tag:blogger.com,1999:blog-549949223388475481.post3935705973519664836..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: 68 minutes with chest compressions, full recovery. Plus recommendations from a 5-member panel on cardiac arrest.Unknownnoreply@blogger.comBlogger27125tag:blogger.com,1999:blog-549949223388475481.post-23358888720924992982015-12-09T08:57:56.697-06:002015-12-09T08:57:56.697-06:00Thanks for the response and the resources! Yep, lo...Thanks for the response and the resources! Yep, lots of good signs of being neuro intact like localizing painful stimuli shortly after resuscitation and documentation by ICU of response to verbal stimuli.Dillonhttps://www.blogger.com/profile/02464651915612045488noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-32601547261269609382015-12-08T11:18:40.618-06:002015-12-08T11:18:40.618-06:00Dillon,
Way to go! Neuro intact? Sounds like he&...Dillon,<br />Way to go! Neuro intact? Sounds like he'll probably survive.<br />Beyond what is in this post, there is nothing new EXCEPT for "head-up" CPR, which we at HCMC have extensively studied in swine with incredible results. Have not yet moved to humans.<br /><br />http://circ.ahajournals.org/content/132/Suppl_3/A16154.short<br /><br />https://www.researchgate.net/profile/Guillaume_Debaty/publication/269184237_Tilting_for_Perfusion_Head-up_position_during_Cardiopulmonary_Resuscitation_Improves_Brain_Flow_in_a_Porcine_Model_of_Cardiac_Arrest/links/5489d1680cf214269f1abcf8.pdf<br /><br />Steve<br />Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-87829421552451681722015-12-08T09:35:11.987-06:002015-12-08T09:35:11.987-06:00Had a recent similar case in an otherwise healthy ...Had a recent similar case in an otherwise healthy and normal 26 year old with a proximal LAD lesion (coronary dissection considered by cardiologist who performed thrombectomy and stenting) leading to v fib arrest during an EMS call for chest pain while he was driving for work. Still in our Unit with ARDS, but off pressors. During resus, I never moved to esmolol because amio, lidocaine, and over 9 shocks for repeated v tach and v fib with response worked. Wondering whether I should have moved quicker to thrombolytics (saw your reference to the negative findings from NEJM trial, but that wasn't for v fib arrest with high suspicion of coronary artery occlusion leading to ventricular fibrillation storm). Figure we (EMS and the ED), probably could have optimized parts of his resuscitation, as he experienced worse shock and ARDS than your case. Been reviewing a lot of foam for ideas and found this post super helpful. Just wondering whether you would recommend any other references (FOAM or traditional) for any updated thoughts on a case like this.<br /><br />Thanks,<br />Dillon<br />Assistant Professor of Emergency Medicine at LSUHSC in Baton Rouge and huge Steve Smith fanDillonhttps://www.blogger.com/profile/02464651915612045488noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-77104366001365189172014-01-20T13:31:37.043-06:002014-01-20T13:31:37.043-06:00Because the LAD is the blood supply to the right b...Because the LAD is the blood supply to the right bundle.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-64362277312314125732014-01-20T09:17:59.927-06:002014-01-20T09:17:59.927-06:00Why does a proximal LAD or Left Main cause a RBBB?...Why does a proximal LAD or Left Main cause a RBBB?Anonymoushttps://www.blogger.com/profile/04803004272316512868noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-23392462441830220932013-11-18T15:01:02.199-06:002013-11-18T15:01:02.199-06:00Steve,
Thanks for your insightful comments!
Steve ...Steve,<br />Thanks for your insightful comments!<br />Steve SmithSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-40429429004419528212013-11-18T11:04:18.574-06:002013-11-18T11:04:18.574-06:00Very good discussion of this case. Thank you so mu...Very good discussion of this case. Thank you so much for the time. I have a question/comment comming into this as a long time ACLS instructor, EMS educator, and proponent of Hgh Performance CPR.<br />As was said by other commenters, I also have some heart burn over your contention on EPI. I originally wrote an extensive reply , but n the end only echoed the others above. <br />I will add this:<br /> The study you mentioned (Hagihara, A. et al. Prehospital epinephrine use and survival among patients with out-of hospital cardiac arrest. JAMA 307, 1161–1168 (2012).) Regarding epinephrine was actually performed during 2005-2008, before the major push for high performance CPR (which was barely mentioned in 2005 but really pushed in 2010…but only has taken off since). <br /> As you mentioned , the use of the LUCAS II CPR device has an impact. So to does the “pit crew” approach to CPR, CPR monitoring devices, RESQ-POD, Hypothermia, and any number of different interventions that were not in as wide use in 2005, or even 2010 compared to today. <br /><br />This, more than the fact that the study subjects were in Asytole/PEO, may be critical.<br /><br /><br />For that study to be truly informative, it should be recreated using current CPR practices and guidelines (wich have improved dramatically). If EPI continues to show decreased outcomes, then we will have to par down the why, what of increased morbidity and mortality. <br />In a nutshell: us of EPI *THEN* and use of EPI **NOW** is not an apple to apple comparison by any means. Drawing conclusions based on that older study is like comparing the processing power of a commodore 64 to that of a modern tablet or smart phone. A faulty comparison may result in an inaccurate assumption) that Epi is a negative predictor of outcomes when it may be another factor altogether (i.e. poor CPR, lack of hypothermia, SIRS/ARDS/MODS, or other causes). <br /><br /> Until that happens, at least in animal models, we cannot discount the 13% improvement in ROSC (which is the first step in recovery) . <br /><br />Respectfully submitted<br /><br />Steve<br />Anonymoushttps://www.blogger.com/profile/06819947178012904905noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-7761013740477673112013-04-14T10:13:46.655-05:002013-04-14T10:13:46.655-05:00The context is that we do not yet know the answer....The context is that we do not yet know the answer. Until we do - we should: i) Continue to look for the answer; ii) Apply beneficial new interventions as they develop (ie, therapeutic hypothermia; advancements in CPR technique); and iii) Contemplate potential pros and cons of Epi (there are both!) when considering use of Epinephrine during cardiac arrest. Again - GREAT case and discussion!ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-3444745826418778822013-04-14T09:50:29.023-05:002013-04-14T09:50:29.023-05:00All true, but the context matters: Epi has never b...All true, but the context matters: Epi has never been shown to be beneficial to outcomes. We only use it because we can get the immediate feedback of an increase in pulse and blood pressure and that feels good and right, but is it?Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-61541132731127103382013-04-14T06:06:39.137-05:002013-04-14T06:06:39.137-05:00Steve- GREAT case and SUPERB discussion - with mos...Steve- GREAT case and SUPERB discussion - with most important this being a wonderful SAVE! So nice to have ready access to resuscitation guru Keith Lurie!<br /><br />I'm glad others asked about calcium - which I thought might have potential adverse effect - but you can't get a better end result than full recovery with normal neurologic function.<br /><br />I did want to comment on use of EPINEPRHRINE during cardiac arrest - about which I totally agree that Epi has never been shown to improve survival to hospital discharge. The optimal role of Epi (if any) in cardiac arrest is really unknown at this time. That said - to my reading, there are problems with the 2012 Hagihara study you reference (Ref 7) that I think question the contention that Epi is harmful.<br /><br />The trial was a non-randomized observational trial - so it isn't proof of cause-and-effect. Most patients did not receive bystander CPR - and 86-92% were in PEA/Asystole at the time EMS arrived - such that the cards were already stacked against potential for surival and improved neurologic outcome. Perhaps Epi did all that could be expected of it (ie, it increased chance for ROSC) - but given that most patients in the Hagihara study were already dead - increasing ROSC led to salvage of more "brain-dead" patients - ergo potential misinterpretation of results from this trial that "Epi was harmful" when the real conclusion to be drawn is that the chance for survival with intact neurologic status from out-of-hospital cardiac arrest with an initial mechanism of PEA/Asystole is extremely small .... <br /><br />Your great discussion clearly highlights the exciting new advances in resuscitation - and indeed the ultimate role of Epi may be far more limited than it was in the past. But to my reading - we do not yet have any firm evidence that Epi per se is harmful - but rather of a need to determine which patients in cardiac arrest should be given Epi. Increasing the chance of attaining ROSC may not be optimal goal in a patient without realisatic chance of survival. All of this is of course even more complicated given recent advances with therapeutic hypothermia and high-quality CPR that are changing the potential for salvage among patients who never would have survived with intact neurologic status in the past.<br /><br />THANKS so much for presenting this inspiring case with positive outcome!ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-61802491548861065262013-04-12T12:00:44.273-05:002013-04-12T12:00:44.273-05:00Brooks, sorry for late reply, found this one in my...Brooks, sorry for late reply, found this one in my junk mail for some reason:<br />Esmolol bolus can be given fast, just push. I was not the primary doc on the case, and my partner ordered the calcium and bicarb. I think he figured, why not? They were formerly on ACLS years ago and taken off. We were throwing in the kitchen sink. But it seems it was the esmolol that did it!<br />SteveSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-38119966837215318142013-04-12T11:10:39.816-05:002013-04-12T11:10:39.816-05:00Jeff,
Great question, and it took me so long to r...Jeff,<br /><br />Great question, and it took me so long to respond because I wanted to get the answer from the guy who knows more than anyone: Keith Lurie. He has great data on this that is embargoed right now, so you have to take his word for it. It will be published in July. There is also an abstract from Ian Stiell which I will reference below Keith's response.<br /><br />This is his response:<br /><br />Too little depth does not generate enough of an increase in intrathoracic pressure to propel blood forward. Too much depth cracks ribs, thus preventing good chest wall recoil which is essential for refilling the heart: it also increases the intrathoracic pressure too much so that the ICP increases to dangerous levels with each compression. A balanced approach is needed. 2” appears to be ideal based upon the ROC data for the total population . Even in obese patients 2” can be effective. The questioner is correct that it would be good to vary depth based upon body size, and chest compliance, and brittleness of ribs, and antero-postero diameter. Given that most cannot even get the rate and recoil right we do not know the importance of adjusting for weight or a large AP distance. Bottom line, 2” is enough for most patients since the pressures achieved in the thorax with that depth do propel blood forward. In the very obese pt we need to worry about pressure from the abdomen pushing against the diaphragm and the mechanics are pretty challenging at any depth…<br /><br /><br />Ian Stiell et al. What Is The Optimal Chest Compression Depth During Out-of-hospital Cardiac Arrest Resuscitation of Adult Patients? Prehospital Emergency Care 2013;17:103. <br /><br /> Results: For 9142 included adult patients, the mean compression depth was 41.9mm, with the following ranges: <38mm 37%, 38-51mm 45%, and >51mm 18%. The adjusted odds ratios for survival to discharge, with depth >51mm as reference, were <38mm, 0.69 (0.53, 0.90) and 38-51mm, 1.03 (0.81, 1.30). Covariate-adjusted spline curves revealed that the maximum survival was associated with a depth of 45.8mm, followed by a decline in survival by 50mm (optimal interval 44-49mm).<br /><br />Conclusions: This study found that more than one-third of patients received very low compression depth. The optimal CPR compression depth for survival appears to be 46mm but falls off after 50mm.<br />Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-58927464278256781162013-04-11T13:10:21.569-05:002013-04-11T13:10:21.569-05:00We had 3 of us doing the resuscitation and I was j...We had 3 of us doing the resuscitation and I was just advising, so that wasn't my order and I can't say for sure, but it might be good for brady arrhythmia and can't hurt. Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-1018630269320976582013-04-11T07:37:50.818-05:002013-04-11T07:37:50.818-05:00I was just wondering what the rationale was for th...I was just wondering what the rationale was for the 1mg of Atropine in what could be considered a tachydysrhythmia?akroezehttps://www.blogger.com/profile/08672077465468282006noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-21487799809933447622013-04-08T17:11:41.614-05:002013-04-08T17:11:41.614-05:00I don't think there is enough data to know. B...I don't think there is enough data to know. But I would use it in refractory v fib or v tach, unresponsive to lidocaine and amiodarone.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-28396931529228589202013-04-08T16:33:44.592-05:002013-04-08T16:33:44.592-05:00Amazing Dr.Smith!! Can Esmolol be used in VFib imm...Amazing Dr.Smith!! Can Esmolol be used in VFib immediately does it have any efect converting to Sinus or its used only in "electrical storm" ?Agonhttps://www.blogger.com/profile/07054193535755369194noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-60161254747061533732013-04-07T13:58:53.464-05:002013-04-07T13:58:53.464-05:00Good questions!
1. Succinylcholine: his jaws were...Good questions!<br /><br />1. Succinylcholine: his jaws were clenched and we could not intubate without paralysis<br />2. We were trying anything. It had been 35 minutes. Years ago, calcium was recommended and later thrown out of the guidelines. We thought we had nothing to lose.<br />3. Same answer with bicarb<br />4. That was a typo, it is corrected now to grams<br /><br />Steve SmithSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-90605794875140131532013-04-07T13:45:24.790-05:002013-04-07T13:45:24.790-05:00Khoi bui Minh
Thanks, Dr Smith for a very interest...Khoi bui Minh<br />Thanks, Dr Smith for a very interesting case. I learnt some critical points from this.<br />I have some questions about drug administration when he was in ED. At that time, he was in VF, so why:<br />- succinylcholin was used? I've never used muscle relaxants for cardiac arrest pt, it's not necessary, I think. Otherwise, it could produce some adverse effect<br />-3g of calcium gluconate was given? It's not standard drug as AHA ACLS algorithm. And also administration of bicarb without bloodgas result, could these steps be done routinely?<br />-10mins later in ED, why 2 miligram (not gram?) MgSO4 was given?<br />Again, method of looking for STE as shown above reminds me of your previous post which made me very surprise and was very useful in many cases<br />Thanks againAnonymoushttps://www.blogger.com/profile/13161488296442341303noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-87453644302895030192013-04-06T15:09:25.911-05:002013-04-06T15:09:25.911-05:00Thanks, Christopher.
I also have this in my files...Thanks, Christopher.<br /><br />I also have this in my files:<br /><br />Use of beta-blockers for the treatment of cardiac arrest due to ventricular fibrillation/pulseless ventricular tachycardia: A systematic review; de Oliveira FC, Feitosa-Filho GS, Ritt LE; Resuscitation (Feb 2012). Resuscitation, Volume 83, Issue 6, June 2012, Pages 674–683.<br /><br />http://www.sciencedirect.com/science/article/pii/S0300957212000433<br /><br />Full text: <br /><br />http://emergencymedicine.pitt.edu/sites/default/files/Carvalho-2012-Use%20of%20beta%20blockers.pdf<br /><br /><br />Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-90186068851945388252013-04-06T14:19:38.458-05:002013-04-06T14:19:38.458-05:00A good overview paper was in Texas Heart Institute...A good overview paper was in Texas Heart Institute Journal, "The Evaluation and Management of Electrical Storm" by Eifling, Razavi, and Massumi. The literature they cite for B-blockers in cardiac arrest is mostly from the 90's and some from the 2000's, typically case reports of VF refractory to traditional therapies fixed with a B-blocker (propanalol, metoprolol, esmolol, etc).<br /><br />From "B-Blockers for the treatment of cardiac arrest from ventricular fibrillation?" in Resuscitation 2007 Dec;75(3):434-44.:<br /><br />"No human prospective randomized controlled trial has studied the effects of beta-blocker administration during VF directly. Prospective trials of anti-arrhythmics with beta-blocking properties have been published, as well as several case reports/case series and experimental animal studies. The evidence thus far suggests that beta-blockade during resuscitation from VF may be associated with increasing rates of resuscitation, greater post-resuscitation survival, and improved post-resuscitation myocardial function."Christopherhttps://www.blogger.com/profile/11415988855392944633noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-79374611557180801372013-04-06T13:02:07.960-05:002013-04-06T13:02:07.960-05:00Hello and what a great save. Way to think outside...Hello and what a great save. Way to think outside the box! Loving the esmolol... We're studing this in Cali also. <br /><br /> My Question is regarding the depth of compressions. Since the ILCOR statements of depth are based on a average size person of 150lbs, why are there so many statements in this article saying you must push 2 inches, when we know so many should get more than that? Pushing 2 inches appears not to be the standard. "At least" 2 inches is. Pushing 2 inches on a 3 hundred pounder seems ineffective. This just bothers me. (I dont know the physical size of the pt, just for discussion)<br /><br />I would like some opinion. <br /><br />Jeff Laabs RCPAnonymoushttps://www.blogger.com/profile/01333266008941280141noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-73789205734495765212013-04-06T11:53:39.705-05:002013-04-06T11:53:39.705-05:00PLEASE keep me posted with your findings. I find t...PLEASE keep me posted with your findings. I find this hugely interesting - one of those things that makes too much sense to ignore. Anonymoushttps://www.blogger.com/profile/17189057300015046250noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-41617983017373706812013-04-06T11:49:52.911-05:002013-04-06T11:49:52.911-05:00Steve -
Amazing case, and great discussion.
- ...Steve -<br /><br />Amazing case, and great discussion. <br /><br /> - How fast do you give the esmolol bolus? I imagine that if I try this in the future, I'll likely be the one pushing it! Looking forward to the retrospective study.<br /> - Why the calcium and bicarb in this case? Of course, I realize that Dr Driver only had so much time for his discussion. <br /><br />BrooksBrooks Walshhttps://www.blogger.com/profile/16108633682893762401noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-64259326010753033272013-04-06T11:17:34.582-05:002013-04-06T11:17:34.582-05:00Ana,
This has been studied and was not effective...Ana, <br /><br />This has been studied and was not effective: http://www.nejm.org/doi/pdf/10.1056/NEJMoa070570 (free full text)<br /><br />Steve SmithSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-90058406765859469562013-04-06T11:12:00.140-05:002013-04-06T11:12:00.140-05:00No, not that I know of. And the two are generall...No, not that I know of. And the two are generally lumped together. Dr. Driver and I are going to do a retrospective on esmolol in cardiac arrest.<br /><br />VT is much more rare and hard to study.<br />Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.com