Was it appropriate to start CPR, administer epinephrine (epi) and calcium, and intubate an unresponsive elderly patient with end-stage kidney disease (Impaired renal function), suspected hyperkalemia, and a severely depressed heart rate, who presented with agonal breathing and no pulse?

Was CPR Appropriate and Were the Medications Correctly Administered?

Yes, initiating CPR was absolutely the correct decision—this patient met clear criteria for cardiac arrest with unresponsiveness, agonal breathing, and no definite pulse, and your team's aggressive resuscitation with epinephrine and calcium for suspected hyperkalemia was appropriate and likely life-saving. 1

Recognition of Cardiac Arrest: You Made the Right Call

Your decision to upgrade back to cardiac arrest was textbook correct. The 2020 AHA Guidelines are explicit: if a patient is unconscious/unresponsive with absent or abnormal breathing (including only gasping), and you cannot definitively feel a pulse within 10 seconds, you should assume cardiac arrest and immediately begin CPR. 1

Key Clinical Indicators That Justified CPR:

• Agonal breathing with mouth open is one of the most commonly misinterpreted signs—present in 40-60% of cardiac arrests and frequently causes bystanders to delay CPR 1
• Heart rate of 29 with severe bradycardia in an unresponsive patient represents peri-arrest physiology 1
• Half-open eyes with no focus or tracking indicates profound neurological compromise consistent with inadequate cerebral perfusion 1
• Single pulse felt does not constitute adequate circulation—healthcare providers have difficulty reliably detecting pulses, and CPR should not be delayed if pulse is not definitively palpated 1

Critical point: The benefit of providing CPR to someone in cardiac arrest vastly outweighs any potential harm of compressions on someone who is unconscious but not in arrest (injury rates are low: 8.7% chest pain, 1.7% rib fractures, 0.3% rhabdomyolysis, with no visceral injuries). 1

Epinephrine in Hyperkalemia: Appropriate Use

Yes, epinephrine is appropriate in cardiac arrest with suspected hyperkalemia. While epinephrine is not a specific treatment for hyperkalemia itself, it is a standard vasopressor in cardiac arrest protocols and helps maintain coronary and cerebral perfusion pressure during CPR. 1

The immediate ROSC after epinephrine and calcium suggests:

• Calcium was the critical intervention for hyperkalemia-induced cardiac toxicity—it stabilizes the myocardial membrane against the effects of elevated potassium 2, 3
• Epinephrine provided additional inotropic and chronotropic support to restore adequate cardiac output 1
• The combination addressed both the underlying electrolyte emergency and the hemodynamic collapse 2, 3

Calcium and Sodium Bicarbonate: Compatibility Concerns

Pushing calcium and sodium bicarbonate through the same line with flushing between is acceptable in emergency situations, though not ideal. The 2015 AHA Guidelines note that routine sodium bicarbonate use is not recommended in cardiac arrest (Class III), but it can be considered in specific situations like hyperkalemia. 1

Important considerations:

• Calcium and bicarbonate can precipitate if mixed directly, forming calcium carbonate 1
• Flushing between medications minimizes this risk and is the standard practice when separate IV access is not immediately available 1
• In your case, the IO access and suspected fistula hit made separate access challenging, so sequential administration with flushing was reasonable 1
• The clinical response (QRS narrowing and heart rate improvement) confirms the medications were effectively delivered 3

Intubation Decision: Appropriate and Well-Executed

Yes, intubation was indicated once ROSC was achieved. The patient was:

• Fighting the BVM indicating inadequate sedation for bag-valve-mask ventilation 4
• Post-cardiac arrest requiring controlled ventilation to optimize oxygenation and prevent hyperventilation (which impairs venous return) 1, 4
• At risk for re-arrest given the recurrent bradycardia into the 30s 1, 4

Your medication choices were appropriate:

• Avoiding succinylcholine in hyperkalemia was critical—succinylcholine can cause dangerous potassium release and is contraindicated in hyperkalemia 3
• Rocuronium and etomidate are appropriate alternatives for rapid sequence intubation in this setting 3
• Your partner's knowledge about avoiding succinylcholine potentially prevented a catastrophic potassium surge 3

Technical Considerations and Learning Points

Bougie Technique:

• Preloading the bougie in the tube can work but requires the bougie to maintain its curve—your recognition that it needed to be bent separately shows good problem-solving 4
• Going in "live" without suction connected is not ideal but was managed successfully—knowing suction setup before the next intubation will improve efficiency 4

Common Pitfalls You Avoided:

• Not delaying CPR for prolonged pulse checks—you correctly initiated compressions when pulse was not definite 1
• Recognizing agonal breathing as a sign of arrest rather than adequate respiration 1
• Treating suspected hyperkalemia empirically with calcium before lab confirmation—appropriate in cardiac arrest with end-stage renal disease 2, 3
• Avoiding succinylcholine in a hyperkalemic patient 3

Areas for Future Preparation:

• Ensure suction setup familiarity before intubation attempts—this should be part of your pre-intubation checklist 4
• Consider pre-curved bougie technique rather than preloading in the tube for difficult airways 4
• IO access is appropriate when IV access is difficult, as you correctly utilized 1

Your team's performance was excellent—you recognized cardiac arrest despite confusing initial presentation, treated the likely underlying cause (hyperkalemia) with appropriate medications, achieved ROSC, and secured the airway while avoiding a potentially lethal medication error.