Asystolic Cardiac Arrest Research Articles

Evaluation of isoproterenol in patients undergoing resuscitation for out-of-hospital asystolic cardiac arrest (the Israel Resuscitation with Isoproterenol Study Prospective Randomized Clinical Trial)

The Israel Resuscitation with Isoproterenol Study included 79 consecutive patients with witnessed out-of-hospital asystolic cardiac arrest who were resuscitated with epinephrine and atropine and randomized to receive additional isoproterenol or no isoproterenol. The rate of return of spontaneous circulation and survival to hospital admission did not differ in patients receiving standard therapy and those receiving additional isoproterenol.

Sudden Cardiac Arrest in the Anhepatic Phase of Living-Related Liver Transplantation: A case report

We experienced a case of unexpected sudden cardiac arrest, which developed during the anhepatic phase of living-related liver transplantation. The patient was a 56-year old man diagnosed with liver cirrosis. He had stable angina and congestive heart failure. Preoperative EKG, chest x-ray, arterial blood gas analysis and vital signs were all within normal limits. Cardiac echography was normal except for left atrial enlargement and diastolic dysfunction (grade I). Coronary angiography showed no coronary stenosis. About 10 min after the inferior vena cava had been clamped, the sinus rhythm changed suddenly to ventricular tachycardia. Lidocaine was administered and the PA catheter removed immediately but ventricular fibrillation and asystolic cardiac arrest followed. Cardiac rhythm returned about 15 min after the onset of asystole, followed by supraventricular tachycardia (up to 180 beats/min). The EKG suddenly returned to a normal sinus rhythm. He had no further episodes of arrhythmia and recovered without complication.

A Randomized Controlled Trial of Intravenous Aminophylline for Atropine‐resistant Out‐of‐hospital Asystolic Cardiac Arrest

Abstract Objectives: Myocardial ischemia, during cardiopulmonary arrest, can lead to atropine‐resistant bradyasystole from interstitial accumulation of endogenous adenosine. Aminophylline is a nonspecific adenosine receptor antagonist capable of reversing ischemia‐induced bradyasystole in a variety of settings. The hypothesis of this study was that aminophylline improves the rate of return of spontaneous circulation (ROSC) in atropine‐resistant asystolic out‐of‐hospital cardiac arrest when used early in the resuscitation effort. Methods: This was a prospective, randomized, double‐blinded, placebo‐controlled trial set in an urban emergency medical services system serving a population of 250,000. All non‐pregnant, normothermic adults suffering nontraumatic out‐of‐hospital cardiac arrest (February 1999 to August 2000) with asystole were eligible. Patients remaining in asystole after initial doses of epinephrine and atropine received either aminophylline 250 mg or matching placebo as a bolus injection through a peripheral intravenous line. All other aspects of the attempted resuscitation proceeded in accordance with standard Advanced Cardiac Life Support (ACLS) guidelines. A sample size of 102 patients was calculated to yield a power of 80% to show an absolute improvement of 25% in ROSC. The aminophylline and control groups were compared by calculating 95% confidence intervals (95% CIs) and the data were modeled using logistic regression. Results: The investigators enrolled 112 consecutive patients. One subject was dropped prior to analysis because of missing data. Data for 111 patients were analyzed on an intention‐to‐treat basis. Baseline characteristics were similar for the two groups. Comparing the control and aminophylline groups, ROSC was achieved in 15.6% (95% CI = 6% to 29%) and 22.7% (95% CI = 13% to 35%), while reversal of asystole occurred in 26.7% (95% CI = 15% to 42%) and 40.9% (95% CI = 29% to 54%), respectively. Group allocation had an odds ratio of 1.8 (95% CI = 0.6 to 5.3) for ROSC. Witnessed arrest was an independent predictor of outcome with an odds ratio of 3.8 (95% CI = 1.3 to 11.2). Conclusions: Addition of aminophylline appears to be a promising new intervention in the ACLS treatment of atropine‐resistant asystolic out‐of‐hospital cardiac arrest.

Postoperative extracorporeal membrane oxygenation for severe intraoperative SIRS 10 h after multiple trauma

A 34-yr-old male suffered multiple trauma in a road traffic accident. He required right thoracotomy and laparotomy to control exanguinating haemorrhage, and received 93 u blood and blood products. Intraoperatively, he developed severe systemic inflammatory response syndrome (SIRS) with coagulopathy and respiratory failure. At the end of the procedure, the mean arterial pressure (MAP) was 40 mm Hg, arterial blood gas analysis showed a pH of 6.9, PaCO2 12 kPa, and PaO2 4.5 kPa, and his core temperature was 29°C. There was established disseminated intravascular coagulation. The decision was made to stabilize the patient on veno-venous extracorporeal membrane oxygenation (ECMO) only 10 h after the accident, in spite of the high risk of haemorrhage. The patient was stabilized within 60 min and transferred to the intensive care unit. He was weaned off ECMO after 51 h. He had no haemorrhagic complications, spent 3 weeks in the intensive care unit, and has made a good recovery.

A 66 Year old Woman with a Severe Lactic Acidosis and Unusual Anion Gap Following Resuscitation from an Asystolic Cardiac Arrest

A 66 Year old Woman with a Severe Lactic Acidosis and Unusual Anion Gap Following Resuscitation from an Asystolic Cardiac Arrest

Issues Involving Sexual Abuse of Nursing Facility Residents

Ms. Irene Reiss was a 22-year-old white woman admitted to Golden Manor Nursing Center of New England in October of 1996. Her past medical history was significant for anoxic brain injury secondary to an asystolic cardiac arrest due to an opiate overdose 3 years earlier. This event left her in a comatose or vegetative state. A percutaneous endoscopic gastric (PEG) feeding tube was inserted during the latter part of 1996 to aid in her nutritional intake as she had lost considerable amounts of weight since 1993. Ms. Reiss remained relatively noncommunicative and noninteractive for the 3 years since her overdose.

Issues Involving Sexual Abuse of Nursing Facility Residents

Ms. Irene Reiss was a 22-year-old white woman admitted to Golden Manor Nursing Center of New England in October of 1996. Her past medical history was significant for anoxic brain injury secondary to an asystolic cardiac arrest due to an opiate overdose 3 years earlier. This event left her in a comatose or vegetative state. A percutaneous endoscopic gastric (PEG) feeding tube was inserted during the latter part of 1996 to aid in her nutritional intake as she had lost considerable amounts of weight since 1993. Ms. Reiss remained relatively noncommunicative and noninteractive for the 3 years since her overdose.

Clinical Significance of Ventricular Fibrillation Developed during Cardiopulmonary Resuscitation in Asystolic Cardiac Arrest

Clinical Significance of Ventricular Fibrillation Developed during Cardiopulmonary Resuscitation in Asystolic Cardiac Arrest

F AMILY P ERSPECTIVE OF M EDICAL C ARE AND G RIEF S UPPORT AFTER F IELD T ERMINATION BY E MERGENCY M EDICAL S ERVICES P ERSONNEL : A P RELIMINARY R EPORT

Objective. To determine the acceptance by family members regarding nontransport of patients in cardiac arrest following unsuccessful resuscitation occurring in private residences. Methods. This was a survey with a structured telephone interview. Inclusion criteria included adult patients in asystolic nontraumatic cardiac arrest. The setting was an urban multitiered emergency medical services (EMS) system. Termination of field resuscitation efforts was authorized by an emergency medicine physician at a medical control base station after set protocol criteria. Support services were provided by trained personnel. Results. Thirty-three follow-up interviews were completed with a family member. Thirty-two (97%) of the contacted family members expressed satisfaction with the services provided by EMS personnel. Twenty-one (64%) patients were not transported to the hospital. All 21 family members of the nontransported were satisfied with both the medical care and the emotional support provided by EMS. Additionally, family members of three of the 12 (25%) transported patients stated they would have preferred to have the patient die at home instead of being transported. Conclusions. In this small sample, family members accept the nontransport of patients by trained EMS personnel after asystolic nontraumatic cardiac arrest occurring in private residences. This may positively impact emergency department resources for other critically ill patients.

Factors affecting survival after prehospital asystolic cardiac arrest in a Basic Life Support-Defibrillation system

Previous studies have shown a low but meaningful survival rate in cases of prehospital cardiac arrest with an initial rhythm of asystole. There may be, however, an identifiable subgroup in which resuscitation efforts are futile. This study identified potential field criteria for predicting 100% nonsurvival when the presenting rhythm is asystole in a Basic Life Support-Defibrillation (BLS-D) system. This prospective cohort study, a component of Phases I and II of the Ontario Prehospital Advanced Life Support (OPALS) Study, was conducted in 21 Ontario communities with BLS-D level of care, and included all adult arrests of presumed cardiac etiology according to the Utstein Style Guidelines. Analyses included descriptive and appropriate univariate tests, as well as multivariate stepwise logistic regression to determine predictors of survival. From 1991 to 1997, 9899 consecutive cardiac arrest cases with the following characteristics: male (67.2%), bystander-witnessed (44.7%), bystander CPR (14.2%), call response interval (CRI) </= 8 minutes (82%) and overall survival (4.3%) were enrolled. Of 9529 cases with available rhythm strip recordings, initial arrest rhythms were asystole in 40.8%, pulseless electrical activity in 21.2% and ventricular fibrillation or ventricular tachycardia in 38%. Of 3888 asystolic patients, 9 (0.2%) survived to discharge; 3 of these cases were unwitnessed arrests with no bystander CPR. There were no survivors if the CRI exceeded 8 minutes. Logistic regression analysis demonstrated that independent predictors of survival to admission were "CRI in minutes" (odds ratio [OR] = 0.87; 95% confidence interval [CI], 0.77-0.98) and "bystander-witnessed" (OR = 2.6; 95% CI, 1.5-4.4). In a BLS-D system, there is a very low but measurable survival rate for prehospital asystolic cardiac arrest. CRIs of over 8 minutes were associated with 100% nonsurvival, whereas unwitnessed arrests with no bystander CPR were not. These data add to the growing literature that will help guide ethical decision-making for protocol development in emergency medical services systems.

Asystole Cardiac Arrest in Melbourne, Australia

Asystole Cardiac Arrest in Melbourne, Australia

Asystolic cardiac arrest in Melbourne, Australia

To study the outcome of victims of out-of-hospital cardiac arrest presenting to the Metropolitan Ambulance Service in asystole, in Melbourne, Australia. A retrospective case-note review of all patients presenting to the Metropolitan Ambulance Service in asystole for 1997 was performed. Metropolitan Ambulance Service case notes and hospital records were examined to determine the presenting rhythm and the patients' outcome. In a 12-month period, 778 patients met the entry criteria. Age mean was 67 years, 36% female, 64% male. Metropolitan Ambulance Service response time to scene time was a mean of 9.76 min. Resuscitation was commenced on 37% of patients. There was one survivor (0.12%). Adult victims of out-of-hospital cardiac arrest presenting as asystole should not receive treatment.

Repair Of Coronary Sinus Rupture Secondary To Internal Cardiac Massage

Injuries secondary to external and internal cardiac massage have been reported. This is the first report of coronary sinus injury secondary to internal cardiac massage. The technique used to repair the coronary sinus injury is described. INTRODUCTION Coronary Sinus Injury is a rare complication of the retrograde delivery of cardioplegia [1, 2]. This report describes coronary sinus injury secondary to internal cardiac massage and the technique used for repair. CASE REPORT A 68-year-old lady underwent coronary artery bypass graft surgery for triple vessel disease. The procedure was uneventful and during insertion of sternal wires, there was an unexplained drop in blood pressure followed by asystolic cardiac arrest. The wires were removed and internal cardiac massage was commenced. This was not particularly helpful and the patient was placed on cardiopulmonary bypass. The internal cardiac massage had caused injuries to the anterior surface of the heart (a small epicardial tear on the surface of the right ventricle) and the coronary sinus. There was a large amount of bleeding from the back of the heart and a large hematoma was present in the region of the coronary sinus. There was considerable venous bleeding from the sinus. The hematoma had obscured the tissue planes and it was not possible to discern clearly the edges of the defect in the coronary sinus all round (Figure 1). Figure 1 Figure 1: Coronary Sinus injury resulted in a large hematoma with obliteration of tissue planes. The edges of the coronary sinus injury were not discernible all round. The cross clamp was applied and the heart arrested with antegrade cardioplegia. The edges of the coronary sinus injury were not clearly defined. A large patch of pericardium (Tissuemed, Leeds, UK) was laid over the defect and sutured to the epicardial fat with Teflon (Bard Inc, Tempe, AZ) reinforced 40 prolene (Ethicon, Somerville, NJ) sutures. Bio glue (Cryolife, Kennesaw, GA) was then liberally applied at the edges of the pericardial patch (Figure 2). Figure 2 Figure 2: Repair of the coronary sinus injury by a pericardial patch sutured to the epicardial fat and secured by glue. The anterior epicardial tear was repaired with 40 prolene sutures. The cross clamp was removed and the patient was weaned off bypass uneventfully. The repair was intact and there was no further bleeding. The cause of the initial aystolic arrest Repair Of Coronary Sinus Rupture Secondary To Internal Cardiac Massage 2 of 3 was unexplained and the patient made an uneventful recovery. DISCUSSION Injuries secondary to internal and external cardiac massage have been reported [3]. Coronary sinus injury can occur secondary to cannulation for delivering retrograde cardioplegia [1,2]. To our knowledge, coronary sinus injury secondary to internal cardiac massage has not been reported. A ruptured coronary sinus is very difficult to repair primarily as the edges are not clearly seen and the hematoma causes obliteration of normal tissue planes. A large pericardial patch can be laid over the defect and sewn to the epicardial fat. This causes re-establishment of venous drainage. The application of glue to the edges of the pericardial patch helped secure a watertight repair and there was no further bleeding from the low-pressure venous system. We believe this technique of repair using a large pericardial patch sewn to the epicardial fat and secured by glue, makes it easy to manage a very difficult complication. CORRESPONDENCE TO Mr V Zamvar Tel : +44-(29)-20747747 Fax: +44-(29)-20745439 Email: zamvarv@hotmail.com Address: University Hospital of Wales, Cardiff CF14 4XW, UK

Part 8: Advanced Challenges in Resuscitation

Part 8: Advanced Challenges in Resuscitation

Bradycardia and asystolic cardiac arrest during spinal anaesthesia: A report of five cases

Sudden, severe bradycardia/asystolic cardiac arrest are considered infrequent, but are certainly the most serious complications of spinal anaesthesia. We report four cases of primary asystole and one of severe bradycardia in young to middle-aged, healthy patients scheduled for minor surgery at the day surgery unit. Bradycardia/asystole were not related to respiratory depression or hypoxaemia/hypercarbia; they occurred at different time intervals after the onset of spinal anaesthesia (10-70 min) and, apparently, were not dependent on the level of sensory block, which varied between T3 and T8. One patient was nauseated seconds before the asystole, otherwise there was no warning signs. All the patients were easily resuscitated with the prompt administration of atropine and ephedrine and, in the case of cardiac arrest, cardiac massage and ventilation with oxygen. One patient was treated with a small dose of adrenaline. Four patients had the surgery, as planned; one had the surgery postponed. All the patients were discharged from hospital in good health and did not suffer any sequelae.

Advanced Heart Block as a Manifestation of a Paraneoplastic Syndrome From Malignant Thymoma

Malignant thymoma is a rare tumor that is associated with paraneoplastic syndrome. Myocarditis as a paraneoplastic syndrome has been rarely described. Reported herein is a young male patient with malignant thymoma and myocarditis as part of a paraneoplastic syndrome. This resulted in high-degree heart block and an asystolic cardiac arrest despite placement of a permanent pacemaker.

Aminophylline in undifferentiated out-of-hospital asystolic cardiac arrest

Primary objective: To determine if the introduction of intravenous aminophylline, a nonspecific adenosine receptor antagonist, into the resuscitation algorithm of asystole will increase return of spontaneous circulation when used in undifferentiated prehospital cardiac arrest. Methods: An urban, prehospital, prospective, randomized, double-blind, placebo-controlled trial of nonpregnant normothermic adults suffering nontraumatic out-of-hospital asystolic cardiac arrest. Subjects were treated in accordance with published advanced cardiac life support guidelines and standard pharmacotherapy. They were randomly assigned to receive either placebo or aminophylline along with the initial boluses of atropine and epinephrine. Cardiac rhythms and carotid pulses were monitored throughout the resuscitation. Results: Eighty-two patients were entered into the trial. Forty-five patients were assigned to the placebo group and 37 received aminophylline. Nine of 45 controls (20%; 95% CI 10–35%) achieved return of spontaneous circulation compared to ten of 37 (27%; 95% CI 14–44%) in the aminophylline group. Conclusions: We were not able to show a statistically significant improvement in return of spontaneous circulation when aminophylline was given during the early resuscitation phase of undifferentiated asystolic cardiac arrest in the prehospital setting with this sample size.

Gastric outflow obstruction caused by gall stones and leading to death by complex metabolic derangement.

A 67 year old woman was admitted with a three week history of vomiting, having become increasingly confused for three days. Investigations revealed deranged serum biochemistry consistent with a combination...

Adenosine receptor antagonism in refractory asystolic cardiac arrest: results of a human pilot study

Primary objective: To determine if adenosine receptor antagonism has any beneficial impact on victims of asystolic cardiac arrest and whether or not it warrants further clinical study as a treatment for cardiac asystole. Materials and methods: A 6-month prospective, randomized, double-blinded, placebo-controlled trial, set in an urban emergency medical services system, in adults with nontraumatic asystolic out-of-hospital cardiac arrest. Patients in whom standard advanced cardiac life support pharmacotherapy failed were randomized to receive placebo or aminophylline, a nonspecific competitive adenosine receptor antagonist. Rhythms were recorded before and after intervention. Results: Twenty-two patients were appropriately entered into the trial. Eight patients served as controls and 14 patients received aminophylline. The groups were similar in all measured parameters except for initial rhythm. None of the patients in the placebo group responded to the intervention. Half of the patients in the treatment group had return of organized cardiac electrical activity. Conclusion: Our results suggest that adenosine receptor antagonism may have a role in the treatment of cardiac asystole. Further clinical studies to validate these findings and clarify the appropriate use of adenosine receptor antagonists in cardiac asystole may be justified.

Different preconditioning stimuli invoke disparate electromechanical and energetic responses to global ischemia in rat hearts

One hypothesized mechanism of the cardioprotection provided by preconditioning is decreased utilization of ATP during ischemia. Although ATP levels in preconditioned heart during ischemia have been previously studied, contractile activity during ischemia has not been investigated. Contractile activity accounts for significant ATP consumption during ischemia. We hypothesized that preconditioning stimuli may conserve energy during the ischemic period by decreasing myocardial contractile energy expenditure prior to asystolic cardiac arrest. We studied three preconditioning stimuli: (i) four cycles of 5-min periods of ischemia (4 x 5' CI), (ii) 2 min of alpha 1-adrenergic stimulation (phenylephrine; PE), and (iii) 2 min of P1-purinergic stimulation (adenosine). The effects of these stimuli on myocardial ATP, ventricular contractility, and the time to cessation of electromechanical function (asystole) during the sustained ischemic period were then examined. Preconditioning stimuli (4 x 5' CI, phenylephrine, and adenosine) improved postischemic functional recovery compared with nonpreconditioned controls. Myocardial ATP contents at the end of 20 min of global ischemia were higher for adenosine-treated (9.0 +/- 1.5 mumol/g dry weight; p < 0.05) and PE-treated (9.9 +/- 1.9 mumol/g dryweight; p < 0.05) hearts than for controls (6.6 +/- 1.2 mumol/g dry weight). The CI hearts began with lower myocardial ATP levels (9.9 +/- 1.2 mumol/g dry weight; p < 0.05) than other groups prior to the sustained ischemic period (control 13.4 +/- 1.0 mumol/g dry weight). As a result of a lower rate of ATP depletion, ATP levels in the CI group were similar to the untreated control after 20 min of sustained ischemia (5.5 +/- 0.7 mumol/g dry weight). Preconditioning with 4 x 5' CI or adenosine (but not PE) led to earlier ventricular arrest. Only adenosine-treated hearts demonstrated a more rapid decline in ventricular contractility during sustained ischemia than did nonpreconditioned control hearts. We conclude that while the final recovery of ventricular contractility after asystolic arrest and reperfusion is improved by preconditioning with different stimuli (4 x 5' CI, adenosine, or PE), each stimulus conferred a characteristic electromechanical and energy conservation strategy during sustained ischemia. Adenosine conserved myocardial ATP content and reduced total cardiac work (developed pressure and heart beats). CI conserved myocardial ATP and minimized the number of ischemic cardiac beats. PE preserved myocardial ATP during ischemia without changing contractile behavior. Thus, energy conservation strategies during ischemia could contribute to the protection afforded by preconditioning stimuli, but the mechanisms appear to differ among stimuli.