Successful extracorporeal life support in cardiac arrest with recurrent ventricular fibrillation unresponsive to standard cardiopulmonary resuscitation

Extracorporeal life support has been used as an extension of conventional cardiopulmonary resuscitation (CPR). However, the appropriate indications for extracorporeal CPR (ECPR) including the duration of CPR are unknown. We present a case of a male, 37-year-old out-of-hospital cardiac arrest patient who received prolonged CPR followed by ECPR. Despite advanced cardiac life support, he did not regain a sustained spontaneous circulation and had recurrent ventricular fibrillation (VF) during the prolonged CPR. VF was unresponsive to CPR, defibrillation, adrenaline (epinephrine), and antiarrhythmics. The CPR time before ECPR was approximately 2h. During extracorporeal life support, the VF did not recur and percutaneous coronary angioplasty was achieved. Ultimately, the patient was discharged without neurological complications. Although cardiac arrest occurred out-of-hospital and CPR was performed for a long time, a patient might be a candidate for ECPR if perfusing rhythms are restored transiently but not successfully maintained due to recurrent VF. ECPR may be used for VF unresponsive to standard CPR techniques.     

Survival from out-of-hospital cardiac arrest. A multivariate analysis

A recursive estimation model is used to investigate the roles of cardiopulmonary resuscitation (CPR) and advanced life support in improving survival from out-of-hospital cardiac arrest. The importance of life support measures is clearly evidenced in the analysis: Fewer elapsed minutes between the cardiac arrest and the start of CPR increase the probabilities of both a favorable cardiac rhythm and defibrillation and the probability of survival. Similarly, a shorter elapsed time between the start of CPR and defibrillation is significantly related to a higher probability of survival of the cardiac arrest. Personal characteristics also contribute to survival, but primarily via their association with a favorable initial postarrest cardiac rhythm and the probability of defibrillation. The initial postarrest cardiac rhythm is shown to be an indicator of the heart's condition, but when other factors associated with survival are included in the analysis, it does not independently influence an individual's probability of survival.     

The attitudes of cardiac arrest survivors and their family members towards CPR courses

OBJECTIVES: to evaluate self-assessment of first aid knowledge, readiness to make use of it in case of a medical emergency and judgement of a 1-day CPR course by cardiac arrest survivors, their family members and friends as compared to the general public. BACKGROUND: the recurrence rate of a cardiac arrest after successful resuscitation is high and most of out-of-hospital cardiac arrests occur at the patient's home. METHODS: medical students trained in basic and advanced life support provided 101 members of the target group and 94 of a sex and age matched control group with a 1-day course in CPR. RESULTS: after the course, half of the participants in both groups considered their knowledge of first aid to be very good or good. The readiness to perform first aid in a medical emergency increased significantly. Of the target group 96% of the participants as compared with the control group where 91% felt confident to recognise a cardiac arrest; 79 versus 68% considered themselves capable to perform CPR if needed. The course was judged as very good in 71 versus 69% and as good in 25 versus 27% with no differences between groups. CONCLUSION: one-day CPR courses are well accepted by cardiac arrest survivors, their family members and friends and help to reduce fears of reacting in medical emergencies. They seem to be more motivated to gain and use first aid knowledge than others.     

Cardiac arrest in the community. How to improve survival rates

A coordinated community response to cardiac arrest can be successful if the response time to administration of cardiopulmonary resuscitation (CPR) is less than four minutes and to administration of advanced cardiac life support (ACLS) is less than eight minutes. Elements needed to achieve this goal include rapid access to the emergency medical system; widespread CPR training; rapid response of first responders trained in basic life support; rapid response time to ACLS, including resuscitation at the scene; and an evaluation system to determine the effectiveness of the response and then implementation of changes to prevent future mistakes. The response to cardiac arrest should be kept simple, and the community should work with the resources it possesses. Most communities already have the necessary elements and simply need to coordinate the effort into a reasonable approach. Perhaps with such an approach, 80% of deaths from sudden cardiac arrest could be prevented.     

Advanced life support drugs: do they really work?

Basic life support and rapid defibrillation for ventricular fibrillation or pulseless ventricular tachycardia are the only two interventions that have been shown unequivocally to improve survival after cardiac arrest. Several drugs are advocated to treat cardiac arrest, but despite very encouraging animal data, no drug has been reliably proven to increase survival to hospital discharge after cardiac arrest. This review focuses on recent experimental and clinical data concerning the use of vasopressin, amiodarone, magnesium, and fibrinolytics during advanced life support (ALS). Animal data indicate that, in comparison with epinephrine (adrenaline), vasopressin produces better vital organ blood flow during cardiopulmonary resuscitation (CPR). These apparent advantages have yet to be converted into improved survival in large-scale trials of cardiac arrest in humans. Data from two prospective, randomized trials suggest that amiodarone may improve short-term survival after out-of-hospital ventricular fibrillation cardiac arrest. On the basis of anecdotal data, magnesium is recommended therapy for torsades de pointes and for shock-resistant ventricular fibrillation associated with hypomagnesemia. In the past, CPR has been a contraindication to giving fibrinolytics, but several studies have demonstrated the relative safety of fibrinolysis during and after CPR. Fibrinolytics are likely to be beneficial when cardiac arrest is associated with plaque rupture and fresh coronary thrombus or massive pulmonary embolism. Fibrinolysis may also improve cerebral microcirculatory perfusion once a spontaneous circulation has been restored. A planned, prospective, randomized trial may help to define the role of fibrinolysis during out-of-hospital CPR.     

Beneficial effects of vasopressin in prolonged pediatric cardiac arrest: a case series

Children who suffer cardiac arrest have a poor prognosis. Based on laboratory animal studies and clinical data in adults, vasopressin is an exciting new vasopressor treatment modality during cardiopulmonary resuscitation (CPR). In particular, vasopressin has resulted in short term resuscitation benefits as a "rescue" pressor agent in the setting of prolonged out-of-hospital CPR for ventricular fibrillation in adults. This retrospective series presents the first evidence for resuscitation benefit of bolus vasopressin therapy in the specific setting of pediatric cardiac arrest. All episodes of CPR initiated in a 120-bed tertiary care children's hospital over a three-year period (1997-2000) were reviewed. Four children in the pediatric ICU received vasopressin boluses as rescue therapy during six cardiac arrest events, following failure of conventional CPR, advanced life support, and epinephrine vasopressor therapy. Return of spontaneous circulation for greater than 60 min occurred in three of four patients (75%) and in four of six CPR events (66%) following vasopressin administration. Two of four vasopressin recipients survived >24 h; one survived to hospital discharge and one had withdrawal of supportive therapies following family discussion. Our observations are AHA level 5 (retrospective case series) evidence that vasopressin administration may be beneficial during prolonged pediatric cardiac arrest. Such reports should pave the way for prospective clinical trials comparing vasopressor medications in the setting of pediatric cardiac arrest.     

Acute-onset dysrhythmia heralding fulminant myocarditis and refractory cardiac arrest treated with ED cardiopulmonary bypass and extracorporeal membrane oxygenation

BACKGROUND: The outcome of refractory cardiac arrest is poor. The purpose of this report is to describe two cases presenting with fulminant myocarditis and refractory cardiac arrest treated with emergency department cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO), with subsequent recovery. METHODS: Report of two cases. RESULTS: Two patients presented with a new onset dysrhythmia heralding fulminant myocarditis and cardiac arrest refractory to advanced life support measures. Chest compressions and positive pressure ventilation maintained oxygenation and perfusion until CPB could be initiated in the ED followed by ECMO. Spontaneous cardiac recovery followed, associated with normal neurocognitive function. CONCLUSION: While CPB and ECMO initiation in the ED is a rare event, this could provide patients with cardiac arrest presentations suggestive of myocarditis, additional time for recovery to occur. Clinical factors suggesting a good outcome are witnessed cardiac arrest in a previously healthy child with immediate initiation of effective CPR and good brain perfusion and function as evidence by substantial bodily movement during CPR. Significant dysrhythmias in a previously healthy child may herald substantial deterioration and cardiac arrest.     

Cardiopulmonary resuscitation. Historical and future perspectives

Although cardiopulmonary resuscitation (CPR) has been practiced for over a century, further study into methods for reviving victims of cardiac arrest is obviously needed. We now know that standard external CPR has numerous drawbacks, and modifications must be tested in a careful, randomized fashion. Three alternatives to standard external CPR (simultaneous compression-ventilation, interposed abdominal compression, and open-chest CPR) are currently being investigated. Of these procedures, open-chest CPR appears to show the most promise. Reproducible animal data must demonstrate the advantages of any method before widespread human studies are begun, however. If techniques seem promising in animals, well-controlled multicenter studies will be needed to verify applicability to humans. Major changes in CPR techniques should be made only after careful study, not on the basis of a limited number of reports from a single source. Resuscitation research must also extend beyond the study of techniques of cardiac massage. Although CPR is effective in some cases, clearly a person's chance of survival is directly linked to the speed of definitive care, that is, defibrillation. Research must continue into ways of providing rapid advanced cardiac care, such as home defibrillators or rapid prehospital response to the victims of cardiac arrest by those trained in advanced cardiac life support (ACLS). In addition, to counteract the problem of neurologic demise after prolonged anoxia, study of postresuscitative care must continue. Only through the combination of these measures will survival rates after cardiac arrest improve.     

Year in review 2010: Critical Care - cardiac arrest and cardiopulmonary resuscitation

This review will summarize some of the data published in 2010 and focus on papers published in Critical Care in regard to cardiac arrest and cardiopulmonary resuscitation. In particular, we discuss the latest research in therapeutic hypothermia after cardiac arrest, including methods of inducing hypothermia, potential protective mechanisms, spontaneous hypothermia versus therapeutic hypothermia, and several predictors of outcome. Furthermore, we will discuss the effects of bystander-initiated cardiopulmonary resuscitation (CPR) in patients with physician-assisted advanced cardiac life support, the role of hypercapnea in near-death experiences during cardiac arrest, markers of endothelial injury and endothelial repair after CPR, and the prognostic value of cell-free plasma DNA as a marker of poor outcome after cardiac arrest.     

Efficacy of chest compression-only BLS CPR in the presence of an occluded airway

Reluctance of the lay public to perform bystander CPR is becoming an increasingly worrisome problem in the USA. Most bystanders who admit such reluctance concede that fear of contagious disease from mouth-to-mouth contact is what keeps them from performing basic life support. Animal models of prehospital cardiac arrest indicates that 24-h survival is essentially as good with chest compression-only CPR as with chest compressions and assisted ventilation. This simpler technique is an attractive alternative strategy for encouraging more bystander participation. Such experimental studies have been criticized as irrelevant however secondary to differences between human and porcine airway mechanics. This study examined the effect of chest compression-only CPR under the worst possible circumstances where the airway was totally occluded. After 6 min of either standard CPR including ventilation with a patent airway or chest compressions-only with a totally occluded airway, no difference in 24 h survival was found (10/10 vs. 9/10). As anticipated arterial blood gases were not as good, but hemodynamics produced were better with chest compression-only CPR (P < 0.05). Chest compression-only CPR, even with a totally occluded airway, is as good as standard CPR for successful outcome following 6.5 min of cardiac arrest. Such a strategy for the first minutes of cardiac arrest, particularly before professional help arrives, has several advantages including increased acceptability to the lay public.     

Alternative cardiopulmonary resuscitation devices

Cardiac arrest survival rates remain low despite increased access to advanced cardiac life support. Survival from cardiac arrest is, at least in part, related to the perfusion pressures and blood flow achieved during cardiopulmonary resuscitation (CPR). A number of alternative CPR devices have been developed that aim to improve the perfusion pressures and/or blood flow achieved during CPR. Active compression-decompression CPR devices are by far the most studied alternative CPR devices, but the results have been inconsistent and conflicting. A number of other devices, including the inspiratory impedance threshold valve, minimally invasive direct cardiac massage, phased chest and abdominal compression-decompression CPR, and vest CPR, are all capable of improving perfusion pressures and/or blood flow compared with standard external chest compressions. However, no convincing human outcome data has been produced yet for any of these devices. Although an interesting area of research, none of the alternative CPR devices convincingly improve long-term patient outcomes.     

Factors influencing variable outcomes after ventricular fibrillation cardiac arrest of 15 minutes in dogs

Animal experiments with cardiac arrest and cardiopulmonary resuscitation (CPR) despite controlled insult and postinsult life support, have yielded variable individual outcomes. This report concerns 10 dog experiments with a standardized model of VF cardiac arrest with no flow for 10 min followed by CPR basic life support (BLS) from VF 10 to 15 min and then CPR advanced life support (ALS) with epinephrine at 15 min. Defibrillating countershocks began at 17 min, for restoration of spontaneous circulation. After controlled ventilation to 20 h and intensive care to 96 h, outcome was evaluated using the overall performance category (OPC) 1 (normal) (n5) vs. OPC 2-4 (impaired) (n5) (P less than 0.001). We searched for correlations between normal vs. impaired outcome in various prearrest, arrest and postarrest factors that are suspected to influence postarrest neurologic deficit. Prearrest variables were similar in the normal and impaired groups. Resuscitation variables were similar in both. Coronary perfusion pressure during CPR-ALS was higher in the normal outcome group (P = 0.03). Among postarrest variables, postarrest reperfusion pressure pattern (initial hypertensive bout), blood glucose, cardiac output, Hct, pHa, PaO2 and PaCO2 were the same. Our data support the importance of maximizing coronary perfusion pressure not only for restoration of heart beat but also as a possible predictor of improved cerebral outcome.     

Survivors of out-of-hospital cardiac arrest: Morbidity and long-term survival

Sudden cardiac death accounts for two thirds of death due to coronary artery disease. Advanced cardiac life support can now be brought directly to patients with out-of-hospital cardiac arrest, and in this country, as many as 30% of such patients can be discharged from the hospital annually. Certain clinical and resuscitation-related factors are predictive of mortality and morbidity. The best clinical predictors of long-term survival are absence of previous history of myocardial infarction, lack of congestive heart failure during hospitalization, and age less than 60 years. Resuscitation-related predictors of long-term survival are a short time from collapse to cardiopulmonary resuscitation (CPR), and a short time from collapse to CPR combined with a short time to provision of definitive care. The majority of cardiac arrest survivors are able to resume previous levels of function.     

Cardiac arrest outcomes at the Melbourne Cricket Ground and shrine of remembrance using a tiered response strategy-a forerunner to public access defibrillation

The provision of medical, paramedical and first aid services at major public events is an important concern for pre-hospital emergency medical care providers. Patient outcomes of a cardiac arrest response strategy employed at the Melbourne Cricket Ground (MCG) and the Shrine of Remembrance by St John Ambulance Australia volunteers are reported. Twenty-eight consecutive events occurring between December 1989 and December 1997 have been analysed. Included are three cardiac arrests managed at ANZAC day parades utilising the same response strategy by the same unit. The incidence of cardiac arrest at the MCG was 1:500000 attendances. Of the 28 patients, 24 (86%) left the venue alive and 20 (71%) were discharged home from hospital. In all cases the initial rhythm was ventricular fibrillation (VF). All 26 patients (93%) who were defibrillated by St John teams had this intervention within 5 min from the documented time of collapse. One patient in VF spontaneously reverted during CPR. Of the eight fatalities, four died at the scene. At major public venues and events, a co-ordinated emergency life support provision strategy, tailor made for the venue, is necessary for the delivery of prompt CPR, timely defibrillation and advanced life support.     

Dispatcher assisted CPR: implementation and potential benefit. A 12-year study

OBJECTIVES: Our objectives are to describe details of the dispatcher assisted cardiopulmonary resuscitation (CPR) instruction program we implemented during a 12 years study and to provide estimates of the potential number of out-of-hospital cardiac arrests that might benefit from such instruction based on data from the last 77 months. METHODS: Basic data were obtained for all episodes of out-of-hospital cardiac arrest in the city of Seattle, as well as all emergency medical services (EMS) dispatches for suspected cardiac arrest. In addition to EMS run reports, data sources included audio tapes of dispatches, and interviews of callers. These data were used in a potential benefit analysis. RESULTS: Over a period of 77 months, 54% (3320/6130) of cardiac arrests received advanced cardiac life support (ACLS) by Seattle Fire Department emergency medical technicians (EMTs) and paramedics. We estimated that 29.9% (994/3320) of cardiac arrests in Seattle treated by EMS could have theoretically benefited from dispatcher assisted CPR. No serious adverse consequences of a dispatcher assisted CPR program were observed. Failure to identify a cardiac arrest by dispatchers was largely attributed to deviation from a well-defined protocol. However, non-arrests identified, initially as arrests appeared to be unavoidable. CONCLUSIONS: In the city of Seattle, some 29.9% of all out-of-hospital cardiac arrest victims who received ACLS had the potential to benefit from dispatcher assisted CPR.     

CPR knowledge and attitude to performing bystander CPR among secondary school students in Norway

Background

Early bystander cardiopulmonary resuscitation (CPR) is essential for survival from out-of-hospital cardiac arrest (OHCA). Young people are potentially important bystander CPR providers, as basic life support (BLS) training can be distributed widely as part of the school curriculum.

Methods

Questionnaires were distributed to nine secondary schools in North Norway, and 376 respondents (age 16-19 years) were included. The completed questionnaires were statistically analysed to assess CPR knowledge and attitude to performing bystander CPR.

Results

Theoretical knowledge of handling an apparently unresponsive adult person was high, and 90% knew the national medical emergency telephone number (113). The majority (83%) was willing to perform bystander CPR in a given situation with cardiac arrest. However, when presented with realistic hypothetical cardiac arrest scenarios, the option to provide full BLS was less frequently chosen, to e.g. a family member (74%), a child (67%) or an intravenous drug user (18%). Students with BLS training in school and self-reported confidence in their own BLS skills reported stronger willingness to perform BLS. 8% had personally witnessed a cardiac arrest, and among these 16% had performed full BLS. Most students (86%) supported mandatory BLS training in school, and three out of four wanted to receive additional training.

Conclusion

Young Norwegians are motivated to perform bystander CPR, but barriers are still seen when more detailed cardiac arrest scenarios are presented. By providing students with good quality BLS training in school, the upcoming generation in Norway may strengthen the first part of the chain of survival in OHCA.     

Cardiopulmonary resuscitation for cardiac arrest: the importance of uninterrupted chest compressions in cardiac arrest resuscitation

Over the last decade, the importance of delivering high-quality cardiopulmonary resuscitation (CPR) for cardiac arrest patients has become increasingly emphasized. Many experts are in agreement concerning the appropriate compression rate, depth, and amount of chest recoil necessary for high-quality CPR. In addition to these factors, there is a growing body of evidence supporting continuous or uninterrupted chest compressions as an equally important aspect of high-quality CPR. An innovative resuscitation protocol, called cardiocerebral resuscitation, emphasizes uninterrupted chest compressions and has been associated with superior rates of survival when compared with traditional CPR with standard advanced life support. Interruptions in chest compressions during CPR can negatively impact outcome in cardiac arrest; these interruptions occur for a range of reasons, including pulse determinations, cardiac rhythm analysis, electrical defibrillation, airway management, and vascular access. In addition to comparing cardiocerebral resuscitation to CPR, this review article also discusses possibilities to reduce interruptions in chest compressions without sacrificing the benefit of these interventions.     

The need for head rotation and abdominal compressions during bystander cardiopulmonary resuscitation

The current AHA-ECC guidelines for basic life support focus on the provision of good chest compressions with minimal interruptions for patients with presumed out-of-hospital cardiac arrest. Moreover, international consensus guidelines now support the use of chest compression-only cardiopulmonary resuscitation (CPR) instructions for dispatcher-assisted CPR given over the phone to untrained bystanders. However, evidence that strongly challenge these recommendations have been overlooked. A review of this evidence argues for the need for head rotation (a hands-free method of airway control) and abdominal compressions during bystander CPR.     

Conjunctival oxygen monitoring during cardiopulmonary resuscitation.

The conjunctival oxygen tension (CjO2) sensor is a non-invasive, continuous index of oxygen delivery in the haemodynamically unstable patient. Human and animal studies have indicated that CjO2 reflects cerebral blood flow and oxygenation. Simple insertion, rapid stabilization and reaction time less than 60 s allow use in the initial stages of cardiopulmonary resuscitation (CPR) where invasive monitoring is often impracticable. CjO2 was monitored to assess cerebral oxygenation during CPR of 15 patients in cardiac arrest in the accident and emergency department (A&E). Patients who arrested out of hospital with delay to advanced cardiac life support and died had CjO2 less than 20 mmHg (normal CjO2 50-60 mmHg) on arrival in A&E. CPR with closed chest cardiac massage (closed CPR) produced no improvement in CjO2. Patients who arrested in ventricular fibrillation (VF) in A&E, and survived with no neurological deficit had CjO2 greater than 20 mmHg during CPR. However, further episodes of VF produced an immediate fall in CjO2 which continued, despite closed CPR, until restoration of spontaneous cardiac output (RSCO) determined by a palpable carotid pulse. In survivors with delay from arrest to CPR the rise in CjO2 with RSCO did not occur for up to 10 min. This study suggests that closed CPR has no value in maintaining or improving cerebral oxygenation during cardiac arrest. Further studies are required to determine the precise relationship of CjO2 to cerebral blood flow and oxygenation during CPR using open and closed techniques of cardiac massage. Open chest cardiac massage (open CPR) has been shown to produce near normal cerebral perfusion and if patients are to survive prolonged resuscitation neurologically intact guidelines for open CPR must be reviewed.     

Sudden cardiac arrest in Israel: factors associated with successful resuscitation

Out-of-hospital cardiac arrests were studied in Israel from 1984 to 1985. More than 3,500 patients in cardiac arrest received paramedic care. Eighty-three percent of cases were caused by underlying heart disease. Overall, 17% of patients with arrest caused by heart disease were admitted and 7% were discharged from the hospital. There was a wide variation in the percent discharged among the 15 paramedic service areas, ranging from 0% to 13%. Factors associated with successful resuscitation included witnessed collapse, rhythm of ventricular fibrillation, short interval from collapse to cardiopulmonary resuscitation (CPR) and delivery of advanced cardiac life support, collapse at public location, and bystander initiation of CPR. Improvements in survival are likely to result if CPR is more frequently and promptly initiated and the time to arrival of definitive paramedic care can be improved.