The Future of Resuscitation in the ED: ECMO-CPR (Part 2)

ecmo-cpr 2
Part 2 of this post continues with the use of ECMO during CPR. To learn more about ECMO, here is the link to Part 1

What is E-CPR?

E-CPR is defined as the utilization of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) in patients who experience a sudden and unexpected pulseless condition secondary to the cessation of cardiac mechanical activity.

Rationale for E-CPR

The idea of E-CPR originated due to deficiencies in conventional CPR (C-CPR), which, even under optimal conditions, only delivers 15-25% of normal cardiac output. This leads to rapid hypoperfusion and ischemic damage to vital organs (what is known as the low-flow state). However, E-CPR is able to supply near-normal levels of organ perfusion; therefore, preserve the brain and other vital organs for days or weeks until cardiac recovery takes place.

In addition, E-CPR facilitates coronary interventions, even in patients with sustained ventricular fibrillation, because V-A ECMO provides stable systemic perfusion. Therefore, E-CPR has been considered a way to buy tome for the subsequent diagnosis and treatment of the underlying cause of cardiac arrest. Moreover, it provides better survival rates and neurologic outcomes.

Indications and patient selection for E-CPR

Up to date, there are no universal inclusion criteria for E-CPR. Inclusion criteria commonly used in E-CPR studies are the following:

  • Patients aged 18 to 65 or 18 to 70 years
  • Witnessed refractory cardiac arrest
  • Immediate bystander CPR
  • Initial shockable rhythm
  • Access to immediate coronary angiography
  • An anticipated low-flow period <60 minutes

Other common inclusion criteria for E-CPR include signs of life and end-tidal CO2 level >10 mm Hg on arrival to the emergency department. Their value in E-CPR is yet to be systematically assessed.

When should the transition to E-CPR occur?

No consensus is available regarding the ideal time to switch from C-CPR to E-CPR. Starting E-CPR too early may predispose patients who could potentially recover without it to a complicated and expensive procedure. On the other hand, delaying E-CPR may take away the core benefit of the intervention, which is, reducing low-flow state time and organ ischemia.

Studies showed that after 35 minutes of C-CPR, only less than 1% of patients achieve ROSC with good neurological outcomes. One study revealed that 16 minutes after the initiation of C-CPR by emergency medical services might be the optimal time to proceed to E‐CPR. Another study showed superior neurological outcome with the transition after 21 minutes in selected patients. However, delivering patients to a hospital within ab appropriate time frame presents a challenge to EMS staff. Prehospital E-CPR provides an alternative solution to this challenge.

Outcomes of C-CPR versus E-CPR:

Up to date, no published randomized controlled trial compared C-CPR versus E-CPR. Most of the evidence comes from retrospective and prospective observational studies, and meta-analysis. These studies included patients with out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). For example, the SAVE-J study, a prospective observational study, revealed that patients with OHCA who underwent E-CPR had a better neurological outcome, measured by a cerebral performance category of 1 or 2, compared to those with C-CPR, at 1 month (12.3% vs 1.5%, P<0.0001) and at 6 months (11.2% vs 2.6%, P=0.001). Kim et al. also reported favourable neurological outcomes at 3 months in the E-CPR group. Moreover, some recent systematic reviews have demonstrated trends that link E-CPR with improved survival and neurologic outcomes. Overall, factors that were associated with better outcomes included young age, witnessed arrest, bystander CPR, rhythm of sustained VF/VT, time from OHCA to E-CPR initiation, and acute coronary syndrome.

The latest study regarding E-CPR for OHCA was published in June 2020. It took place in Paris and included 13.191 OHCA cases. Of the 12,396 patients managed with C-CPR, 1061 (8.6%) survived to hospital discharge, compared with 44 (8.4%) of 523 E-CPR patients. E-CPR was attempted but failed in 58 (11%) patients. Factors associated with survival in the E-CPR group included an initial shockable rhythm and transient return of spontaneous circulation (ROSC) prior to E-CPR. This study posed major questions regarding the effectiveness of E-CPR in patients with OHCA. The fact that there was no statistical difference between C-CPR and E-CPR made the science community to realize the need to reevaluate the literature and for more and larger randomized clinical trials.

Prehospital E-CPR:

Pre-hospital ECMO aims to reduce the time to E-CPR initiation and increase potential positive outcomes (Figure 2). A cohort performed in Paris attempted to initiate E-CPR after 20 minutes of failed C-CPR and within 60 minutes of arrest. Outcomes revealed reduced low-flow state by 20 minutes and improved survival with neurologically intact patients up to 29% (21% absolute increase, P<0.001). This concluded that prehospital E‐CPR reduced low‐flow duration significantly and increased the rate of ROSC, but it was not an independent predictor of survival to discharge.

APACAR2 (A Comparative Study Between a Pre‐hospital and an In‐hospital Circulatory Support Strategy (ECMO) in Refractory Cardiac Arrest), an ongoing promising RCT, is randomizing patients with OHCA to either prehospital or hospital E‐CPR groups, depending on their location and predicted transport time to the hospital. It will reveal more about E-CPR use in the prehospital setting.

Limitations and closing remarks:

Current evidence concerning the effectiveness of E-CPR seems low quality, making drawing strong conclusions on OHCA E-CPR impossible. Additionally, positive outcomes may be associated with the whole “E-CPR bundle of care”, which include rapid hospital transfer, C-CPR and coronary angiography. Consequently, the effectiveness of E-CPR on its own is uncertain and more RCTs are needed.

Lastly, the survival rate of approximately 25-30% with E-CPR for IHCA already represents a huge financial and resource burden to the family and healthcare systems. If survival with OHCA E-CPR is potentially less than 10%, is it worth the burden or should we better invest in reducing cardiovascular morbidity and improve conventional bystander CPR?

prehospital ecmo-cpr
Figure 2: Prehospital ECMO (Ref: 11 - Nickson, C. (2020). Extracorporeal Membrane Oxygenation. Accessed Feb 26, 2021, from https://litfl.com/ecmo-extra-corporeal-membrane-oxygenation/)
Cite this article as: Amani Khalouf, UAE, "The Future of Resuscitation in the ED: ECMO-CPR (Part 2)," in International Emergency Medicine Education Project, March 24, 2021, https://iem-student.org/2021/03/24/ecmo-cpr-part-2/, date accessed: September 30, 2022

References and Further Reading

  1. Berdowski, J., Berg, R. A., Tijssen, J. G., & Koster, R. W. (2010). Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation, 81(11), 1479-1487.
  2. Bougouin, W., Dumas, F., Lamhaut, L., Marijon, E., Carli, P., Combes, A., … & Jouven, X. (2020). Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study. European Heart Journal, 41(21), 1961-1971.
  3. Dennis, M., Lal, S., Forrest, P., Nichol, A., Lamhaut, L., Totaro, R. J., Burns, B., & Sandroni, C. (2020). In-Depth Extracorporeal Cardiopulmonary Resuscitation in Adult Out-of-Hospital Cardiac Arrest. Journal of the American Heart Association, 9(10), e016521.
  4. Gräsner, J. T., Lefering, R., Koster, R. W., Masterson, S., Böttiger, B. W., Herlitz, J., … & Zeng, T. (2016). EuReCa ONE-27 Nations, ONE Europe, ONE Registry: A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation, 105, 188–195.
  5. Grunau, B., Reynolds, J., Scheuermeyer, F., Stenstom, R., Stub, D., Pennington, S., … & Christenson, J. (2016). Relationship between time-to-ROSC and survival in out-of-hospital cardiac arrest ECPR candidates: when is the best time to consider transport to hospital?. Prehospital Emergency Care, 20(5), 615-622.
  6. Hutin, A., Abu-Habsa, M., Burns, B., Bernard, S., Bellezzo, J., Shinar, Z., … & Lamhaut, L. (2018). Early ECPR for out-of-hospital cardiac arrest: best practice in 2018. Resuscitation, 130, 44-48.
  7. Hutin, A., Loosli, F., Lamhaut, L., Mantz, B., & Corrocher, R. (2017). How Physicians Perform Prehospital ECMO on the Streets of Paris. Accessed Feb 26, 2021, from https://www.jems.com/patient-care/how-physicians-perform-prehospital-ecmo-on-the-streets-of-paris/
  8. Inoue, A., Hifumi, T., Sakamoto, T., & Kuroda, Y. (2020). Extracorporeal Cardiopulmonary Resuscitation for Out‐of‐Hospital Cardiac Arrest in Adult Patients. Journal of the American Heart Association, 9(7), e015291.
  9. Kim, S. J., Jung, J. S., Park, J. H., Park, J. S., Hong, Y. S., & Lee, S. W. (2014). An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest: a propensity-matched study. Critical Care, 18(5), 1-15.
  10. MacLaren, G., Masoumi, A. & Brodie, D. (2020). ECPR for out-of-hospital cardiac arrest: more evidence is needed. Critical Care24, 7
  11. Nickson, C. (2020). Extracorporeal Membrane Oxygenation. Accessed Feb 26, 2021, from https://litfl.com/ecmo-extra-corporeal-membrane-oxygenation/
  12. Singer, B., Reynolds, J. C., Lockey, D. J., & O’Brien, B. (2018). Pre-hospital extra-corporeal cardiopulmonary resuscitation. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 26(1), 1-8.
  13. Tan, B. K. K. (2017). Extracorporeal membrane oxygenation in cardiac arrest. Singapore Medical Journal, 58(7), 446.

The Future of Resuscitation in the ED: ECMO-CPR (Part 1)

ecmo-cpr 1

As a junior emergency department (ED) physician, I clearly remember my first code -first cardiopulmonary resuscitation (CPR) attended- and the mixed feelings of sorrow and helplessness for not being able to bring that soul back to life despite our best efforts. After a couple of more codes, listening to the sounds of the hearts slowly fading away, my mind started to question: How effective is the current standard Advanced Cardiac Life support (ACLS) protocol we follow?

I remember admitting to one of my attendings how desperate I felt about the ACLS during every code, expecting very abysmal neurological and overall outcomes, even if the patient was lucky enough to achieve the return of spontaneous circulation (ROSC). It almost felt that what we did was completely futile. A couple of weeks later, during my cardiology rotation, I had a field trip in the cardiac intensive care unit (ICU) with one of the cardiologists who introduced me to different advanced mechanical support devices, including extracorporeal membrane oxygenation (ECMO), intra-aortic balloon pump (IABP) and others. While he explained the basic concepts behind how they functioned, it almost immediately occurred to me: “Well! That’s what we need in cardiac arrest patients!”

While certainly, it was not a very novel idea, it did urge me to search into the available evidence and where we stood in terms of bringing this idea into more practical terms. This is how I was introduced, as a postgraduate year one (PGY-1) ED resident, to the concept of ECMO-CPR.

What is ECMO?

Extracorporeal membrane oxygenation (ECMO) is the use of a blood pump and an oxygenator to support either pulmonary or both pulmonary and cardiac function. An ECMO circuit is usually made of a centrifugal pump and a membrane oxygenator for oxygen delivery, CO2 removal, and temperature management.

What are the types of ECMO?

There are two main types of ECMO circuits:

Veno-venous (V-V) ECMO

Veno-venous (V-V) ECMO provides lung support only so it requires a functional heart. Venous cannulae are usually placed in the right or left common femoral vein (for drainage) and right internal jugular vein (for infusion). The tip of the femoral cannula should be maintained near the junction of the inferior vena cava and right atrium, while the tip of the internal jugular cannula should be maintained near the junction of the superior vena cava and right atrium.

Veno-arterial (V-A) ECMO

Veno-arterial (V-A) ECMO provides both cardiac and pulmonary support. The drainage (access) cannula is placed into the inferior vena cava via the femoral vein, and the “return” cannula is inserted into the femoral artery to the level of the common iliac artery.

We will focus on V-A ECMO given its relation with E-CPR.

How does V-A ECMO work?

Venous blood (blue) drained via a cannula positioned at the inferior vena cava to the right atrial junction passes through the extracorporeal membrane where oxygenation and CO2 removal occurs. The oxygenated blood (red) is returned via a “return” cannula positioned in the common iliac artery or descending aorta. After ECMO support is established, the distal perfusion catheter is inserted into the superficial femoral artery distal to the insertion point of the femoral return cannula, and it supplies oxygenated blood to the distal limb to prevent distal limb ischemia (Figure 1).

ecmo-cpr
Figure 1: V-A ECMO Configuration (Ref: 3 - Dennis, M., Lal, S., Forrest, P., Nichol, A., Lamhaut, L., Totaro, R. J., Burns, B., & Sandroni, C. (2020). In-Depth Extracorporeal Cardiopulmonary Resuscitation in Adult Out-of-Hospital Cardiac Arrest. Journal of the American Heart Association, 9(10), e016521.)

What are the indications for VA-ECMO?

  • Cardiac arrest
  • Low Cardiac Index (<2L/min/m2) and hypotension despite inotropic support and an IABP.
  • Failure to wean from cardiopulmonary bypass
  • Cardiogenic shock or severe cardiac failure, caused by:
    • Acute coronary syndrome
    • Ventricular tachycardia storm or refractory arrhythmias.
    • Sepsis
    • Drug overdose/toxicity
    • Myocarditis
    • Massive pulmonary embolism
    • Cardiac trauma
    • Acute anaphylaxis

What are the contraindications for VA-ECMO?

The list below includes both absolute and relative contraindications:

  • Patients with non-recoverable cardiac dysfunction who are not candidates for left ventricular assist device (LVAD) or transplantation
  • Chronic organ dysfunction
  • Prolonged CPR without adequate tissue perfusion
  • Disseminated malignancy
  • Known severe brain injury
  • Unwitnessed cardiac arrest
  • Contraindications to therapeutic-dose anticoagulation
  • Severe aortic regurgitation
  • Aortic dissection
  • Existent multiorgan failure
  • Mechanical ventilation >7–10 days
  • Advanced age

We will continue with the use of ECMO during CPR in the part 2. Stay tuned!

Cite this article as: Amani Khalouf, UAE, "The Future of Resuscitation in the ED: ECMO-CPR (Part 1)," in International Emergency Medicine Education Project, March 22, 2021, https://iem-student.org/2021/03/22/ecmo-cpr-part-1/, date accessed: September 30, 2022

References and Further Reading

  1. Berdowski, J., Berg, R. A., Tijssen, J. G., & Koster, R. W. (2010). Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation, 81(11), 1479-1487.
  2. Bougouin, W., Dumas, F., Lamhaut, L., Marijon, E., Carli, P., Combes, A., … & Jouven, X. (2020). Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study. European Heart Journal, 41(21), 1961-1971.
  3. Dennis, M., Lal, S., Forrest, P., Nichol, A., Lamhaut, L., Totaro, R. J., Burns, B., & Sandroni, C. (2020). In-Depth Extracorporeal Cardiopulmonary Resuscitation in Adult Out-of-Hospital Cardiac Arrest. Journal of the American Heart Association, 9(10), e016521.
  4. Gräsner, J. T., Lefering, R., Koster, R. W., Masterson, S., Böttiger, B. W., Herlitz, J., … & Zeng, T. (2016). EuReCa ONE-27 Nations, ONE Europe, ONE Registry: A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation, 105, 188–195.
  5. Grunau, B., Reynolds, J., Scheuermeyer, F., Stenstom, R., Stub, D., Pennington, S., … & Christenson, J. (2016). Relationship between time-to-ROSC and survival in out-of-hospital cardiac arrest ECPR candidates: when is the best time to consider transport to hospital?. Prehospital Emergency Care, 20(5), 615-622.
  6. Hutin, A., Abu-Habsa, M., Burns, B., Bernard, S., Bellezzo, J., Shinar, Z., … & Lamhaut, L. (2018). Early ECPR for out-of-hospital cardiac arrest: best practice in 2018. Resuscitation, 130, 44-48.
  7. Hutin, A., Loosli, F., Lamhaut, L., Mantz, B., & Corrocher, R. (2017). How Physicians Perform Prehospital ECMO on the Streets of Paris. Accessed Feb 26, 2021, from https://www.jems.com/patient-care/how-physicians-perform-prehospital-ecmo-on-the-streets-of-paris/
  8. Inoue, A., Hifumi, T., Sakamoto, T., & Kuroda, Y. (2020). Extracorporeal Cardiopulmonary Resuscitation for Out‐of‐Hospital Cardiac Arrest in Adult Patients. Journal of the American Heart Association, 9(7), e015291.
  9. Kim, S. J., Jung, J. S., Park, J. H., Park, J. S., Hong, Y. S., & Lee, S. W. (2014). An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest: a propensity-matched study. Critical Care, 18(5), 1-15.
  10. MacLaren, G., Masoumi, A. & Brodie, D. (2020). ECPR for out-of-hospital cardiac arrest: more evidence is needed. Critical Care24, 7
  11. Nickson, C. (2020). Extracorporeal Membrane Oxygenation. Accessed Feb 26, 2021, from https://litfl.com/ecmo-extra-corporeal-membrane-oxygenation/
  12. Singer, B., Reynolds, J. C., Lockey, D. J., & O’Brien, B. (2018). Pre-hospital extra-corporeal cardiopulmonary resuscitation. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 26(1), 1-8.
  13. Tan, B. K. K. (2017). Extracorporeal membrane oxygenation in cardiac arrest. Singapore Medical Journal, 58(7), 446.

Dead on Arrival, What Should We Do?

Dead on Arrival, What Should We Do

If you have worked long enough in the emergency department (ED), you probably have seen several patients with cardiac arrest on arrival during your shifts. The question is: Would you consider your patient already dead or still alive? It seems an easy enough question but another question follows: Are you sure about that?

I had many night shifts in the ED. I remember a night when an unconscious 55-year-old gentleman came with mydriatic pupils and no pulse. His wife’s cries broke my heart! Suddenly, my mind went so blank that I couldn’t even recall the basic life support! I needed to resuscitate him, but what was next Epinephrine or cardioversion? In my perplexity, I felt to my bones that everything I learnt and memorised was in vain. The nurses were waiting for my instructions, but I was petrified myself. Why couldn’t I think systematically? At that point in time, I swore to myself that I would try again, harder and harder, to learn -and implement- life support better. And, I had to be quick about it, because soon this year, I would be handling patients myself (even though I still have to report each case to the staff).

Long after that moment, I came to realise that death means different things to different people. Even for the same people, it will be different from each perspective -Biologically, spiritually, medically, metaphorically, metaphysically, existentially, chemically, anatomically, ethically, legally, or on a cellular basis. So, now that I am about to take more responsibility of my patients, the fundamental question remains: How do we make sure that the patient without a pulse on arrival is positively dead? Or more importantly, how should we act?

Between 10% and 50% of deaths occur before reaching hospitals (1-2). Death on arrival (DoA) can refer to two different patient groups: those who were declared dead upon arrival to an ED with no resuscitation attempt or those who died after failed resuscitation, usually within the first hour of arrival (3). The studies show that in addition to prehospital and hospital care, basic life support by laypeople plays a crucial role in reducing deaths (4).

lay person CPR

Do you know this?

Sometimes, when we put the defibrillator paddles on an arrest patient, the first rhythm we see is ventricular fibrillation (VF). It’s an easy call – which means if we quickly resuscitate the patient, we can save him or her. At other times, the patient arrives with mydriatic pupils, no breathing, and no pulse, and a flat line. This decision is more challenging because the patient might have passed the critical period for resuscitation or what causes pupils to be mydriatic could be a recent amphetamine or cocaine overdose. What is the best course of action in this scenario

  1. American Heart Association realised that this is a worldwide problem (5). Therefore, they made a statement about this very situation. According to it:
    At the time of cardiac arrest, there is no way to assess reliably brain death or neurologic outcome.
  2. From an ethical perspective, withholding resuscitation during resuscitation and discontinuation of life-sustaining treatment after are equivalent.
  3. If the prognosis is not clear, starting resuscitation without delay is reasonable so that more information can be gathered about the situation to predict the clinical course and the outcome, and learn the patient’s end-of-life preferences.

In other words, not being able to diagnose a patient with DoA at the first glance is OK. Once we don’t feel the pulse, we start CPR! We should learn more about the situation to be sure. In this way, we avoid any adverse outcomes, which might be associated with the delay of treatment.

What steps should we take to save the patient?

My Opinion

Personally, I find pronouncing someone DoA difficult. Dead on arrival diagnosis is an irreversible verdict. Devastating news for families who lost their loved ones forever.

Of course, we can declare someone dead if obvious clinical signs of irreversible death (eg, rigour mortis, dependent lividity, decapitation, transection, decomposition) are present. Otherwise, I feel that we should try and give patients the best possible chance for survival.

The key to a good doctor is three-pronged: comprehensive knowledge, mastery of skills, and proper attitude. Ever doctor, especially those who are dealing with emergencies, must know the process of death, master skills to provide help to those who can benefit, and remain dedicated to serving.

Take-home messages

  • Don’t memorise the algorithm, understand it clearly.
  • Try not to panic even though it’s your first time. There is a first time for everything.
  • Little acts of help can save someone’s life.

References and Further Reading

  1. Arreola-Risa, Carlos, et al. “Low-cost improvements in prehospital trauma care in a Latin American city.” Journal of Trauma and Acute Care Surgery 48.1 (2000): 119.
  2. Roudsari, Bahman S., et al. “Emergency Medical Service (EMS) systems in developed and developing countries.” Injury 38.9 (2007): 1001-1013.
  3. Khursheed, Munawar, et al. “Dead on arrival in a low-income country: results from a multicenter study in Pakistan.” BMC emergency medicine 15.2 (2015): 1-7.
  4. Calland, James Forrest, et al. “The effect of dead-on-arrival and emergency department death classification on risk-adjusted performance in the American College of Surgeons Trauma Quality Improvement Program.” Journal of Trauma and Acute Care Surgery 73.5 (2012): 1086-1092.
  5. Panchal, Ashish R., et al. “Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.” Circulation 142.16_Suppl_2 (2020): S366-S468.
Cite this article as: Cicilia Evajelista, "Dead on Arrival, What Should We Do?," in International Emergency Medicine Education Project, March 15, 2021, https://iem-student.org/2021/03/15/dead-on-arrival/, date accessed: September 30, 2022

Question Of The Day #30

question of the day
qod30

Which of the following is the most appropriate next step in management for this patient?

This patient arrives to the Emergency department with the return of spontaneous circulation (ROSC) from a ventricular fibrillation cardiac arrest. His regaining of pulses was likely due to his limited downtime, prompt initiation of CPR, and prompt diagnosis and treatment of ventricular fibrillation with electrical defibrillation. Important elements of emergency post-ROSC care include avoiding hypotension, hypoxia, hyperthermia, and hypo or hyperglycemia. Maintaining proper perfusion to the brain and peripheral organs is crucial in all ROSC patients. A 12-lead EKG should always be obtained early after ROSC is achieved in order to look for signs of cardiac ischemia. Cardiac catheterization should be considered in all post-ROSC patients, but especially in patients with cardiac arrest from ventricular fibrillation or ventricular tachycardia.

Patients who achieve ROSC can vary markedly in terms of their clinical exam. Some patients may be awake and conversive, while others are comatose and non-responsive. The neurological exam immediately post-ROSC does not predict long-term outcomes, so decisions on prognosis should not be based on these factors in the emergency department. For this reason, resuscitation efforts should not be considered medically futile in this scenario (Choice A). Vasopressors (Choice B) are medications useful in post-ROSC patients who have signs of hemodynamic collapse, such as hypotension. This patient is not hypotensive and does not meet the criteria for initiation of vasopressors. A CT scan of the head (Choice D) is a study to consider in any patient who presents to the emergency department with collapse to evaluate intracranial bleeding (i.e., subarachnoid bleeding). Although not impossible, the history of chest pain before collapse makes brain bleeding a less likely cause of death in this patient. Targeted Temperature Management (Choice C), also known as Therapeutic Hypothermia, is the best next step in this patient’s management.

Targeted Temperature Management involves a controlled lowering of the patient’s body temperature to 32-34ᵒC in the first 24 hours after cardiac arrest. This treatment has been shown to improve neurologic and survival outcomes. The theory behind this treatment is that hypothermia post-ROSC reduces free radical damage and decreases cerebral metabolism. Data behind targeted temperature management shows the greatest benefit in cardiac arrest patients due to ventricular fibrillation, but arrest from ventricular tachycardia, pulseless electrical activity, and asystole may also show benefit. Adverse effects of this treatment include coagulopathy, bradycardia, electrolyte abnormalities (i.e., hypokalemia), and shivering. Important contraindications to this treatment are an awake or alert patient (post-ROSC GCS >6), DNR or DNI status, another reason to explain comatose state (i.e., intracranial bleeding, spinal cord injury), age under 17 years old, a poor functional status prior to the cardiac arrest (i.e., nonverbal, bedbound), or an arrest caused by trauma. Correct Answer: C

References

 

Cite this article as: Joseph Ciano, USA, "Question Of The Day #30," in International Emergency Medicine Education Project, March 12, 2021, https://iem-student.org/2021/03/12/question-of-the-day-30/, date accessed: September 30, 2022

Question Of The Day #23

question of the day
qod23
3. PEA

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient presented to the emergency department with acute pleuritic chest pain, dyspnea, and experienced a cardiac arrest prior to a detailed physical examination. The cardiac monitor shows a narrow complex sinus rhythm morphology. In the setting of a cardiac arrest and pulselessness, this cardiac rhythm is known as pulseless electric activity (PEA). PEA includes any cardiac rhythm that is not asystole, ventricular fibrillation, or pulseless ventricular tachycardia. The ACLS algorithm divides the management of patients with pulseless ventricular tachycardia (pVT) or ventricular fibrillation (VF) and patients with pulseless electric activity (PEA) or asystole. Assuming adequate staff and medical resources are present, patients with all of these rhythms receive high-quality CPR, IV epinephrine, and airway management. Patients with pVT or VF receive electrical cardioversion, while patients with PEA or asystole do not receive electrical cardioversion. Patients with PEA or asystole generally have a poorer prognosis than those with pVT or VF. Out of hospital cardiac arrests that present to the emergency department with PEA or asystole on initial rhythm have a survival rate of under 3%. The etiology of PEA in cardiac arrest includes a wide variety of causes. A traditional approach to remembering the reversible causes of PEA are the “Hs & Ts”. The list of the “Hs & Ts” along with their individual treatments are listed in the table below.

PEA treatments

Sodium bicarbonate (Choice A) would be the correct choice for a patient whose PEA arrest was caused by severe acidosis. This can occur in severe lactic acidosis (i.e. sepsis), diabetic ketoacidosis, certain toxic ingestions (i.e. iron, salicylates, tricyclic antidepressants), as well as other causes. Calcium gluconate (Choice B) would be the correct choice for a patient whose PEA arrest was caused by hyperkalemia. This can occur in renal failure, in the setting of certain medications, rhabdomyolysis (muscle tissue breakdown), and other causes. Blood products (Choice D) would be the correct choice for a patient whose PEA arrest was due to severe hemorrhage, such as gastrointestinal bleeding or in the setting of traumatic injuries. This patient has symptoms and risk factors for pulmonary embolism, including pleuritic chest pain, dyspnea, and a cancer history. These details make pulmonary embolism the most likely cause of PEA arrest in this scenario. The best treatment for this diagnosis would be thrombolysis (Choice C).

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #23," in International Emergency Medicine Education Project, December 4, 2020, https://iem-student.org/2020/12/04/question-of-the-day-23/, date accessed: September 30, 2022

Question Of The Day #22

question of the day
qod22
1. VFib

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient presents to the Emergency Department after a cardiac arrest with an unknown medical history. Important components of Basic Life Support (BLS) include early initiation of high-quality CPR at a rate of 100-120 compressions/minute, compressing the chest to a depth of 5 cm (5 inches), providing 2 rescue breaths after every 30 compressions (30:2 ratio), avoiding interruptions to CPR, and allowing for adequate chest recoil after each compression. In the Advanced Cardiovascular Life Support (ACLS) algorithm, intravenous epinephrine is administered every 3-5 minutes and a “pulse check” is performed after every 2 minutes of CPR. The patient’s cardiac rhythm, along with the clinical history, helps decide if the patient should receive additional medications or receive unsynchronized cardioversion (defibrillation, or “electrical shock. The ACLS algorithm divides management in patients with pulseless ventricular tachycardia (pVT) or ventricular fibrillation (VF) and patients with pulseless electric activity (PEA) or asystole.

The cardiac rhythm seen during the pulse check for this patient is ventricular fibrillation. The ACLS algorithm advises unsynchronized cardioversion at 150-200 Joules for patients with pVT or VF. Continuing chest compressions (Choice A) with minimal interruptions is a crucial component of BLS, however, this patient’s cardiac rhythm is shockable. Defibrillation (Choice B) takes precedence over CPR in this scenario. Amiodarone (Choice C) is an antiarrhythmic agent that is recommended in patients with pVT, in addition to unsynchronized cardioversion. This patient has VF, not pVT. Sodium bicarbonate (Choice D) is an alkaline medication that is helpful in cardiac arrests caused by severe acidosis or certain toxins (i.e. salicylates or tricyclic antidepressants). The next best step in this patient scenario would be defibrillation for the patient’s VF (Choice B).

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #22," in International Emergency Medicine Education Project, November 27, 2020, https://iem-student.org/2020/11/27/question-of-the-day-22/, date accessed: September 30, 2022

Question Of The Day #21

question of the day
qod21

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient experienced a witnessed cardiac arrest at home, after which pre-hospital providers initiated cardiopulmonary resuscitation (CPR, or “chest compressions”) and Advanced Cardiovascular Life Support (ACLS). ACLS includes the tenets of Basic Life Support (BLS), such as early initiation of high-quality CPR at a rate of 100-120 compressions/minute, compressing the chest to a depth of 5 cm (2 inches), providing 2 rescue breaths after every 30 compressions (30:2 ratio), avoiding interruptions to CPR, and allowing for adequate chest recoil after each compression. In the ACLS algorithm, intravenous epinephrine is administered every 3-5 minutes and a “pulse check” is performed after every 2 minutes of CPR. The patient’s cardiac rhythm, along with the clinical history, helps decide if the patient should receive defibrillation (“electrical shock”) or additional medications. The ACLS algorithm divides management into patients with pulseless ventricular tachycardia (pVT) or ventricular fibrillation (VF) and patients with pulseless electric activity (PEA) or asystole.

The cardiac rhythm seen during the pulse check for this patient is a wide complex tachycardia with a regular rhythm. In the setting of cardiac arrest, chest pain prior to collapse, and a history of acute coronary syndrome, ventricular tachycardia is the most likely cause. The ACLS algorithm advises unsynchronized cardioversion at 150-200 Joules for patients with pVT or VF. Watching the cardiac monitor for a rhythm change (Choice A) or checking for a pulse (Choice D) are not recommended after defibrillation. A major priority of both BLS and ACLS is to avoid interruptions to CPR, so the best next step in management is to continue CPR (Choice B) after defibrillation. Administration of intravenous adrenaline (Choice C) is helpful for cardiac arrests to initiate shockable rhythm and should be repeated every 3-5 minute or every 2 cycle of CPR, particularly valuable in asystole patients. Calcium gluconate is another drug that can be used in patients with hyperkalemia and indicated in a patient with known kidney disease, missed hemodialysis sessions, or a history of usage of medications that can cause hyperkalemia. Magnesium can be used for patients who show polymorphic VT, particularly Torsades de Pointes. The next best step in this scenario is to continue CPR, regardless of the etiology of the cardiac arrest. Correct Answer: B.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #21," in International Emergency Medicine Education Project, November 13, 2020, https://iem-student.org/2020/11/13/question-of-the-day-21/, date accessed: September 30, 2022

Just Some Broken Ribs

Just Some Broken Ribs

The phone was ringing incessantly. I barely woke up. In my pitch dark bedroom, the ringing phone was the only light source. I slowly grabbed my phone while involuntarily rubbing my eyes. I looked at the caller I.D. It was my father. And what time was it? 1:30 am! In a typical day, this might be an early hour for me, but I was attending a local Emergency Medicine conference that day; so I went to bed early.

I cradled the phone between my ear and shoulder. My father’s voice was fussy. “Someone lies unconscious on the street,” he said hastily. “Can you come and help us?” I asked him to call for an ambulance by that time. He said that he already called. 

While I was preparing in a hurry, my heart started to beat faster and my mind swelled with CPR guidelines, syncope algorithms and my past experiences.

My home is down the block from my parents. I ran there and saw a crowd gathered around a man who was lying on the street. When I passed through I realized someone was doing CPR. I have spotted my parents standing in the crowd and my eyes met with my father. He pointed my younger brother, a trainee surgeon also lives in the same area and was taking his turn on the CPR and checking his pulse. I rushed near them and he filled me in with all they know about the citizen at that point.

The first responder to the cries of the patient’s wife was an ambulance driver with ten years of experience. He said he pulled the patient out of his vehicle. He laid down the man in his 50s suffered from heartburn for the last couple of hours and was about to go to the hospital but lost his consciousness as soon as he started the engine. Since the man wasn’t responding, the former driver started the CPR. About 3 minutes later, my brother showed up along with my father and he took the turn while they kept checking for any response. He said that the rhythm never lasted longer than 10 seconds. So I asked them to keep it up and I took my turn till the ambulance shows up.

It was clear that the patient endured a heart-related condition, probably a myocardial infarction. And I knew by experience that with a proper CPR and early defibrillation, these patients have a high chance of returning of spontaneous circulation, and survival.

The ambulance arrived in a couple of minutes. Paramedics jumped out of the vehicle and rushed to the scene and recognized that I am an Emergency Medicine resident at the State Research and Education Hospital. They let me control the situation. The first rhythm was read on the screen as ventricular fibrillation (VF) and we delivered a shock and started chest compressions again. With the equipment they’ve brought, I intubated the patient while they monitored him with the defibrillator from the ambulance. The nearest hospital was 10 minutes away, and we have shocked-compressed for at least 4 or 5 times in an ambulance moving fast. IT-WAS-HARD!

We have arrived at the hospital. After 10 minutes of additional CPR and proper mediations, spontaneous circulation of the patient returned spontaneous circulation. And a control ECG was consistent with Inferior MI. In a couple of minutes, we were in a different ambulance, headed to the nearest hospital with a coronary angiography unit and ICU.

I took a deep breath after we have delivered the patient to the ICU safe and sound. It was over, for now. One week later, he returned to his home with full recovery, without any neurological sequelae. They were very thankful.

Later on, I’ve heard many funny words people were chattering about this incident. One has particularly given me the giggle. It was coming from an ENT specialist. He said, “So that was no big deal, they probably overreacted and caused him a couple of broken ribs.”

Yeah, there were just some broken ribs… and a life saved.

Further Reading

Cite this article as: Ibrahim Sarbay, Turkey, "Just Some Broken Ribs," in International Emergency Medicine Education Project, August 16, 2019, https://iem-student.org/2019/08/16/just-some-broken-ribs/, date accessed: September 30, 2022