Volume 3 - Issue 11-1
Consultant, Dept of Emergency, Kauvery Hospital, Chennai, India
On a busy evening on 23 Mar 21, I was engaged with my patients in the ER, but stealing a look at my watch from time to time to plan my handover by 9 pm, the end of my shift, so that I can get home to take my son who was looking forward to a nice dinner at his favorite restaurant.
Just then, I received a 27 years-aged young man who had developed sudden onset chest discomfort, not relieved by antacids, since 6 pm. His symptoms had rapidly worsened and he became unresponsive at his residence. He was rushed to us in an autorickshaw at 8 pm with a downtime of less than 10 min.
Upon arrival at the ED, he had no signs of life; he lay unresponsive, pulseless, and with dilated pupils.
As an ER Physician, I had to act fast as Time was Life. The only thought running in my mind, as I alerted my team and swiftly began CPR, was "I have to save this young man's life, who has a pregnant wife".
With my multidisciplinary team and following the AHA ACLS protocol, we continued to provide high-quality CPR and quickly secured his airway.
The defibrillator monitor showed Ventricular Fibrillation (VF), a lethal rhythm.
Multiple DC shocks were administered.
Initial ABG showed
We surmised that he had a refractory VT degenerating to VF, and got an expert cardiologist on board, while the CPR continued.
After nearly 12 shocks, and 40mins of aggressive CPR, he was finally reverted back to sinus rhythm and return of spontaneous circulation (ROSC) was obtained.
A post- resuscitation ECG was done
It was showing an Acute Anterior wall ST Elevation MI with a wide QRS, RBBB pattern.
2D Echo showed stunned anterior wall, septum, and low LVEF - <20%.
Post ROSC ABG was still showing severe metabolic lactic acidosis
The wife of the patient was informed about the critical situation and the need for emergency Extra Corporeal Membrane Oxygenation (ECMO) supported Angioplasty treatment.
After obtaining informed high-risk consent, the patient was wheeled into the CATH lab and, under ultrasound guidance, an immediate Veno-Arterial ECMO cannulation was done.
Angiogram revealed a totally occluded proximal Left Anterior Descending Artery (LAD) with no flow. ECMO-supported Primary Per Cutaneous Intervention (PCI) to proximal LAD was done with Bio-Resorbable Scaffold implant and restoration of normal blood flow in the coronaries was established.
ABG post-ECMO assisted PCI revealed good resolution with a pH: 7.40, po2: 120, PCo2: 30, HCO2: 24, Lac: 3.6.
Immediate Post-interventional period was uneventful.
The patient regained consciousness on 3rd post-procedure day. Weaning from ECMO was initiated on the same day, with close hemodynamic monitoring.
After successfully weaning him from ECMO, he planned for extubation, which he tolerated well too. He made rapid progress, recovered well with no neurological deficit, and was finally discharged home to his loved ones after one week of hospitalization.
Globally, it is estimated that on average, less than 10% of all patients with Out of Hospital Cardiac Arrest (OHCA) would survive. The time it takes to initiate CPR has the greatest impact on survival. It therefore beholds the community to watch and learn how to offer CPR and maintain viability till emergency services arrive.
The 6 links in the adult out-of-hospital Chain of Survival are:
(a). Recognition of cardiac arrest and activation of the emergency response system
(b). Early cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions
(c). Rapid defibrillation
(d). Advanced resuscitation by Emergency Medical Services and other healthcare providers
(e). Post-cardiac arrest care
(f). Recovery (including additional treatment, observation, rehabilitation, and psychological support)
A strong Chain of Survival can improve the chances of survival and recovery for victims of cardiac arrest. The unpredictable and time-sensitive nature of OHCA makes it a unique medical emergency. In no other medical situation is there such a vital reliance on the community.
OHCA has a poor prognosis, with survival rates between 4 and 39.3%. Cardiac arrest patients can tolerate only a short period of circulatory disturbance and the chances of survival decrease rapidly when cardiopulmonary resuscitation (CPR) lasts over 15â€“30 min. Furthermore, refractory cardiac arrest, defined as persistent circulatory failure despite more than 30 min of appropriate CPR, is usually fatal in the intensive care unit.
Extracorporeal Membrane Oxygenation (ECMO) is an aggressive and invasive type of extracorporeal life support (ECLS) that has been suggested for refractory cardiac arrest. ECMO can be performed during resuscitation, and it provides sufficient perfusion of vital organs during the treatment of cardiac arrest and provides injured myocardium with the chance to recover
With a well-trained multidisciplinary team approach that was swiftly adopted by doctors, nurses, and other paramedical staff, as it was on that day at our hospital, supported by the state-of-the-art facilities and resources, we were able to save a life that day.
Though I missed my moment with my son that evening, I got immense pleasure from what I did that day.
A doctor is someone capable to save and help others life in ways that are not possible in other careers. I feel proud to work in one of the most modern and state of the art multispecialty tertiary care hospitals in Chennai.
Never give up on life--- the life you save may restore hope to a family!!!
 https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/ algorithm
 Editorial. Out-of-hospital cardiac arrest: a unique medical emergency. Lancet 2018;391(10124):P911.
 Lee JJ, Han SJ, Kim HS, et al. Out-of-hospital cardiac arrest patients treated with cardiopulmonary resuscitation using extracorporeal membrane oxygenation: focus on survival rate and neurologic outcome. Scand J Trauma Resusc Emerg Med. 2016;24:74.