Case Reports

Success of multiple new therapies in cardiac arrest


 
 

Charles Lick, MD | Paul Satterlee, MD | From the The Truth about CPR Issue


Traditional American Heart Association (AHA) training states that survival from cardiac arrest declines by 10% for every minute the brain goes without blood flow.(1) Although this is commonly used when discussing cardiac arrest without CPR, it’s also well recognized that traditional CPR provides less-than-adequate cerebral and cardiac perfusion.(2)

We report three patients within a 12-month period who survived out-of hospital cardiac arrest with no neurologic deficits despite an average of 30 minutes of CPR prior to return of spontaneous circulation (ROSC). The therapy during each resuscitation included implementation of 2005 AHA guidelines, early use of the ResQPOD impedance threshold device (ITD), use of a mechanical CPR device called LUCAS and therapeutic hypothermia using ice packs initiated by the first ALS providers.

These cases illustrate the success of multiple new therapies in cardiac arrest that together are improving the outcomes in victims of cardiac arrest, despite prolonged periods without spontaneous circulation.

Case #1
A 72-year-old female with no previous cardiac disease became unresponsive while playing a card game. Family members immediately started CPR, which was taken over by police first responders on arrival. The ALS ambulance crew arrived five minutes after dispatch received the family’s call for help.

They continued with the resuscitation, which included immediate placement of ResQPOD, IV epinephrine and a LUCAS device. Further care included at least two defibrillations for ventricular fibrillation (V-fib) and medications, including amiodarone, vasopressin and epinephrine. After 25 minutes, the patient’s rhythm changed to bradycardia with a pulse. External cooling was initiated with ice packs on the groin, axilla and anterior neck.

The patient was transported by helicopter to a cardiac catheterization lab, where she underwent simultaneous therapeutic hypothermia via Arctic Sun and angiography with stenting of a lesion in her left anterior descending (LAD) artery.

She was discharged on hospital day 11. Her cerebral performance categories (CPC) score was 1.

Case #2
An 80-year-old male with a known history of severe cardiomyopathy, ejection fraction (EF) of 10–15% and coronary artery disease (CAD), including a previous stent in his right coronary artery, suffered a cardiac arrest in the car while his wife was driving him to the local hospital to be evaluated for weakness. On arrival at the hospital, he was brought into the emergency department (ED) and a LUCAS was placed. Other interventions included placement of an endotracheal (ET) tube, ResQPOD and medications, including epinephrine, vasopressin and amiodarone. His initial rhythm on arrival at the hospital was asystole with periods of V-fib that responded to defibrillation.

Throughout the 50-minute resuscitation, he was defibrillated six times and required intermittent CPR. Therapeutic hypothermia using an Arctic Sun unit was initiated prior to transport to a regional cardiac care center.

The patient’s angiogram showed no significant CAD. He remained in the hospital for 15 days and was discharged to a nursing home for treatment of nosocomial pneumonia with a CPC score of 1.

Case #3
A 68-year-old male suffered cardiac arrest in a movie theater. Bystanders initiated CPR, which was continued by first responders upon their arrival after confirming the patient had no pulse. Their AED advised them to defibrillate the patient one time, which they did and then continued CPR. ALS providers arrived 16 minutes after the patient collapsed. They placed an ET tube with an ITD. CPR was transitioned to a LUCAS.

Throughout the resuscitation, the monitor showed a slow, wide complex rhythm, likely of ventricular origin. He was given three 1 mg doses of epinephrine via IV and 50 mEq of sodium bicarbonate. The crew also attempted transcutaneous pacing. ROSC was identified 50 minutes after the initial call and maintained. Therapeutic hypothermia was initiated in the field using ice packs.

On arrival at the hospital, the patient had an emergent angiogram that showed no significant coronary artery blockages but an EF of 20%. An implantable cardiac defibrillator was placed.

He remained hospitalized for 21 days before being discharged with minimal cognitive deficits and a CPC score of 1.

Discussion
We report on these cases because of the length of time CPR was performed during the events. There’s some evidence that using mechanical CPR devices improves adherence to accepted CPR guidelines.(3) Although the survival of these patients can’t be attributed solely to the use of a mechanical CPR device, the device provided good cerebral perfusion throughout the arrest. For these reasons, we’ve deployed a LUCAS device in each of our 33 ALS ambulances since 2007. This addition has been an integral part of our success in treating cardiac arrest.

Conclusion
Survival from sudden cardiac arrest hasn’t improved in years. Recent advances in the care of these patients may lead to increased survival and good neurologic outcomes when implemented together. It may also lead to increased survival after prolonged cardiac arrest, contrary to past practice. These three cases do not define a medical breakthrough, but they indicate a need for further investigation of the use of ITDs, mechanical CPR and therapeutic hypothermia as complementary therapies in the care of cardiac arrest.

Disclosure: The authors have reported no conflicts of interest with the sponsor of this supplement.

References

  1. ECC Committee, Subcommittees and Task Forces of the American Heart Association: "2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care." Circulation. 112(24 Suppl), IV1–203, 2005.
  2. Ristagno G, Tang W, Sun S, et al: "Cerebral cortical microvascular flow during and following cardiopulmonary resuscitation after short duration of cardiac arrest." Resuscitation. 77(2):229–234, 2008.
  3. Olasveengen TM, Wik L & Steen PA: "Quality of cardiopulmonary resuscitation before and during transport in out-of-hospital cardiac arrest." Resuscitation. 76(2):185–190, 2008.



Connect: Have a thought or feedback about this? Add your comment now
Related Topics: Patient Care, Cardiac and Circulation, Operations and Protcols, Patient Management

Charles Lick, MDCharles Lick, MD, is the medical director for Allina Medical Transportation in St. Paul, Minn., the medical director for Allina’s Buffalo Hospital emergency department and an emergency room physician.

BROWSE FULL BIO & ARTICLES >

Paul Satterlee, MDPaul Satterlee, MD,is the associate medical director for Allina Medical Transportation. He is also on staff at Abbott Northwestern Hospital’s emergency department.

BROWSE FULL BIO & ARTICLES >

What's Your Take? Comment Now ...

Buyer's Guide Featured Companies

Featured Careers & Jobs in EMS

Get JEMS in Your Inbox

 

Fire EMS Blogs


Blogger Browser

Today's Featured Posts

 

EMS Airway Clinic

Mechanical CPR is Producing Resuscitation Results Beyond Expectations

Discover why clinical studies are finding mechanical CPR just as effective as optimally-performed CPR.
More >

Multimedia Thumb

New York First Responders Take Extraordinary Steps to Help Residents

Snow causes fire and EMS crews to go beyond call of duty.
Watch It >


Multimedia Thumb

Raw Video: Explosion and Fire at California Business

Over a dozen hurt in Santa Paula blaze.
Watch It >


Multimedia Thumb

Four Workers Killed at Texas Chemical Plant

Five employees exposed to methyl mercaptan in La Porte.
Watch It >


Multimedia Thumb

Worker Killed in North Carolina Bridge Collapse

A fatal construction site collapse occurred in Wake County.
Watch It >


Multimedia Thumb

Plane Crashes into Chicago Home

Pilot reported engine trouble after takeoff.
More >


Multimedia Thumb

Switzerland Landslide Kills Two, Injures Four

Slide hits residential building near Lugano.
More >


Multimedia Thumb

World Trade Center Rescue

Technical rescue work is done at nation’s tallest skyscraper.
More >


Multimedia Thumb

Field Bridge Xpress ePCR on iPad, Android, Kindle Fire

Sneak peek of customizable run forms & more.
Watch It >


Multimedia Thumb

VividTrac offered by Vivid Medical - EMS Today 2013

VividTrac, affordable high performance video intubation device.
Watch It >


Multimedia Thumb

Braun Ambulances' EZ Door Forward

Helps to create a safer ambulance module.
Watch It >


More Product Videos >