Advanced Cardiac Life Support Protocols Research Articles

Neutrophil-lymphocyte ratio: A prognostic tool in patients with in-hospital cardiac arrest.

BACKGROUNDIn-hospital cardiac arrest (IHCA) portends a poor prognosis and survival to discharge rate. Prognostic markers such as interleukin-6, S-100 protein and high sensitivity C reactive protein have been studied as predictors of adverse outcomes after return of spontaneous circulation (ROSC); however; these variables are not routine laboratory tests and incur additional cost making them difficult to incorporate and less attractive in assessing patient’s prognosis. The neutrophil-lymphocyte ratio (NLR) is a marker of adverse prognosis for many cardiovascular conditions and certain types of cancers and sepsis. We hypothesize that an elevated NLR is associated with poor outcomes including mortality at discharge in patients with IHCA.AIMTo determine the prognostic significance of NLR in patients suffering IHCA who achieve ROSC.METHODSA retrospective study was performed on all patients who had IHCA with the advanced cardiac life support protocol administered in a large urban community United States hospital over a one-year period. Patients were divided into two groups based on their NLR value (NLR < 4.5 or NLR ≥ 4.5). This cutpoint was derived from receiving operator characteristic curve analysis (area under the curve = 0.66) and provided 73% positive predictive value, 82% sensitivity and 42% specificity for predicting in-hospital death after IHCA. The primary outcome was death or discharge at 30 d, whichever came first.RESULTSWe reviewed 153 patients with a mean age of 66.1 ± 16.3 years; 48% were female. In-hospital mortality occurred in 65%. The median NLR in survivors was 4.9 (range 0.6-46.5) compared with 8.9 (0.28-96) in non-survivors (P = 0.001). A multivariable logistic regression model demonstrated that an NLR above 4.55 [odds ratio (OR) = 5.20, confidence interval (CI): 1.5-18.3, P = 0.01], older age (OR = 1.03, CI: 1.00-1.07, P = 0.05), and elevated serum lactate level (OR = 1.20, CI: 1.03-1.40, P = 0.02) were independent predictors of death.CONCLUSIONAn NLR ≥ 4.5 may be a useful marker of increased risk of death in patients with IHCA.

Drowning Management.

Highly skilled swimmers and aquatically adaptable service members such as U.S. Navy Divers, Sea, Air and Land (SEAL) Teams, and Explosive Ordnance Disposal (EOD) technicians, die every year from drowning. Drowning is the cause of over 500,000 deaths annually across the globe. This Clinical Practice Guideline (CPG) provides an overview of drowning and associated conditions based on the best available current medical evidence. Unlike basic life support and advanced cardiac life support protocols, rescue breathing should be initiated prior to chest compressions to re-expand water-filled alveoli. These guidelines should be used as a standardized framework to guide first responders, prehospital emergency medical service personnel, and medical department personnel in evaluating, diagnosing, and managing common in water pathologies.

Implementation of a real-time qualitative app to evaluate resuscitation performance in an Advanced Cardiac Life Support course.

Objective:In addition to high-quality chest compression, parameters of resuscitation efficiency such as early chest compression, early defibrillation, and decreased hands-off time are also vital in the Advanced Cardiac Life Support (ACLS) protocol. However, because of limited time and equipment in ACLS courses, efficiency of performance is difficult to evaluate.Materials and Methods:A free, easy-to-use iOS and Android app (CodeTracer®) was developed for real-time recording of cardiopulmonary resuscitation (CPR) performance. Interventions performed during resuscitation were set up as buttons. When the simulated scenario in the ACLS course began, instructors recorded every intervention and the team performed by pushing the appropriate buttons. When the scenario ended, the CodeTracer® automatically computed parameters, including the percentage of no-flow time, time to initiating CPR, and time to initiating defibrillation and also generated a graphic log for later discussion.Results:A total of 76 resuscitation episodes were recorded, 27 in the practice scenarios and 49 in the final Megacode simulations. After the course, the average percentage of no-flow time decreased 5.79%, time to initiating CPR decreased 3.05 s, and time to initiating defibrillation decreased up to 20.27 s. Of note, physicians as leaders seem to have better performance after the ACLS course than before, but the results were insignificant except for the percentage of no-flow time.Conclusions:CodeTracer® can record and calculate objective parameters for resuscitation performance in ACLS courses and can assist instructors in disseminating important concepts to participants. It can be a useful tool in ACLS courses.

Incorporating Nonphysician Stroke Specialists Into the Stroke Team.

Stroke care is team-based care, but trainees in neurology programs may have little experience in working directly with stroke specialists from other disciplines. Outside of an intensive care unit, nurses and physicians rarely round as a team, and stroke neurologists often have few interactions with prehospital care providers besides a quick handoff in the emergency room. However, nonphysician stroke specialists bring a broad base of expertise which overlaps with and complements the stroke neurologist’s knowledge. Increasingly, integrated stroke care is being provided by multidisciplinary teams. Team structures may vary from hospital to hospital and country to country, but often include integration of emergency medical services (EMS; particularly where mobile stroke treatment units are used); specialized nurses and nurse practitioners (NPs); and specialized therapy teams including speech and language pathologists, occupational therapists, and physical therapists with particular expertise in poststroke care. The stroke chain of survival begins with the 911 call, yet even high-level paramedics receive little formal stroke training outside of standard Advanced Cardiac Life Support protocols. EMS providers are often the first point of contact for the stroke patient and have the opportunity to collect vital information about timing of symptoms and medication use. First responders to stroke 911 calls may be Basic Life Support or Advanced Cardiac Life Support level. EMS providers should be familiar with validated prehospital stroke scales such as the Cincinnati Prehospital Stroke Scale.1 EMS providers who have more experience with stroke, such as paramedics who staff mobile stroke treatment units, find stroke to be an exciting field because of the time-critical nature of the treatment. Therefore, it is imperative that stroke neurologists reach out to EMS providers to offer additional training in stroke care. A basic understanding of stroke syndromes is both fascinating and extremely useful to EMS providers, who are often eager …

A retrospective study of pulseless electrical activity, bedside ultrasound identifies interventions during resuscitation associated with improved survival to hospital admission. A REASON Study

ObjectiveOur objective was to determine whether organized or disorganized cardiac activity is associated with increased survival in patients who present in pulseless electrical activity (PEA) treated with either 1) standard advanced cardiac life support (ACLS) medications or 2) other interventions. MethodsThis was a secondary analysis of a prospective, multi-center observational study utilizing ultrasound in out-of-hospital or inemergency department PEA arrest. Bedside ultrasound was performed as ACLS protocol started and during pulse checks. Only cases with visible cardiac activity on ultrasound were included in the present analysis. Cardiac activity was categorized as disorganized (agonal twitching) or organized (contractions with changes in ventricular dimensions). Patients were categorized as receiving either standard bolus ACLS medications or alternative medications during the resuscitation (continuous adrenergic agents, thrombolytics, others). The primary outcome was survival to hospital admission. The secondary outcome was return of spontaneous circulation (ROSC). Multivariate modeling was performed to assess association between survival to hospital admission in patients with intravenous adrenergic agents and cardiac activity. ResultsIn our cohort of 225 patients in PEA cardiac arrest with cardiac activity on ultrasound, the overall survival rate was higher in patients with organized cardiac activity than with disorganized cardiac activity. PEA cardiac arrest patients with organized cardiac activity treated with standard ACLS interventions demonstrated improved survival to hospital admission compared to those with disorganized activity (37.7% (95%CI 24.8–50.2%) versus 17.9% (95%CI 10.9–28%). PEA cardiac arrest patients with organized cardiac activity who received continuous adrenergic agents during the resuscitation and prior to ROSC demonstrated higher survival to hospital admission 45.5% (95%CI 26.9–65.4%) and ROSC 90.9% (95%CI 71.0–98.7%) compared to those with disorganized cardiac activity who received continuous adrenergic agents during the resuscitation 0% (95%CI 0–23.0%) and 47.1% (95%CI 26–69%). Regression analysis demonstrates an association between increased survival in patients receiving intravenous adrenergic agents and organized cardiac activity. ConclusionSurvival in patients following PEA arrest is higher in patients with organized cardiac activity. The initiation of continuous adrenergic agents during PEA was associated with improved survival to hospital admission in patients with organized cardiac activity on bedside ultrasound, but this improvement was not seen in patients in PEA with disorganized cardiac activity. Bedside ultrasound may identify a subset of patients that respond differently to ACLS interventions.

Reversible Causes in Cardiovascular Collapse at the Emergency Department Using Ultrasonography (REVIVE-US)

Ultrasonographic evaluation of patients in cardiac arrest is currently not protocolised in the advanced cardiac life support (ACLS) algorithm. Potentially reversible causes may be identified using bedside ultrasonography that is ubiquitous in most emergency departments (EDs). This study aimed to evaluate the incidence of sonographically detectable reversible causes of cardiac arrest by incorporating an ultrasonography protocol into the ACLS algorithm. Secondary objectives include rates of survival to hospital admission, hospital discharge, and 30-day mortality. We conducted a prospective study using bedside ultrasonography to evaluate for potentially reversible causes in patients with cardiac arrest at the ED of National University Hospital, Singapore, regardless of the initial electrocardiogram rhythm. A standardised ultrasonography protocol was performed during the 10-second pulse check window. Between June 2015 and April 2016, 104 patients were recruited, corresponding to 65% of all out-of-hospital cardiac arrest patients conveyed to the ED. Median age was 71 years (interquartile range, 55 to 80) and 71 (68.3%) patients were male. The most common rhythm on arrival was asystole (45.2%). Four (3.8%) patients had ultrasonographic findings suggestive of massive pulmonary embolism while 1 received intravenous thrombolysis and survived until discharge. Pericardial effusion without tamponade was detected in 4 (3.8%) patients and 6 (5.8%) patients had intra-abdominal free fluid. Twenty (19.2%) patients survived until admission, 2 of whom (1.9%) survived to discharge and beyond 30 days. Bedside ultrasonography can be safely incorporated into the ACLS protocol. Detection of any reversible causes may alter management and improve survival in selected patients.

Receiving Hospital Characteristics Associated With Survival in Patients Transported by Emergency Medical Services After Out-of-hospital Cardiac Arrest.

To test whether primary emergency medical services (EMS) transport to hospitals with certain characteristics (24/7 percutaneous coronary intervention [PCI] availability, trauma center status, large [>24 bed] intensive care unit [ICU]) versus hospitals without those characteristics is associated with improved hospital survival after out-of-hospital cardiac arrest (OHCA). This is an analysis of a prospectively collected EMS database, which archives patients with OHCA treated by a single large metropolitan EMS system. The database contains Utstein data, EMS transport data, and survival to hospital discharge. EMS providers uniformly apply advanced cardiac life support protocols to OHCA patients in the field. Patients with return of spontaneous circulation (ROSC) are transported to one of 10 hospitals in the area. If ROSC is not achieved within 30 minutes, efforts are terminated and the patient is not transported. We used multivariate logistic regression to test if receiving hospital characteristics were independently associated with survival among those transported after ROSC. We excluded patients not transported to a hospital and patients with incomplete outcome data. Between January 2011 and December 2014, a total of 1,188 OHCA patients were resuscitated in the field and transported to an area hospital. After patients with missing data were excluded, 1,024 patients were included in the analysis. The mean (±SD) age was 61.1 (±17.0) years, and 57.7% were male. Of transported patients, 76% were taken to 24/7 PCI centers, 46% were taken to trauma centers, and 37% were taken to hospitals with large ICUs. There was considerable overlap in these hospital characteristics. A multivariate logistic regression model including age, sex, shockable rhythm, EMS time to scene, and dispatch complaint of cardiac arrest found that none of the hospital characteristics were independently associated with increased survival to discharge. The odds ratios (95% confidence intervals) for survival were as follows: PCI center, 1.28 (0.80 to 2.04); trauma center, 1.44 (0.73 to 2.85); and large ICU, 1.39 (0.69 to 2.80). After adjusting for patient demographic data, we found no significant independent association between receiving hospital characteristics and survival to discharge among OHCA patients transported after ROSC by a single EMS agency.

Are Amiodarone and Lidocaine Effective for Out-of-Hospital Cardiac Arrest?

Advanced cardiac life support protocols recommend antiarrhythmic medications, such as amiodarone and lidocaine, as mainstays of treatment for patients

Induced Hypothermia: Implications for Free Flap Survival.

Plastic surgeons may not be aware that the new advanced cardiac life support (ACLS) guidelines released in 2010 include induced hypothermia as an adjuvant treatment to improve neurologic outcomes following cardiac arrest [1]. Induced hypothermia (IH) is thought to mitigate ischemic damage by lowering metabolic demand and preventing noxious byproducts of resuscitation. IH is recommended for patients who experience the return of spontaneous circulation after cardiac arrest, but remain unconscious [2]. The hypothermia protocol involves the reduction of body temperature to 32℃–34℃ for 12 to 24 hours, followed by slow rewarming [1,2]. However, the use of induced hypothermia in microvascular free tissue transfer has not been studied. We present the case of a patient who underwent IH following free-flap reconstruction of a head and neck cancer defect. A 69-year-old male with a history of coronary artery disease and three-vessel coronary artery bypass grafting presented with recurrent basal cell carcinoma of the left ear canal. He underwent total auriculectomy and lateral temporal bone resection, and the defect was reconstructed with a left vertical rectus abdominis myocutaneous free flap. On the second postoperative day, the patient was found unresponsive in pulseless electrical activity cardiac arrest. The ACLS protocol was initiated, including mechanical ventilation and vasopressors for hemodynamic support. The patient was successfully resuscitated but suffered a second cardiac arrest with ventricular fibrillations. He was resuscitated again but remained unresponsive. Hypothermia was induced, with the patient cooled to 32℃ for 48 hours (Fig. 1). The free flap remained well perfused with an audible Doppler signal during the cardiac arrests, vasopressor therapy, hypothermic cooling, and the remainder of his hospitalization (Fig. 2). Unfortunately, the patient had no meaningful neurologic recovery and magnetic resonance imaging showed diffuse hypoxic brain injury. Therefore, the family elected to withdraw care on postoperative day 10. Fig. 1 Temperature curve showing induced hypothermia to 32℃–34℃, from postoperative day three until postoperative day five. Fig. 2 A 69-year-old male underwent composite resection of the left auriculotemporal area and temporal bone for recurrent basal cell carcinoma, and the defect was reconstructed with a left vertical rectus abdominis myocutaneous free flap. The effects of systemic hypothermia on free tissue transfer are not fully understood. Limited animal and human studies have demonstrated conflicting results. Some data have suggested that hypothermia causes decreased perfusion, vasospasm, and thrombosis, while other animal experiments have shown a protective effect of mild hypothermia on free flaps [3,4,5]. Clotting enzymes, platelets, and leukocytes function less effectively in a hypothermic setting; however, no reports have been published on the effect of severe hypothermia (<34℃) on free flap survival in humans. This is the first reported case of induced hypothermia after free tissue transfer. Plastic surgeons should be aware of ongoing changes to the ACLS algorithm and its impact on perioperative care. In this case, a free tissue transfer remained viable despite induced hypothermia and vasopressors, which is a single data point suggesting that free flaps can tolerate such interventions. However, further research is needed to clarify the effects of hypothermia on free tissue transfer.

Echocardiography integrated ACLS protocol versus conventional cardiopulmonary resuscitation in patients with pulseless electrical activity cardiac arrest

Objective:To examine the utility of bedside echocardiography in detecting the reversible causes of pulseless electrical activity (PEA) cardiac arrest and predicting the resuscitation outcomes. Methods:In this prospective interventional study, patients presenting with PEA cardiac arrest were randomized into two groups. In Group A, ultrasound trained emergency physicians performed echocardiography evaluating cardiac activity, right ventricle dilation, left ventricle function, peri-cardial effusion/tamponade and IVC size along with the advanced cardiac life support (ACLS) protocol. Patients in Group B solely underwent ACLS protocol without applying echocardiography. The presence or absence of mechanical ventricular activity (MVA) and evidences of PEA reversible causes were recorded. The return of spontaneous circulation (ROSC) and death were evaluated in both groups. Results:One hundred patients with the mean age of (58±6.1) years were enrolled in this study. Fifty patients(Group A) had echocardiography detected in parallel with cardiopulmonary resuscitation (CPR). Among them, 7 patients (14%) had pericardial effusion, 11 (22%) had hypovolemia, and 39 (78%) were revealed the presence of MVA. In the pseudo PEA subgroup (presence of MVA), 43% had ROSC (positive predictive value) and in the true PEA subgroup with cardiac standstill (absence of MVA), there was no recorded ROSC (negative predictive value). Among patients in Group B, no reversible etiology was detected. There was no significant difference in resuscitation results between Groups A and B observed (P=0.52). Conclusion:Bedside echocardiography can identify some reversible causes of PEA. However, there are no significant changes in survival outcome between the echo group and those with traditional CPR.

Is flat line truly asystole?

Sir, A 72-year-old man presented with gastric outlet obstruction. He was diagnosed to have adenocarcinoma of the pyloric region. He was posted for diagnostic laparoscopy followed by total gastrectomy/gastrojejunostomy. His general condition was poor; he was cachectic and had generalised oedema. His exercise tolerance was poor, and he was barely managing daily activities, equivalent to three metabolic equivalents. His vitals were stable. Pre-operative electrocardiogram (ECG) and echocardiogram (ECHO) were normal. The case was performed under general anaesthesia with controlled ventilation. An arterial line and a central venous pressure line were introduced. Diagnostic laparoscopy confirmed the inoperability of the case and feeding jejunostomy was planned. Patient was maintaining a normal ECG pattern on the monitor (GE B40® patient monitor, GE Healthcare United Kingdom); pulse rate was 75–80/min and invasive blood pressure (IBP) was 102/76 mm Hg. Midline incision was made; midway through the procedure, the patient developed fall in O2 saturation. Just before the desaturation 1 mg vecuronium (top up dose) was injected through the central line inserted in the internal jugular vein. In a matter of 2 min, SpO2 had fallen from 98 to 10. Arterial line tracing was absent. Immediate cardiopulmonary resuscitation (CPR) was started. The rhythm noted was pulseless ventricular tachycardia (VT). Patient was defibrillated with 200J biphasic defibrillator and adrenaline 1 mg was administered. Resuscitation was continued as per American Heart Association guidelines (CPR at the rate of 100/min with ventilation every 6–8 s) checking the rhythm every 2 min.[1] After 35 min of resuscitation, a stable rhythm was established. The surgeon was asked to hasten and close the abdominal defect. With the BP at 90 mm systolic, dopamine drip was started. Meanwhile, patient developed ventricular fibrillation (VF). Even after 20 min of resuscitation following advanced cardiac life support (ACLS) protocol, no evidence of cardiac activity was noticed. (Flat line seen in the ECG monitor). We were about to declare death when a timely intervention prevented a major error. We increased the gain of ECG on the monitor from 0.5 to 7, and there was perfect normal sinus rhythm. On checking carotid pulse was present. Surgery was completed, and the patient was shifted to the post-anaesthesia care unit. Patient's post-operative ECG and cardiac enzymes were normal, confirming that high-quality CPR was administered (and successful). As the hypoxic events unfolded after the injection through the central line, a possible air embolism was considered as the reason for the arrest. The post-operative ECG did not show S1Q3T3 pattern, nor any evidence of emboli; no right ventricular strain was noted in ECHO.[2] Post-operative X-ray was also normal. Patient recovered from effect of relaxant (vecuronium) after 4 h. The next morning, sedatives were stopped and sensorium assessed. He responded to oral commands. After 5 days of intensive care, he was extubated. Asystole is defined as a cardiac arrest rhythm in which there is no discernible electrical activity on the ECG monitor. Asystole is sometimes referred to as a “flat line”, which may be encountered during cardiac arrest with VF or VT, before returning to spontaneous circulation.[3] Confirmation that a “flat line” is truly asystole is an important step in the ACLS protocol. On seeing a flat line on the monitor, one has to ensure that asystole is not another rhythm that looks like a “flat line.” Fine-VF can appear to be asystole, and “flat line” on a monitor can be due to operator error or equipment failure. The common cause for the isoelectric line that is not asystole is loose or disconnected leads and a low signal on the ECG monitor.[4] We decided to post this case to highlight two main points. That adequate training helps a long way in providing high-quality CPR and that in case of asystole, simple measures such as checking the ECG leads for disconnection and increasing the gain can avoid major mistakes before deciding to stop resuscitation and declare death.

Con: cardiac anesthesiologists should not be the intensivists of the operating room.

ANESTHESIOLOGISTS can be challenged when caring for patients who are critically ill before surgery and by those who develop critical illness during a surgical procedure. The care of critically ill patients can be fundamentally different from the routine care rendered in the operating room. In the setting of a major intraoperative crisis such as cardiac arrest, massive unexpected hemorrhage, or hypoxemia refractory to aggressive therapies, the skill set of the operating room team can be pushed to the limit. Operating room crises require rapid, coordinated management in a stressful, time-critical setting, and successful resuscitation depends largely on clinicians’ retained knowledge and skill. Failure to adhere to critical steps in the management of such crises is common and may be hazardous to patients. A high-fidelity simulation study of ventricular fibrillation cardiac arrests in the operating room revealed that 61% of anesthesiologists demonstrated “major deviations” from advanced cardiac life support protocols. 1 The availability of specialized teams and resources for support during management of crisis situations is essential and is the focus of ongoing investigations. 2,3 Physicians with expertise in the care of critically ill patients and who regularly manage acute crisis situations must be available to provide consultation in the operating room when the need arises. With formal training and daily experience in managing critically ill patients, the fellowship-trained critical care anesthesiologist is the obvious choice to fulfill this role. Unfortunately, the specialty of critical care medicine is facing a staffing crisis. 4–6 The growing shortage of intensivists and its implications for hospitalized Americans is well documented and remains an ongoing concern for hospitals, clinicians, and the federal government. 6 The mismatch between intensivist

Efficacy of resuscitation with Intralipid in a levobupivacaine-induced cardiac arrest model.

Cardiac toxicity due to the administration of local anesthetics may be fatal. In this study, we evaluated the efficacy of a 20% lipid solution combined with epinephrine in a levobupivacaine-induced cardiac arrest model. A total of 14 New Zealand rabbits were sedated and mechanically ventilated. Asystole was induced with intravenous levobupivacaine injection. The rabbits were randomized into groups receiving the same volume of either 0.9% saline (CR group) or a 20% lipid solution (LE group) along with a 100 μg/kg epinephrine bolus, which were administered immediately upon asystole. Standard advanced cardiac life support protocols were performed. Four subjects in the LE group as well as 3 subjects in the CR group had a spontaneous recovery (P = 0.592). In the 20th minute after arrest, 3 subjects in the LE group had maintained spontaneous circulation, while there was only 1 subject from the CR group with the same outcome. We found that adding a lipid solution to epinephrine for the resuscitation of rabbits that underwent levobupivacaine- induced cardiac arrest increased recovery rates of circulation and therefore the likelihood of survival. Further studies are needed to develop clinical therapies for the systemic toxicity of local anesthetics.

Rescue Thrombolysis

Rescue Thrombolysis

Delayed recovery of spontaneous circulation following cessation of cardiopulmonary resuscitation in an older patient: a case report

IntroductionThis report describes the apparent ‘resurrection’ of a patient in an emergency department setting. Befittingly named the ‘Lazarus phenomenon’, the recovery of spontaneous circulation after cessation of cardiopulmonary resuscitation is an extremely rare occurrence that was first described in 1982 and has been mentioned only 38 times in the medical literature. Our patient’s case is remarkable in that it helps illustrate many of the mechanisms of this rare phenomenon. It also serves as a reminder of our limitations in determining when to terminate cardiopulmonary resuscitation and suggests that cessation of cardiopulmonary resuscitation should be approached with more care.Case presentationAn 89-year-old Caucasian woman with a medical history of hypertension, atrial fibrillation, hypothyroidism, aortic insufficiency, lymphedema and hypoxia secondary to partial lung resection presented to our hospital after a witnessed fall unassociated with head trauma or loss of consciousness. On examination, our patient was saturating at 85 percent and exhibited a decreased range of motion of the upper extremities and left hip. Radiographic images revealed a left femoral neck and left distal radius fracture. Our patient was stabilized on 100 percent fraction of inspired oxygen and was awaiting transfer to an in-patient unit when, at 3:30 a.m., she went into cardiac arrest. An advanced cardiac life support protocol was initiated, at which time our patient was intubated and administered epinephrine, vasopressin and sodium bicarbonate. Our patient remained unresponsive and asystolic so cardiopulmonary resuscitation was abandoned at 3:48 a.m. After five minutes a ventricular contraction was noted at 3:51 a.m. This progressed to sinus rhythm with a pulse at 3:53 a.m. Our patient was stabilized on norepinephrine and moved to our Intensive Care Unit. At 10:55 a.m., however, our patient again arrested and, despite resuscitative efforts, was pronounced dead at 11:03 a.m.ConclusionsOur patient’s case clearly illustrates many of the proposed mechanisms for delayed return of spontaneous circulation including pulmonary hyper-inflation, hyperkalemia, delayed drug onset, and embolism dislodgement. Our patient represents a humbling and disturbing reminder that our medical acumen does not necessarily dictate the fate of our patients and that the decision to discontinue cardiopulmonary resuscitation should be approached with care by incorporating techniques such as end-tidal carbon dioxide, ventilator disconnect and passive monitoring.

Successful Prolonged Resuscitation of Ventricular Fibrillation Arrest in a Patient With Acute Myocardial Infarction

A 67-year-old man presented to the emergency department with symptoms of acute myocardial infarction. Electrocardiogram showed ST segment elevations in leads II, III, and AVF. While waiting for cardiac catheterization, he developed prolonged ventricular fibrillation lasting for 69 minutes, throughout which he was resuscitated as per the 2010 Advanced Cardiac Life Support protocol. The patient was transferred to the catheterization lab while undergoing active resuscitation, where a stent was placed in his right coronary artery. He was neurologically intact postcatheterization and discharged home on the sixth day of admission.

699 Cardiac Arrest After Cardiac Surgery : Role of Simulation for the Intensive Care Team Performance

699 Cardiac Arrest After Cardiac Surgery : Role of Simulation for the Intensive Care Team Performance

Hand-Held Echocardiography in the Management of Cardiac Arrest

November 2012 • Volume 115 • Number 5 A 65-year-old diabetic man underwent toe amputations. The patient collapsed on postoperative day 3 due to cardiac arrest with pulseless electrical activity (PEA). During Advanced Cardiac Life Support (ACLS) protocol, an intensivist-physician with extensive echocardiographic experience performed a point-of-care transthoracic echocardiogram (TTE) using a hand-held ultrasound device (VscanTM; GE Healthcare, Wauwatosa, WI ; see Fig. 3). A subcostal view was used to record images both during resuscitation and after return of spontaneous circulation. The echocardiographic examination did not interfere with cardiopulmonary resuscitation (CPR) or the ACLS protocol. The images demonstrated a large echo-dense mass in the right atrium moving through the tricuspid valve into the right ventricle (RV), suggestive of a clot in transit (Fig. 1) (Video 1, mobile mass in RV; see Supplemental Digital Content 1, http://links.lww. com/AA/A428). In this postoperative patient, pulmonary embolism (PE) was the most likely etiology of hemodynamic collapse. Shortly thereafter, a repeated focused examination by the intensivist with a conventional echocardiography machine confirmed the findings seen on the hand-held device (Fig. 2) (Video 2, mobile mass in RV; see Supplemental Digital Content 2, http://links.lww.com/ AA/A429). Based on these results, heparin and recombinant tissue plasminogen activator were administered IV during the code. A follow-up TTE 40 minutes later demonstrated absence of the mass in the RV (Video 2, http://links.lww.com/AA/A429), indicating that the mass either dissolved or moved forward into the pulmonary artery. Because of refractory shock, the patient was transferred to the catheterization lab for embolectomy or local recombinant tissue plasminogen activator infusion. Unfortunately, a right heart catheterization demonstrated diffuse clot burden in the entire left lung not amendable to therapy. The patient experienced repeated episodes of PEA arrest and ultimately died.

Therapeutic Hypothermia After Cardiac Arrest

Irreversible brain damage and death are common outcomes after cardiac arrest, even when resuscitation is initially successful. Chances for both survival and a good neurologic outcome are improved when mild hypothermia is induced shortly after reperfusion. Unfortunately, this treatment is often omitted from advanced cardiac life support protocols. The authors discuss the efficacy of therapeutic hypothermia, indications and contraindications for its use, various induction methods, associated complications and adverse effects, and nursing care specific to patients undergoing this procedure.

Anesthesia advanced circulatory life support.

PurposeThe constellation of advanced cardiac life support (ACLS) events, such as gas embolism, local anesthetic overdose, and spinal bradycardia, in the perioperative setting differs from events in the pre-hospital arena. As a result, modification of traditional ACLS protocols allows for more specific etiology-based resuscitation.Principal findingsPerioperative arrests are both uncommon and heterogeneous and have not been described or studied to the same extent as cardiac arrest in the community. These crises are usually witnessed, frequently anticipated, and involve a rescuer physician with knowledge of the patient’s comorbidities and coexisting anesthetic or surgically related pathophysiology. When the health care provider identifies the probable cause of arrest, the practitioner has the ability to initiate medical management rapidly.ConclusionsRecommendations for management must be predicated on expert opinion and physiological understanding rather than on the standards currently being used in the generation of ACLS protocols in the community. Adapting ACLS algorithms and considering the differential diagnoses of these perioperative events may prevent cardiac arrest.