American Journal of Emergency Medicine 33 (2015) 474.e5–474.e6
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Prolonged pulseless electrical activity: successful resuscitation using extracorporeal membrane oxygenation☆,☆☆ Abstract Pulseless electrical activity (PEA) can rapidly transform into sudden cardiac death, if the etiology cannot be identified and corrected immediately. The clinical challenge is how to resuscitate the patient with prolonged PEA. We present a case of a 51-year-old man with PEA due to acute myocardial infarction caused by total occlusion of the main coronary artery, which was refractory to prolonged conventional cardiopulmonary resuscitation. Extracorporeal membrane oxygenation was initiated approximately 75 minutes after prolonged cardiopulmonary resuscitation; this achieved a sustained return of spontaneous circulation, which permitted adequate time for subsequent coronary intervention. He was discharged on day 16 without any further sequelae or neurologic deficits. A 51-year-old man was brought to the emergency department with a 1-hour history of chest tightness that was unrelieved by 2 doses of sublingual nitroglycerin. The patient had a history of coronary artery disease; 5 years back, he underwent primary percutaneous coronary intervention after an acute myocardial infarction. On arrival with the aforementioned complaint, he was semicomatose and diaphoretic, with a blood pressure of 52/28 mm Hg and a pulse of 73 beats per minute. A chest radiograph showed pulmonary edema. The electrocardiogram (ECG) showed a ST-segment elevation of 2 to 3 mm in lead aVR and tall T waves in V2 and V3 and a ST-segment depression of greater than 2 mm in leads II, III, aVF, and V4 through V6 (Figure). Immediately after ECG, his blood pressure and carotid pulse became undetectable, and he became unresponsive. The cardiac monitor revealed a slow and wide complex rhythm, but the carotid pulses could not be obtained. Furthermore, sudden cardiac arrest with pulseless electrical activity (PEA) developed, and an advanced cardiopulmonary life support was provided. During resuscitation, epinephrine and mechanical chest compression was performed for prolonged cardiac arrest. The laboratory data were significant for a high level of cardiac enzymes (Creatine phosphokinase (CPK), 12 519 U/L; creatine phosphokinase muscle-brain subtype (CPK-MB), N680 ng/mL). At this point, we performed cardiopulmonary resuscitation (CPR) for more than 55 minutes, and although there had been a transient return of spontaneous circulation (ROSC), it could not be sustained. Therefore, we decided to resuscitate the patient in our emergency department using extracorporeal membrane oxygenation (ECMO) support. Venoarterial ECMO catheters were inserted into the right femoral vessels, and sustained ROSC was achieved with further resuscitation. In addition, prompt percutaneous coronary intervention was performed for a ☆ Disclosure: The authors did not have conflict of interest to disclose. ☆☆ The authors did not receive any fund for this article. 0735-6757/© 2014 Elsevier Inc. All rights reserved.
presumed acute myocardial infarction, and the coronary arteriogram revealed a total occlusion of the left main artery. After a successful percutaneous coronary intervention with thrombosuction and direct stenting of the left main stem artery, continuous venovenous hemofiltration was performed for acute renal failure. Follow-up laboratory data revealed a lactate level of 4.2 mmol/L on day 2, and serial echocardiography revealed a recovery of heart contractility on day 4. Extracorporeal membrane oxygenation was then weaned off, but he later developed complications including pneumonia and gastrointestinal bleeding, which required prolonged hospitalization. He was discharged on day 16 without any further sequelae or neurologic deficits. In this case, acute coronary syndrome was associated with PEA and sudden cardiac arrest. Because of the persisting PEA, we considered that the patient had concomitant disease. The clinical challenge was how to resuscitate the patient with prolonged PEA due to acute myocardial infarction or other etiology. Emergency coronary angiography and other interventions were impossible at the time of ongoing CPR; therefore, resuscitation with ECMO support was necessary as a bridge to diagnosis and treatment. We clinically suspected the occlusion of the left main coronary artery based on the clinical features and ECG showing the ST-segment elevation in lead aVR with coexistent multilead ST-segment depression [1,2], which was compatible with the finding of emergency coronary angiography. Thus, prolonged cardiac arrest with PEA was secondary to occlusion of the left main artery. However, this life-threatening condition was refractory to conventional CPR, and ECMO support was initiated approximately 75 minutes after prolonged CPR, resulting in sustained ROSC, which allowed an adequate time for subsequent intervention. Although prolonged CPR can lead to multiple complications [3,4], the patient recovered completely with intact cerebral performance. In cases of prolonged PEA caused by acute myocardial infarction with occlusion of the left main artery, health care providers should consider ECMO for cardiopulmonary support and as a bridge to definitive diagnosis and treatment. Hsi-Wen Huang, MD 1 Chun-Chieh Chiu, MD 1 Department of Emergency Medicine Changhua Christian Hospital, Changhua, Taiwan Hsu-Heng Yen, MD 1 Department of Internal Medicine Changhua Christian Hospital, Changhua, Taiwan College of Medicine, Chung Shan Medical University, Taichung, Taiwan Yao-Li Chen, MD 1 Department of Cardiovascular Surgery Changhua Christian Hospital, Changhua, Taiwan
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H.-W. Huang et al. / American Journal of Emergency Medicine 33 (2015) 474.e5–474.e6
Figure. The 12-lead electrocardiogram showed an ST-segment elevation of 2.3 mm in lead aVR and tall T-waves in V2 and V3 and a ST-segment depression of greater than 2 mm in leads II, III, aVF, and V4 through V6.
Fu-Yuan Siao, MD 2 Department of Emergency Medicine Changhua Christian Hospital, Changhua, Taiwan Corresponding author. Department of Emergency Medicine Changhua Christian Hospital, Changhua, Taiwan E-mail address: [email protected] 1 2
Care of the patient, drafting and final approval and drafting of the manuscript. Drafting, writing, and final approval and drafting of the manuscript.
http://dx.doi.org/10.1016/j.ajem.2014.08.030
References [1] de Winter RJ, Verouden NJ, Wellens HJ, Wilde AA. Interventional Cardiology Group of the Academic Medical Center. A new ECG sign of proximal LAD occlusion. N Engl J Med 2008;359(19):2071–3. [2] Hennings JR, Fesmire FM. A new electrocardiographic criteria for emergent reperfusion therapy. Am J Emerg Med 2012;30(6):994–1000. [3] Chen YS, Yu HY, Huang SC, Lin JW, Chi NH, Wang CH, et al. Extracorporeal membrane oxygenation support can extend the duration of cardiopulmonary resuscitation. Crit Care Med 2008;36(9):2529–35. [4] Massetti M, Tasle M, Le Page O, Deredec R, Babatasi G, Buklas D, et al. Back from irreversibility: extracorporeal life support for prolonged cardiac arrest. Ann Thorac Surg 2005;79(1):178–83.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Prolonged pulseless electrical activity: successful resuscitation using extracorporeal membrane oxygenation☆,☆☆ Abstract Pulseless electrical activity (PEA) can rapidly transform into sudden cardiac death, if the etiology cannot be identified and corrected immediately. The clinical challenge is how to resuscitate the patient with prolonged PEA. We present a case of a 51-year-old man with PEA due to acute myocardial infarction caused by total occlusion of the main coronary artery, which was refractory to prolonged conventional cardiopulmonary resuscitation. Extracorporeal membrane oxygenation was initiated approximately 75 minutes after prolonged cardiopulmonary resuscitation; this achieved a sustained return of spontaneous circulation, which permitted adequate time for subsequent coronary intervention. He was discharged on day 16 without any further sequelae or neurologic deficits. A 51-year-old man was brought to the emergency department with a 1-hour history of chest tightness that was unrelieved by 2 doses of sublingual nitroglycerin. The patient had a history of coronary artery disease; 5 years back, he underwent primary percutaneous coronary intervention after an acute myocardial infarction. On arrival with the aforementioned complaint, he was semicomatose and diaphoretic, with a blood pressure of 52/28 mm Hg and a pulse of 73 beats per minute. A chest radiograph showed pulmonary edema. The electrocardiogram (ECG) showed a ST-segment elevation of 2 to 3 mm in lead aVR and tall T waves in V2 and V3 and a ST-segment depression of greater than 2 mm in leads II, III, aVF, and V4 through V6 (Figure). Immediately after ECG, his blood pressure and carotid pulse became undetectable, and he became unresponsive. The cardiac monitor revealed a slow and wide complex rhythm, but the carotid pulses could not be obtained. Furthermore, sudden cardiac arrest with pulseless electrical activity (PEA) developed, and an advanced cardiopulmonary life support was provided. During resuscitation, epinephrine and mechanical chest compression was performed for prolonged cardiac arrest. The laboratory data were significant for a high level of cardiac enzymes (Creatine phosphokinase (CPK), 12 519 U/L; creatine phosphokinase muscle-brain subtype (CPK-MB), N680 ng/mL). At this point, we performed cardiopulmonary resuscitation (CPR) for more than 55 minutes, and although there had been a transient return of spontaneous circulation (ROSC), it could not be sustained. Therefore, we decided to resuscitate the patient in our emergency department using extracorporeal membrane oxygenation (ECMO) support. Venoarterial ECMO catheters were inserted into the right femoral vessels, and sustained ROSC was achieved with further resuscitation. In addition, prompt percutaneous coronary intervention was performed for a ☆ Disclosure: The authors did not have conflict of interest to disclose. ☆☆ The authors did not receive any fund for this article. 0735-6757/© 2014 Elsevier Inc. All rights reserved.
presumed acute myocardial infarction, and the coronary arteriogram revealed a total occlusion of the left main artery. After a successful percutaneous coronary intervention with thrombosuction and direct stenting of the left main stem artery, continuous venovenous hemofiltration was performed for acute renal failure. Follow-up laboratory data revealed a lactate level of 4.2 mmol/L on day 2, and serial echocardiography revealed a recovery of heart contractility on day 4. Extracorporeal membrane oxygenation was then weaned off, but he later developed complications including pneumonia and gastrointestinal bleeding, which required prolonged hospitalization. He was discharged on day 16 without any further sequelae or neurologic deficits. In this case, acute coronary syndrome was associated with PEA and sudden cardiac arrest. Because of the persisting PEA, we considered that the patient had concomitant disease. The clinical challenge was how to resuscitate the patient with prolonged PEA due to acute myocardial infarction or other etiology. Emergency coronary angiography and other interventions were impossible at the time of ongoing CPR; therefore, resuscitation with ECMO support was necessary as a bridge to diagnosis and treatment. We clinically suspected the occlusion of the left main coronary artery based on the clinical features and ECG showing the ST-segment elevation in lead aVR with coexistent multilead ST-segment depression [1,2], which was compatible with the finding of emergency coronary angiography. Thus, prolonged cardiac arrest with PEA was secondary to occlusion of the left main artery. However, this life-threatening condition was refractory to conventional CPR, and ECMO support was initiated approximately 75 minutes after prolonged CPR, resulting in sustained ROSC, which allowed an adequate time for subsequent intervention. Although prolonged CPR can lead to multiple complications [3,4], the patient recovered completely with intact cerebral performance. In cases of prolonged PEA caused by acute myocardial infarction with occlusion of the left main artery, health care providers should consider ECMO for cardiopulmonary support and as a bridge to definitive diagnosis and treatment. Hsi-Wen Huang, MD 1 Chun-Chieh Chiu, MD 1 Department of Emergency Medicine Changhua Christian Hospital, Changhua, Taiwan Hsu-Heng Yen, MD 1 Department of Internal Medicine Changhua Christian Hospital, Changhua, Taiwan College of Medicine, Chung Shan Medical University, Taichung, Taiwan Yao-Li Chen, MD 1 Department of Cardiovascular Surgery Changhua Christian Hospital, Changhua, Taiwan
474.e6
H.-W. Huang et al. / American Journal of Emergency Medicine 33 (2015) 474.e5–474.e6
Figure. The 12-lead electrocardiogram showed an ST-segment elevation of 2.3 mm in lead aVR and tall T-waves in V2 and V3 and a ST-segment depression of greater than 2 mm in leads II, III, aVF, and V4 through V6.
Fu-Yuan Siao, MD 2 Department of Emergency Medicine Changhua Christian Hospital, Changhua, Taiwan Corresponding author. Department of Emergency Medicine Changhua Christian Hospital, Changhua, Taiwan E-mail address: [email protected] 1 2
Care of the patient, drafting and final approval and drafting of the manuscript. Drafting, writing, and final approval and drafting of the manuscript.
http://dx.doi.org/10.1016/j.ajem.2014.08.030
References [1] de Winter RJ, Verouden NJ, Wellens HJ, Wilde AA. Interventional Cardiology Group of the Academic Medical Center. A new ECG sign of proximal LAD occlusion. N Engl J Med 2008;359(19):2071–3. [2] Hennings JR, Fesmire FM. A new electrocardiographic criteria for emergent reperfusion therapy. Am J Emerg Med 2012;30(6):994–1000. [3] Chen YS, Yu HY, Huang SC, Lin JW, Chi NH, Wang CH, et al. Extracorporeal membrane oxygenation support can extend the duration of cardiopulmonary resuscitation. Crit Care Med 2008;36(9):2529–35. [4] Massetti M, Tasle M, Le Page O, Deredec R, Babatasi G, Buklas D, et al. Back from irreversibility: extracorporeal life support for prolonged cardiac arrest. Ann Thorac Surg 2005;79(1):178–83.
