Strive to Revive

1. Gill Heart Institute Strive to Revive Case Study 1

2. Case Objectives • Discuss critical aspects of initial resuscitation that affected outcomes • Discuss important aspects of post-resuscitation care: • ECMO • Management of VT

3. 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.

4. 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

5. 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

6. 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

7. HISTORY • Medications: • Levothyroxine 200 mcg daily • Lisinopril 10 mg daily • Metformin 500 mg twice daily • MetoprololSuccinate 25 mg daily • Allergies: No known drug or food allergies

8. 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

9. Initial ECG

10. 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

11. 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

12. 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 Hypokinesisw/ EF<30% • Left Heart catheterization • LVEDP: 30 mmHg

13. 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

14. Telemetry strips in CCU

15. Telemetry strips in CCU

16. Polymorphic ventricular tachycardia noted soon after arrival to the CCU • Defibrillated X 1 with return of sinus rhythm

17. First ECG after Defibrillation

18. Initial Labs: • CBC unremarkable • 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

19. Initial Labs: • CBC unremarkable • 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

20. Initial assessment • Cardiogenic shock with new global LV dysfunction • Etiology non-ischemic • EtOHvs other non-ischemic etiology • Stunning from either CPR or initial arrest • Afibw/ RVR secondary to this? • AG metabolic acidosis w/ respiratory compensation • Profound hyperkalemia and hypomagnesemia • QT prolongation • Mg and QT prolonging agents

21. 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

22. 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

23. 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

24. 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

25. Summary of Hospital Course • Timeline

26. 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

27. DM • Questions