27
Gill Heart Institute Strive to Revive Case Study 1

Strive to Revive

  • Upload
    karena

  • View
    49

  • Download
    0

Embed Size (px)

DESCRIPTION

Gill Heart Institute. Strive to Revive. Case 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 - PowerPoint PPT Presentation

Citation preview

Page 1: Strive to Revive

Gill Heart Institute

Strive to ReviveCase Study 1

Page 2: Strive to Revive

Case Objectives

• Discuss critical aspects of initial resuscitation that affected outcomes

• Discuss important aspects of post-resuscitation care:– ECMO– Management of VT

Page 3: Strive to Revive

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.

Page 4: Strive to Revive

• 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

Page 5: Strive to Revive

• 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

Page 6: Strive to Revive

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

Page 7: Strive to Revive

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

Page 8: Strive to Revive

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

Page 9: Strive to Revive

Initial ECG

Page 10: Strive to Revive

• 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-Hospitalization

•CPR initiated•Regained pulse

OSH

Course

•Intubated•Started on Amiodarone

ED Course

Early Hospitalization and Worku

p

Rest of

Hospitalization

Page 11: Strive to Revive

• 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-Hospitalization

•CPR initiated•Regained pulse

OSH

Course

•Intubated•Started on Amiodarone

ED Course

Early Hospitalization and Worku

p

Rest of

Hospitalization

Page 12: Strive to Revive

• 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

Page 13: Strive to Revive

• 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

Page 14: Strive to Revive

Telemetry strips in CCU

Page 15: Strive to Revive

Telemetry strips in CCU

Page 16: Strive to Revive

• 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

Page 17: Strive to Revive

First ECG after Defibrillation

Page 18: Strive to Revive

• 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

Page 19: Strive to Revive

• 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

Page 20: Strive to Revive

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

Page 21: Strive to Revive

• 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-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•Cardiac catheterization•PA sat: 27%•ECMO•Workup – QT prolonged•Mg of 1.3

Rest of

Hospitalization

Page 22: Strive to Revive

• 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-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•Cardiac catheterization•PA sat: 27%•ECMO•Workup – QT prolonged•Mg of 1.3

Rest of

Hospitalization

Page 23: Strive to Revive

• 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-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•Cardiac catheterization•PA sat: 27%•ECMO•Workup – QT prolonged•Mg of 1.3

Rest of

Hospitalization

Page 24: Strive to Revive

• 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-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•Cardiac catheterization•PA sat: 27%•ECMO•Workup – QT prolonged•Mg of 1.3

Rest of

Hospitalization

Page 25: Strive to Revive

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 Hospitalization 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

Page 26: Strive to Revive

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

Page 27: Strive to Revive

DM

• Questions