Ultra-long cardiopulmonary resuscitation with thrombolytic therapy for a sudden cardiac arrest patient with pulmonary embolism Tian Hsin, Fang Wei Chun, Hsieh Lu Tao PII: DOI: Reference:

S0735-6757(14)00279-4 doi: 10.1016/j.ajem.2014.04.035 YAJEM 54265

To appear in:

American Journal of Emergency Medicine

Received date: Revised date: Accepted date:

7 April 2014 13 April 2014 17 April 2014

Please cite this article as: Hsin Tian, Chun Fang Wei, Tao Hsieh Lu, Ultra-long cardiopulmonary resuscitation with thrombolytic therapy for a sudden cardiac arrest patient with pulmonary embolism, American Journal of Emergency Medicine (2014), doi: 10.1016/j.ajem.2014.04.035

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ACCEPTED MANUSCRIPT Title: Ultra-long cardiopulmonary resuscitation with thrombolytic therapy for a sudden cardiac arrest patient with pulmonary embolism

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Authors: Tian Hsina. Fang Wei Chuna . Hsieh Lu Taoa

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Running title: Ultra long CPR with thrombolytic therapy

Address, sources of support, the name of organization:

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Department of

Emergency, Lishui City Central Hospital, Lishui City, ZheJiang Province, China.

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Keywords: Cardiopulmonary resuscitation(CPR) ; Pulmonary embolism ; Thrombolytic therapy; Renal failure ; Continuous renal replacement therapy

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(CRRT)

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Title: Ultra-long cardiopulmonary resuscitation with thrombolytic therapy for a sudden cardiac arrest patient with pulmonary embolism

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Keywords: Cardiopulmonary resuscitation;Pulmonary embolism; Thrombolytic therapy; Renal failure; Continuous renal replacement therapy (CRRT) Abstract: The recovery of cardiac arrest patients with pulmonary

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embolism who are given an ultra-long duration of CPR with manual chest

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compressions is very rare. We reported a 52-year-old woman who came to the hospital because of paroxysmal dyspnea, She experienced in-hospital cardiac

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arrest and underwent prolonged CPR with manual chest compressions for 160

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minutes. The patient presented with several episodes of cardiac electrical activity that lasted 10-20 seconds without consciousness. Blood gas analysis revealed: pH 7.27, PaO2 51 mmHg and D-dimer 3723 μg/ml. Additionally, acute pulmonary embolism was considered due to the patient’s symptoms. Thrombolytic therapy was given 100 minutes after the CPR was implemented. Sixty minutes later her sinus

rhythm

was

restored.

After

the

continuous

renal

replacement

therapy(CRRT) for renal failure was administered, and other conservative treatments were given for the complications following the CPR with thrombolytic therapy, she finally recovered and was discharged. This case report

ACCEPTED MANUSCRIPT supports the use of persistent ongoing CPR efforts and the use of thrombolytic therapy.

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Case report: The patient was a 52 year old female. She came to our hospital because of “paroxysmal dyspnea for one week, aggravating for five

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minutes.” The patient came to the clinic one week ago for reiterative dyspnea that was relieved with rest. The chest CT revealed: 1) Bilateral pulmonary

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inflammation, and 2) Right atrial and right ventricular enlargement. The echo showed right heart enlargement and pulmonary arterial hyperpiesia. Blood, hepatic function and renal function tests were unremarkable. Hours after the

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patient’s admission, her dyspnea worsened and was accompanied by cyanosis.

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Physical examination: T 36.2°C, R 29/min, SpO2 fluctuating between 70%-80% under high flow oxygen through a face mask, BP 100/86mmHg, heart rate

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120-130 beats/min. No cardiac murmur or distention of the jugular veins were

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found. Two minutes later, the patient’s heartbeat suddenly stopped and CPR was performed immediately. Blood gas analysis revealed: pH 7.27,PaO2 51 mmHg and D-dimer 3723 μg/ml. No signs of myocardial infarction were present, based on an ECG. Acute pulmonary embolism was evident. And thrombolytic therapy (urokinase 106u added in 100 ml of physiological saline via intravenous infusion for 30minutes) was administered 100 minutes after CPR was initiated. Before thrombolytic therapy was started the patient presented with several episodes of cardiac electrical activity that lasted 10-20 seconds, and the longest time without any cardiac electrical activity was 30 minutes. Forty-five minutes after

ACCEPTED MANUSCRIPT thrombolytic therapy was initiated, the patient’s SpO2 began to rise. Sixty minutes later sinus rhythm was restored, and resuscitation attempts followed.

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Then the patient was sent to the emergency intensive care unit (EICU) for advanced life support. The second day, the patient’s chest enhanced CT scan

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revealed: 1) Rib fracture (Fig.1) 2) Multiple pulmonary artery emboli in the dorsal segment of the lower lobe of the left lung (Fig.2.3) and 3) Moderate ascites

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(Fig.4).

Twenty-four hours later in the EICU, the patient developed renal failure, and continuous renal replacement therapy was initiated. Since the CT scan

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revealed moderate ascites, abdominal paracentesis was performed. The ascites

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turned out to be non-coagulated blood which was considered a complication of thrombolytic therapy. Under the monitoring of intra-abdominal fluid and blood

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hemoglobin level, the patient received a blood transfusion 48 hours later. The

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patient’s tranquillizer was withdrawn and she was able to perform some activity under a doctor’s instruction. The seventh day in the EICU, the patient was extubated, and her neurological examination was unremarkable. A second CT scan revealed that, most of the intra-abdominal fluid had been reabsorbed. The patient was transferred to a general wards for further therapy on the nineth day. She finally recovered and was discharged two months later. Discussion: The recovery of cardiac arrest patients following 160 minutes of CPR with manual chest compressions is very rare. Taking a review of the patient’s recovery process, we owe the success to relentless long-duration CPR

ACCEPTED MANUSCRIPT and the use of thrombolytic therapy. There have been some case reports of prolonged CPR with the use of extracorporeal membrane oxygenation

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(ECMO)(1), but but the recovery of patients without ECMO, after administration of ultra-long CPR with manual chest compressions(1)

(2)

has

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rarely been reported. Our patient experienced two episodes of zero cardiac electrical activity that lasted 30 minutes. The thrombolytic therapy played a

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very important role in this patient’s recovery. We should strongly consider thrombolytic therapy when a pulmonary embolism is highly suspected according to the classic clinical symptoms and laboratory test results

(3)(4)

. CPR

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time should be prolonged after the patient receives thrombolytic therapy.

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Furthermore, the complications following the thrombolytic therapy must be treated properly, and in the case of our patient, the early use of CRRT proved to

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be very helpful in mitigating her renal failure. The persistent, long-duration

life.

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CPR with manual chest compressions and early thrombolytic therapy saved her

References:

1. Yu H-Y, et al. Ultra long cardiopulmonary resuscitation with intact cerebral performance for an asystolic patient with acute myocarditis. Resusciation 2007 May; 73(2): 307-308. 2. Nobre C, Mesquita D, Thomas B. Prolonged chest compressions during cardiopulmonary resuscitation for cardiac arrest due to acute pulmonary embolism. Chest 2014 Mar; 145(3 Suppl): 532A.

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3. Neumar RW,OttoCW,Link MS,et al. Part8: Adult advanced cardiovascular

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life support:2010 AmericanHeart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122(18

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Suppl 3): 735-746.

4. Meneveau N. Therapy for acute high-risk pulmonary embolism: thrombolytic

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therapy and embolectomy. Curr Opin Cardiol 2010;V25N6: 560-567.

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Ultra-long cardiopulmonary resuscitation with thrombolytic therapy for a sudden cardiac arrest patient with pulmonary embolism.

The recovery of cardiac arrest patients with pulmonary embolism who are given an ultra-long duration of cardiopulmonary resuscitation(CPR) with manual...
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