Reanimate life within one hour of CPR: CPR on Day 1 to Coffee on Day 5

Mohammed Ghouse Khan

Emergency Physician, Kauvery Hospital, Heart City, Trichy, Tamil Nadu

Presentation

A 56 years old gentleman who developed chest pain was rushed within the hour, from his home to Kauvery Hospital Heartcity, in their car. He had a cardiac arrest on the way to the hospital. Patient was brought to Emergency Department at 02:00pm

He had been recently diagnosed to have diabetes, and had no other known and significant comorbidities.

On Examination

The patient was unconscious, unresponsive, carotid pulse was not felt, and was  gasping. Immediate CPR was initiated as per the ACLS protocol and he was intubated. Cardiac monitor showed a shockable rhythm of Ventricular Fibrillation.

Initiation of CPR with effective Cardio Cerebral Perfusion

As per the ACLS protocol for shockable rhythm, CPR was done with defibrillation. He had a Refractory VF. So, multiple shocks were delivered along with CPR.

CPR was continued for one hour. The observations made during CPR were:

  • During every chest compression the patient responded with active limb movements.
  • During a brief pause in chest compressions, (during the hand change or rhythm analysis) patient showed no signs of response or movement.

High quality CPR continued, with effective chest compressions. Patient started responding and moving limbs.

This clearly showed that an adequate cardio cerebral perfusion was maintained during CPR and that cerebral hypoxia was minimized / prevented which made the patient to respond. This response for cardio cerebral restitution (CCR) encouraged us to continue CPR for 1 hour.

Successful resuscitation

After 1 hr at 3:00pm, patient’s carotid pulse was felt at 5 pulse/10 sec. ECG was done immediately and ionotropic supports were started.

  • ECG showed Acute IWPWMI with third degree AV block.
  • ECHO revealed IWPW hypopkinesia and mild LV dysfunction.

Emergency Pacing with PCI

With ionotropic support patient was shifted to Cath lab. Temporary pacemaker implantation was done. Coronary Angiogram (CAG) revealed coronary artery disease (CAD) with triple vessel disease.

Immediate PTCA was done, with stenting to osteo- proximal to mid RCA (DES) with optimal results, and no post procedural complications.

Patient was shifted to CCU on ventilator. He reverted to sinus rhythm and hence TPI was removed.

His blood investigations indicated elevated total white cell counts, elevated procalcitonin and elevated renal parameters for which he was treated appropriately. Nephrologist opinion obtained and his orders were carried out.

Patient’s return to normalcy

On Day 3 and Day 4 patient’s general condition was stable. He was extubated. He remained symptomatically well. All IV medications (diuretics/ Inotropic) supports were and oxygen support were weaned off.

Coffee at Day 5 & Discharge

The patient was shifted to ward on Day 5 and was cheerfully having coffee with family. He was discharged with appropriate drug advice.

Discussions

Outside hospital cardiac arrest is usually associated with a poor prognosis, with a survival rate of approximately 10% [1]. Only 40% of such patients are successfully resuscitated, and only 25% of them survive to hospital discharge [1].

Many of these cases are associated with acute myocardial infarction, the cardiac arrest is caused by ventricular fibrillation, occurring during the first hours after the onset of symptoms, and before the patient being admitted to hospital [2]. In these critical cases, implementation of SOP and dedicated networks are crucial for providing effective advanced cardiac life support.

European guidelines indicate immediate angiography and primary revascularization in all patients with resuscitated cardiac arrest and ST-segment elevation on ECG, and also in patients with resuscitated cardiac arrest without ST-segment elevation, but with high probability of an ongoing infarction (indication Class Ib) [2].

Take Home Messages

  1. All outside cardiac arrest are not non- resuscitative.
  2. High quality CPR and complete chest compressions will maintain adequate Cardio Cerebral Perfusion which made the patient to respond on every chest compression.
  3. All times CPR can be continued beyond recommended time (or) protocol if considered appropriate

Reference

  • Kern KB.. Optimal Treatment of Patients Surviving Out-of Hospital Cardiac Arrest. JACC Cardiovasc Interv. 2012(5):597–605. doi: 10.1016/j.jcin.2012.01.017.
  • Steg G, James SK, Atar D. et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology. Eur Heart J. 2012(33):2569–619. doi: 10.1093/eurheartj/ehs215.

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