Reversible Causes Of Cardiac Arrest Research Articles

Abstract 16926: Cardiac Ultrasound Has the Potential to Detect Tension Pneumothorax as a Reversible Cause of Cardiac Arrest - An Experimental Porcine Study

Introduction: Survival from cardiac arrest (CA) with a non-shockable rhythm is unlikely unless a reversible cause is identified and treated. Tension pneumothorax (tPTX) is a potentially reversible cause of CA, however the diagnosis can easily be missed. Cardiac ultrasound has the potential to detect reversible causes of CA. tPTX is believed to compress the heart and great vessels, causing the diameter of the right ventricle (RV) to decrease. In ventricular fibrillation and hypoxia induced CA blood accumulates on the right side of the heart causing RV distension, however the cardiac ultrasonographic characteristics of tPTX before and during CA are unknown. Hypotheses: 1) In the period up to CA tPTX will decrease RV diameter compared to hypoxia induced CA. 2) At the onset of CA and start of CPR the RV diameter will increase, abolishing group difference. Methods: Pigs were randomized to CA induced by either unilateral tPTX (n=9) or hypoxia (n=9). tPTX was induced by injecting increments of air into the intrapleural cavity to a total volume of 50 ml/kg (90% of total lung capacity), while hypoxia was induced by gradually reducing the tidal volume over 30 min. tPTX was decompressed after 7 cycles of CPR. Subcostal 5-chamber ultrasound images of the RV were obtained during induction of CA and CPR. The primary endpoints were RV diameter at the onset CA and after 3 cycles of CPR. Results: At baseline the RV diameter was (mean (95%CI)): 24.2 (21.1-27.4) mm in the tPTX group and 24.2 (20.6-27.8) mm in the hypoxia group. Induction of CA, elicited a decrease in RV diameter in the tPTX group to 16.8 (13.0-20.6) mm and an increase in the hypoxia group to 36.2 (32.5-40.0) mm (p-value for comparison to baseline and between groups at CA; p<0.01). After three cycles of CPR RV diameter was significantly smaller in the tPTX group at 11.8 (7.3-16.2) mm when compared to the hypoxia group of 28.2 (24.5-31.9) mm (p<0.01). Immediately after decompression no difference existed between groups: tPTX 28.9 (23.4-34.3) mm vs. hypoxia 29.2 (20.1-38.2) mm (p = 0.94). Conclusion: tPTX causes a significantly smaller diameter of the RV compared to hypoxia prior to CA. This difference persisted during CPR, enabling cardiac ultrasound to detect tPTX as a reversible cause of CA. There was no RV difference after tPTX decompression.

European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances

Irrespective of the cause of cardiac arrest, early recognition and calling for help, including appropriate management of the deteriorating patient, early defibrillation, high-quality cardiopulmonary resuscitation (CPR) with minimal interruption of chest compressions and treatment of reversible causes, are the most important interventions.In certain conditions, however, advanced life support (ALS) guidelines require modification. The following guidelines for resuscitation in special circumstances are divided into three parts: special causes, special environments and special patients. The first part covers treatment of potentially reversible causes of cardiac arrest, for which specific treatment exists, and which must be identified or excluded during any resuscitation. For improving recall during ALS, these are divided into two groups of four, based upon their initial letter – either H or T – and are called the ‘4Hs and 4Ts’: Hypoxia; Hypo-/hyperkalaemia and other electrolyte disorders; Hypo-/hyperthermia; Hypovolaemia; Tension pneumothorax; Tamponade (cardiac); Thrombosis (coronary and pulmonary); Toxins (poisoning). The second part covers cardiac arrest in special environments, where universal guidelines have to be modified due to specific locations or location-specific causes of cardiac arrest. The third part is focused on patients with specific conditions, and those with certain long-term comorbidities where a modified approach and different treatment decisions may be necessary.

A survey demonstrating lack of consensus on the sequence of medications for treatment of hyperkalemia among pediatric critical care providers.

Hyperkalemia is one of the reversible causes of cardiac arrest in children. The Advanced Cardiovascular Life Support guidelines have specific recommendations on the choice and sequence of medications for treatment of life-threatening hyperkalemia. However, the Pediatric Advanced Life Support guidelines have no specific treatment recommendations. The objective of this study was to measure the extent to which opinions diverge among pediatricians on the choice and sequence of medication administration in the management of hyperkalemia during cardiac arrest. Scenario-based survey. A hypothetical hospital area covered by the pediatric rapid response team. A hypothetical scenario of a 7-year old child receiving a blood transfusion who is suddenly unresponsive and found to be in pulseless ventricular tachycardia with stat labs revealing a potassium level of 8.3. A scenario-based survey of PICU fellows and attendings at a PICU Fellows Boot Camp. Eighty-four fellows and 24 attendings responded to the survey. The response rate was 89%. Calcium was chosen most frequently as the first drug to be administered (calcium chloride, 40/115 [34.8%]; calcium gluconate, 62/115 [53.9%]) while 38 of 115 respondents (33%) chose a drug other than calcium. Only 17 of 115 respondents (15%) would use calcium, sodium bicarbonate, insulin, and dextrose in the advanced cardiovascular life support-recommended sequence. PICU attendings were significantly more likely to administer the advanced cardiovascular life support-recommended sequence than fellows (attendings, 8/24 [33%] vs fellows, 9/84 [11%]; p = 0.007). This survey revealed notable variability in the choice and sequence of medications for treatment of life-threatening hyperkalemia with surprisingly few participants in compliance with the advanced cardiovascular life support hyperkalemia guidelines. A standardized approach for pediatric life-threatening hyperkalemia is recommended to improve resuscitation quality.

A Case Report of Successful Resuscitation of Prolonged Cardiac Arrest Due To Severe Hyperkalaemia, Hypovolemia and Severe Metabolic Acidosis

Hyperkalemia, Hypokalemia, Hypovolemia, Acidosis, hypoxia, Hypothermia, thrombosis-coronary and pulmonary, Cardiac tamponade, toxins and tension pneumothorax are the reversible causes of cardiac arrest. We report a case of successful resuscitation of cardiac arrest due to severe hyperkalemia, hypovolemia and severe metabolic acidosis in a patient of Diabetic Keto Acidosis. Our patient is unique for the fact that he had multiple long standing co morbidities, in prolonged cardiac arrest for about 45 minutes with non-shockable cardiac rhythm with multiple reversible causes such as hyperkalemia, hypovolemia and severe metabolic acidosis and was successfully resuscitated with the complete neurological recovery.

CRITICAL CARE ECHO ROUNDS: Echo in cardiac arrest.

Management of medical cardiac arrest is challenging. The internationally agreed approach is highly protocolised with therapy and diagnosis occurring in parallel. Early identification of the precipitating cause increases the likelihood of favourable outcome. Echocardiography provides an invaluable diagnostic tool in this context. Acquisition of echo images can be challenging in cardiac arrest and should occur in a way that minimises disruption to cardiopulmonary resuscitation (CPR). In this article, the reversible causes of cardiac arrest are reviewed with associated echocardiography findings.CaseA 71-year-old patient underwent right upper lobectomy for lung adenocarcinoma. On the 2nd post-operative day, he developed respiratory failure with rising oxygen requirement and right middle and lower lobe collapse and consolidation on chest X-ray. He was commenced on high-flow oxygen therapy and antibiotics. His condition continued to deteriorate and on the 3rd post-operative day he was intubated and mechanically ventilated. Six hours after intubation, he became suddenly hypotensive with a blood pressure of 50 systolic and then lost cardiac output. ECG monitoring showed pulseless electrical activity. CPR was commenced and return of circulation occurred after injection of 1 mg of adrenaline. Focused echocardiography was performed, which demonstrated signs of massive pulmonary embolism. Thrombolytic therapy with tissue plasminogen activator was given and his condition stabilised.

Using a context-sensitive ranking method to organize reversible causes of cardiac arrest in a digital cognitive aid

Medical doctors typically identify reversible causes associated with cardiac arrest by recalling them from memory, using a mnemonic. External techniques, such as cognitive aids (e.g., iPad-based applications), have been shown to produce an increase in performance in medical diagnosis. We studied two alternative approaches to the traditional method of using mnemonics to identify reversible causes of cardiac arrest. One approach displayed the causes in alphabetical order (alphabetical scheme) while the other approach displayed causes ordered by their relevance to the patient-context (context-sensitive scheme). We recorded performance and usability measures for these two approaches in two simulated cardiac arrest scenarios for each group. It took significantly longer for the participants to identify the causes using the context- sensitive scheme. However, the context-sensitive scheme resulted in significantly fewer unnecessary keystrokes. The two schemes did not differ significantly in terms of their usability ratings.

The Role of Emergency Ultrasonography in Cardiopulmonary Resuscitation

Emergency ultrasonography has a potential to identify reversible causes of cardiac arrest (CPA) at bedside and improve the effectiveness of cardiopulmonary resuscitation (CPR). However, very little is known about the efficacy of emergency ultrasonography during CPR. The aim of our study was to determine how effectively emergency physicians detect the etiology of CPA by using emergency ultrasonography.

Desaturation time in a swine model of hemorrhagic shock: Effects of the severity of hemorrhagic shockStatus: PendingCategory: Trauma/Disaster Med

Background:Major trauma resulting in periand actual cardiac rrest is associatedwith significantmortality. Reversiblepathology, ncluding hypovolaemia, obstructive cardiac tamponade, hypoxia nd tension pneumothorax must be rapidly identified and corected if the patient is to survive. No universal algorithm exists or the management of traumatic cardiac arrest. Methods:We reviewed the published literature and devised an lgorithm for use by London’s Air Ambulance pre-hospital trauma eam.Thedescribedalgorithm isused routinelyduringpre-hospital rauma care in London for both blunt and penetrating trauma esulting in perior cardiac arrest. Results: The algorithm describes an immediate, systematic pproach to themanagement of traumatic cardiac arrest. Considertion for immediate resuscitative thoracotomy to treat obstructive ardiac tamponade is given in cases of penetrating thoracic or bdominal trauma. The acronym HOT (hypovolaemia, oxygenaion, tension pneumothorax) is used to describe simultaneous nterventions to rapidly treat reversible causes of cardiac arrest. ypovolaemia is managed with external haemorrhage control, elvic and limb fracture splintage and intra-venous/intra-ossesous uid administration. Oxygenation is maximised through basic and dvanced airway techniques. Tension pneumothorax is treated by eedleoropenchestdecompression. If returnof spontaneous circuation is achieved, rapid transport to theatreorhospital is described, epending on patient location. Conclusion: Routine use of a clinical treatment algorithm in raumatic cardiac arrest management would standardise care, apidly excluding reversible causes of traumatic cardiac arrest. This ould potentially result in improved clinical care and improve surival.

Clinical Integrated Ultrasound in Peri Cardiac Arrest and Cardiac Arrest

Early recognition of the deteriorating patient and prevention of cardiac arrest is the first link in the Chain of Survival. Once cardiac arrest occurs, fewer than 20% of patients having an in-hospital cardiac arrest will survive to go home. Peri cardiac arrest period is the recognized period, either just before or just after a full cardiac arrest, when the patient’s condition is very unstable and care must be taken to prevent progression or regression into a full cardiac arrest. So all instable patient is at risk of cardiac arrest. A rapid identification of reversible causes of cardiac arrest is crucial for the correct treatment and outcome of these patients. As well to identify precociously the peri cardiac arrest conditions prevents cardiac arrest. Ultrasound seems to be an ideal tool for a rapid diagnosis. The integration of data that can rapidly be obtain from heart, lung, inferior vena cava, abdomen and leg vein examination are often essential for the diagnosis and treatment. The role and potentiality of integrated ultrasound in peri and cardiac arrest are considered in this paper.

Extracorporeal cardiopulmonary resuscitation for post-operative cardiac arrest: indications, techniques, controversies, and early results – what is known (and unknown)

Extracorporeal cardiopulmonary resuscitation may be defined as the use of extracorporeal membrane oxygenation for the support of patients who do not respond to conventional cardiopulmonary resuscitation. Data from national and international paediatric databases indicate that the use of extracorporeal cardiopulmonary resuscitation is increasing. Guidelines from the American Heart Association suggest that any patient with refractory cardiopulmonary resuscitation and potentially reversible causes of cardiac arrest is a candidate for extracorporeal cardiopulmonary resuscitation. One possible framework for selection of patients for extracorporeal cardiopulmonary resuscitation includes dividing patients on the basis of favourable or unfavourable characteristics. Favourable characteristics include cardiac disease, witnessed event in the intensive care unit, ability to deliver effective cardiopulmonary resuscitation, active patient monitoring present, favourable arterial blood gases, and early institution of extracorporeal membrane oxygenation. Unfavourable characteristics potentially include non-cardiac disease, an unwitnessed cardiac arrest, ineffective cardiopulmonary resuscitation, and severely acidotic arterial blood gases. Considering the significant resources and cost involved in the use of extracorporeal cardiopulmonary resuscitation, its use needs to be critically examined to improve outcomes, assess neurological recovery and quality of life, and help identify populations and other factors that may help guide in the selection of patients for successful extracorporeal cardiopulmonary resuscitation.

Cardiopulmonary resuscitation: state of the art in 2011

Failure to recognise the signs of sudden cardiac arrest or impending cardiac arrest will lead to delayed intervention. Cardiopulmonary resuscitation (CPR) must be initiated without delay, irrespective of the level of skill of the caregiver. The 2010 CPR guidelines emphasise the importance of chest compressions, which have now become the first step in the CPR sequence [compressions, airway, breathing or circulation, airway, breathing (CAB), instead of airway, breathing, compressions, or airway, breathing, circulation (ABC)]. Hands-only CPR should be encouraged where untrained caregivers are involved. Although ventilation may be an important step in some cases of arrest, e.g. primary asphyxia, excessive and inappropriate ventilation is detrimental. Rapid defibrillation is an essential life-saving step for specific arrest rhythms. Always consider reversible causes of cardiac arrest, and “find it, flag it, fix it and follow up!” Ideally, and especially during an inhospital cardiac arrest, skilled providers should strive to work as a team. Team performance must be reviewed regularly to improve CPR efforts and ultimately outcome. Resuscitation and CPR during the perioperative period is unique, and therefore should be tailored individually to each specific clinical situation. A detailed knowledge of the most up-to-date resuscitation algorithms is essential. These are available from any resuscitation council.

Peri-resuscitation echocardiography: Training the novice practitioner

Aims Echocardiography performed in an ALS-compliant manner provides a tool whereby some of the potentially reversible causes of cardiac arrest can be diagnosed in real time by minimally trained practitioners. One of the major concerns this raises is how to deliver effective training to the required standard. The objective of this study was to determine the effectiveness of number of different educational methods used teach echocardiography to novices. This involved assessment of cognitive, psychomotor skills and affective aspects in five key areas. Methods The study population was a convenience sample from participants attending standardised structured one-day training courses in peri-resuscitation echocardiography ( n = 204). Subjects were assessed for five learning outcomes including knowledge and image interpretation, practical performance of echocardiography including time taken to obtain a diagnostic view, integration into the ALS algorithm and overall compliance with established resuscitation guidelines. Results There was a significant improvement in knowledge and interpretation of echocardiographic images before and after completion of the one-day course (pre 62%, post 78%, p < 0.01). Skills acquisition resulted in 100% of participants being able to obtain a subcostal view of diagnostic quality by the end of the course, and 86% with a mean time to acquisition of <10 s. On completion of the training programme, incorporation of echocardiography into current resuscitation practice did not compromise ALS-compliance. Conclusion Novice echocardiographers can obtain knowledge and skills relevant to ALS-compliant peri-resuscitation echocardiography using a range of educational techniques. In addition to the standard one-day training courses available, continued mentored practice and didactic adherence to ALS algorithms is required.

C.A.U.S.E.: Cardiac arrest ultra-sound exam—A better approach to managing patients in primary non-arrhythmogenic cardiac arrest

Cardiac arrest is a condition frequently encountered by physicians in the hospital setting including the Emergency Department, Intensive Care Unit and medical/surgical wards. This paper reviews the current literature involving the use of ultrasound in resuscitation and proposes an algorithmic approach for the use of ultrasound during cardiac arrest. At present there is the need for a means of differentiating between various causes of cardiac arrest, which are not a direct result of a primary ventricular arrhythmia. Identifying the cause of pulseless electrical activity or asystole is important as the underlying cause is what guides management in such cases. This approach, incorporating ultrasound to manage cardiac arrest aids in the diagnosis of the most common and easily reversible causes of cardiac arrest not caused by primary ventricular arrhythmia, namely; severe hypovolemia, tension pneumothorax, cardiac tamponade, and massive pulmonary embolus. These four conditions are addressed in this paper using four accepted emergency ultrasound applications to be performed during resuscitation of a cardiac arrest patient with the aim of determining the underlying cause of a cardiac arrest. Identifying the underlying cause of cardiac arrest represents the one of the greatest challenges of managing patients with asystole or PEA and accurate determination has the potential to improve management by guiding therapeutic decisions. We include several clinical images demonstrating examples of cardiac tamponade, massive pulmonary embolus, and severe hypovolemia secondary to abdominal aortic aneurysm. In conclusion, this protocol has the potential to reduce the time required to determine the etiology of a cardiac arrest and thus decrease the time between arrest and appropriate therapy.

Knowing potentially reversible causes of cardiac arrest does not influence adequate treatment in PEA

Knowing potentially reversible causes of cardiac arrest does not influence adequate treatment in PEA

Assessment of the success of cardiopulmonary resuscitation attempts performed in a Turkish university hospital

The success rate of cardiopulmonary resuscitation (CPR) may differ from institution to institution, even within different sites in the same institution. A variety of factors may influence the outcome. In this study, we assessed the adequacy of CPR attempts guided by the current standards and aimed to define the factors influencing the outcome following in-hospital cardiac arrest. One hundred and thirty-four patients who required CPR were studied prospectively. Different variables for the CPR performance were recorded using forms designed for this study in the light of the guidelines. In these CPR forms various data including the demographics, history, monitoring, number, composition and experience of the anaesthesiologists, the site of CPR, time of day, the delay before onset of CPR, tracheal intubation, duration of arrest, initial rhythm in ECG monitored patients, management of CPR, drug administration and reversible causes of cardiac arrest were recorded. Our rates of immediate survival, survival at 24 h and survival to discharge 49.3%, 28.5% and 13.4%, respectively. The extent of monitoring prior to arrest, the attendance of one or more experienced anesthesiologists in the CPR team, CPR during office hours, CPR in ICU or operating room, early initiation of CPR and tracheal intubation prior to arrest were found as the factors increasing discharge survival. We conclude that early initiation of CPR with an experienced team in a well-equipped hospital sites increases the discharge survival rate following cardiac arrest.

To lead or not to lead? Prospective controlled study of emergency nurses’ provision of advanced life support team leadership

Background and objectives: In many emergency departments advanced life support (ALS) trained nurses do not assume a lead role in advanced resuscitation. This study investigated whether emergency nurses with previous...