(sorry for the lengthy post about background, just feel like a clear picture necessary.)
Code last week at my hospital I responded to: Pt admitted for NSTEMI (non-ST Elevation Myocardial Infarction) that night with troponins in the 40s to 50s (I believe) to card tele unit.
Fairly soon after admission, per report, NP was called to bedside for the patient rapidly begining to get more symptomatic moving more toward an ACS picture (minimal prior apparently). This is around 0345h.
I think the they were about to pursue an emergent heart cath and page cath lab, the patient experienced a PEA arrest and a code was called.
Now we (Pulm Critical Care Fellow and I) got there in a couple minutes and the MICU Residents following in shortly after. The MICU resident (PGY-3 ED on his MICU rotation) intubates then quickly overruns the code and even his Fellow which is already unfortunate. He basically was ignoring/talking over everyone.
While the mid-level and myself where discussing going ahead and activating a STEMI, he continues plowing over everyone on basic ACLS (which obviously both the Fellow and myself were easily able to do) which was very disruptive to us helping manage the code.
About 10-15min in, he has decided he is going to give TNK. I asked why and he said it would treat both a STEMI and PE (Alteplase available with call to pharm), ignoring that we are planning on calling Cath Lab. He keeps talking about the TNK over everyone.
I let him know we have a 20g AC IV only right now as well, and he says put in an IO which I remind him is contraindicated with thrombolytics (ignores me). He continues to yell how he is drawing up the TNK. I rotate in on compressions, blood starts blowing into the ETT, and relate this (loudly, twice) which he also does not respond to.
No one I saw was in agreement about the TNK, but…
We are now about 20mins into the code I believe. No ROSC. Rhythm has gone from PEA/ventricular standstill that didn't respond to pacing to vfib only. He gives the TNK, after a couple more rounds of CPR we end up calling it.
Now I've never seen TNK given during a code. I've personally only even seen it given for STEMI (even from an outlying facility) once. Cath Lab generally activated at night and depending on the interventionalist, we may even travel while doing ACLS on the bed (I know…I know). We typically do Alteplase for suspected massive PEs with arrest.
I was just wondering what y'alls thoughts are with this situation?
-Kev
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