The Journal of Emergency Medicine, Vol. 47, No. 6, pp. 632–634, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.06.066
Clinical Communications: Adults FULL RECOVERY AFTER PROLONGED CARDIAC ARREST AND RESUSCITATION WITH MECHANICAL CHEST COMPRESSION DEVICE DURING HELICOPTER TRANSPORTATION AND PERCUTANEOUS CORONARY INTERVENTION Alessandro Forti, MD,*†‡ Giovanna Zilio, MD,*†‡ Paolo Zanatta, MD,*† Marialuisa Ferramosca, MD,‡ Cristiano Gatto, PN,‡ Antonio Gheno, PN,‡ and Paolo Rosi, MD‡ *Anesthesia Department, †Intensive Care Department, and ‡Emergency Department, Regional Hospital Treviso, Treviso, Italy Reprint Address: Alessandro Forti, MD, Emergency Department, Regional Hospital Treviso, 31100 Treviso, Italy
, Abstract—Background: Despite early cardiopulmonary resuscitation (CPR) by bystanders and early advanced cardiac life support (ACLS) maneuvers, some patients present to the emergency department with persistent cardiac arrest caused by a coronary artery occlusion. Although emergency percutaneous intervention (PCI) has been shown to be effective in improving survival, transporting patients in cardiac arrest to the hospital is not considered to be effective, due to the poor quality of CPR in the ambulance. In the case reported here, a mechanical chest compression device was used while transporting the patient by helicopter emergency medical services (HEMS). Case Report: A mechanical chest compression device was used to deliver chest compressions to a 53-year-old man in cardiac arrest. This device permitted the transfer of the patient by HEMS helicopter to the catheterization laboratory facility for a PCI. Return of spontaneous circulation was achieved 115 min after cardiac arrest and the patient survived without any neurological deficit. Why Should an Emergency Physician Be Aware of This?: The mechanical chest compression device has permitted safe and effective CPR during helicopter transportation. Although this is only a single case, it may present a new perspective for the treatment of prehospital cardiac arrest that is refractory to ACLS therapies. Ó 2014 Elsevier Inc.
INTRODUCTION Thanks to educational programs and prearrival instructions by emergency medical services (EMS) dispatching center operators, early cardiopulmonary resuscitation (CPR) delivered by bystanders has become more common over the years, improving the chance of survival after a cardiac arrest. However, despite early CPR and early Advanced Cardiac Life Support (ACLS) by EMS teams, in many patients the return of spontaneous circulation (ROSC) cannot be achieved, due to a recurrent ventricular fibrillation or persistent pulseless electrical activity. In some of these patients, these conditions can be due to a coronary artery occlusion, which maintains the dysrhythmia or impairs myocardial contractility. Emergency percutaneous coronary intervention (PCI) during cardiac arrest has been demonstrated to improve survival (1). However, because quality of manual CPR during transportation is very poor, it is linked to extremely low survival rates, and can pose significant danger to prehospital providers (2). In such cases, in most EMS systems, termination of resuscitation efforts in the field has been considered to be the only option. The LUCAS-2Ô (Physio-Control/Jolife AB, Lund, Sweden) is a mechanical device that delivers chest compressions at a constant rate of 100 compressions per minute, to a depth of 4 to 5 cm, using a piston with an attached
, Keywords—LUCAS; mechanical chest compression device; cardiopulmonary resuscitation; HEMS helicopter; emergency percutaneous intervention; survival
RECEIVED: 27 November 2013; FINAL SUBMISSION RECEIVED: 1 April 2014; ACCEPTED: 30 June 2014 632
Mechanical Chest Compression for Cardiac Arrest
suction cup that helps the chest to return to its normal expanded position. The rate and depth of compressions are compliant with international guidelines on CPR (3). LUCAS-2 can greatly improve the quality of CPR during transportation, providing uninterrupted chest compressions, thus sustaining adequate circulation and allowing safe transportation of the patient to the catheterization laboratory (4). The feasibility of PCI during LUCAS-2 CPR has been demonstrated (5,6). CASE REPORT On an early afternoon in September 2013, the EMS Dispatching Centre of Treviso, Italy received a call from a person who told the operator that her cousin, a 53-yearold man with a previous history of inferior myocardial infarction, had suddenly fallen down while walking at home. While dispatching the nearest ambulance, the dispatcher provided CPR prearrival instructions to the caller, according to standard protocols. An EMS helicopter, staffed by an emergency physician and a nurse, was dispatched to the scene. The first emergency unit, staffed by a nurse and an emergency technician, reached the patient within 10 min of the call and found the woman performing chest compressions as instructed by the dispatching center operator. EMS observed ventricular fibrillation on the monitor, and ACLS resuscitation procedures according to international guidelines were started. Pupillary diameter was normal. One shock with an automated external defibrillator was delivered but was not effective in restoring normal rhythm. Intubation and cannulation of the external jugular vein were performed and infusion of saline solution was started. Adrenaline (epinephrine) 1 mg every 3 min and an amiodarone bolus of 300 mg were administered intravenously. The helicopter medical team reached the patient 10 min after the first unit started ACLS. At that time, three shocks with the automated external defibrillator had been delivered and 3 mg of adrenaline had been administered. The cardiac rhythm was a persistent ventricular fibrillation. The helicopter medical team applied the LUCAS-2 to the patient. Weak carotid and femoral pulses were detected during mechanical chest compressions. The skin color of the face turned from a dark gray to a middle red-gray. Peripheral O2 saturation was 89%, with 100% FiO2. The pupillary diameter was still normal. After 40 min of ACLS, cardiac rhythm converted into pulseless electrical activity. Taking into consideration the age of the patient and the limited no-flow time, the medical team decided to transport him by helicopter to Treviso hub-hospital (10 min flight time). Ice packs were positioned over the body of
633
the patient to achieve a mild hypothermia. The patient was transported directly to the catheterization laboratory, where selective percutaneous coronary angiography was performed with ongoing continuous mechanical chest compressions. A thrombotic sub-occlusion of the left anterior descending coronary artery (LD) and an occlusion of the circumflex coronary artery (CX) were detected. Coronary angioplasty was performed on both vessels and a nude stent was positioned on the LD (IntegrityÔ 22 2.5 mm; Medtronic, Minneapolis, MN) and on the CX (Integrity 26 2.5 mm, Medtronic). Arterial blood gas analysis showed pO2 of 50.1 mm Hg, pCO2 of 81.1 mm Hg, pH of 7.05, HCO3 of 15.6 mmol/L, arterial base excess of 10.6 mmol/L, hemoglobin of 13.6 gr/dL, O2 saturation of 67%, sodium of 140 mEq/L, potassium of 4.6 mEq/L, glucose of 80 mg/ dL, lactate of 11.1 mmol/L, and anion gap of 24.2 mEq/L. ROSC was achieved after PCI. The total duration of cardiac arrest was 115 min; the duration of LUCAS-2 compressions was 90 min. Systolic blood pressure was 110 mm Hg, diastolic blood pressure 65 mm Hg, and heart rate 110 beats/ min. Left ventricular ejection fraction was 25%. An intra-aortic balloon pump was inserted through the right femoral artery. A bolus of 5000 IU of sodium heparin was administered and an infusion of 0.4 mg/kg/min of tirofiban was started intravenously. Creatinine was 2.3 mg/dL, troponin T was 7.4 ng/mL (0.00–0.06), and creatine kinase was 6756 mg/L. One hour after intensive care unit (ICU) admission, the patient developed a large left pectoral hematoma. An angio-computed tomography scan was performed, revealing bleeding from a left intercostal artery. Immediately, the patient was transferred to the angiographic procedural room, where an arterial embolization with a Complex Helical - 18 Fibered Platinum Coil (Boston Scientific, Marlborough, MA) was performed. At the end of this procedure the patient was readmitted to the ICU where, after hemodynamic stabilization, a somatosensory evoked potential and an electroencephalogram were recorded. The electroencephalogram showed a slow and reactive alpha rhythm; only the post-central (C30 –C40 ) derivations were markedly depressed in frequency and amplitude. The cortical somatosensory evoked potential (N20/P25) was markedly depressed in amplitude (30 min and standard CPR in the helicopter would have been impossible to perform, the patient would have been declared dead at the scene if the LUCAS-2 had not been available. The mechanical chest compression device permitted us to maintain effective CPR during helicopter flight and during PCI procedures. The bleeding complication cannot be certainly ascribed to LUCAS-2, as it has been reported also with manual chest compressions, but regardless, it is considered only a minor complication (6).
WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? The mechanical chest compression device permitted safe and effective CPR during helicopter transportation. Transportation of the patient directly to the catheterization laboratory permitted removal of the coronary artery occlusions, which were preventing the ROSC. Although this is only a single case, it may present a new perspective for the treatment of prehospital cardiac arrest that is refractory to ACLS therapies.
REFERENCES 1. Agostoni P, Cornelis K, Vermeersch P. Successful percutaneous treatment of an intraprocedural left main stent thrombosis with the support of an automatic mechanical chest compression device. Int J Cardiol 2008;124:e19–21. 2. Kramer-Johansen J, Myklebust H, Wik L, et al. Quality of out of hospital cardiopulmonary resuscitation with real time automated feedback: a prospective interventional study. Resuscitation 2006;71: 283–92. 3. International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 2: Adult basic life support. Resuscitation 2005;67:187–201. 4. Wik L, Steen PA, Bircher NG. Quality of bystander cardiopulmonary resuscitation influences outcome after prehospital cardiac arrest. Resuscitation 1994;28:195–203. 5. Wagner H, Terkelsen C, Friberg H, et al. Cardiac arrest in the catheterisation laboratory: a 5-year experience of using mechanical chest compression to facilitate PCI during prolonged resuscitation efforts. Resuscitation 2010;81:383–7. 6. Axelsson C, Herrera M, Fredriksson M, Lindqvist J, Herlitz J. Implementation of mechanical chest compression in out-of-hospital cardiac arrest in an emergency medical service system. Am J Emerg Med 2013;31:1196–200.
http://dx.doi.org/10.1016/j.jemermed.2014.06.066
Clinical Communications: Adults FULL RECOVERY AFTER PROLONGED CARDIAC ARREST AND RESUSCITATION WITH MECHANICAL CHEST COMPRESSION DEVICE DURING HELICOPTER TRANSPORTATION AND PERCUTANEOUS CORONARY INTERVENTION Alessandro Forti, MD,*†‡ Giovanna Zilio, MD,*†‡ Paolo Zanatta, MD,*† Marialuisa Ferramosca, MD,‡ Cristiano Gatto, PN,‡ Antonio Gheno, PN,‡ and Paolo Rosi, MD‡ *Anesthesia Department, †Intensive Care Department, and ‡Emergency Department, Regional Hospital Treviso, Treviso, Italy Reprint Address: Alessandro Forti, MD, Emergency Department, Regional Hospital Treviso, 31100 Treviso, Italy
, Abstract—Background: Despite early cardiopulmonary resuscitation (CPR) by bystanders and early advanced cardiac life support (ACLS) maneuvers, some patients present to the emergency department with persistent cardiac arrest caused by a coronary artery occlusion. Although emergency percutaneous intervention (PCI) has been shown to be effective in improving survival, transporting patients in cardiac arrest to the hospital is not considered to be effective, due to the poor quality of CPR in the ambulance. In the case reported here, a mechanical chest compression device was used while transporting the patient by helicopter emergency medical services (HEMS). Case Report: A mechanical chest compression device was used to deliver chest compressions to a 53-year-old man in cardiac arrest. This device permitted the transfer of the patient by HEMS helicopter to the catheterization laboratory facility for a PCI. Return of spontaneous circulation was achieved 115 min after cardiac arrest and the patient survived without any neurological deficit. Why Should an Emergency Physician Be Aware of This?: The mechanical chest compression device has permitted safe and effective CPR during helicopter transportation. Although this is only a single case, it may present a new perspective for the treatment of prehospital cardiac arrest that is refractory to ACLS therapies. Ó 2014 Elsevier Inc.
INTRODUCTION Thanks to educational programs and prearrival instructions by emergency medical services (EMS) dispatching center operators, early cardiopulmonary resuscitation (CPR) delivered by bystanders has become more common over the years, improving the chance of survival after a cardiac arrest. However, despite early CPR and early Advanced Cardiac Life Support (ACLS) by EMS teams, in many patients the return of spontaneous circulation (ROSC) cannot be achieved, due to a recurrent ventricular fibrillation or persistent pulseless electrical activity. In some of these patients, these conditions can be due to a coronary artery occlusion, which maintains the dysrhythmia or impairs myocardial contractility. Emergency percutaneous coronary intervention (PCI) during cardiac arrest has been demonstrated to improve survival (1). However, because quality of manual CPR during transportation is very poor, it is linked to extremely low survival rates, and can pose significant danger to prehospital providers (2). In such cases, in most EMS systems, termination of resuscitation efforts in the field has been considered to be the only option. The LUCAS-2Ô (Physio-Control/Jolife AB, Lund, Sweden) is a mechanical device that delivers chest compressions at a constant rate of 100 compressions per minute, to a depth of 4 to 5 cm, using a piston with an attached
, Keywords—LUCAS; mechanical chest compression device; cardiopulmonary resuscitation; HEMS helicopter; emergency percutaneous intervention; survival
RECEIVED: 27 November 2013; FINAL SUBMISSION RECEIVED: 1 April 2014; ACCEPTED: 30 June 2014 632
Mechanical Chest Compression for Cardiac Arrest
suction cup that helps the chest to return to its normal expanded position. The rate and depth of compressions are compliant with international guidelines on CPR (3). LUCAS-2 can greatly improve the quality of CPR during transportation, providing uninterrupted chest compressions, thus sustaining adequate circulation and allowing safe transportation of the patient to the catheterization laboratory (4). The feasibility of PCI during LUCAS-2 CPR has been demonstrated (5,6). CASE REPORT On an early afternoon in September 2013, the EMS Dispatching Centre of Treviso, Italy received a call from a person who told the operator that her cousin, a 53-yearold man with a previous history of inferior myocardial infarction, had suddenly fallen down while walking at home. While dispatching the nearest ambulance, the dispatcher provided CPR prearrival instructions to the caller, according to standard protocols. An EMS helicopter, staffed by an emergency physician and a nurse, was dispatched to the scene. The first emergency unit, staffed by a nurse and an emergency technician, reached the patient within 10 min of the call and found the woman performing chest compressions as instructed by the dispatching center operator. EMS observed ventricular fibrillation on the monitor, and ACLS resuscitation procedures according to international guidelines were started. Pupillary diameter was normal. One shock with an automated external defibrillator was delivered but was not effective in restoring normal rhythm. Intubation and cannulation of the external jugular vein were performed and infusion of saline solution was started. Adrenaline (epinephrine) 1 mg every 3 min and an amiodarone bolus of 300 mg were administered intravenously. The helicopter medical team reached the patient 10 min after the first unit started ACLS. At that time, three shocks with the automated external defibrillator had been delivered and 3 mg of adrenaline had been administered. The cardiac rhythm was a persistent ventricular fibrillation. The helicopter medical team applied the LUCAS-2 to the patient. Weak carotid and femoral pulses were detected during mechanical chest compressions. The skin color of the face turned from a dark gray to a middle red-gray. Peripheral O2 saturation was 89%, with 100% FiO2. The pupillary diameter was still normal. After 40 min of ACLS, cardiac rhythm converted into pulseless electrical activity. Taking into consideration the age of the patient and the limited no-flow time, the medical team decided to transport him by helicopter to Treviso hub-hospital (10 min flight time). Ice packs were positioned over the body of
633
the patient to achieve a mild hypothermia. The patient was transported directly to the catheterization laboratory, where selective percutaneous coronary angiography was performed with ongoing continuous mechanical chest compressions. A thrombotic sub-occlusion of the left anterior descending coronary artery (LD) and an occlusion of the circumflex coronary artery (CX) were detected. Coronary angioplasty was performed on both vessels and a nude stent was positioned on the LD (IntegrityÔ 22 2.5 mm; Medtronic, Minneapolis, MN) and on the CX (Integrity 26 2.5 mm, Medtronic). Arterial blood gas analysis showed pO2 of 50.1 mm Hg, pCO2 of 81.1 mm Hg, pH of 7.05, HCO3 of 15.6 mmol/L, arterial base excess of 10.6 mmol/L, hemoglobin of 13.6 gr/dL, O2 saturation of 67%, sodium of 140 mEq/L, potassium of 4.6 mEq/L, glucose of 80 mg/ dL, lactate of 11.1 mmol/L, and anion gap of 24.2 mEq/L. ROSC was achieved after PCI. The total duration of cardiac arrest was 115 min; the duration of LUCAS-2 compressions was 90 min. Systolic blood pressure was 110 mm Hg, diastolic blood pressure 65 mm Hg, and heart rate 110 beats/ min. Left ventricular ejection fraction was 25%. An intra-aortic balloon pump was inserted through the right femoral artery. A bolus of 5000 IU of sodium heparin was administered and an infusion of 0.4 mg/kg/min of tirofiban was started intravenously. Creatinine was 2.3 mg/dL, troponin T was 7.4 ng/mL (0.00–0.06), and creatine kinase was 6756 mg/L. One hour after intensive care unit (ICU) admission, the patient developed a large left pectoral hematoma. An angio-computed tomography scan was performed, revealing bleeding from a left intercostal artery. Immediately, the patient was transferred to the angiographic procedural room, where an arterial embolization with a Complex Helical - 18 Fibered Platinum Coil (Boston Scientific, Marlborough, MA) was performed. At the end of this procedure the patient was readmitted to the ICU where, after hemodynamic stabilization, a somatosensory evoked potential and an electroencephalogram were recorded. The electroencephalogram showed a slow and reactive alpha rhythm; only the post-central (C30 –C40 ) derivations were markedly depressed in frequency and amplitude. The cortical somatosensory evoked potential (N20/P25) was markedly depressed in amplitude (30 min and standard CPR in the helicopter would have been impossible to perform, the patient would have been declared dead at the scene if the LUCAS-2 had not been available. The mechanical chest compression device permitted us to maintain effective CPR during helicopter flight and during PCI procedures. The bleeding complication cannot be certainly ascribed to LUCAS-2, as it has been reported also with manual chest compressions, but regardless, it is considered only a minor complication (6).
WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? The mechanical chest compression device permitted safe and effective CPR during helicopter transportation. Transportation of the patient directly to the catheterization laboratory permitted removal of the coronary artery occlusions, which were preventing the ROSC. Although this is only a single case, it may present a new perspective for the treatment of prehospital cardiac arrest that is refractory to ACLS therapies.
REFERENCES 1. Agostoni P, Cornelis K, Vermeersch P. Successful percutaneous treatment of an intraprocedural left main stent thrombosis with the support of an automatic mechanical chest compression device. Int J Cardiol 2008;124:e19–21. 2. Kramer-Johansen J, Myklebust H, Wik L, et al. Quality of out of hospital cardiopulmonary resuscitation with real time automated feedback: a prospective interventional study. Resuscitation 2006;71: 283–92. 3. International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 2: Adult basic life support. Resuscitation 2005;67:187–201. 4. Wik L, Steen PA, Bircher NG. Quality of bystander cardiopulmonary resuscitation influences outcome after prehospital cardiac arrest. Resuscitation 1994;28:195–203. 5. Wagner H, Terkelsen C, Friberg H, et al. Cardiac arrest in the catheterisation laboratory: a 5-year experience of using mechanical chest compression to facilitate PCI during prolonged resuscitation efforts. Resuscitation 2010;81:383–7. 6. Axelsson C, Herrera M, Fredriksson M, Lindqvist J, Herlitz J. Implementation of mechanical chest compression in out-of-hospital cardiac arrest in an emergency medical service system. Am J Emerg Med 2013;31:1196–200.
