American Journal of Emergency Medicine 33 (2015) 130.e3–130.e4
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Cardiac arrest with anaphylactic shock: a successful resuscitation using extracorporeal membrane oxygenation
Abstract Anaphylactic shock is a serious allergic reaction, setting in rapidly, which may lead to life-threatening circulatory failure and necessitates aggressive support to ensure full recovery. We report the case of a 50year-old man who developed cardiovascular collapse and cardiac arrest to iodine contrast media, occurring during coronary angiography. He was required temporary mechanical circulatory support with an venoarterial extracorporeal membrane oxygenation system by failure of conventional therapy and intra-aortic balloon pump counterpulsation therapy. He had full recovery of cardiac function and released from the hospital 21 days after admission without a neurologic deficit. Iodine contrast agent allergic reaction is the most serious adverse reactions in the process of imaging examination. Although the newer low-osmolality, nonionic contrast media have less adverse reaction, it is widely recognized that they give rise to immediate adverse reactions in susceptible individuals [1]. Most serious adverse reactions, such as anaphylactic shock, have fatal consequences, which may lead to cardiovascular collapse. Acute ventricular dysfunction after anaphylactic shock is a well-reported phenomenon [2,3]. The exact aetiology of ventricular dysfunction after anaphylactic shock is unknown. Kounis syndrome or “allergic angina” describes an acute coronary syndrome occurring during an anaphylactic reaction thought to be secondary to mast cell degranulation and circulating inflammatory mediators [4]. When the anaphylactic shock leads to acute cardiac function obstacle, treatment is very difficult. Here, we report a fatal case of anaphylactic shock due to contrast medium resulting in hemodynamic collapse requiring a temporary extracorporeal membrane oxygenation (ECMO) support. A 50-year-old man was referred to our hospital for acute inferior wall myocardial infarction 2 days before. He has a 5-year history of diabetes, which is treated with oral hypoglycemic medication. He quit smoking 2 years ago and has a 20 pack-year history. He has an allergy to penicillins. Her initial vital signs included temperature of 36.2°C, heart rate of 88 beats per minute, blood pressure of 120/70 mm Hg, and respiratory rate of 20 breaths per minute. There was Q waves in leads III and aVF on electrocardiogram, and chest x-ray revealed no acute changes. Hypokinesia of the interior wall motion was detected by transthoracic echocardiography, but ejection fraction was normal. Laboratories revealed a leukocytosis of 10.09 × 10 9/L, C-reactive protein of 7.04 mg/L, lactate of 1.5 mmol/L, interleukin 8 of 258 pg/mL, interleukin 6 of 9.22 pg/mL, tumor necrosis factor α of 25.1 pg/mL, and the serum levels of troponin I of 28.157 ng/mL (reference range, 0-0.04 ng/mL). 0735-6757/© 2014 Elsevier Inc. All rights reserved.
A week after admission, coronary angiography was performed to evaluate the coronary arteries. After administration of ioversol injection (10 mL), coronary angiogram revealed that the left main coronary artery and the proximal segments of left anterior descending and circumflex artery were normal, but he had acute onset of acute respiratory distress, hypotension, and altered mental status, soon followed by cardiac arrest. Cardiopulmonary resuscitation (CPR) was immediately started. After 10 minutes of cardiopulmonary resuscitation, he was resuscitated with epinephrine, corticosteroids, volume, and intubation. An intra-aortic balloon pump (IABP) was immediately inserted for hemodynamic support. Emergent bedside echocardiogram examination ruled out a cardiac tamponade and revealed severe global hypokinesia of the left ventricle with a left ventricular ejection fraction of 15%. The most likely diagnosis was concerning for anaphylactic shock. So, we ended the further coronary angiography examination, and the patient was taken to the cardiac care unit to continue to rescue. Despite using IABP support and large amounts of fluid resuscitation, epinephrine and vasopressin were titrated to maximum doses; his hemodynamic status continued to worsen. He required circulatory support with ECMO, which was inserted in a venoarterial configuration by cannulation on left femoral vessels. The situation was stabilized under vasoactive agents, IABP, and ECMO support. He was eventually weaned off ECMO and extubated on day 11 of admission (4 days of mechanical ventilation and ECMO support) because of his improved clinical condition and left ventricular systolic function (ejection fraction of 45%). Intra-aortic balloon pump was discontinued on day 13 of admission. He was discharged on day 21 when the ejection fraction on the echocardiogram was approximately 50% and without any serious complications or neurologic deficits. The present case report illustrates the benefit of ECMO to restore cardiovascular collapse and has been shown to be effective for the treatment of refractory anaphylactic shock. Anaphylaxis is a systemic type I hypersensitivity reaction, and anaphylactic shock is a potentially lethal complication, which may lead to fatal consequences. Because it rapidly transforms into lifethreatening circulatory failure and massive fluid shifts, first-line treatment is epinephrine and volume expansion by intravenous fluids. However, when the anaphylactic shock results in acute cardiac function obstacle, traditional drug treatment is very limited. In our case, anaphylactic shock, which is caused by imaging contrast agent, had led to cardiovascular collapse and cardiac arrest, and hemodynamics could not be stable despite using large amounts of fluid resuscitation, vascular active drugs, and IABP support. Therefore, in this situation, ECMO, finally, as a bridge to recovery for the patient played an important role.
130.e4
Z. Zhang et al. / American Journal of Emergency Medicine 33 (2015) 130.e3–130.e4
In recent years, ECMO provides cardiopulmonary support and has been shown to be effective in providing circulatory support in patients with cardiogenic shock or cardiac arrest due to various pathophysiological situations, including acute myocarditis and ischemic heart disease [5,6]. Successful use of ECMO with other reasons for shock, such as septic shock, has been reported in a few cases [7]. However, application of the ECMO in anaphylactic shock patients has seldom been reported. Only 1 case of a 15-year-old adolescent boy who developed anaphylactic shock after amiodarone infusion resulting in haemodynamic collapse has been reportedly treated with left ventricular assist device as a resuscitation tool. He had full recovery of cardiac function and returned to baseline neurologic status. This is the first report of successful left ventricular assist device use for recovery from cardiovascular collapse due to anaphylaxis [3]. In our case, although he was admitted to the hospital with acute inferior wall myocardial infarction, his hemodynamics was stable. He was ruled out of other causes of serious complications, such as left main lesion and cardiac rupture. Therefore, the main cause of the patient with cardiovascular collapse and cardiac arrest should first been considered the anaphylactic shock. Because anaphylactic shock leading to cardiac function obstacle was temporary, ECMO had acted as a bridge to recovery from the life-threatening but reversible disease.
Zhi-ping Zhang, MD ⁎ Xi Su, PhD Chen-wei Liu, PhD Cardiac Care Unit, Wuhan Asia Heart Hospital, Wuhan, 430022, China ⁎ Corresponding author. E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.06.034 References [1] Nagai Y, Tanaka Y, Nakazato Y, Sugawara N, Arai M, Okada E, et al. Autopsy case of delayed anaphylactic shock due to contrast medium. J Dermatol 2012;39(10):852–4. [2] Kurt IH, Yalcin F. Anaphylactic shock due to intravenous amiodarone. Am J Emerg Med 2012;30(1):265.e1–2. [3] Averin K, Lorts A, Connor C. Anaphylactic shock after amiodarone infusion resulting in haemodynamic collapse requiring a temporary ventricular assist device. Cardiol Young 2013:1–3. [4] Kounis NG. Kounis syndrome (allergic angina and allergic myocardial infarction): a natural paradigm? Int J Cardiol 2006;110(1):7–14. [5] Kim H, Lim SH, Hong J, Hong YS, Lee C, Jung JH, et al. Efficacy of veno-arterial extracorporeal membrane oxygenation in acute myocardial infarction with cardiogenic shock. Resuscitation 2012;83(8):971–5. [6] Beurtheret S, Mordant P, Paoletti X, Marijon E, Celermajer D, Léger P, et al. Emergency circulatory support in refractory cardiogenic shock patients in remote institutions: a pilot study (the cardiac-RESCUE program). Eur Heart J 2013;34(2):112–20. [7] Sharma AS, Weerwind PW, Maessen JG. Extracorporeal membrane oxygenation resuscitation in adult patients with refractory septic shock. J Thorac Cardiovasc Surg 2014;147(4):1441–2.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Cardiac arrest with anaphylactic shock: a successful resuscitation using extracorporeal membrane oxygenation
Abstract Anaphylactic shock is a serious allergic reaction, setting in rapidly, which may lead to life-threatening circulatory failure and necessitates aggressive support to ensure full recovery. We report the case of a 50year-old man who developed cardiovascular collapse and cardiac arrest to iodine contrast media, occurring during coronary angiography. He was required temporary mechanical circulatory support with an venoarterial extracorporeal membrane oxygenation system by failure of conventional therapy and intra-aortic balloon pump counterpulsation therapy. He had full recovery of cardiac function and released from the hospital 21 days after admission without a neurologic deficit. Iodine contrast agent allergic reaction is the most serious adverse reactions in the process of imaging examination. Although the newer low-osmolality, nonionic contrast media have less adverse reaction, it is widely recognized that they give rise to immediate adverse reactions in susceptible individuals [1]. Most serious adverse reactions, such as anaphylactic shock, have fatal consequences, which may lead to cardiovascular collapse. Acute ventricular dysfunction after anaphylactic shock is a well-reported phenomenon [2,3]. The exact aetiology of ventricular dysfunction after anaphylactic shock is unknown. Kounis syndrome or “allergic angina” describes an acute coronary syndrome occurring during an anaphylactic reaction thought to be secondary to mast cell degranulation and circulating inflammatory mediators [4]. When the anaphylactic shock leads to acute cardiac function obstacle, treatment is very difficult. Here, we report a fatal case of anaphylactic shock due to contrast medium resulting in hemodynamic collapse requiring a temporary extracorporeal membrane oxygenation (ECMO) support. A 50-year-old man was referred to our hospital for acute inferior wall myocardial infarction 2 days before. He has a 5-year history of diabetes, which is treated with oral hypoglycemic medication. He quit smoking 2 years ago and has a 20 pack-year history. He has an allergy to penicillins. Her initial vital signs included temperature of 36.2°C, heart rate of 88 beats per minute, blood pressure of 120/70 mm Hg, and respiratory rate of 20 breaths per minute. There was Q waves in leads III and aVF on electrocardiogram, and chest x-ray revealed no acute changes. Hypokinesia of the interior wall motion was detected by transthoracic echocardiography, but ejection fraction was normal. Laboratories revealed a leukocytosis of 10.09 × 10 9/L, C-reactive protein of 7.04 mg/L, lactate of 1.5 mmol/L, interleukin 8 of 258 pg/mL, interleukin 6 of 9.22 pg/mL, tumor necrosis factor α of 25.1 pg/mL, and the serum levels of troponin I of 28.157 ng/mL (reference range, 0-0.04 ng/mL). 0735-6757/© 2014 Elsevier Inc. All rights reserved.
A week after admission, coronary angiography was performed to evaluate the coronary arteries. After administration of ioversol injection (10 mL), coronary angiogram revealed that the left main coronary artery and the proximal segments of left anterior descending and circumflex artery were normal, but he had acute onset of acute respiratory distress, hypotension, and altered mental status, soon followed by cardiac arrest. Cardiopulmonary resuscitation (CPR) was immediately started. After 10 minutes of cardiopulmonary resuscitation, he was resuscitated with epinephrine, corticosteroids, volume, and intubation. An intra-aortic balloon pump (IABP) was immediately inserted for hemodynamic support. Emergent bedside echocardiogram examination ruled out a cardiac tamponade and revealed severe global hypokinesia of the left ventricle with a left ventricular ejection fraction of 15%. The most likely diagnosis was concerning for anaphylactic shock. So, we ended the further coronary angiography examination, and the patient was taken to the cardiac care unit to continue to rescue. Despite using IABP support and large amounts of fluid resuscitation, epinephrine and vasopressin were titrated to maximum doses; his hemodynamic status continued to worsen. He required circulatory support with ECMO, which was inserted in a venoarterial configuration by cannulation on left femoral vessels. The situation was stabilized under vasoactive agents, IABP, and ECMO support. He was eventually weaned off ECMO and extubated on day 11 of admission (4 days of mechanical ventilation and ECMO support) because of his improved clinical condition and left ventricular systolic function (ejection fraction of 45%). Intra-aortic balloon pump was discontinued on day 13 of admission. He was discharged on day 21 when the ejection fraction on the echocardiogram was approximately 50% and without any serious complications or neurologic deficits. The present case report illustrates the benefit of ECMO to restore cardiovascular collapse and has been shown to be effective for the treatment of refractory anaphylactic shock. Anaphylaxis is a systemic type I hypersensitivity reaction, and anaphylactic shock is a potentially lethal complication, which may lead to fatal consequences. Because it rapidly transforms into lifethreatening circulatory failure and massive fluid shifts, first-line treatment is epinephrine and volume expansion by intravenous fluids. However, when the anaphylactic shock results in acute cardiac function obstacle, traditional drug treatment is very limited. In our case, anaphylactic shock, which is caused by imaging contrast agent, had led to cardiovascular collapse and cardiac arrest, and hemodynamics could not be stable despite using large amounts of fluid resuscitation, vascular active drugs, and IABP support. Therefore, in this situation, ECMO, finally, as a bridge to recovery for the patient played an important role.
130.e4
Z. Zhang et al. / American Journal of Emergency Medicine 33 (2015) 130.e3–130.e4
In recent years, ECMO provides cardiopulmonary support and has been shown to be effective in providing circulatory support in patients with cardiogenic shock or cardiac arrest due to various pathophysiological situations, including acute myocarditis and ischemic heart disease [5,6]. Successful use of ECMO with other reasons for shock, such as septic shock, has been reported in a few cases [7]. However, application of the ECMO in anaphylactic shock patients has seldom been reported. Only 1 case of a 15-year-old adolescent boy who developed anaphylactic shock after amiodarone infusion resulting in haemodynamic collapse has been reportedly treated with left ventricular assist device as a resuscitation tool. He had full recovery of cardiac function and returned to baseline neurologic status. This is the first report of successful left ventricular assist device use for recovery from cardiovascular collapse due to anaphylaxis [3]. In our case, although he was admitted to the hospital with acute inferior wall myocardial infarction, his hemodynamics was stable. He was ruled out of other causes of serious complications, such as left main lesion and cardiac rupture. Therefore, the main cause of the patient with cardiovascular collapse and cardiac arrest should first been considered the anaphylactic shock. Because anaphylactic shock leading to cardiac function obstacle was temporary, ECMO had acted as a bridge to recovery from the life-threatening but reversible disease.
Zhi-ping Zhang, MD ⁎ Xi Su, PhD Chen-wei Liu, PhD Cardiac Care Unit, Wuhan Asia Heart Hospital, Wuhan, 430022, China ⁎ Corresponding author. E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.06.034 References [1] Nagai Y, Tanaka Y, Nakazato Y, Sugawara N, Arai M, Okada E, et al. Autopsy case of delayed anaphylactic shock due to contrast medium. J Dermatol 2012;39(10):852–4. [2] Kurt IH, Yalcin F. Anaphylactic shock due to intravenous amiodarone. Am J Emerg Med 2012;30(1):265.e1–2. [3] Averin K, Lorts A, Connor C. Anaphylactic shock after amiodarone infusion resulting in haemodynamic collapse requiring a temporary ventricular assist device. Cardiol Young 2013:1–3. [4] Kounis NG. Kounis syndrome (allergic angina and allergic myocardial infarction): a natural paradigm? Int J Cardiol 2006;110(1):7–14. [5] Kim H, Lim SH, Hong J, Hong YS, Lee C, Jung JH, et al. Efficacy of veno-arterial extracorporeal membrane oxygenation in acute myocardial infarction with cardiogenic shock. Resuscitation 2012;83(8):971–5. [6] Beurtheret S, Mordant P, Paoletti X, Marijon E, Celermajer D, Léger P, et al. Emergency circulatory support in refractory cardiogenic shock patients in remote institutions: a pilot study (the cardiac-RESCUE program). Eur Heart J 2013;34(2):112–20. [7] Sharma AS, Weerwind PW, Maessen JG. Extracorporeal membrane oxygenation resuscitation in adult patients with refractory septic shock. J Thorac Cardiovasc Surg 2014;147(4):1441–2.
