Thursday, May 29, 2014

30 Year Old with Cardiac Arrest, PEA, then Cardiac Ultrasound

A 30 year old collapsed after complaining of chest pain intermittently.  He was unconscious.  First responders thought they palpated a thready pulse.

When medics arrived, there was no pulse.  Full CPR was initiated with the LUCAS device.  The  patient was intubated, an ITD (ResQPod) was used.  Other standard cardiac arrest measures were undertaken.

Here is the rhythm strip (these are two separate tracings):

The initial rhythm is regular and wide complex, with concordant ST elevation, suggesting STEMI.  The next rhythm appears to be ventricular fibrillation.

The patient could not be resuscitated, but was transported to the ED after about 30 minutes of full arrest.

Upon arrival, as is customary, a very brief ultrasound was performed to assess ventricular function.


What do you see?  See below, with arrows











White arrows outline a very large thrombus (clot) in the pericardium.  Red arrow points to a small amount of liquid blood in the pericardium.  Blue arrow points to the RV, where there is full stasis of blood flow.  Green arrow points to barely beating LV


Here is one more brief view before chest compressions resumed:




Here is a view during LUCAS chest compressions




Of course, chest compressions are not of any use when there is massive tamponade.  Even when the heart is fully beating on its own, it will arrest if there is severe tamponade because it cannot generate adequate pressures for myocardial perfusion.  So how would external compressions have any effect?

For cardiac compression to work, the clot must be evacuated.

Although there seemed little hope of recovery, a left thoracotomay was quickly performed.  A pericardiotomy was performed and this clot was evacuated:

Huge clot extracted from pericardium.  This is about 30 cm x 15 cm on the cart.


In spite of internal cardiac compressions, intracardiac epinephrine, several internal defibrillations for V fib, and other standard attempts at resuscitation, he could not be resuscitated.  The resuscitation was futile.



What caused this hemopericardium?

Possible etiologies include:
1. Hemorrhagic pericarditis, but this would be mostly effusion with some blood, not hemopericardium and certainly not clotted blood.
2. Myocardial rupture from MI.
3. Myocardial rupture from trauma (could be occult, could be due to chest compressions)
4. Ruptured coronary artery aneurysm



Here is an ED ultrasound of the aorta through the suprasternal notch:



This is annotated with arrows below:

These arrows point to a flap.  This is aortic dissection.   The aortic diameter is also excessive (greater than 4 cm is abnormal, here it is about 6 cm)


Autopsy showed a DeBakey 1 dissection ( from the arch all the way to the iliac bifurcation)

Thus, this unfortunate young man had an aortic dissection at a very young age.  It dissected back into his pericardium, resulting in hemopericardium and tamponade, which caused hemodynamic collapse.  His pulses by first responders were thready, but not enough to perfuse his brain.  Thus he was unconscious.  Shortly thereafter, the hypotension with consequent poor perfusion of his coronary arteries resulted in severe ischemia with transmural/subepicardial ischemia, and a wide complex then eventually ventricular fibrillation.



Causes of  Pulseless Electrical Activity (5 H's and 5 T's), as advertised by ACLS
Those bolded are particularly likely with a narrow QRS

Hypovolemia
Hypoxia
Hydrogen ions (acidosis)
Hyper/Hypokalemia
Hypo/Hyperglycemia

Tamponade
Toxins
Tension Pneumothorax
Thrombosis (myocardial infarction)
Thromboembolism (Pulmonary embolism)


Was there any chance of resuscitation with thoracotomy? Probably not, but worth a try.

Once there is full arrest from tamponade, and it has been ongoing for this long, I believe that resuscitation is futile.  However, with a health 30 year old, one must try.

Here is a case in which the patient was alive in the ED and then arrested, had a thoracotomy (in this case subxiphoid) and survived.  The blood was not clotted.

In contrast, in this study of out of hospital cardiac arrest from non-traumatic pericardial fluid on ultrasound, only 1 of 23 patients survived.  None had dissection and none had clotted blood on hemopericardium.  The survivor had liquid blood from myocardial rupture.

Here is a case of myocardial rupture.

Here is another case of myocardial rupture.

Here is a great published case series of myocardial rupture, by my colleague Dave Plummer.  Plummer D et al. Emergency Department Two-Dimensional Echocardiography in the Diagnosis of Nontraumatic Cardiac Rupture. Annals of EM 23(6):1333-1342; June 1994.  All of these patients had ECGs with ST elevation, but ultrasound showed pericardial fluid (not clot) and the patient had MI with rupture.






13 comments:

  1. Lovely images and documentation of an interesting and unfortunate case.

    I'm not sure I'm in full agreement re: the necessity of almost-assuredly futile measures, but that decision can be made on an individual basis depending on the resource utilization being subtracted from needs of other patients in the Department at the time.

    I recently had a pericardiocentesis case for tamponade following aortic dissection in the very elderly – which went emergently to OR for operative repair and survived. Unfortunately, there was devastating downstream multifocal intracranial ischemic damage and the family ultimately allowed natural death.

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    1. Ryan,
      I don't think you're taking into consideration all of the elements of this case: collapse, prolonged time without a pulse, not just "effusion" or "pericardial blood" but clotted blood. Put all of these variables together and you have near certain futility.
      Steve

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    2. Great images. I initially thought the first one was a subcostal view, mistaking the large clot for the liver!

      One small thought about the "5 Hs" though. Hypoglycemia made a brief appearance in the 2005 ACLS guidelines, but disappeared in 2010. No evidence was offered as support either time. So, not an H anymore, and likely never was. Frankly, I have yet to even hear a good anecdote about D50 working in cardiac arrest, let alone read a published case study!

      Keep adding the echocardiograms to the cases - very helpful!

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    3. Brooks,
      I just had a 21yo asystolic cardiac arrest case two days ago. We could not resuscitate her. At the end of the case the blood tests came back with a glucose less than 10. She was not diabetic. I think this is the reason she arrested. I never thought of it. I don't think I could have resuscitated her with dextrose if I had given it early, but it is a possible etiology of arrest (brain malfunction leading to resp arrest leading to asystole).
      Steve.

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    4. Thanks for the great case! I learned very much and appreciate it as always.

      I'd like to revisit Dr. Radecki's comment above. I think he agreed with you to begin with - that the resuscitation was almost assuredly futile. I still wonder whether resuscitation in this scenario is the right thing to do, even assuming Dr. Radecki's stipulation "resource utilization being subtracted from needs of other patients in the Department at the time" is favorably satisfied.

      It seems to me that an additional critical piece of information we need is: of those who survive, what are the chances of favorable neurologic outcome? As Dr. Radecki alluded to, just because we feel the overwhelming, automatic human desire to do something in response to a young healthy person having a terrible event doesn't mean that the benefits outweigh the harms in the rare case that the patient survives.

      Of course, I don't think we will find a reliable estimate of this particular risk/benefit ratio which I would like to see. And in the absence of this information, when a decision like this must be made in reality, I can't see how it could be called wrong to either try resuscitation or not try.

      But I feel that this is an excellent opportunity to point out that, when clinicians make these decisions, it's always possible that they are doing more harm than good. Allowing our minds to hide this reality from us is how we create unsubstantiated medical dogma and the inertia that prolongs the time gap between data acquisition and data implementation (and more importantly, the misinterpretation of that data when it finally is implemented). It is the same bias that assures me that case reports of such resuscitated patients who had a good neurological outcome are more likely to be written/published than those who did not. If the day ever comes that we find a good answer to this particular question, I don't want assumptions that "doing more and trying harder is probably better" to keep us from objectively interpreting that data.

      In summary, it seems impossible that anyone could be faulted for attempting resuscitation in this situation at this point in time, and there is certainly a possibility that it's truly the right thing to do. But we must not forget that our human bias and the collective medical culture that results is a strong influence that makes us assume and believe that our actions usually have benefits that outweigh the harms, with or without (and sometimes contrary to) the actual evidence.

      That said, I think we can all agree on the benefits of sharing this excellent teaching case with us. Thank you!

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    5. Pendell,
      Great comments.
      I would disagree on one point, however. There has been a lot of data on cardiac arrest patients in the last decade. Very few end up with severe disability. Ultimately, they either die or live a reasonably able life.
      That was a misplaced worry in the past and not one which we worry about in the present.
      Thanks for your input!
      Steve

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    6. Thanks for the clarification!

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  2. Steve, would you still classify the initial rhythm as wide complex? Although it is wide by ECG standards it is narrower than many PEA rhythms we tend to see. Or are the standard definitions the same? It certainly helps narrow the differential when you are able to differentiate wide vs narrow complexes. Thanks again for this great website and resource.

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    Replies
    1. Frank, great to hear from you!! I hear you are in Afghanistan?
      I do think this is wide complex, not VERY wide, but greater than 120 ms.
      Steve

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  3. Unfortunate case. That said - I find it TRULY AMAZING that you have put together this EXTRAORDINARY teaching case with MANY important lessons to be learned. It is hard not to try to do everything in a case like this when a 30 year was previously healthy and then collapses - so I'd agree all efforts are justified. THANK YOU for putting this superb teaching case together.

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  4. Dr. Smith, as a premedical student I found this post very interesting and informative. I had a question regarding the case in specific. Did the fluid in the pericardium build up over time due to the patient's dissection or was it triggered by something?

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    Replies
    1. The fluid is blood dissecting back into the pericardium from the aortic dissection and it is hard to know how quickly it accumulated.

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