Open-chest Cardiopulmonary Resuscitation Research Articles

Atrial Cannulation During Resuscitative Clamshell Thoracotomy.

Resuscitative thoracotomy and clamshell thoracotomy are performed in the setting of traumatic arrest with the intent of controlling hemorrhage, relieving tamponade, and providing open chest cardiopulmonary resuscitation. Historically, return of spontaneous circulation rates for penetrating traumatic arrest as well as out of hospital survival have been reported as low as 40% and 10%. Vascular access can be challenging in patients who have undergone a traumatic arrest and can be a limiting step to effective resuscitation. Atrial cannulation is a well-established surgical technique in cardiac surgery. Herein, we present a case series detailing our application of this technique in the context of acute trauma resuscitation during clamshell thoracotomy for traumatic arrest in the emergency department. A retrospective case series of atrial cannulation during traumatic arrest was conducted in Charlotte, NC at Carolinas Medical Center an urban level 1 trauma center. The mean rate of return of spontaneous circulation in our series, 60%, was greater than previously published upper limit of return of spontaneous circulation for penetrating causes of traumatic arrest. Intravenous access can be difficult to establish in the hypovolemic and exsanguinating patient. Traditional methods of vascular access may be insufficient in the setting of central vascular injury. Atrial appendage cannulation during atrial cannulation is a quick and reliable technique to achieve vascular access that employs common methods from cardiac surgery to improve resuscitation of traumatic arrest.

Successful ECMO-assisted open chest cardiopulmonary resuscitation in a postpartum patient with delayed amniotic fluid embolism

BackgroundAmniotic fluid embolism (AFE) is a rare but potentially dangerous severe obstetrics complication, which is accompanied by an incidence between 1.9 and 6.1 per 100,000 births.Case presentationHere, we report an AFE case after cesarean delivery diagnosed on a cardiac arrest complicated by acute respiratory distress syndrome and coagulopathy. Diagnosis, risk factors and pathophysiology for AFE have been fully discussed, besides, extracorporeal membrane oxygenation in the early management of cardiac arrest was used, describing the indication, efficacy and successful performed of open-chest cardiopulmonary resuscitation for the patient.ConclusionIn AFE with cute cardiovascular collapse, extracorporeal membrane oxygenation support can be considered as the alternative therapies.

Comparison of left fourth and fifth intercostal space thoracotomy for open-chest cardiopulmonary resuscitation in dogs.

ObjectiveTo determine whether ease of access to thoracic structures for performing open‐chest cardiopulmonary resuscitation (OC‐CPR) differed between fourth and fifth intercostal space (ICS) left lateral thoracotomies in dogs, and to determine if “shingling” improved access for OC‐CPR manipulations.DesignProspective single‐blinded study.SettingLaboratory.AnimalsTwelve mixed breed canine cadavers weighing approximately 20 kg.InterventionsLeft lateral thoracotomies were performed at the 4th ICS (n = 6) or 5th ICS (n = 6). Shingling at the 4th or 5th ICS, as applicable, was performed after initial data collection and outcomes were reassessed.Measurements and main resultsThree evaluators blinded to the surgical approach scored the following parameters on a 0 to 10 scale (0 = easiest, 10 = most difficult): ease of access of the phrenicopericardial ligament, ease of pericardial incision, ease of appropriate hand position, ease of aortic access, ease of Rumel tourniquet application, and ease of proper placement of defibrillation paddles. Objective measurements (time to completion or number of attempts) were made for all but ease of pericardial incision and ease of appropriate hand position. Outcomes were reassessed after shingling.The 5th ICS was superior for ease of aortic access (P = 0.042), time to visualization of aorta (P = 0.009), and ease of application of a Rumel tourniquet (P = 0.019). When comparing scores pre‐ and post‐shingling, shingling improved time to visualization of the aorta (P < 0.001), time to placement of Rumel tourniquet (P < 0.001), ease of paddle placement (P = 0.017), and time to paddle placement (P < 0.001).ConclusionsEither 4th or 5th ICS thoracotomy may provide adequate access to intrathoracic structures pertinent to performing OC‐CPR in dogs weighing approximately 20 kg, but 5th ICS was preferred for most manipulations, and shingling improved access for most of the measured parameters.

Open-chest versus closed-chest cardiopulmonary resuscitation in trauma patients with signs of life upon hospital arrival: a retrospective multicenter study

BackgroundThe effectiveness and indications of open-chest cardiopulmonary resuscitation (OCCPR) have been still debatable. Although current guidelines state that the presence of signs of life (SOL) is an indication for OCCPR, scientific evidence corroborating this recommendation has been scarce. This study aimed to compare the effectiveness of OCCPR to closed-chest cardiopulmonary resuscitation (CCCPR) in severe trauma patients with SOL upon arrival at the emergency department (ED).MethodsA retrospective cohort study analyzing data from the Trauma Quality Improvement Program (TQIP) database, a nationwide trauma registry in the USA, between 2010 and 2016 was conducted. Severe trauma patients who had SOL upon arrival at the hospital and received cardiopulmonary resuscitation within the first 6 h of ED admission were identified. Survival to hospital discharge was evaluated using logistic regression analysis, instrumental variable analysis, and propensity score matching analysis adjusting for potential confounders.ResultsA total of 2682 patients (OCCPR 1032; CCCPR 1650) were evaluated; of those 157 patients (15.2%) in the OCCPR group and 193 patients (11.7%) in the CCCPR group survived. OCCPR was significantly associated with higher survival to hospital discharge in both the logistic regression analysis (adjusted odds ratio [95% confidence interval] = 1.99 [1.42–2.79], p < 0.001) and the instrumental variable analysis (adjusted odds ratio [95% confidence interval] = 1.16 [1.02–1.31], p = 0.021). In the propensity score matching analysis, 531 matched pairs were generated, and the OCCPR group still showed significantly higher survival at hospital discharge (89 patients [16.8%] in the OCCPR group vs 58 patients [10.9%] in the CCCPR group; odds ratio [95% confidence interval] = 1.66 [1.13–2.42], p = 0.009).ConclusionsCompared to CCCPR, OCCPR was associated with significantly higher survival at hospital discharge in severe trauma patients with SOL upon ED arrival. Further studies to confirm these results and to assess long-term neurologic outcomes are needed.

Feasibility of open-chest cardiopulmonary resuscitation through a transdiaphragmatic approach in dogs.

To describe and evaluate the feasibility of a transdiaphragmatic (TD) approach for open-chest cardiopulmonary resuscitation (OCCPR) as an alternative to a traditional lateral thoracotomy (LT) in a canine cadaver model. Randomized noninferiority ex vivo study. Fourteen canine cadavers weighing 17.4-30.2 kg. An LT and a TD approach to the heart were performed in each cadaver. The order of procedures as well as an assignment to specific operators were randomized before starting the study. Data recorded included the time between incision and initiation of cardiac compressions; time between initiation of the first suture placement and closure of the intrapleural space; time between initiation of the first suture placement and final skin suture; trauma to pulmonary, cardiac, hepatic and neurovascular structures; distance between the caval foramen and diaphragmatic incision; the intercostal space entered during LT; and appropriate closure. The mean time between incision and initiation of cardiac compressions for the TD approach (85 ± 35 seconds) was noninferior to the LT (84 ± 28 seconds). The pleural space was closed faster after the TD approach (531 ± 276 seconds) than after the lateral approach (817 ± 294 seconds, P = .03). Total duration of closure did not differ between techniques (P = .11). There was no difference between the complication rates of each approach. The TD approach did not prolong the procedure or increase the complication rate compared with an LT. This study provides evidence to support additional investigation of the TD approach for OCCPR to determine its efficacy and safety in live animals.

Invited Commentary

In recent years, much attention has been devoted to resuscitation techniques in adults and children in hopes of improving what have historically been dismal outcomes. Meert and colleagues [1Meert K.L. Delius R. Slomine B.S. et al.One-year survival and neurologic outcomes after pediatric open-chest cardiopulmonary resuscitation.Ann Thor Surg. 2019; 107: 1441-1447Abstract Full Text Full Text PDF Scopus (4) Google Scholar] report encouraging results in neurologic outcomes of children after open-chest resuscitation, the vast majority of whom were infants who had undergone cardiac operations, and most of whom were also supported by extracorporeal membrane oxygenation (ECMO). Their thoughtful analysis of data obtained through the Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital trial demonstrated that about half of the children had 1-year survival with good neurologic outcomes. Although the researchers’ hands were somewhat tied by limitations of data collection defined by the original study design, it is equally strengthened by the entry requirement to be comatose, thus including the highest-risk patients. Most would agree that the outcomes are good, perhaps even better than expected given such an aggressive approach in this high-risk population. The authors’ discussion focuses on predictors of outcome to help guide clinicians and parents in management decisions; however, I believe that there is a larger, perhaps hidden, takeaway message. In the mid-1990s the Extracorporeal Life Support Organization examined its database to determine the survival rate of neonates supported on ECMO after the Norwood procedure. It was zero—not a single reported survivor. Some centers concluded that this specific population were therefore not ECMO candidates, but others realized that we needed to change our approach. An improved understanding of shunt management led to improved outcomes, with current post-Norwood ECMO survival rates of 17% to 54% [2Tabbutt S. Ghanayem N. Ravishankar C. et al.Risk factors for hospital morbidity and mortality after the Norwood procedure: a report from the Pediatric Heart Network Single Ventricle Reconstruction trial.J Thorac Cardiovasc Surg. 2012; 144: 882-895Abstract Full Text Full Text PDF PubMed Scopus (235) Google Scholar], including 25% survival beyond Fontan completion [3Friedland-Little J.M. Aiyagari R. Yu S. Donohue J.E. Hirsch-Romano J.C. Survival through staged palliation: fate of infants supported by extracorporeal membrane oxygenation after the Norwood operation.Ann Thorac Surg. 2014; 97: 659-665Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar]—a notable improvement over zero. A similar response is warranted with the current report. Rather than settle for the documented outcomes, we must carefully examine our management strategies, including techniques of sternotomy during cardiopulmonary resuscitation, timing of ECMO utilization, appropriate ECMO flow rates, use of vasoconstrictors, and temperature management, among other factors. We are guided by experience, intuition, and inherent biases, but we lack the support of data. Well-designed studies will provide the information needed for management evolution and continually improved results. Finally, we should congratulate the authors of this and the original trial, which like most quality clinical research, provides us with as many new questions and challenges as conclusions. One-Year Survival and Neurologic Outcomes After Pediatric Open-Chest Cardiopulmonary ResuscitationThe Annals of Thoracic SurgeryVol. 107Issue 5PreviewLimited data exist about neurobehavioral outcomes of children treated with open-chest cardiopulmonary resuscitation (CPR). Our objective was to describe neurobehavioral outcomes 1 year after arrest among children who received open-chest CPR during in-hospital cardiac arrest and to explore factors associated with 1-year survival and survival with good neurobehavioral outcome. Full-Text PDF

One-Year Survival and Neurologic Outcomes After Pediatric Open-Chest Cardiopulmonary Resuscitation

Limited data exist about neurobehavioral outcomes of children treated with open-chest cardiopulmonary resuscitation (CPR). Our objective was to describe neurobehavioral outcomes 1 year after arrest among children who received open-chest CPR during in-hospital cardiac arrest and to explore factors associated with 1-year survival and survival with good neurobehavioral outcome. The study is a secondary analysis of the Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital Trial. Fifty-six children who received open-chest CPR for in-hospital cardiac arrest were included. Neurobehavioral status was assessed using the Vineland Adaptive Behavior Scales, Second Edition (VABS-II) at baseline before arrest and 12 months after arrest. Norms for VABS-II are 100 ± 15 points. Outcomes included 12-month survival, 12-month survival with VABS-II decreased by no more than 15 points from baseline, and 12-month survival with VABS-II of 70 or more points. Of 56 children receiving open-chest CPR, 49 (88%) were after cardiac surgery and 43 (77%) were younger than 1 year. Forty-four children (79%) were cannulated for extracorporeal membrane oxygenation (ECMO) during CPR or within 6 hours of return of spontaneous circulation. Thirty-three children (59%) survived to 12 months, 22 (41%) survived to 12 months with VABS-II decreased by no more than 15 points from baseline, and of the children with baseline VABS-II of 70 or more points 23 (51%) survived to 12 months with VABS-II of 70 or more points. On multivariable analyses, use of ECMO, renal replacement therapy, and higher maximum international normalized ratio were independently associated with lower 12-month survival with VABS-II of 70 or more points. Approximately one-half of children survived with good neurobehavioral outcome 1 year after open-chest CPR for in-hospital cardiac arrest. Use of ECMO and postarrest renal or hepatic dysfunction may be associated with worse neurobehavioral outcomes.

Open-chest versus closed-chest cardiopulmonary resuscitation in blunt trauma: analysis of a nationwide trauma registry

BackgroundAlthough open-chest cardiopulmonary resuscitation (OCCPR) is often considered as the last salvage maneuver in critically injured patients, evidence on the effectiveness of OCCPR has been based only on the descriptive studies of limited numbers of cases or expert opinions. This study aimed to compare the effectiveness of OCCPR with that of closed-chest cardiopulmonary resuscitation (CCCPR) in an emergency department (ED).MethodsA nationwide registry-based, retrospective cohort study was conducted. Patients with blunt trauma, undergoing cardiopulmonary resuscitation (CPR) in an ED between 2004 and 2015 were identified and divided into OCCPR and CCCPR groups. Their outcomes (survival to hospital discharge and survival over 24 hours following ED arrival) were compared with propensity score matching analysis and instrumental variable analysis.ResultsA total of 6510 patients (OCCPR, 2192; CCCPR, 4318) were analyzed. The in-hospital and 24-hour survival rates in OCCPR patients were 1.8% (40/2192) and 5.6% (123/2192), and those in CCCPR patients were 3.6% (156/4318) and 9.6% (416/4318), respectively. In the propensity score-matched subjects, OCCPR patients (n = 1804) had significantly lower odds of survival to hospital discharge (odds ratio (95% CI)) = 0.41 (0.25–0.68)) and of survival over 24 hours following ED arrival (OR (95% CI) = 0.59 (0.45–0.79)) than CCCPR patients (n = 1804). Subgroup analysis revealed that OCCPR was associated with a poorer outcome compared to CCCPR in patients with severe pelvis and lower extremity injury.ConclusionsIn this large cohort, OCCPR was associated with reduced in-hospital and 24-hour survival rates in patients with blunt trauma. Further comparisons between OCCPR and CCCPR using additional information, such as time course details in pre-hospital and ED settings, anatomical details regarding region of injury, and neurological outcomes, are necessary.

The influence of sildenafil on myocardial catecholamine level in a swine model of ventricular fibrillation

Objective To reveal the changes of catecholamine and lactate levels in myocardial interstitial fluid during cardiopulmonary resuscitation in order to prove the protective effects of sildenafil pretreatment on post-resuscitation myocardial function in swine model of ventricular fibrillation(VF). Methods Twenty-four swine were randomly(random number) divided into three groups: saline group, sildenafil group and shame operation group. Sildenafil in dose of 0.5 mg/kg dissolved in 40 mL of saline was given to swine once intraperitoneally 40 min prior to VF in sildenafil group.The equivalent volume of saline (0.9% NaCl) alone was administered instead in saline groups. There was no treatment in shame operation group. After ventricular fibrillation untreated for 8 min, open-chest cardiopulmonary resuscitation was initiated. The hemodynamic variables were recorded at baseline, 4 min, 1 h and 6 h after restoration of spontaneous circulation(ROSC). The interstitial fluid from the left ventricle wall was collected by using the microdialysis tubes at given intervals, in which the levels of dopamine, norepinephrine, epinephrine, and lactate were measured. The samples for pathological examination were taken at 24 hours after ROSC. Results The levels of catecholamine and lactate in the sildenafil group were lower than those in saline group at all different intervals(P<0.05 or P<0.01). The cumulative defibrillation energy was lower in the sildenafil group than that in the saline group(P<0.05). The hemodynamic changes and myocardial histological damage in sildenafil group were milder than those in saline group(P<0.05). The pathologic changes of myocardium and mitochondria in saline group were more severe than those in sildenafil group. Conclusions Sildenafil pretreatment prior to VF can effectively reduce endogenous catecholamine secretion and lactate levels in myocardial tissue, protecting the myocardium and improving post-resuscitation myocardial function. Key words: Sildenafil; Cardiopulmonary resuscitation; Microdialysis; Catecholamine; Lactate; Hemodynamics

Out-of-hospital open-chest cardiopulmonary resuscitation after cardiac arrest in cases of blunt chest or abdominal trauma: A consecutive series of 40 cases

Out-of-hospital open-chest cardiopulmonary resuscitation after cardiac arrest in cases of blunt chest or abdominal trauma: A consecutive series of 40 cases

Blunt Traumatic Cardiac Rupture Presenting as Massive Haemothorax

Cardiac rupture following blunt thoracic trauma in motor vehicle crash generally causes death at scene, and is rarely diagnosed preoperatively. However, early emergency thoracotomy in the emergency department (ED) or operating room might reduce the mortality but the benefit is still controversial. A haemodynamically unstable 28-year-old woman following motor vehicle crash was detected to have right haemothorax on chest X-ray. Thoracic computed tomography (CT) revealed additional lung contusions and multiple bone fractures. She developed cardiac arrest during open thoracotomy and had restored spontaneous circulation after open-chest cardiopulmonary resuscitation (CPR). This report highlights that CT scan in haemodynamically unstable patients could delay surgical control of the injury. Open-chest CPR can be life-saving for blunt chest injury developing cardiac arrest. (Hong Kong j.emerg.med. 2015;22:320-323)

The protective effects of a phosphodiesterase 5 inhibitor, sildenafil, on postresuscitation cardiac dysfunction of cardiac arrest: metabolic evidence from microdialysis.

IntroductionRecent experimental and clinical studies have indicated the cardioprotective role of sildenafil during ischemia/reperfusion injury. The aim of this study was to determine, by obtaining metabolic evidence from microdialysis, if sildenafil could reduce the severity of postresuscitation myocardial dysfunction and lead to cardioprotection through beneficial effects on energy metabolism.MethodsTwenty-four male piglets were randomly divided into three groups: sildenafil (n = 8), saline (SA; n = 8) and sham operation (n = 8). Sildenafil pretreatment consisted of 0.5 mg/kg sildenafil administered once intraperitoneally 30 minutes prior to ventricular fibrillation (VF). The myocardial interstitial fluid (ISF) concentrations of glucose, lactate, pyruvate, glutamate and glycerol were determined by microdialysis before VF. Afterward, the piglets were subjected to 8 minutes of untreated VF followed by 15 minutes of open-chest cardiopulmonary resuscitation. ISF was collected continuously, and the experiment was terminated 24 hours after resuscitation.ResultsAfter 8 minutes of untreated VF, the sildenafil group exhibited higher glucose and pyruvate concentrations of ISF and lower lactate and glutamate levels in comparison with the SA group, and these data reached statistical significance (P < 0.05). Advanced cardiac life support was delivered to both groups, with a 24-hour survival rate showing a promising trend in the sildenafil group (7 of 8 versus 3 of 8 survivors, P < 0.05). Compared with the SA group, the sildenafil group had a better outcome in terms of hemodynamic and oxygen metabolism parameters (P < 0.05). Myocardial tissue analysis revealed a dramatic increase in the contents of ATP, ADP and phosphocreatine in the sildenafil group versus the SA group at 24 hours after return of spontaneous circulation (ROSC; P = 0.03, P = 0.02 and P = 0.02, respectively). Furthermore, 24 hours after ROSC, the sildenafil group had marked elevations in activity of left ventricular Na+-K+-ATPase and Ca2+-ATPase compared with the SA group (P = 0.03, P = 0.04, respectively).ConclusionsSildenafil could reduce the severity of postresuscitation myocardial dysfunction, and it produced better clearance of metabolic waste in the ISF. This work might provide insights into the development of a novel strategy to treat postresuscitation myocardial dysfunction.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0641-7) contains supplementary material, which is available to authorized users.

Resuscitation after cardiac arrest in a septic porcine model: adding vasopressin vs epinephrine alone administration.

BackgroundVasopressin administration has been tested in cardiac arrest. However it has not been tested when cardiac arrest occurs in certain circumstances, as in sepsis, where it may have a major role. The aim of the study was to investigate survival after cardiac arrest in a septic porcine model compared with healthy animals and to explore the effectiveness of adding vasopressin vs epinephrine alone administration.MethodsThirty five healthy piglets of both genders were studied. The piglets were randomly assigned into three groups: group A (n = 8), group B (n = 14), group C (n = 13). Animals of groups B and C were given endotoxin to mimic a septic state before arrest. We applied the same resuscitation protocol to all pigs but we replaced the first dose of epinephrine with vasopressin in pigs of group C. Following surgical preparation and 30 min resting period, baseline measurements were recorded. In order to assess tissue oxygenation, we implemented Near Infrared Spectroscopy (NIRS) with the vascular occlusion technique (VOT) in thirteen lipopolysaccharide (LPS)-treated animals, occluding abdominal aorta and inferior vena cava. Afterwards, LPS (100 μg/kg) was infused in a 30 min period to animals of groups B and C and normal saline to group A. New NIRS measurements were obtained again. Subsequently, we provoked ventricular fibrillation (VF). After 3 min of untreated VF, open chest cardiopulmonary resuscitation (CPR) was performed manually. Primary end point was the restoration of spontaneous circulation (ROSC).ResultsThe chance of ROSC for the groups A, B and C was 75%, 35.7%, and 30.7% respectively. A significant difference in ROSC was established between septic (group B + C) and non septic piglets (group A) (P = 0.046). Vasopressin administration had no effect in outcome. LPS administration decreased oxygen consumption rate, as assessed by NIRS, in peripheral tissues (22.6 ± 7.2. vs 18.5 ± 7.2, P = 0.07).ConclusionSeptic piglets have fewer chances to survive after cardiac arrest. No difference in outcome was observed when the first dose of epinephrine was replaced with vasopressin to treat cardiac arrest in the LPS-treated animals.

Adrenaline increases blood-brain-barrier permeability after haemorrhagic cardiac arrest in immature pigs

Adrenaline (ADR) and vasopressin (VAS) are used as vasopressors during cardiopulmonary resuscitation. Data regarding their effects on blood-brain barrier (BBB) integrity and neuronal damage are lacking. We hypothesised that VAS given during cardiopulmonary resuscitation (CPR) after haemorrhagic circulatory arrest will preserve BBB integrity better than ADR. Twenty-one anaesthetised sexually immature male piglets (with a weight of 24.3 ± 1.3 kg) were bled 35% via femoral artery to a mean arterial blood pressure of 25 mmHg in the period of 15 min. Afterwards, the piglets were subjected to 8 min of untreated ventricular fibrillation followed by 15 min of open-chest CPR. At 9 min of circulatory arrest, piglets received amiodarone 1.0 mg/kg and hypertonic-hyperoncotic solution 4 ml/kg infusions for 20 min. At the same time, VAS 0.4 U/kg was given intravenously to the VAS group (n = 9) while the ADR group received ADR 20 μg/kg (n = 12). Internal defibrillation was attempted from 11 min of cardiac arrest to achieve restoration of spontaneous circulation. The experiment was terminated 3 h after resuscitation. The intracranial pressure (ICP) in the post-resuscitation phase was significantly greater in ADR group than in VAS group. VAS group piglets exhibited a significantly smaller BBB disruption compared with ADR group. Cerebral pressure reactivity index showed that cerebral blood flow autoregulation was also better preserved in VAS group. Resuscitation with ADR as compared with VAS after haemorrhagic circulatory arrest increased the ICP and impaired cerebrovascular autoregulation more profoundly, as well as exerted an increased BBB disruption though no significant difference in neuronal injury was observed.

Resuscitation with amiodarone increases survival after hemorrhage and ventricular fibrillation in pigs.

Supplemental digital content is available in the text. The aim of this experimental study was to compare survival and hemodynamic effects of a low-dose amiodarone and vasopressin compared with vasopressin in hypovolemic cardiac arrest model in piglets. Eighteen anesthetized male piglets (with a weight of 25.3 [1.8] kg) were bled approximately 30% of the total blood volume via the femoral artery to a mean arterial blood pressure of 35 mm Hg in a 15-minute period. Afterward, the piglets were subjected to 4 minutes of untreated ventricular fibrillation followed by 11 minutes of open-chest cardiopulmonary resuscitation. At 5 minutes, circulatory arrest amiodarone 1 mg/kg was intravenously administered in the amiodarone group (n = 9), while the control group received the same amount of saline (n = 9). At the same time, all piglets received vasopressin 0.4 U/kg intravenously administered and hypertonic-hyperoncotic solution 3-mL/kg infusion for 20 minutes. Internal defibrillation was attempted from 7 minutes of cardiac arrest to achieve restoration of spontaneous circulation. The experiment was terminated 3 hours after resuscitation. Three-hour survival was greater in the amiodarone group (p = 0.02). After the successful resuscitation, the amiodarone group piglets had significantly lower heart rate as well as greater systolic, diastolic, and mean arterial pressure. Troponin I plasma concentrations were lower and urine output was greater in the amiodarone group. Combined resuscitation with amiodarone and vasopressin after hemorrhagic circulatory arrest resulted in greater 3-hour survival, better preserved hemodynamic parameters, and smaller myocardial injury compared with resuscitation with vasopressin only.

Battery Ingestion Resulting in an Aortoesophageal Fistula

A 4-YR-OLD, 13-kg girl presented to the emergency department in cardiopulmonary arrest after acute episodes of bright red hematemesis. The patient had no witnessed foreign body ingestion or past medical history. Once stabilized, the patient was transferred to the pediatric intensive care unit. Chest radiograph (fig. A) revealed a 23-mm, round foreign body with a peripheral rim (suggesting the presence of a battery) in the central mediastinum within the distal esophagus posterior to the heart. She was taken to the operating room for emergency thoracotomy. Upon transfer to the operating room table, the patient experienced cardiopulmonary arrest. The surgeons cross clamped the aorta and initiated open-chest cardiopulmonary resuscitation. Despite ongoing resuscitation, the patient never regained a sustainable cardiac rhythm and expired. Postmortem examination confirmed the presence of a battery-induced aortoesophageal fistula (fig. B).Battery ingestion is an increasing hazard with potentially fatal clinical implications. Public awareness is essential in preventing complications because early recognition of battery ingestion and removal is key to therapeutic management. If battery ingestion is suspected, a chest radiograph should be obtained immediately. Patients with ingested batteries larger than 12 mm should go to the operating room within 2 h for endoscopic removal and inspection of the esophageal mucosa. Even if the battery is smaller than 12 mm, patients are still at risk for injury or death. It is essential to make a decision based on symptoms and clinical judgment. Failure to remove batteries within 2 h can lead to esophageal necrosis and aortoesophageal fistulas. After removal of the battery, patients with mucosal injuries should be observed for delayed complications such as abscesses, perforations, mediastinitis, and strictures for up to several months.

RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 4: Advanced life support

AbstractObjectiveTo systematically evaluate the evidence of the effect of advanced life support techniques on outcome in veterinary cardiopulmonary resuscitation (CPR) and to outline knowledge gaps.DesignStandardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality, and development of consensus on conclusions for application of the concepts to clinical practice.SettingAcademia, referral practice, and general practiceResultsSixteen population, intervention, control group, outcome questions were evaluated to determine if recommendations could be made concerning drug therapy, including vasopressors, vagolytics, corticosteroids, reversal agents, buffer therapy, and correction of electrolyte disturbances. Electrical defibrillation strategies as well as other advanced interventions such as open‐chest CPR, impedance threshold devices, and special considerations regarding anesthesia‐related cardiopulmonary arrest (CPA) were also investigated.ConclusionsThere is strong evidence supporting the use of standard‐dose (0.01 mg/kg) epinephrine in CPR, as well as early electrical defibrillation for animals experiencing CPA due to ventricular fibrillation or pulseless ventricular tachycardia, preferentially using a biphasic defibrillator. For CPA due to certain causes and with the availability of advanced postcardiac arrest support, open chest CPR is preferred. Many knowledge gaps regarding other pharmacologic and advanced therapies were identified, and further studies are recommended to better systematically address these questions.

Modulation of nitric oxide expression with methylene blue does not improve outcome after hypovolemic cardiac arrest

Aim of the study We recently reported that female sex protects against cerebral and cardiac injury after hypovolemic cardiac arrest (CA), independent of sex hormone effects. As female sex was also associated with a smaller increase in inducible and neuronal nitric oxide synthase (NOS), we hypothesised that nitric oxide inhibition with methylene blue (MB) improves the outcome, primarily in male animals. Methods Twenty sexually immature piglets (10 males and 10 females) were bled to mean arterial blood pressure of 35 mmHg, and were subjected to 2 min of untreated CA followed by 8 min of open chest cardiopulmonary resuscitation (CPR). Volume resuscitation was started during CPR with intravenous administration of 3 ml kg −1 hypertonic saline-dextran. Methylene blue was then administered as bolus of 2.5 mg kg −1 over 20 min, followed by 1.5 mg kg −1 infusion over 40 min. Historical data from 21 animals were used as control (no MB). Hemodynamic parameters, myocardial injury (troponin I), and short-term survival (3-h) were evaluated. Histopathological evaluation of heart specimens was performed. Results There were no differences between male and female animals in survival or resuscitation rate. After CA female piglets had significantly greater systolic and mean arterial pressures, and had lower troponin I plasma concentrations compared to male piglets, with or without MB. No difference was observed in histopathological analysis of heart specimens between sexes. Conclusions After resuscitation from hypovolemic CA, female sex protects against cardiac injury, independent of sex hormones. Modulation of NO expression with MB does not improve survival or myocardial histological injury in either sex.

Neuroprotective Effects of 17β-Estradiol After Hypovolemic Cardiac Arrest in Immature Piglets

We recently reported that cerebral and cardiac injuries are mitigated in immature female piglets after severe hemorrhage with subsequent cardiac arrest. Female sex was also associated with a smaller increase in the cerebral expression of inducible nitric oxide synthase (iNOS) and neuronal nitric oxide synthase (nNOS). In the current study, we tested the hypothesis that exogenously administered 17β-estradiol (E₂) can improve neurological outcome by NOS modulation. Thirty-nine sexually immature piglets were bled to a mean arterial pressure of 35 mmHg over 15 min. Fifty micrograms per kilogram of E₂ was then administered to 10 male and 10 female animals (estradiol group), whereas control animals (n = 10 males and 9 females) received equal volume of normal saline. The animals were then subjected to ventricular fibrillation (4 min) followed by up to 15 min of open-chest cardiopulmonary resuscitation. Vasopressin 0.4 U · kg⁻¹ and amiodarone 0.5 mg · kg⁻¹ were given, and 3 mL · kg⁻¹ of 7.5% saline with 6% dextran was administered over 20 min. All surviving animals were killed after 3 h, and their brains examined for histological injury and NOS expression. No significant differences were observed in survival or hemodynamics between the groups. Compared with the control group, animals in the E₂ group exhibited a significantly smaller increase in nNOS and iNOS expression, a smaller blood-brain-barrier disruption, and a mitigated neuronal injury. There was a significant correlation between nNOS and iNOS levels and neuronal injury. Interestingly, estradiol attenuated cerebral damage (including lower activation of nNOS and iNOS) both in male and female piglets. In conclusion, in our immature piglet model of hypovolemic cardiac arrest, E₂ downregulates iNOS and nNOS expression and results in decreased blood-brain-barrier permeability disruption and smaller neuronal injury.

Part 7: CPR Techniques and Devices

Part 7: CPR Techniques and Devices : 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Threatment Recommendations