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.     

A cadaveric model for transesophageal echocardiography transducer placement training: A pilot study

BACKGROUND: Transesophageal echocardiography(TEE) is used in the emergency department to guide resuscitation during cardiac arrest. Insertion of a TEE transducer requires manual skill and experience, yet in some residency programs cardiac arrest is uncommon, so some physicians may lack the means to acquire the manual skills to perform TEE in clinical practice. For other infrequently performed procedural skills, simulation models are used. However, there is currently no model that adequately simulates TEE transducer insertion. The aim of this study is to evaluate the feasibility and efficacy of using a cadaveric model to teach TEE transducer placement among novice users.METHODS: A convenience sample of emergency medicine residents was enrolled during a procedure education session using cadavers as tissue models. A pre-session assessment was used to determine prior knowledge and confidence regarding TEE manipulation. Participants subsequently attended a didactic and hands-on education session on TEE placement. All participants practised placing the TEE transducer until they were able to pass a standardized assessment of technical skill(SATS). After the educational session, participants completed a post-session assessment. RESULTS: Twenty-five residents participated in the training session. Mean assessment of knowledge improved from 6.2/10 to 8.7/10(95% confidence interval [CI] of knowledge difference 1.6–3.2, P<0.001) and confidence improved from 1.6/5 to 3.1/5(95% CI of confidence difference 1.1–2.0, P<0.001). There was no relationship between training level and the delta in knowledge or confidence.CONCLUSIONS: In this pilot study, the use of a cadaveric model to teach TEE transducer placement methods among novice users is feasible and improves both TEE manipulation knowledge and confidence levels.     

RESCUE transesophageal echocardiography for monitoring of mechanical chest compressions and guidance for extracorporeal cardiopulmonary resuscitation cannulation in refractory cardiac arrest

There is a growing interest in using point-of-care transesophageal echocardiography (TEE) during cardiac arrest. TEE is effective at identifying the etiology of sudden cardiovascular collapse and guiding management during the resuscitation. In selected patients with refractory cardiac arrest, extracorporeal cardiopulmonary resuscitation (ECPR) can be considered. ECPR requires percutaneous vascular access for the implantation of veno-arterial extracorporeal membrane oxygenation circuit. We present a case of prolonged cardiac arrest in which rescue TEE was pivotal in narrowing the differential diagnosis, monitoring of mechanical chest compression performance, and guiding cannulation for ECPR.     

Diagnosis of aortic dissection by transesophageal echocardiography during cardiopulmonary resuscitation

ObjectivesEarly identification of the causes of cardiac arrest is helpful in determining the resuscitation measures during cardiopulmonary resuscitation (CPR). We aimed to evaluate the feasibility of transesophageal echocardiography (TEE) during CPR in diagnosing aortic dissection and the influence of aortic dissection on resuscitation outcome in adult patients with prolonged non-traumatic cardiac arrest.MethodsAdult patients aged >20 years with non-traumatic cardiac arrest who underwent prolonged CPR (>10 min) and TEE examination during CPR were enrolled. The enrolled patients were grouped according to the presence of aortic dissection on TEE: the aortic dissection (AD) group and the non-AD group. Variables related to cardiac arrest event, CPR, and resuscitation outcome were compared between the two groups.ResultsForty-five patients (median age, 71 years; 26 men) were enrolled. Ten (22.2%) and 35 (77.8%) patients were included in the AD and non-AD groups, respectively. No patients in the AD group survived. Aortic dissection on TEE was inversely related to the rate of return of spontaneous circulation on multivariate analysis (odds ratio, 0.019; 95% confidence interval, 0.001–0.750; p = .035).ConclusionTEE is a useful tool for diagnosing aortic dissection as a cause of cardiac arrest during CPR. Aortic dissection is associated with poor resuscitation outcomes.     

Emergency department initiation of cardiopulmonary bypass: a case report and review of the literature

Background

Out-of-hospital cardiac arrest carries a dismal prognosis. Percutaneous extracorporeal membrane oxygenation (ECMO) has been used with success for in-hospital arrests, and some literature suggests improvement in long-term survival for out-of-hospital arrests as well.

Objectives

This case highlights the use of ECMO in the emergency department.

Case Report

We report a case in which emergency physician-initiated ECMO was used as a bridge to definitive care in an out-of- hospital cardiac arrest in the United States.

Conclusions

ECMO is a novel adjunct for patients in cardiac arrest in whom the usual advanced life support techniques have failed.     

The Use of Transesophageal Echocardiography During Cardiac Arrest Resuscitation: A Literature Review

We propose that transesophageal echocardiography (TEE) can be used to guide cardiac arrest resuscitation. We undertook a literature search (Medline and EMBase) to assess articles on that topic. Our search yielded 55 articles falling into 3 categories: TEE used in operating rooms, TEE used in emergency departments, and TEE used in other settings. In many cases, TEE changed the direction of the resuscitation; however, it is unclear whether TEE changed patient‐oriented outcomes, such as neurologically intact survival. Few adverse events related to TEE have been documented. There is growing evidence that physicians can learn to use TEE during resuscitations and apply the findings to clinical decisions.     

Transesophageal echocardiography during cardiopulmonary arrest in the emergency department

Management of patients in cardiopulmonary arrest is challenging and can be resource consuming. Outcomes continue to be poor and physicians may feel a sense of futility when running a resuscitation. Bedside ultrasound has been utilized to guide resuscitations, diagnose correctable cardiac pathology leading to an arrest and has proved to have a prognostic value when utilized in the initial stages of resuscitation. Bedside emergency ultrasound is limited by inability to scan during chest compression and poor image quality in obese patients and those with emphysema. During cardiopulmonary resuscitation pulse checks need to be rapid and leave little time for transducer manipulation during image acquisition. Recent American Heart Association guidelines further stress the need for quality chest compressions and minimizing intervals with no compressions. Transesophageal echocardiography offers high resolution and clarity of images in the vast majority of patients. It allows for constant visualization of the heart, even during chest compressions, cardioversion and other procedures. This case series describes the use of transesophageal echocardiography (TEE) during cardiac arrest by emergency physicians. The cases illustrate some of the potential benefits of TEE during cardiopulmonary arrest.     

Emergency echocardiography

Emergency echocardiography refers to the use of cardiac ultrasound to address critical and time-sensitive clinical questions during the initial evaluation and treatment of the critically ill patient presenting to the emergency department. The information obtained can be pivotal to a physician's clinical decision making and can guide further diagnostic or therapeutic interventions. This article provides an evidence-based discussion of the common uses of emergency transthoracic echocardiography, as well as its benefits and limitations in the current practice of emergency medicine.     

Non-traumatic aortic dissection or rupture as cause of cardiac arrest: presentation and outcome

OBJECTIVE: To evaluate the frequency, presentation and outcome of non-traumatic aortic dissection/rupture as a cause of cardiac arrest. DESIGN: Retrospective analysis of a cardiac arrest registry in a tertiary care hospital emergency department. RESULTS: Over 11.5 years, aortic dissection/rupture was identified as the immediate cause of cardiac arrest in 46 (2,3%) out of 1990 patients with sudden cardiac arrest, primarily affecting the abdominal aorta in 25 and the thoracic aorta in 21 cases. The characteristics of the 46 patients were as follows: male gender (74%), median age 71 years (IQR 59-76), high co-morbidity (89%), previously known aortic aneurysm (33%), pulseless electric activity (70%) as initial cardiac rhythm. When performed, bedside abdominal sonography or echocardiography was almost always diagnostic. Patients with abdominal aortic dissection/rupture had abdominal (52%) and/or flank pain (32%). Patients with thoracic aortic dissection/rupture complained of chest pain (48%) or dyspnoea (19%). Return of spontaneous circulation occurred in 12 (26%) of 46 patients, emergency surgery was performed in eight of these patients, 2 (4%) survived to discharge in good neurological condition. CONCLUSIONS: Cardiac arrest caused by aortic dissection/rupture is rare, and mortality remains very high, even when circulation can be restored initially. Common features such as previously known aortic aneurysm, old age, male gender and pulseless electrical activity as initial cardiac rhythm should increase suspicion of the condition.     

Extracorporeal cardiopulmonary resuscitation for adult cardiac arrest patients

Cardiac arrest is a major cause of unexpected death in developed countries, and patients with cardiac arrest generally have a poor prognosis. Despite the use of conventional cardiopulmonary resuscitation (CPR), few patients could achieve return of spontaneous circulation (ROSC). Even if ROSC was achieved, some patients showed re-arrest and many survivors were unable to fully resume their former lifestyles because of severe neurological deficits. Safar et al reported the effectiveness of emergency cardiopulmonary bypass in an animal model and discussed the possibility of employing cardiopulmonary bypass as a CPR method. Because of progress in medical engineering, the system of veno-arterial extracorporeal membrane oxygenation (ECMO) became small and portable, and it became easy to perform circulatory support in cardiac arrest or shock patients. Extracorporeal cardiopulmonary resuscitation (ECPR) has been reported to be superior to conventional CPR in in-hospital cardiac arrest patients. Veno- arterial ECMO is generally performed in emergency settings and it can be used to perform ECPR in patients with out-of-hospital cardiac arrest. Although there is no sufficient evidence to support the efficacy of ECPR in patients with out-of-hospital cardiac arrest, encouraging results have been obtained in small case series.     

Transesophageal Echocardiography Training of Emergency Physicians Through an E-Learning System

BackgroundTransesophageal echocardiography (TEE) has been shown to be a powerful tool that emergency physicians can use to guide resuscitation efforts during cardiac arrest. Currently, there is no standardized curriculum to teach TEE to emergency physicians.ObjectiveWe hypothesized that the use of a pilot training course combining interactive e-learning and hands-on simulation would increase the percentage of students achieving a score of ≥80% on a multiple-choice test of knowledge and increase self-reported comfort using TEE.MethodsWe designed a 2.5-h TEE course for emergency physicians and medical intensive care unit fellows. Participants took a test of knowledge and a survey of comfort—both online—before, just after, and 4 weeks after taking the course. Survey responses measured participants self-reported comfort with using TEE in clinical practice. A normal binomial approximation was used to calculate the 95% confidence interval.ResultsOf the 3 tests of knowledge, 15 participants completed all tests. Of the surveys of comfort, 31 participants completed the precourse survey, 32 completed the postcourse survey, and 19 completed the 4-week follow-up survey. The proportion of students scoring ≥80% improved from 40% on the precourse test to 80% on the postcourse test (95% confidence interval 1–79). The proportion of students indicating comfort with using TEE improved from 3% precourse to 53% postcourse (95% confidence interval 28–71).ConclusionsA TEE training course resulted in a 50% increase in surveyed participants feeling comfortable using TEE in cardiac arrest and a 40% increase in participants scoring ≥80% on a test of knowledge.     

The emergency cardiac arrest response team (eCART): A novel strategy for improving therapeutic hypothermia utilization following out-of-hospital cardiac arrest

BackgroundOut-of hospital cardiac arrest (OHCA) is associated with significant mortality. Therapeutic hypothermia is one of the few interventions that have been shown to increase post-arrest survival as well as enhance neurologic recovery. Despite clinical guidelines recommending the use of therapeutic hypothermia (TH) following cardiac arrest, utilization rates by physicians remain low. We hypothesized that the development of a multi-disciplinary emergency cardiac arrest response team (eCART) would enhance therapeutic hypothermia utilization in the emergency department for OHCA.Methods and resultsAn eCART (emergency department cardiac arrest response team) was created at a single site academic urban emergency department. The eCART team consisted of a physician hypothermia consultant, a cardiologist, a clinical pharmacist, a respiratory therapist and a chaplain. These providers were notified by page prior to the arrival of an OHCA patient and responded to the ED in person or by phone to support the resuscitation. Analysis of pre- and post-intervention data demonstrated a significant increase in the rate of TH utilization (64% to 96%). There was a non-significant decrease in the time to target temperature.ConclusionsThe creation of a coordinated, multi-disciplinary care team, providing real-time support for OHCA patients increased TH utilization in an emergency department.     

Incidence and causes of hypokalemia associated with cardiac resuscitation

To further investigate the incidence and etiology of hypokalemia during cardiac arrest, the authors compared data on 74 adult nontrauma cardiac arrest patients (44 men, 30 women, age 65 +/- 13 years) who had a serum potassium (K+) level documented during or immediately following resuscitation with data on 53 adult controls with life-threatening medical emergencies presenting to the emergency department who did not experience arrest. Hypokalemia (serum K+ less than 3.6 mEq/l) occurred in 25 arrest patients (34%) compared with nine controls (17%). Serum K+ was not significantly different shortly before (3.7 +/- 0.4) versus immediately after arrest (3.6 +/- 0.8) in a small subgroup of patients, making intracellular shifting of K+ because of metabolic events during resuscitation an unlikely etiology. Hypokalemia was associated with a 2.5-fold increase in relative risk for cardiac arrest. Patients who were receiving diuretics without K+ supplementation had the highest risk of arrest (4.4-fold increase). Supplementation of K+ appeared to be protective in patients on diuretics. The authors confirm the association between hypokalemia and cardiac arrest and suggest that this metabolic abnormality may be an important risk factor for cardiac arrest.     

Nontraumatic prehospital cardiac arrest ages 1 to 39 years

Clinical and autopsy records were retrospectively reviewed for 105 patients between the ages of 1 and 39 years who came in to the emergency department with nontraumatic cardiac arrest. There were 65 male (62%) and 40 female patients (38%). Forty-eight percent of the patients were resuscitated. Long-term survival rate was 23%. The most common presenting rhythm was ventricular fibrillation (45%). Cardiac diseases constituted the most common cause of arrest (38%). Atherosclerotic coronary artery disease represented 50% of all cardiac causes. The second most common etiology was overdose or toxic exposure (21%). Witnessed arrest and an etiology of primary cardiac dysrhythmia for arrest were statistically significant factors related to favorable outcome. Asystole as the initial cardiac rhythm was a negative prognostic indicator. Age, sex, race, bystander cardiopulmonary resuscitation, and paramedic response time were not significant prognostic factors for long-term survival.     

Extracorporeal Membrane Oxygenation for Hypokalemia and Refractory Ventricular Fibrillation Associated with Caffeine Intoxication

BackgroundCaffeine has been reported as a cause of cardiac arrest after massive overdose. Here, we report the case of a patient with caffeine intoxication, which can cause fatal dysrhythmias and severe hypokalemia. They were successfully treated with extracorporeal membrane oxygenation (ECMO).Case ReportA 43-year-old woman with a history of bipolar disorder presented to the emergency department after suicidal drug ingestion (caffeine and amitriptyline). Immediately after arrival, she experienced multiple episodes of ventricular fibrillation with severe hypokalemia requiring cardiopulmonary resuscitation and medical therapy. However, conventional treatment was not successful. We instituted ECMO early during resuscitation because prolonged hypokalemia refractory to aggressive potassium replacement precluded the use of antidysrhythmic medications for refractory circulatory compromise with ventricular fibrillation. The use of ECMO provided time to correct hypokalemia (19.3 g potassium) and reduce the caffeine level with hemodialysis. Although she had sustained cardiac arrest, she recovered fully and was discharged home.Why Should an Emergency Physician be Aware of This?Our case indicates the potential effectiveness of ECMO in severely poisoned patients with fatal dysrhythmias. ECMO could provide time for removal of toxic drugs and correction of electrolyte abnormalities.     

Emergency echocardiography.

Emergency physicians need an understanding of the utility of echocardiography in the Emergency Department. With the recent emphasis of emergency department use of portable ultrasonography, emergency physicians will have the opportunity to gain proficiency in using echocardiography to diagnose certain conditions. Echocardiography may aid in the diagnosis of acute MI, pericardial effusion and tamponade, acute valvular dysfunction, acute aortic dissection, and post-traumatic cardiac disorders. An understanding of the potential limitations of echocardiography, combined with experience in its techniques, will ultimately help the emergency physician with its use in daily patient care.     

Causes of in-hospital cardiac arrest and influence on outcome

Aim of the study

To evaluate the relationship between cause and outcome of in-hospital cardiac arrest.

Methods

Retrospective analysis of resuscitation data, causes of cardiac arrest and outcome with a follow-up to 6 months of a cardiac arrest registry in an emergency department of a tertiary care hospital, covering a 17.5-year period.

Results

Of 1041 patients, 653 were male (63%), the median age was 64 years (IQR 53–73), 51% suffered cardiac arrest in the emergency department. The first recorded rhythm showed PEA in 432 (41%), ventricular fibrillation in 404 (39%) and asystole in 205 (20%) patients. Cardiac arrest of cardiac origin occurred in 63% of all patients, with 35% of them due to acute myocardial infarction. Non-cardiac causes were mostly due to pulmonary causes (15% of all patients). Aortic dissection/rupture, exsanguination, intoxication and adverse drug reactions, metabolic, cerebral, sepsis and accidental hypothermia each ranged between 1 and 4% of the cohort. Of all patients, 376 (36%) were discharged in good neurologic condition. Overall, patients with cardiac causes had a significantly better outcome than those with non-cardiac causes (44% vs. 23%, p < 0.01). Patients with pulmonary causes survived in 24%. The other subgroups showed widely divergent survival results (3–65%). Patients who had suffered cardiac arrest in the emergency department had a better outcome then patients of the regular ward or radiology department.

Conclusion

In hospital cardiac arrest is caused mainly by cardiac and pulmonary causes, outcome depends on the cause, with a big variability.     

体外心肺复苏启动前因素对患者预后的影响

目的:分析体外心肺复苏（extracorporeal cardiopulmonary resuscitation,ECPR）启动前因素对患者预后的影响,以探讨ECPR的干预时机和改进策略。方法:回顾性分析2018年7月至2021年4月在湖南师范大学附属第一医院（湖南省人民医院）行ECPR的29例患者。按患者是否存活出院分为生存组( n=13)及死亡组( n=16),分析两组常规心肺复苏（conventional cardiopulmonary resuscitation,CCPR）时间（开始心肺复苏到体外膜肺氧合运转的时间）、ECPR前初始心律、院外及院内心搏骤停的构成比、外院转运病例构成比。按CCPR时间分为≤45 min组、45~60 min组及>60 min组分别比较其出院存活率及持续自主循环恢复（sustained return of spontaneous circulation,ROSC）率。本院院内心搏骤停患者按心搏骤停（cardiac arrest,CA）发生地点分为本科室亚组和其他科室亚组,比较其存活率。 结果:29例患者总体生存率44.83%,体外膜肺氧合（extracorporeal membrane oxygenation,ECMO）平均辅助时长114（33.5,142.5） h,CCPR平均时长60（44.5,80） min。生存组ECMO辅助时间（140.15±44.80）h较死亡组长（ P=0.001）,生存组CCPR时间明显低于死亡组（ P=0.010）。初始心律为可除颤心律组生存率更高（ P=0.010）。OHCA较IHCA患者病死率高（ P=0.020）。外院转运病例病死率高于本院病例（ P=0.025）。CCPR时间≤45min、45~60 min、>60 min三组患者出院生存率依次递减（ P=0.001）,ROSC率依次递减（ P=0.001)。本院院内心搏骤停患者,CA发生地点在本科室（急诊医学科）组与其他科室组生存率差异无统计学意义（ P=0.54）。 结论:ECPR出院存活率高于国内外报道的CCPR存活率,ECPR对难治性心搏骤停是有效的。ECPR的预后跟CCPR时间、CA初始心律、CA发生地点明显相关,提高ECPR存活率需加强宣教及团队建设。     

Emergency Cardiac Support With Extracorporeal Membrane Oxygenation for Cardiac Arrest

A 46-year-old woman with no major medical history presented to the emergency department with chest pain and evidence of anterior, anterolateral, and inferior ST-elevation myocardial infarction. Her condition quickly deteriorated into cardiogenic shock with ventricular arrhythmia. Despite revascularization of the left anterior descending artery and intravenous inotrope and antiarrhythmic therapy, her unstable hemodynamics and arrhythmias persisted. Early emergency initiation of venoarterial extracorporeal membrane oxygenation (ECMO) led to prompt hemodynamic and rhythm stability; however, adequate endogenous cardiac output did not ensue, and she was not able to be weaned from ECMO until hospital day 8. She subsequently recovered and continues to do well in the outpatient setting. This case demonstrates the remarkable hemodynamic and rhythm stability that early initiation of ECMO can provide in the setting of unstable myocardial infarction.     

Multiple boluses of alteplase followed by extracorporeal membrane oxygenation for massive pulmonary embolism

Thrombolytics and extracorporeal membrane oxygenation (ECMO) are potential management options for massive pulmonary embolism (PE). There are early data supporting the use of repeated alteplase 50 mg bolus for massive PE. However, there is sparse literature addressing placement of ECMO catheters after systemic thrombolysis, and there are no reports of initiating ECMO after repeated bolus of alteplase. We present the case of a patient with massive PE who received two boluses of alteplase for recurrent cardiac arrest, followed by initiation of ECMO. The patient stabilized with these interventions, and ultimately had a good outcome with normal neurologic and functional status.