Gill Heart Institute
Strive to Revive
Case Study 1
Case Objectives
• Discuss critical aspects of initial
resuscitation that affected outcomes
• Discuss important aspects of postresuscitation 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.
Pre-Hospitalization
OSH Course
ED Course
Early
Hospitalization
and Workup
Rest of
Hospitalization
• 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
PreHospitalization
OSH Course
ED Course
Early
Hospitalization
and Workup
Rest of
Hospitalization
•CPR initiated
•Regained pulse
• 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
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
PreHospitalization
•CPR initiated
•Regained pulse
OSH Course
ED Course
Early
Hospitalization
and Workup
Rest of
Hospitalization
•Intubated
•Started on
Amiodarone
• 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
PreHospitalization
•CPR initiated
•Regained pulse
OSH Course
ED Course
Early
Hospitalization
and Workup
Rest of
Hospitalization
•Intubated
•Started on
Amiodarone
• 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
PreHospitalization
•CPR initiated
•Regained pulse
OSH Course
•Intubated
•Started on
Amiodarone
ED Course
Early Hospitalization
and Workup
Rest of
Hospitalization
•Given Diltiazem 10
mg x 1
•Followed by DCCV
• 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
PreHospitalization
•CPR initiated
•Regained pulse
OSH Course
•Intubated
•Started on
Amiodarone
ED Course
Early Hospitalization
and Workup
Rest of
Hospitalization
•Given Diltiazem 10
mg x 1
•Followed by DCCV
• 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
Telemetry strips in CCU
Telemetry strips in CCU
PreHospitalization
•CPR initiated
•Regained pulse
OSH Course
•Intubated
•Started on
Amiodarone
ED Course
Early Hospitalization
and Workup
Rest of
Hospitalization
•DCCV
• Polymorphic ventricular tachycardia noted
soon after arrival to the CCU
• Defibrillated X 1 with return of sinus
rhythm
First ECG after Defibrillation
PreHospitalization
•CPR initiated
•Regained pulse
OSH Course
•Intubated
•Started on
Amiodarone
ED Course
•Given Diltiazem 10
mg x 1
•Followed by DCCV
• Initial Labs:
– CBC unremarkable
–
–
–
–
–
–
–
–
Early Hospitalization
and Workup
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
Rest of
Hospitalization
PreHospitalization
•CPR initiated
•Regained pulse
OSH Course
•Intubated
•Started on
Amiodarone
ED Course
Rest of
Hospitalization
•Given Diltiazem 10
mg x 1
•Followed by DCCV
• Initial Labs:
– CBC unremarkable
–
–
–
–
–
–
–
–
Early Hospitalization
and Workup
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
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
Pre-Hospitalization
• CPR initiated
• Regained pulse
OSH Course
• Intubated
• Started on
Amiodarone
ED Course
• Given Diltiazem 10 mg
x1
• Followed by DCCV
Early
Hospitalization and
Workup
Rest of Hospitalization
• Cardiac catheterization
• PA sat: 27%
• ECMO
• Workup – QT
prolonged
•Mg of 1.3
• 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
x1
• Followed by DCCV
Early
Hospitalization and
Workup
Rest of Hospitalization
• Cardiac catheterization
• PA sat: 27%
• ECMO
• Workup – QT
prolonged
•Mg of 1.3
• 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
x1
• Followed by DCCV
Early
Hospitalization and
Workup
Rest of Hospitalization
• Cardiac catheterization
• PA sat: 27%
• ECMO
• Workup – QT
prolonged
•Mg of 1.3
• 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
x1
• Followed by DCCV
Early
Hospitalization and
Workup
Rest of Hospitalization
• Cardiac catheterization
• PA sat: 27%
• ECMO
• Workup – QT
prolonged
•Mg of 1.3
• 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
Summary of Hospital Course
• Timeline
PreHospitalization
• 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
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