a soft outcome?

This also comes at a time where adrenalin is having a hard time in the resusc circles. The criticism is that we might give too much of it and it causes a cerebral vasoconstriction, thus, we save lives but people that leave the hospital have worst neurological outcomes. Maybe some group of patients just needed small vasopressor boluses because they were in a low flow state, not in PEA? Humm…

I see this post more as an introduction, just a thought raise in the air. I havent not look at studies too much, just a gut feeling. For the next weeks I will meditate on this and see what the litterature have to say.

Any thoughts?

Do not forget to make ER great again. MEGA.