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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 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. 

4 comments:

  1. very informative.please keep posting other such knowledge enhancing and interesting articles.thank you very much

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  2. Thankx for sharing lakshya. In this particular case, pt is a young man, no Co morbids. Many a times, going beyond protocols N relaying on ones clinical judgement, saves life.
    Rachana

    ReplyDelete
    Replies
    1. Could not agree more with your opinion Rachana

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