He simply looks sick…

Initial actions, after assessing the ABCs, should include:

• Manage in a resuscitation area
• Get help
• Administer high-low oxygen via a non-rebreather mask
• Attach monitoring/ defibrillator — SpO2, RR, ECG, BP
• Obtain large bore IV access (2 big peripheral lines) and take bloods
• Perform a 12-lead ECG

Blood glucose has already been checked.

“Somewhere between ABC and CBC, [there’s scope to] lose a lot of patients…”
— Amal Mattu

Perform bedside ultrasound.

In particular look for a pericardial effusion and check for an aortic aneurysm. About half of aortic emergencies present without chest or back pain and simply ‘look sick’. Abdominal ultrasound can often easily identify an abdominal aortic aneurysm and pericardial tamponade is a common mechanism of death in aortic dissection. Ultrasound can also diagnose tension pneumothorax, potential causes of hypovolemia, effusions and cardiac failure.

“’Classic presentation’ means it occurs 15% of the time.”
— Amal Mattu

Pulseless electrical activity is a non-shockable rhythm. This is the Australian/ New Zealand Resuscitation Council’s algorithm for adult cardiorespiratory arrest:

Thrombolysis is often suggested as myocardial infarction and pulmonary embolism are common causes of a PEA arrest.

By all means, get ready to administer thrombolytics but consider other causes of PEA arrest first. As part of this do the bedside ultrasound — arrests from aortic emergencies also commonly result in PEA. Needless to say, thrombolysis won’t do these patients any favours…

Remember the 6Hs:

• Hypovolemia
• Hypoxia
• Hydrogen ions (acidosis)
• Hyperkalemia or hypokalemia
• Hypoglycemia
• Hypothermia

and the 6Ts:

• Tablets and toxins
• Tamponade (cardiac)
• Tension pneumothorax
• Thrombosis (myocardial infarction)
• Thrombosis (pulmonary embolism)
• Trauma

Note that this commonly used memory aid doesn’t include:

• aortic emergencies —see Die Like A King
• dynamic hyperinflation

In this case, bedside ultrasound shows a pericardial effusion and a dilated aortic root.

“Every time you see a sick patient, perform bedside ultrasound. Look at the heart, look at the belly. You will save lives.”
— Amal Mattu

Put simply, the next steps are:

• Continue effective CPR — don’t stop!
• Urgently notify the on-call cardiothoracic surgeon, or arrange transfer to an appropriate center.
• Emergency drainage of the pericardial effusion to correct the pericardial tamponade (preferably ultrasound guided).
• If there is ‘return of spontaneous circulation’, initiate post-resuscitation care.

Don’t let the patient die like a King.

“The aorta is a ticking bomb, a grenade waiting to go off.”
— Amal Mattu

• Kurimoto Y, Morishita K, Narimatsu E, Asai Y, Abe T. Satisfactory recovery after 45 minutes of resuscitation in acute aortic dissection. Crit Care Med. 2002 Sep;30(9):2030-1. PMID: 12352036.
• Mattu, A. ‘The Crashing patient‘ — Free Emergency Medicine Talks.
• Meron G, Kürkciyan I, Sterz F, Tobler K, Losert H, Sedivy R, Laggner AN, Domanovits H. Non-traumatic aortic dissection or rupture as cause of cardiac arrest: presentation and outcome. Resuscitation. 2004 Feb;60(2):143-50. PMID: 15036731.