Gill Heart Institute Strive to Revive Case Study 1

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

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.

Patient was transferred to OSH Pre-Hospitalization OSH Course ED Course Early Hospitalization and Workup Rest of Hospitalization 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

Found to be in Atrial Fibrillation with Rapid ventricular response Pre-Hospitalization CPR initiated Regained pulse OSH Course ED Course Early Hospitalization and Workup Rest of Hospitalization 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

HISTORY PMHx: PSurgHx: FamHx: SocHx: ROS: 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

HISTORY Medications: Allergies: No known drug or food allergies Levothyroxine 200 mcg daily Lisinopril 10 mg daily Metformin 500 mg twice daily Metoprolol Succinate 25 mg daily Allergies: No known drug or food allergies

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

Initial ECG

Concern that patient had inadequate perfusion with SBP<100 Pre-Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Early Hospitalization and Workup Rest of Hospitalization 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

Cardiology consulted for evaluation Pre-Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Early Hospitalization and Workup Rest of Hospitalization 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

Pre-Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Rest of Hospitalization 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 Hypokinesis w/ EF<30% Left Heart catheterization LVEDP: 30 mmHg

Given inotropes in the cath lab, with minimal improvement Pre-Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Rest of Hospitalization 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

Telemetry strips in CCU

Telemetry strips in CCU

Defibrillated X 1 with return of sinus rhythm Pre-Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course DCCV Early Hospitalization and Workup Rest of Hospitalization Polymorphic ventricular tachycardia noted soon after arrival to the CCU Defibrillated X 1 with return of sinus rhythm

First ECG after Defibrillation

Initial Labs: ABG: CBC unremarkable Na: 138 K: 6.3 Cl: 106 CO2: 11 Pre-Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Rest of Hospitalization 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

Initial Labs: ABG: CBC unremarkable Na: 138 K: 6.3 Cl: 106 CO2: 11 Pre-Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Rest of Hospitalization 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

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

Was initially on dopamine, but went into polymorphic VT Pre-Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Cardiac catheterization PA sat: 27% ECMO Workup – QT prolonged Mg of 1.3 Rest of Hospitalization 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

Did not require vasopressors Was cautiously diuresed Pre-Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Cardiac catheterization PA sat: 27% ECMO Workup – QT prolonged Mg of 1.3 Rest of Hospitalization 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

Repeat ECG showed QTc of 530. Pre-Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Cardiac catheterization PA sat: 27% ECMO Workup – QT prolonged Mg of 1.3 Rest of Hospitalization 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

Final Assessment: Cardiogenic shock 2/2 non-ischemic CM – resolved Pre-Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Cardiac catheterization PA sat: 27% ECMO Workup – QT prolonged Mg of 1.3 Rest of Hospitalization 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

Summary of Hospital Course Timeline Pre-Hospitalization CPR initiated Regained pulse OSH Course Intubated Started on Amiodarone ED Course Given Diltiazem 10 mg x 1 Followed by DCCV Early Hospitalization and Workup Cardiac catheterization PA sat: 27% ECMO Workup – QT prolonged Mg of 1.3 Rest of Hospitalization Polymorphic VT Stopped QT prolonging agents Corrected Mg Isoproterenol Extubated Neurologically intact

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

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