Have you ever declared a patient dead after a prolonged resuscitation, just for the patient to “come back” the moment you stop CPR? It happened to me once when I was a resident.

An elderly patient with severe emphysema was admitted for a COPD exacerbation. He was getting progressively less responsive after he was taken to a medical floor. The patient was likely retaining CO2 leading to a carbon dioxide narcosis.

Eventually, his heart stopped. The code blue was called. CPR was initiated. The breathing tube was placed. The patient was bag-ventilated by a respiratory therapist. The patient was being resuscitated according to ACLS protocol. Pulseless electrical activity (electrical rhythm on a monitor with an absence of heart beat or pulse) was noted on a monitor. Twenty to twenty five minutes into the code – there is still no pulse.

The patient was pronounced dead. CPR was discontinued and bag-ventilation was stopped. A few seconds later – the patient still had a rhythm. What is even more shocking, he had a thready pulse. Resuscitation resumed and he was transferred to ICU.

So, what happened?
Reviewing this case later, we came up with the conclusion that the excessive bagging during the code caused air-trapping in the patient’s lungs leading to a significant Auto-PEEP(PEEP- positive end expiratory pressure, or residual pressure in the lungs after an expiration) and increased intrathoracic pressure (pressure inside your chest). This significantly diminished venous return to the patient’s heart and precluded him from regaining a pulse. Once he was disconnected from the bag, the pressures in his lungs equilibrated allowing for his heart to fill with blood.

In the rush of the moment, nobody noticed that he was being overzealously bagged by the respiratory therapist. Patients with emphysema require a prolonged expiratory time and tend to trap air if not allowed to exhale completely. Excessive bagging can cause air-trapping and Auto-PEEP.

Since then, I often ask to slow down bag-ventilation during a cardiac arrest to allow the patient to exhale by the elastic recoil of the chest.

The patient above did not do well and the family decided to withdraw care.