An hour-long CPR to restart the heart

Vigneshvarprashanth Umapathy¹,*, S. Aravindakumar², Z. Mohamed Ghouse Khan³, Nithish⁴, Jasper Shekinah5

¹Resident Internal Medicine, Kauvery Hospital, Tennur, Trichy, India

²Chief Consultant Interventional Cardiologist, Kauvery Heart City, Trichy, India

³Consultant Emergency Physician, Incharge of Emergency department, Kauvery Heart City, Trichy, India

^4,5Duty Medical Officer, Kauvery Heart City, Trichy, India

*Correspondence: [email protected] (Vigneshvarprashanth Umapathy)

Abstract

Just four days after the International Day of Emergency medicine, we had the opportunity to successfully revive a 56-year-old gentleman from cardiac arrest after an hour-long CPR.

Keywords: Cardiopulmonary resuscitation; Cardiac arrest; Neurological outcome; Ventricular fibrillation; Prolonged CPR

Background

Cardiopulmonary resuscitation (CPR), a life-saving process, integrates the use of chest compressions and artificial ventilation to maintain circulatory flow and oxygenation during cardiac arrest. Although survival rates and neurologic outcomes are poor for patients with cardiac arrest, early appropriate resuscitation including early defibrillation, when needed, and appropriate implementation of post-cardiac arrest care led to improved survival and neurologic outcomes [1]. We present a case report of successful recovery from cardiac arrest without any neurological deficit or significant organ damage, following prolonged CPR.

Case Presentation

A 56-year-old gentleman was brought to us in an unresponsive state. His attendant revealed that he complained of chest pain and sweating for one hour after which he was taken to a nearby hospital where ECG (Figure 1) revealed myocardial infarction (MI), and was then referred here. He had a cardiac arrest on the way and was unconscious on arrival. Blood pressure, heart rate, and oxygen saturation were not recordable and carotid pulse was not felt. Cardiopulmonary resuscitation (CPR) was started. The defibrillator monitor showed ventricular fibrillation (VF) (Figure 2). DC shock and adrenaline were given. ACLS protocol was followed. His VF persisted. The attendants started losing hope. But the indefatigable doctors continued resuscitation. They took their turns. Return of spontaneous circulation (ROSC) was obtained after an hour. Noradrenaline and dopamine infusion were started. Bicarbonate and fluid bolus were given. Lidocaine, amiodarone, and magnesium sulphate were also administered during the process. He was intubated and ventilated. He developed a complete heart block (Figure 3) with a heart rate of 25/min which improved to 45/min with atropine. Emergency temporary pacemaker implantation (TPI) was done. Ticagrelor, aspirin, atorvastatin, heparin, and a broad-spectrum antibiotic were started. He was then taken to the Cath lab and a coronary angiogram (CAG) was done. CAG showed triple vessel disease including 100% occlusion of the right coronary artery (RCA). Percutaneous transluminal coronary angioplasty (PTCA) of the RCA was performed. There were no procedural or post-procedural complications. The temporary pacemaker was removed. He required inotropes to maintain mean arterial pressure. However, he gradually improved, and inotrope support was first tapered and then weaned off. Echocardiography showed mild left ventricular dysfunction. There was a transient elevation in creatinine during his stay. He was newly diagnosed to have type 2 diabetes mellitus. He subsequently recovered and was then discharged with advice to follow up.

Figure 1: ECG (taken in nearby hospital) suggestive of inferior and posterior wall MI

Figure 2: Defibrillator showing Ventricular fibrillation

Figure 3: ECG taken during resuscitation suggestive of inferior and posterior wall MI with complete heart block

Figure 4: ECG taken after PTCA

Discussion

Out-of-hospital cardiac arrest (OHCA) is a time-sensitive, life-threatening emergency that occurs millions of times every year. Only about 10% of people who experience OHCA are expected to survive with a favourable neurological outcome [2].

Key components of high-quality CPR [4]

Minimise interruption – aim for chest compression fraction above 80%

Chest compression rate 100-120/min

Compression depth at least 5 cm in adults

Full chest recoil

Avoid excessive ventilation (less than 12 breaths/min and minimal chest rise)

Some studies suggest that conventional resuscitation is most effective within the first 10 – 15 minutes (with a 75% rate of neurologic recovery when ROSC is achieved) and that the probability of favourable neurologic recovery fell to 2% beyond this point [4]. Despite this overall poor prognosis, multiple cases of successful prolonged resuscitation with neurologically intact survival have been reported [5].

To stop or continue CPR?

A general approach is to stop CPR after 20 minutes if there is no ROSC or viable cardiac rhythm re-established, and no reversible factors present that would potentially alter the outcome. However, the decision to stop CPR should be tailored according to the specifics of the individual case and is based on clinical judgement. The decision is best made by the team leader in consultation with other team members. Always initial resuscitation efforts have to be maintained until adequate information is available to make the call to discontinue [3].

When to stop CPR?	When to continue CPR?
ROSC – resuscitation guidelines require 2 minutes of CPR post defibrillation prior to checking for ROSC; may be identified by an upsurge in ETCO2	Continue in young people who have persistent VF until reversible factors have been fixed or therapeutic options exhausted
Pre-existing chronic illness preventing meaningful recovery (nursing home resident with dementia, disseminated cancer)	Hypothermia (â€œnot dead until warm and dead)
Acute illness preventing recovery (100% burns, non-survivable injuries, catastrophic TBI with no brain stem reflexes)	Asthma (need to correct dynamic hyperinflation)
No response to ACLS after 20 minutes of efficient resuscitation in absence of ROSC, a shockable rhythm or reversible causes	Toxicological arrest (full neurological recovery after >4 hours CPR is possible; asystole may be a direct drug effect that will recover in time)
	Thrombolytics given during CPR (should continue up to 2 hours post-administration)
	Pregnancy prior to resuscitative caesarean section

(TBI – traumatic brain injury; ACLS – advanced cardiovascular life support)

Conclusion

Timely, continuous and high-quality CPR by a well-trained and co-ordinated emergency department team is crucial in managing such cases. The team leader in discussion with other members can make the call to stop or continue CPR based on clinical judgement.

References

Jesse Borke. Cardiopulmonary Resuscitation. Medscape. Updated 2021. https://emedicine.medscape.com/article/1344081
Brooks SC, et al. Optimizing outcomes after out-of-hospital cardiac arrest with innovative approaches to public-access defibrillation: A scientific statement from the International Liaison Committee on Resuscitation. Circulation. 2022 Mar 29;145(13):e776-801.
Life In the Fast Lane Blog, Cessation of CPR, https://litfl.com/cessation-of-cpr/
Vandervelden S, et al. Prolonged CPR. Trends in Anaesthesia and Critical Care. 2016 Sep 1;9:13-9.
Youness H, et al. Review and outcome of prolonged cardiopulmonary resuscitation. Critical Care Research and Practice. 2016 Jan 1;2016.