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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, July 27, 2015

Auto-resuscitation: Lazarus Syndrome!


What is Lazarus Syndrome?

Lazarus syndrome/ phenomenon is a rare and probably under reported condition where delayed return of spontaneous circulation (ROSC) after cessation of cardiopulmonary resuscitation (CPR) is seen. This was first reported in 1982, so far 38 cases of delayed ROSC have been published and majority of them come from anaesthesia and critical care literature. 

In the cases reported so far, ROSC very often occurred within 10 minutes of stopping CPR. Less than half of them achieved good neurological recovery following ROSC and the rest died soon after.




What are the possible mechanisms that explain Lazarus Syndrome?

The exact mechanism of delayed ROSC is unclear and not well understood. This is possibly multifactorial:

1. Positive end expiratory pressure

Dynamic hyperinflation of the lung causing increased positive end expiratory pressure (PEEP) is one of the proposed mechanisms.

2. Delayed action of drugs

Some authors suggest delayed action of drugs administered during CPR as a mechanism for delayed ROSC. It is possible that drugs injected through a peripheral vein are inadequately delivered centrally due to impaired venous return, and when venous return improves after stopping the dynamic hyperinflation, delivery of drugs could contribute to return of circulation.

3. Myocardial stunning

Prolonged myocardial dysfunction can occur following myocardial ischaemia, taking up to several hours before normal function returns. Myocardial Infarction was present in about 1/3 of the cases reported so far which could have contributed to transient myocardial ischaemia and stunning.


What can be the implications for emergency health care providers with delayed ROSC?

Delayed ROSC can lead to serious professional and legal consequences. Questions can be raised about the quality of resus and whether it was stopped too soon. The  physicians might also be accused of negligence or incompetence and even be sued for the damages.

In such a scenario, the conduct of resuscitation can only be assessed from the documentation, so it is vital to record the events during cardiac arrest as accurately as possible. It is absolutely essential to get a consensus from the arrest team and to document the reason for termination of CPR. 



So, What makes Lazarus Syndrome important for us?

We need to realize that death is not an event, but a process. It is a process during which various organs supporting the continuation of life fail. Cessation of circulation and respiration is such an example. The physical findings to support this—absence of heartbeat and respiration—are the traditional and the most widely used criteria to certify death. Since these findings alone are not a sign of definitive death, it is quite possible to declare death in the interval between cessation of CPR and delayed ROSC.

Some recommend that the patients should be passively monitored for few minutes following unsuccessful CPR. It should also be mentioned that the patient is being closely monitored to establish death. Death should not be certified in any patient immediately after stopping CPR, and one should wait at least 5-10 minutes, if not longer, to verify and confirm death beyond doubt.  


The time honoured criteria of the stoppage of the heart beat and circulation are indicative of death only when they persist long enough for the brain to die.

KEY POINTS

  • Lazarus phenomenon is delayed ROSC after cessation of CPR.
  • Understand death: It is a process, Stop looking at it like a single event.
  • Observe the patients for 5-10 minutes the cessation of CPR before confirming death. (Get an EKG or bedside ECHO before you declare death)
  • Re-read and scrutinise the chart before signing it off. 

References: 
  1. Adhiyaman V, Adhiyaman S, Sundaram R. The Lazarus phenomenon. Journal of the Royal Society of Medicine. 2007;100(12):552-557.Bray JG. The Lazarus phenomenon revisited. Anesthesiology 1993;78: 991
  2. Linko K, Honkavaara P, Salmenpera M. Recovery after discontinued cardiopulmonary resuscitation. Lancet 1982;1: 106-7  
  3. Martens P, Vandekerckhove Y, Mullie A. Restoration of spontaneous circulation after cessation of cardiopulmonary resuscitation. Lancet 1993;341: 841 
  4. Braunwald E, Kloner RA. The stunned myocardium: prolonged, postischemic ventricular dysfunction. Circulation 1982;66: 1146-9 
  5. De Salvia A, Guardo A, Orrico M, De Leo D. A new case of Lazarus phenomenon? Forensic Sci Int2004;146: S13-5  
  6. Monticelli F, Bauer N, Meyer HJ. Lazarus phenomenon. Current resuscitation standards and questions for the expert witness (German). Rechtmedizin 2006;16: 57-63
  7. Lantos JD. The Lazarus Case: Life and Death Issues in Neonatal Intensive Care. Baltimore: Johns Hopkins University Press, 2001
  8. Conference of Medical Royal Colleges and their Faculties in the United Kingdom 1979. Diagnosis of death. BMJ 1979;1: 332. 
  9. Sweet WH. Brain death. NEJM 1978;299: 410-2  

Monday, July 20, 2015

Monday, July 13, 2015

Resuscitation: When do we call it off?

I have a case this week, that made me question some of the dogmas that I was always taught:

DOGMAS:

  1. CPR > 20 min is of no use
  2. No pupillary reaction means they are dead - do not resuscitate
  3. pH < 7.0, too bad - they are not gonna come back

0900AM: I was signing off after the night shift, when they wheeled in this man,

50/M, unresponsive, H/O preceding chest pain
Downtime: 10 minutes
No comorbid conditions 
and this is was his initial rhythm


Our team braced up and we started running the code. Eventually he ended up getting these meds/procedures over the course of next 45 minutes in addition to high quality compressions via a mechanical device.
  • Intubation
  • IV access
  • 200J X 8 Shocks
  • 13 amps Epinephrine
  • Amiodarone 300mg then 150mg
  • Lidocaine 100mg
  • 2gm Magnesium
  • + Dopamine was started during the compressions
  • Intra arrest ECHO
Just when all of us were loosing the hopes, we got his pulses back and this was the ECG.


Cardiology was already paged during the compressions on the basis of the ECHO that demonstrated RWMA. Cardio registrar was with us during the later half of the resus, witnessing everything with a fair amount of skepticism.

On getting the pulses back, his first remark was "Ahh. Why are you guys even doing this for the last 45 minutes". He is in Hypoxic encephalopathy, there is no pupillary reaction. He is never going to make it. Did you look at his blood gas!!  And then he insisted on a Neurology Consult to comment about his CNS function. But this chap was lucky enough because he coded during the morning hours, so we could get things moving fast in terms of getting the consult and convincing cardiology to push him to the cathlab. No surprise here, he had a >95% LAD lesion that was taken care off.

Post Resus ABG 
Next morning the ED docs were upstairs in the ICU to review this guy, and guess what he was propped up, ready for extubation, looking around, GCS: E4M6VT!! And the same cardiology registrar was right next to him. And then, much to my surprise he said "You guys saved him".

So, This guy who was almost "brought dead", walked out of the hospital after about 14 days, neurologically intact.

This leaves us with a few questions:

1. When should we stop resuscitation? 20 minutes?
The general consensus about CPR, at least among the other specialists (non-EM) is to "STOP AFTER 20 MINUTES" or else you are going to leave them in a persistent vegetative state. Some specialities those are far away from resuscitation consider cardiac arrest - an irreversible event and have a really pessimistic attitude towards it. Well this is not always true and this was a perfect example. And as Emergency Physicians, we all have seen such scenarios. In this particular case, we got the pulses back after about 45 minutes, in addition to the downtime of 10 minutes.

Key Message: Traditionally prolonged CPR is recommended for LA toxicity, Intra arrest lysed PE, Hypothermia aka special situations. But individualise this timeline with every patient. 20 minutes is not a deadline for everyone. Use age and co morbidities before you make the decision to stop.



2. What is the role of pupillary reaction and blood gas in terms of gauging the prognosis in the immediate post resus period?

Pupils - NOT RELIABLE
This guy had non reactive pupils post resus, but he had a favourable outcome. Therefore, we cannot rely on pupils in the immediate post resus period.  


Blood Gas (ABG) - NEVER!
His initial blood gas was thought to be "incompatible with life". Well to compare and contrast, this was his ABG the next morning in the ICU (about 21 hours after the first ABG).
ABG next morning
Key Message: Pupillary reaction suggests a favourable prognosis but non reactive pupils in post resus period do not convey anything. Though after a period of 72 hours, if they still have non reactive pupils, then that suggests a bad outcome.
And numbers on the blood gas cannot dictate the prognosis and your decision to stop/continue the resuscitation should never be based on them.



3. What can be done to avoid the delays when dealing with specialists in such situations?
We lost 10-15 crucial minutes, while getting neurology to see him and also convincing the cardiologists to take him for cath. Fortunately, it was a clean and smooth conversation without any clash of egos. Still we ROSC to balloon time 45 minutes!

Well, these potential delays can be avoided if you have pre-existing protocols about these issues. For this particular case, it could have been anything from "taking them to Cath with mechanical CPR" or "treating with thrombolytics" based on the ECHO findings. You can't be discussing these logistics in the heat of resus when you should be providing the post arrest care!

There is a ton of stuff that we can do depending on the resources we have:

Mechanichal CPR
Double Shocks/Mg/Beta blockers for incessant VF
Intra arrest ECHO/Thrombolytics
Empirical thrombolytics
Intraarrest PCI
PCI for all cardiac arrests with a worrisome history
ED initiated intra peritoneal dialysis
ECMO
Resuscitative Thoracotomy
REBOA

This is only possible when all the team members are completely aware of the resus plan. For instance, If you are planning a resuscitative thoracotomy, better make sure that your Cardiothoracic team of surgeons is okay with that and they must be on the same page with ED in terms of indications of doing this procedure because surgeons often refuse to take up a patient if they were never in favour of doing this procedure at the first place, and things get ugly from there.
Key message: Have set written protocols to avoid the delays and keep everyone on the same page.


Learning Points:
  • 20 minutes -  does not fit all.
  • Don't be fooled by those numbers on the blood and non reacting pupils are not good enough.
  • Have pre existing protocols, don't not fight with the logistics when you are stressed. 

Monday, July 6, 2015

Are you a good or bad PIMP?

What is pimping in Medical education?
In medicine, 'Pimping' refers to a more knowledgeable person (pimper) questioning others with less experience (pimpee) to test their knowledge. For example a students who has been questioned may say "Dr. XYZ pimped me about the Autonomic Nervous System today". 


Pimping
Pimping is a thin line between education and bullying. You can look at PIMPing as an opportunity for the seniors to humiliate the junior members of their team OR as a valid educational tool: a provocative method that might help students to think and retain the knowledge. I call that good pimping.

But trainees very often report back, complaining maltreatment by seniors (Registrars, Attendings), that too in front of patients and colleagues during the grand rounds. Some seniors make nasty comments and justify that by saying that "the trainee is going to remember that forever" and thus is unlikely to make the same error again. So they say "Pimping did not hinder, it helped"

Though pimping and socrates method look similar, there are differences between them. Pimping (or Bad Pimping) often uses the power of status to embarrass and humiliate the learner in a group environment. The goal of pimping is evaluative and thus answering questions becomes a competition. Often, rhetorical questions are asked.  Students might be asked about vague facts of certain diseases, or faculty can push students by questioning them about something challenging beyond the normal expectations. With this approach students might walk away in shame and embarrassment if the don't come up with the correct answer. Many, also consider pimping to be an abusive type of questioning. 


Socrates Method of teaching
Pimping somewhat resembles the Socratic method of teaching through questions and answers rather than a lecture kind of teaching. Socrates method of teaching involves discussion between individuals, based on questions and answers to stimulate critical thinking and to illuminate new ideas. When using Socrates method the goal of the question is known and follow-up questions lead the learner to solve the problem himself using his baseline knowledge. Its focus is on diagnosing the level of the learner and then teaching them appropriately.

Is pimping good or bad?
In recent years pimping has been looked down by some in medical education because it involves embarrassing and humiliating the medical students. Students and trainees develop negative associations with group learning methods and after start avoiding the pimp (Registrar or Attending). If they don't come up with an answer, they are made to look like "fools". However, pimpers argue saying that some amount of stress as a result of pimping can enhance the performance of learners because it gives them a fear of being put to shame and humiliation. 

If you are pimping, make sure that the questions asked are focussed, make sense, must follow up with other thought provoking questions and an explanation should be provided if no one comes up with the answer. Almost always when we ask a question as an educator, we already know if the learner knows the answer or not! So, Students do benefit from pimping, rather I should say "good pimping".


BAD/ MALIGNANT PIMPING
  • Trivial facts
  • Evaluative
  • Rhetorical questions
  • Passing humiliating comments 
  • Embarrassing students
  • Incessant use of questions
  • Pushing the learner to his emotional as well as intellectual limits.





GOOD/ KIND/ BETTER PIMPING
  • Focus is on concepts
  • Connects the new knowledge with existing knowledge
  • Questioning always starts from juniors, only then passed to the seniors 
  • Reframes the questions
  • Encouraging the learner to achieve his highest level of clinical reasoning
  • Offers an explanation and emphasise important learning points
  • Praise them
Surprisingly, a survey of medical students revealed that more than half like "being pimped" and even said that they would also pimp when they climb up the academic ladder though most of them made a distinction between good and bad pimping. So, Attendings and residents should feel free to pimp,  just as long as they are not demeaning or insulting. 


Key Point: It is okay to "pimp them" but don't be mean!




Further Reading:

  • Brancati, FL. The art of pimping. JAMA. 1989;262(1)89 
  • Detsky, AS. The art of pimping. JAMA. 2009;301(13):1379-81



Last week, one of our Trauma experts/ Prehospitalist and Resuscitationist (Dr. John Hinds) passed away in a road crash in Dublin. I never got an opportunity to meet him personally, but heard him few months back on emcrit.org and was totally amused with the kind of work he did. My heart felt condolences with his family.