A rare case of survival after one hour of cardiopulmonary resuscitation

Manuscript type : Brief Report | Article Date : 2015/07/25

  • Autors

    1. Salkar Amit
    2. Kumar Uday
    3. Chitihoti Suneeta
    4. Shashikant T
    5. Misale Vijay
  • Abstract

    In general, outcomes after cardiac arrest remain poor, especially in patients with risk factors such as unwitnessed arrest, unfavorable initial rhythm, older age, and prolonged resuscitation without return of spontaneous circulation (ROSC). Nonetheless, successful resuscitation and good recovery after prolonged arrest have been documented.As the field of cardiopulmonary resuscitative medicine evolves, new techniques are being implemented to improve outcomes in patients who are in cardiac arrest. We present an example of how recent research findings in resuscitative medicine improved chances of survival of one patient. This case demonstrates that seemingly desparate long term resuscitation may sometimes be successful. Our case went home with no residual cognitive deficit or neurologic sequelae after one hour of cardiopulmonary resuscitation (CPR ).
  • Description

    BRIEF REPORT

    In general, outcomes after cardiac arrest remain poor, especially in patients with risk factors such as unwitnessed arrest, unfavorable initial rhythm, older age, and prolonged resuscitation without return of spontaneous circulation (ROSC).1-4 Nonetheless, successful resuscitation and good recovery after prolonged ar-rest have been documented.5-8 As the field of cardio-pulmonary resuscitative medicine evolves, new techniques are being implemented to improve outcomes in patients who are in cardiac arrest. We present an example of how recent research findings in resuscitative medicine improved one patient’s chances of survival. In Oct 2014, a 42-year-old man with a history of acute anterior wall myocardial infarct thrombolysed with Streptokinase, known case of hypertension, and chronic tobacco use presented to us on day 2 post-thrombolytic state for angiography and further man-agement. On admission he was asymptomatic. An electrocardiogram (ECG) showed persistent ST-seg-ment elevation in the anterior leads. He was hemody-namically well compensated. He was admitted to the cardiovascular care unit (CCU) and was treated conservatively with dual anti-platelet, anticoagulant, and antihypertensive therapy. The next morning, a coronary angiogram revealed an occluded proximal left anterior descending coronary artery (Fig. 1). On hospital day 3 he remained hemodynamically stable in the CCU and was subsequently transferred to the medicine floor. At 10:05 AM on hospital day 5, the patient developed sustained ventricular tachycardia and then lost con-sciousness. He had no spontaneous respirations, and neither the carotid nor femoral pulses could be pal-pated. His airway was secured, and positive-pressure ventilation was initiated. Simultaneously, cardiopul-monary resuscitation (CPR) was started by first re-sponders. After the first 2 minutes of CPR, ventricular fibrillation (VF) was detected. The resuscitation con-tinued in strict accordance with American Heart As-sociation/American College of Cardiology Advanced Cardiac Life Support (ACLS) guidelines, including defibrillation. After the initial 200 J shock, the patient continued to have VF, so again CPR was continued and escalated doses of DC shock were given with no response. During the resuscitation patient was on appropriate pharmacologic support. All possible reversible causes of sustained VT/VF were evaluated, and the patient was found to be in refractory cardiogenic shock. And then loaded with amiodarone. MgSO4, CaCl and 3 ampules of sodium bicarbonate were given. Patient continued to have VF, at 10:25 AM CPR machine (LUCAS machine) (Fig. 2) was installed and was rapidly moved to ICCU where CPR was continued. At 10:35 AM patient had two episodes of seizures for which 1gm Leveteracitam was given and hypother-mia was initiated with a temperature goal of 32 to 34 °C, to decrease the neurological damage. Patient continued to have VF and CPR continued with CPR Machine. At 10:55 AM last DC shock was given and patient was found to have pulseless electrical activity, and CPR was again initiated. ROSC was achived at 11:05 AM, and the patient’s hemodynamic status was stabi-lized at 11:10 AM. From 11:10AM to 11:30 AM, the patient had palpable pulses with sinus rhythm; how-ever, he remained hypotensive despite continuous sa-line infusion and increased inotrops and vasopressor administration. Slowly his blood pressure raised to 100/70 he was taken for CAG which showed reca-nalised LAD with TIMI 3 flow (Figure-3) in distal segment with residual mild disease in proximal LAD and intra-aortic balloon pump (IABP) was subse-quently placed to decrease myocardial work and im-prove coronary perfusion. Patient was continued on hypothermia therapy and ventilator support for next 24 hrs and following which his neurological status was checked and slowly over next 24 hrs he was extubated and IABP was removed and thereafter he was hemodynamically stable and was discharged in stable condition with moderate LV dysfunction and antiarrythmic therapy. In 1965 Stemmler conducted a small study of 103 pa-tients for whom the average resuscitation time was 15- 30 mins. Since then most physicians have adopted this as the relative time for cessation of resuscitation if there is no ROSC. Unfortunately little progress has been made to determine the ideal time for stopping resuscitative efforts and the AHA and ERC (Europe-an Resuscitation Council) currently make no defini-tive statement on when resuscitation attempts should be terminated. Studies have shown that for prolonged resuscitation in a patient with cardiac arrest for more than 12- 15 minutes is an independent predictor of death and studies done in the Emergency Room showed an improved outcome with a total resuscita-tion time of less than 15 minutes. Furthermore many argue against prolonged resuscitation as the Cost per patient for a relatively poor outcome can range in the tens of thousands.9 Recently, Goldberger et al. (Sep, 2012) did an obser-vational study of 64,339 patients with cardiac arrest for whom resuscitation was attempted. Of these, hos-pitals which resuscitated patients for an average of and ROSC (adjusted risk ratio 1.12, 95% CI 1.06–1.18; p
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