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 ID: 698354
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Slide1
Gill Heart Institute
Strive to Revive
Case Study 1Slide2
Case ObjectivesDiscuss critical aspects of initial resuscitation that affected outcomes
Discuss important aspects of post-resuscitation care:ECMOManagement of VTSlide3
CASE DETAILSCC: 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. Slide4
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 tachycardicPatient was transferred to OSH Slide5
At OSH, patient was intubated for airway protection and hypoxic respiratory failure
Found to be in Atrial Fibrillation with Rapid ventricular responseLoaded on Amiodarone
at OSHTransferred to UK as a Trauma AlertSlide6
HISTORYPMHx
:HTNHypothyroidismDMOA
ObesityPSurgHx:s/p Gastric Bypass Surgery >10 years agoHernia repairTotal 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 obtainableSlide7
HISTORYMedications:Levothyroxine
200 mcg dailyLisinopril 10 mg dailyMetformin 500 mg twice daily
Metoprolol Succinate 25 mg dailyAllergies: No known drug or food allergiesSlide8
PHYSICAL EXAM
Vitals: HR: 169, BP: 97/63, RR: 39, SpO2 of 99% on 100% FiO2Gen: Obese, mechanically ventilated, cool to touchHead: Atraumatic, plethoric and cool
Eyes: Left pupil is 5 mm and right is 3 mm, reactiveNose: Nares patent, no dischargeMouth: 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 assessSlide9
Initial ECGSlide10
Afib with RVR to the 170sConcern that patient had inadequate perfusion with SBP<100DCCV at 200 J x 1 with conversion to sinus rhythm transiently then return to
Afib with RVRTrauma called – no significant trauma notedSlide11
Work-upCT PE – negativeCT head and spine – no significant acute findings other than rib fractures
Thought to be related to CPRCardiology consulted for evaluationSlide12
Patient went emergently to cardiac cath lab given cardiovascular arrest and subsequent arrhythmia
RHCRA: 26 mmHgPA: 52/24, mean of 38 mmHgPCWP: 30 mmHgPA saturation: 24%
CO , CI: 3.8 L/min , 1.9 L/min/m2Selective coronary angiographyNon-obstructive CADLeft ventriculographyGlobal
Hypokinesis w/ EF<30%Left Heart catheterization
LVEDP: 30 mmHgSlide13
Given inotropes in the cath lab, with minimal improvement
Placed emergently on VA ECMOTransferred to the CVICU under the care of the CCU teamSlide14
Telemetry strips in CCUSlide15
Telemetry strips in CCUSlide16
Polymorphic ventricular tachycardia noted soon after arrival to the CCUDefibrillated X 1 with return of sinus rhythmSlide17
First ECG after DefibrillationSlide18
Initial Labs:
CBC unremarkableNa: 138K: 6.3Cl
: 106CO2: 11BUN/Cr: 14/1.14Mag: 1.3Ca: 7.9Phos: 6.1
ABG:
pH: 7.32
PaCO2: 22
PaO2: 291
Base Deficit: 13
Albumin 2.3
AG: 21
TnI
: 0.29Slide19
Initial Labs:
CBC unremarkableNa: 138K: 6.3Cl
: 106CO2: 11BUN/Cr: 14/1.14Mag: 1.3Ca: 7.9Phos
: 6.1
ABG:
pH: 7.32
PaCO2: 22
PaO2: 291
Base Deficit: 13
Albumin:2.3
AG: 21
TnI
: 0.29Slide20
Initial assessment
Cardiogenic shock with new global LV dysfunctionEtiology non-ischemic EtOH
vs other non-ischemic etiologyStunning from either CPR or initial arrestAfib w/ RVR secondary to this?AG metabolic acidosis
w/ respiratory compensationProfound hyperkalemia and
hypomagnesemia
QT prolongation
Mg and QT prolonging agentsSlide21
Was initially on dopamine, but went into polymorphic VTMagnesium aggressively repleted
Amiodarone and other QT prolonging agents had been stoppedStarted on isoproterenol to increase basal heart rate and decrease opportunity for
myocytes to spontaneously depolarizeSlide22
Did not require vasopressorsWas cautiously diuresed
Close monitoring of electrolytesAdded afterload reduction as a part of a CHF regimen
LisinoprilSpironolactoneMetoprolol switched to CarvedilolSlide23
Repeat ECG showed QTc of 530. Had an episode of
Afib while on isoproterenol requiring DCCVNo more VT after improvement in QTc
and correction of MgWeaned off ECMO with stable HDExtubated and transferred to the floor Neurologically intactSlide24
Final Assessment:Cardiogenic shock 2/2 non-ischemic CM – resolved
LV dysfunction – not resolvedPolymorphic VT – resolvedProlonged QTc – improved, but not resolved
Respiratory failure after arrest – resolvedSlide25
Summary of Hospital CourseTimelineSlide26
Resuscitative Measures
CPR delayed until EMS arrivedFortunately, no evidence of anoxic brain injuryRole of ECMONeeds clearly defined end point
In this case, to allow time and interventions for resolution of cardiogenic shock and VTManagement of VTReversible causesImportant to understand etiology of VTSlide27
DMQuestions