Return of spontaneous circulation in patients with out-of-hospital cardiac arrest caused by pulmonary embolism using early point-of-care ultrasound and timely thrombolytic agent application: Two case reports

Introduction: Acute pulmonary embolism is a confirmed cause of up to 5% of out-of-hospital cardiac arrest and 5%–13% of unexplained cardiac arrest in patients. However, the true incidence may be much higher, as pulmonary embolism is often clinically underdiagnosed. Thrombolytic therapy is a recognized therapy for pulmonary embolism–associated cardiac arrest but is not routinely recommended during cardiopulmonary resuscitation. Therefore, clinicians should attempt to identify patients with suspected pulmonary embolism. Many point-of care ultrasound protocols suggest diagnosis of pulmonary embolism for cardiac arrest patients. Case presentation: We describe two male patients (60 years and 66 years, respectively) who presented to the emergency department with cardiac arrest within a period of 1 week. With administration of point-of care ultrasound during the ongoing cardiopulmonary resuscitation in both patients, fibrinolytic therapy was initiated under suspicion of cardiac arrest caused by pulmonary embolism. Both patients had return of spontaneous circulation; however, only the second patient, who received fibrinolytic therapy relatively early, was discharged with a good outcome. In this report, we discussed how to diagnose and manage patients with cardiac arrest–associated pulmonary embolism with the help of point-of care ultrasound. We also discuss the different clinical outcomes of the two patients based on the experience of the clinicians and the timing of thrombolytic agent application. Conclusions: If acute pulmonary embolism is suspected in patients with out-of-hospital cardiac arrest, we recommend prompt point-of care ultrasound examination. Point-of care ultrasound may help identify patients with pulmonary embolism during cardiopulmonary resuscitation, leading to immediate treatment, although the clinical outcomes may vary.

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Survival after Cardiac Arrest Secondary to Massive Pulmonary Embolism

Case Reports in Emergency Medicine ◽

10.1155/2018/8076808 ◽

2018 ◽

Vol 2018 ◽

pp. 1-4

Author(s):

Abdullah E. Laher ◽

Muhammed Moolla ◽

Feroza Motara ◽

Fathima Paruk ◽

Guy Richards

Keyword(s):

Pulmonary Embolism ◽

Cardiac Arrest ◽

Point Of Care ◽

Massive Pulmonary Embolism ◽

Fibrinolytic Therapy ◽

Pulmonary Angiography ◽

Spontaneous Circulation ◽

Point Of Care Ultrasound ◽

Postresuscitation Care ◽

The Right

Introduction. It is estimated that the diagnosis of pulmonary embolism (PE) is missed in as many as 84% of all cases of PE. Cardiac arrest following PE is generally associated with poor outcomes. Case Report. A 43-year-old man presented to the Emergency Department (ED) in cardiac arrest. Swelling of his right lower limb was noted on arrival. Point of care ultrasound was performed during ongoing cardiopulmonary resuscitation (CPR) and showed a thrombus in the right iliofemoral vein as well as dilatation of the right ventricle. Fibrinolytic therapy was initiated immediately and a return of spontaneous circulation (ROSC) was achieved 30 minutes later. The diagnosis of PE was finally confirmed on computed tomography pulmonary angiography once haemodynamic stability was achieved. The patient was thereafter transferred to the intensive care unit for postresuscitation care and further management. Several days later, he was discharged home neurologically intact and fully recovered. Discussion. Since outcomes after cardiac arrest following PE are generally dismal, available and potentially life-saving interventions to restore pulmonary circulation should be rapidly implemented when PE is the likely cause of cardiac arrest.

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The Effect of Implementing Mechanical Cardiopulmonary Resuscitation Devices on Out-of-Hospital Cardiac Arrest Patients in an Urban City of Taiwan

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18073636 ◽

2021 ◽

Vol 18 (7) ◽

pp. 3636

Author(s):

Yi-Rong Chen ◽

Chi-Jiang Liao ◽

Han-Chun Huang ◽

Cheng-Han Tsai ◽

Yao-Sing Su ◽

...

Keyword(s):

Cardiac Arrest ◽

Cardiopulmonary Resuscitation ◽

Primary Outcome ◽

Medical Service ◽

Spontaneous Circulation ◽

High Quality ◽

Urban City ◽

Service Response Time ◽

Mechanical Cpr ◽

Hospital Cardiac Arrest

High-quality cardiopulmonary resuscitation (CPR) is a key element in out-of-hospital cardiac arrest (OHCA) resuscitation. Mechanical CPR devices have been developed to provide uninterrupted and high-quality CPR. Although human studies have shown controversial results in favor of mechanical CPR devices, their application in pre-hospital settings continues to increase. There remains scant data on the pre-hospital use of mechanical CPR devices in Asia. Therefore, we conducted a retrospective cohort study between September 2018 and August 2020 in an urban city of Taiwan to analyze the effects of mechanical CPR devices on the outcomes of OHCA; the primary outcome was attainment of return of spontaneous circulation (ROSC). Of 552 patients with OHCA, 279 received mechanical CPR and 273 received manual CPR, before being transferred to the hospital. After multivariate adjustment for the influencing factors, mechanical CPR was independently associated with achievement of any ROSC (OR = 1.871; 95%CI:1.195–2.930) and sustained (≥24 h) ROSC (OR = 2.353; 95%CI:1.427–3.879). Subgroup analyses demonstrated that mechanical CPR is beneficial in shorter emergency medical service response time (≤4 min), witnessed cardiac arrest, and non-shockable cardiac rhythm. These findings support the importance of early EMS activation and high-quality CPR in OHCA resuscitation.

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Abstract 421: Point of Care Ultrasound Sonography (POCUS) in Cardiac Arrest: Predicting Survivorship

Circulation ◽

10.1161/circ.140.suppl_2.421 ◽

2019 ◽

Vol 140 (Suppl_2) ◽

Author(s):

Ada Wong ◽

Hassan Patail ◽

Sahar Ahmad

Keyword(s):

Cardiac Arrest ◽

Tricuspid Valve ◽

Prospective Observational Study ◽

Thrombus Formation ◽

Point Of Care ◽

Spontaneous Circulation ◽

Point Of Care Ultrasound ◽

Short Term ◽

Flow Stasis

Introduction: Survival after in hospital (IH) cardiac arrest (CA) is at 17% suggesting that CA represents an arena of medical practice which deserves more attention. Ultrasound (US) may have a role in both intra-arrest management and peri-arrest prognosis. Very little is known about the role of ultrasound for IH CA. Hypothesis: Intra- arrest POCUS can provide prognostic value. Methods: This was a single center, prospective observational study and we included all IH CA which occurred when a provider was available to perform a standardized POCUS protocol. US and echocardiography imaging was collected during the intra- arrest period and compared with outcome measures of return of spontaneous circulation (ROSC) and survival to 24 hours post-ROSC. Results: Echocardiographic features which may reflect survivorship include cardiac standstill, right ventricle (RV) blood flow stasis, and the appearance of thrombus formation at or around the tricuspid valve. 10 of 16 (62.50%) patients with cardiac standstill alone and 1 of 3 (33.33%) RV stasis alone did not achieve ROSC. Of those that did achieve ROSC in these two groups, none of the patients survived beyond 24 hours of the CA. 11 of 19 (57.89%) patients with RV stasis in combination with cardiac standstill did not achieve ROSC, and of the remaining 8 patients that achieved ROSC, only 1 patient survived past 24 hours. The combination of cardiac standstill, RV stasis, and tricuspid valve thrombus had 2 of 3 (66.67%) patients fail to achieve ROSC, with the remaining 1 patient surviving only to 24 hours. The presence of cardiac standstill alone confers an association with death, with an odds ratio (OR) of 1.212. RV stasis plus cardiac standstill on intra-arrest POCUS confer a markedly higher OR 0.8250 in association with death. Conclusions: Our preliminary work brings to light the role of POCUS for predicting short term survivorship based on echocardiographic patient features. This may have implications for resource utilization in such events.

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Do combined ultrasound and electrocardiogram-rhythm findings predict survival in emergency department cardiac arrest patients? The Second Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED2) study

CJEM ◽

10.1017/cem.2019.397 ◽

2019 ◽

Vol 21 (6) ◽

pp. 739-743 ◽

Cited By ~ 1

Author(s):

Nicole Beckett ◽

Paul Atkinson ◽

Jacqueline Fraser ◽

Ankona Banerjee ◽

James French ◽

...

Keyword(s):

Emergency Department ◽

Cardiac Arrest ◽

Hospital Discharge ◽

Point Of Care ◽

Cardiac Activity ◽

Pulseless Electrical Activity ◽

Spontaneous Circulation ◽

Point Of Care Ultrasound ◽

Electrocardiogram Ecg ◽

Higher Sensitivity

ABSTRACTObjectivesPoint-of-care ultrasound (POCUS) is used increasingly during resuscitation. The aim of this study was to assess whether combining POCUS and electrocardiogram (ECG) rhythm findings better predicts outcomes during cardiopulmonary resuscitation in the emergency department (ED).MethodsWe completed a health records review on ED cardiac arrest patients who underwent POCUS. Primary outcome measurements included return of spontaneous circulation (ROSC), survival to hospital admission, and survival to hospital discharge.ResultsPOCUS was performed on 180 patients; 45 patients (25.0%; 19.2%–31.8%) demonstrated cardiac activity on initial ECG, and 21 (11.7%; 7.7%–17.2%) had cardiac activity on initial POCUS; 47 patients (26.1%; 20.2%–33.0%) achieved ROSC, 18 (10.0%; 6.3%–15.3%) survived to admission, and 3 (1.7%; 0.3%–5.0%) survived to hospital discharge. As a predictor of failure to achieve ROSC, ECG had a sensitivity of 82.7% (95% CI 75.2%–88.7%) and a specificity of 46.8% (32.1%–61.9%). Overall, POCUS had a higher sensitivity of 96.2% (91.4%–98.8%) but a similar specificity of 34.0% (20.9%–49.3%). In patients with ECG-asystole, POCUS had a sensitivity of 98.18% (93.59%–99.78%) and a specificity of 16.00% (4.54%–36.08%). In patients with pulseless electrical activity, POCUS had a sensitivity of 86.96% (66.41%–97.22%) and a specificity of 54.55% (32.21%–75.61%). Similar patterns were seen for survival to admission and discharge. Only 0.8% (0.0–4.7%) of patients with ECG-asystole and standstill on POCUS survived to hospital discharge.ConclusionThe absence of cardiac activity on POCUS, or on both ECG and POCUS together, better predicts negative outcomes in cardiac arrest than ECG alone. No test reliably predicted survival.

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P2760Prehospital cardiopulmonary resuscitation duration and favourable neurological outcome after out-of-hospital cardiac arrest in patients without prehospital return of spontaneous circulation

European Heart Journal ◽

10.1093/eurheartj/ehx502.p2760 ◽

2017 ◽

Vol 38 (suppl_1) ◽

Author(s):

A. Funada ◽

Y. Goto ◽

H. Tada ◽

R. Teramoto ◽

M. Shimojima ◽

...

Keyword(s):

Cardiac Arrest ◽

Cardiopulmonary Resuscitation ◽

Neurological Outcome ◽

Spontaneous Circulation ◽

Return Of Spontaneous Circulation ◽

Hospital Cardiac Arrest

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The influence of past experiences on future willingness to perform bystander cardiopulmonary resuscitation

International Journal of Emergency Medicine ◽

10.1186/s12245-019-0256-5 ◽

2019 ◽

Vol 12 (1) ◽

Cited By ~ 1

Author(s):

Keng Sheng Chew ◽

Shazrina Ahmad Razali ◽

Shirly Siew Ling Wong ◽

Aisyah Azizul ◽

Nurul Faizah Ismail ◽

...

Keyword(s):

Cardiac Arrest ◽

Cardiopulmonary Resuscitation ◽

Chest Compression ◽

Hospital Setting ◽

Spontaneous Circulation ◽

Cardiac Events ◽

Validated Questionnaire ◽

Bystander Cardiopulmonary Resuscitation ◽

Past Experiences ◽

Hospital Cardiac Arrest

Abstract Background The influence of past familial experiences of receiving cardiopulmonary resuscitation (CPR) and medical help in various cardiac arrest and nonfatal cardiac events toward willingness to “pay it forward” by helping the next cardiac arrest victim was explored. Methods Using a validated questionnaire, 6248 participants were asked to rate their willingness to perform bystander chest compression with mouth-to-mouth ventilation and chest compression-only CPR. Their past familial experiences of receiving cardiopulmonary resuscitation (CPR) and medical help in various cardiac arrest and nonfatal cardiac events were also recorded. Results Kruskal-Wallis test with post hoc Dunn’s pairwise comparisons showed that the following were significantly more willing to perform CPR with mouth-to-mouth ventilation: familial experience of “nonfatal cardiac events” (mean rank = 447) vs “out-of-hospital cardiac arrest with no CPR” (mean rank = 177), U = 35442.5, z = −2.055, p = 0.04; “in-hospital cardiac arrest and successful CPR” (mean rank = 2955.79) vs “none of these experiences” (mean rank = 2468.38), U = 111903, z = −2.60, p = 0.01; and “in-hospital cardiac arrest with successful CPR” (mean rank = 133.45) vs “out-of-hospital arrest with no CPR” (mean rank = 112.36), U = 4135.5, z = −2.06, p = 0.04. For compression-only CPR, Kruskal-Wallis test with multiple runs of Mann-Whitney U tests showed that “nonfatal cardiac events” group was statistically higher than the group with “none of these experiences” (mean rank = 3061.43 vs 2859.91), U = 1194658, z = −2.588, p = 0.01. The groups of “in-hospital cardiac arrest with successful CPR” and “in-hospital cardiac arrest with transient return of spontaneous circulation” were the most willing groups to perform compression-only CPR. Conclusion Prior familial experiences of receiving CPR and medical help, particularly among those with successful outcomes in a hospital setting, seem to increase the willingness to perform bystander CPR.

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Point-of-care Ultrasound Diagnosis of Pulmonary Embolism with Thrombus in Transit

Clinical Practice and Cases in Emergency Medicine ◽

10.5811/cpcem.2018.11.40377 ◽

2019 ◽

Vol 3 (2) ◽

pp. 11-12 ◽

Cited By ~ 2

Author(s):

Nicolas Kahl ◽

Christopher Gabriel ◽

Shadi Lahham ◽

Maxwell Thompson ◽

Wirachin Hoonpongsimanont

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Point Of Care ◽

Skilled Nursing Facility ◽

Point Of Care Ultrasound ◽

Right Heart ◽

Skilled Nursing ◽

Chamber View ◽

The Right ◽

In Transit

A 95-year-old female with a history of dementia and atrial fibrillation (not on anticoagulation) presented to the emergency department (ED) by ambulance from her skilled nursing facility due to hypoxia. Point-of-care ultrasound was performed, and showed evidence of a large mobile thrombus in the right ventricle on apical four-chamber view. Further evidence of associated right heart strain was seen on the corresponding parasternal short-axis view. These ultrasound findings in combination with the patient’s clinical presentation are diagnostic of acute pulmonary embolism with right heart strain. Point-of-care transthoracic cardiac ultrasound in the ED is an effective tool to promptly diagnose acute pulmonary embolism with right heart strain and thrombus in transit and guide further treatment.

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Management of EMS on-scene time during advanced life support in out-of-hospital cardiac arrest: a retrospective observational trial

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872620925681 ◽

2020 ◽

Vol 9 (4_suppl) ◽

pp. S82-S89

Author(s):

Michael Poppe ◽

Mario Krammel ◽

Christian Clodi ◽

Christoph Schriefl ◽

Alexandra-Maria Warenits ◽

...

Keyword(s):

Cardiac Arrest ◽

Cardiopulmonary Resuscitation ◽

Emergency Medical Services ◽

Life Support ◽

Advanced Life Support ◽

Spontaneous Circulation ◽

Medical Services ◽

Extracorporeal Cardiopulmonary Resuscitation ◽

Emergency Medical ◽

Hospital Cardiac Arrest

Objective Most western emergency medical services provide advanced life support in out-of-hospital cardiac arrest aiming for a return of spontaneous circulation at the scene. Little attention is given to prehospital time management in the case of out-of-hospital cardiac arrest with regard to early coronary angiography or to the start of extracorporeal cardiopulmonary resuscitation treatment within 60 minutes after out-of-hospital cardiac arrest onset. We investigated the emergency medical services on-scene time, defined as emergency medical services arrival at the scene until departure to the hospital, and its association with 30-day survival with favourable neurological outcome after out-of-hospital cardiac arrest. Methods All patients of over 18 years of age with non-traumatic, non-emergency medical services witnessed out-of-hospital cardiac arrest between July 2013 and August 2015 from the Vienna Cardiac Arrest Registry were included in this retrospective observational study. Results Out of 2149 out-of-hospital cardiac arrest patients, a total of 1687 (79%) patients were eligible for analyses. These patients were stratified into groups according to the on-scene time (<35 minutes, 35–45 minutes, 45–60 minutes, >60 minutes). Within short on-scene time groups, out-of-hospital cardiac arrest occurred more often in public and bystander cardiopulmonary resuscitation was more common (both P<0.001). Patients who did not achieve return of spontaneous circulation at the scene showed higher rates of 30-day survival with favourable neurological outcome with an on-scene time of less than 35 minutes (adjusted odds ratio 5.00, 95% confidence interval 1.39–17.96). Conclusion An emergency medical services on-scene time of less than 35 minutes was associated with higher rates of survival and favourable outcomes. It seems to be reasonable to develop time optimised advance life support protocols to minimise the on-scene time in view of further treatments such as early coronary angiography as part of post-resuscitation care or extracorporeal cardiopulmonary resuscitation in refractory out-of-hospital cardiac arrest.

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Massive pulmonary embolism in pregnancy: intra-arrest thrombolysis and resuscitative hysterotomy

BMJ Case Reports ◽

10.1136/bcr-2019-234083 ◽

2020 ◽

Vol 13 (4) ◽

pp. e234083 ◽

Cited By ~ 1

Author(s):

John Edward Ashbridge Taylor ◽

Chen Wen Ngua ◽

Matthew Carwardine

Keyword(s):

Pulmonary Embolism ◽

Cardiac Arrest ◽

Massive Pulmonary Embolism ◽

Spontaneous Circulation ◽

Postmortem Examination ◽

Right Heart ◽

Hypoxic Injury ◽

Injury Treatment ◽

Ct Brain ◽

Hospital Cardiac Arrest

Massive pulmonary embolism (PE) is a leading cause of maternal death and may require intra-arrest thrombolysis as well as resuscitative hysterotomy. The case presented is a primigravida in her mid-30s at 28 weeks gestation. The patient presented to the emergency department after out-of-hospital cardiac arrest. Return of spontaneous circulation (ROSC) was achieved but not sustained. Episodic cardiopulmonary resuscitation with epinephrine boluses was required. Resuscitative hysterotomy was performed intra-arrest. Echocardiography revealed a dilated right heart consistent with massive PE and thrombolysis was administered. ROSC was obtained thereafter and output was sustained. Subsequent CT brain revealed irreversible hypoxic injury. Treatment was withdrawn with the support of family. Postmortem examination confirmed massive PE. Thrombolysis can restore and improve cardiovascular status in cardiac arrest caused by massive PE. Thrombolysis is not contraindicated in maternal resuscitation where resuscitative hysterotomy may also be required.

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