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Gill Heart Institute
Strive to ReviveCase Study 1
Case Objectives
• Discuss critical aspects of initial resuscitation that affected outcomes
• Discuss important aspects of post-resuscitation care:– ECMO– Management of VT
CASE DETAILS• CC: unconscious during MVA
• HPI: 58 yo female w/ PMHx notable for obesity s/p gastric bypass surgery, DM, HTN, hypothyroidism who presented as a trauma alert after a MVA. Patient reportedly had swerved off the road and slowed to a stop with minimal trauma. Bystanders noted that patient was unconscious, and called EMS.
• EMS called – found patient to be pulseless. CPR initiated. Primary rhythm was PEA, and was given epinephrine and chest compression– Regained Pulse in the field and was found to
be tachycardic
• Patient was transferred to OSH
Pre-Hospitalization
OSH Course
ED Course
Early Hospitalization and Workup
Rest of Hospitalization
• At OSH, patient was intubated for airway protection and hypoxic respiratory failure
• Found to be in Atrial Fibrillation with Rapid ventricular response– Loaded on Amiodarone at OSH
• Transferred to UK as a Trauma Alert
Pre-Hospitalization
•CPR initiated•Regained pulse
OSH
Course
ED Course
Early Hospitalization and Worku
p
Rest of
Hospitalization
HISTORY
• PMHx:– HTN– Hypothyroidism– DM– OA– Obesity
• PSurgHx:– s/p Gastric Bypass
Surgery >10 years ago– Hernia repair– Total Knee replacement
• FamHx:– No history of SCD or ICD
placement. Detailed family history unavailable
• SocHx:– Significant EtOH abuse per
family that was present.– No known illicit drug use. – Significant social stressors –
Recent death of husband and premature birth of grandchildren
–
• ROS: – Not obtainable
HISTORY
• Medications:– Levothyroxine 200 mcg daily– Lisinopril 10 mg daily– Metformin 500 mg twice daily– Metoprolol Succinate 25 mg daily
• Allergies: No known drug or food allergies
PHYSICAL EXAM
• Vitals: HR: 169, BP: 97/63, RR: 39, SpO2 of 99% on 100% FiO2• Gen: Obese, mechanically ventilated, cool to touch• Head: Atraumatic, plethoric and cool• Eyes: Left pupil is 5 mm and right is 3 mm, reactive• Nose: Nares patent, no discharge• Mouth: Endotracheal tube in place • Neck: Trachea midline• Respiratory: Distant breath sounds • CV: Irregularly irregular, tachycardic, 1+ central pulses• Abdomen: Soft nontender distended• Extremities: Cool, absent distal pulses• Neuro: She is intermittently flexing upper extremities with no
purposeful movement, no response to pain• Psych: Unable to assess
Initial ECG
• Afib with RVR to the 170s• Concern that patient had inadequate
perfusion with SBP<100• DCCV at 200 J x 1 with conversion to
sinus rhythm transiently then return to Afib with RVR
• Trauma called – no significant trauma noted
Pre-Hospitalizatio
n•CPR initiated•Regained pulse
OSH
Course
•Intubated•Started on Amiodarone
ED Course
Early Hospitalization and Worku
p
Rest of
Hospitalization
• Work-up– CT PE – negative– CT head and spine – no significant acute
findings other than rib fractures• Thought to be related to CPR
• Cardiology consulted for evaluation
Pre-Hospitalizatio
n•CPR initiated•Regained pulse
OSH
Course
•Intubated•Started on Amiodarone
ED Course
Early Hospitalization and Worku
p
Rest of
Hospitalization
• Patient went emergently to cardiac cath lab given cardiovascular arrest and subsequent arrhythmia– RHC
• RA: 26 mmHg• PA: 52/24, mean of 38 mmHg• PCWP: 30 mmHg• PA saturation: 24%
– CO , CI: 3.8 L/min , 1.9 L/min/m2
– Selective coronary angiography• Non-obstructive CAD
– Left ventriculography• Global Hypokinesis w/ EF<30%
– Left Heart catheterization• LVEDP: 30 mmHg
Pre-Hospitalization
•CPR initiated•Regained pulse
OSH
Course
•Intubated•Started on Amiodarone
ED Course
•Given Diltiazem 10 mg x 1•Followed by DCCV
Early Hospitalization and Worku
p
Rest of
Hospitalization
• Given inotropes in the cath lab, with minimal improvement
• Placed emergently on VA ECMO• Transferred to the CVICU under the care
of the CCU team
Pre-Hospitalization
•CPR initiated•Regained pulse
OSH
Course
•Intubated•Started on Amiodarone
ED Course
•Given Diltiazem 10 mg x 1•Followed by DCCV
Early Hospitalization and Worku
p
Rest of
Hospitalization
Telemetry strips in CCU
Telemetry strips in CCU
• Polymorphic ventricular tachycardia noted soon after arrival to the CCU
• Defibrillated X 1 with return of sinus rhythm
Pre-Hospitalization
•CPR initiated•Regained pulse
OSH
Course
•Intubated•Started on Amiodarone
ED Course
•DCCV
Early Hospitalization and Worku
p
Rest of
Hospitalization
First ECG after Defibrillation
• Initial Labs:– CBC unremarkable
– Na: 138– K: 6.3– Cl: 106– CO2: 11– BUN/Cr: 14/1.14– Mag: 1.3– Ca: 7.9– Phos: 6.1
• ABG:– pH: 7.32– PaCO2: 22– PaO2: 291– Base Deficit: 13– Albumin 2.3– AG: 21– TnI: 0.29
Pre-Hospitalization
•CPR initiated•Regained pulse
OSH
Course
•Intubated•Started on Amiodarone
ED Course
•Given Diltiazem 10 mg x 1•Followed by DCCV
Early Hospitalization and Worku
p
Rest of
Hospitalization
• Initial Labs:– CBC unremarkable
– Na: 138– K: 6.3– Cl: 106– CO2: 11– BUN/Cr: 14/1.14– Mag: 1.3– Ca: 7.9– Phos: 6.1
• ABG:– pH: 7.32– PaCO2: 22– PaO2: 291– Base Deficit: 13– Albumin:2.3– AG: 21– TnI: 0.29
Pre-Hospitalization
•CPR initiated•Regained pulse
OSH
Course
•Intubated•Started on Amiodarone
ED Course
•Given Diltiazem 10 mg x 1•Followed by DCCV
Early Hospitalization and Worku
p
Rest of
Hospitalization
Initial assessment
• Cardiogenic shock with new global LV dysfunction– Etiology non-ischemic
• EtOH vs other non-ischemic etiology• Stunning from either CPR or initial arrest
– Afib w/ RVR secondary to this?
• AG metabolic acidosis w/ respiratory compensation
• Profound hyperkalemia and hypomagnesemia• QT prolongation
– Mg and QT prolonging agents
• Was initially on dopamine, but went into polymorphic VT– Magnesium aggressively repleted– Amiodarone and other QT prolonging agents
had been stopped– Started on isoproterenol to increase basal
heart rate and decrease opportunity for myocytes to spontaneously depolarize
Pre-Hospitalizatio
n•CPR initiated•Regained pulse
OSH
Course
•Intubated•Started on Amiodarone
ED Course
•Given Diltiazem 10 mg x 1•Followed by DCCV
Early Hospitalization and Worku
p•Cardiac catheterization•PA sat: 27%•ECMO•Workup – QT prolonged•Mg of 1.3
Rest of
Hospitalization
• Did not require vasopressors• Was cautiously diuresed
– Close monitoring of electrolytes
• Added afterload reduction as a part of a CHF regimen– Lisinopril– Spironolactone– Metoprolol switched to Carvedilol
Pre-Hospitalizatio
n•CPR initiated•Regained pulse
OSH
Course
•Intubated•Started on Amiodarone
ED Course
•Given Diltiazem 10 mg x 1•Followed by DCCV
Early Hospitalization and Worku
p•Cardiac catheterization•PA sat: 27%•ECMO•Workup – QT prolonged•Mg of 1.3
Rest of
Hospitalization
• Repeat ECG showed QTc of 530. • Had an episode of Afib while on
isoproterenol requiring DCCV• No more VT after improvement in QTc and
correction of Mg• Weaned off ECMO with stable HD• Extubated and transferred to the floor • Neurologically intact
Pre-Hospitalizatio
n•CPR initiated•Regained pulse
OSH
Course
•Intubated•Started on Amiodarone
ED Course
•Given Diltiazem 10 mg x 1•Followed by DCCV
Early Hospitalization and Worku
p•Cardiac catheterization•PA sat: 27%•ECMO•Workup – QT prolonged•Mg of 1.3
Rest of
Hospitalization
• Final Assessment:– Cardiogenic shock 2/2 non-ischemic CM –
resolved– LV dysfunction – not resolved– Polymorphic VT – resolved– Prolonged QTc – improved, but not resolved– Respiratory failure after arrest – resolved
Pre-Hospitalizatio
n•CPR initiated•Regained pulse
OSH
Course
•Intubated•Started on Amiodarone
ED Course
•Given Diltiazem 10 mg x 1•Followed by DCCV
Early Hospitalization and Worku
p•Cardiac catheterization•PA sat: 27%•ECMO•Workup – QT prolonged•Mg of 1.3
Rest of
Hospitalization
Summary of Hospital Course
• Timeline
Pre-
Hospitalization
•CPR initiated•Regained pulse
OSH Course
•Intubated•Started on Amiodarone
ED
Course
•Given Diltiazem 10 mg x 1•Followed by DCCV
Early Hospitalizatio
n and Workup
•Cardiac catheterization
•PA sat: 27%•ECMO•Workup – QT prolonged•Mg of 1.3
Rest of Hospitalization
•Polymorphic VT•Stopped QT prolonging agents•Corrected Mg•Isoproterenol•Extubated•Neurologically intact
Resuscitative Measures
• CPR delayed until EMS arrived– Fortunately, no evidence of anoxic brain injury
• Role of ECMO– Needs clearly defined end point– In this case, to allow time and interventions for
resolution of cardiogenic shock and VT
• Management of VT– Reversible causes– Important to understand etiology of VT
DM
• Questions