RESUMO
A 24-year-old man suffered a witnessed cardiac arrest after a padel game. Basic life support was immediately provided. The pre-hospital emergency services team continued the resuscitation efforts, and the patient was accepted for extracorporeal cardiopulmonary resuscitation. The return of spontaneous circulation was achieved in 45 minutes. The initial assessment revealed a ST-segment elevation in leads V4-V6 and a dilated left ventricle with severe systolic dysfunction. Coronary angiography was normal. An improvement in left ventricular systolic function was observed and extracorporeal cardiac support was discontinued after 48 hours. Cardiovascular magnetic resonance imaging demonstrated hypokinesia and subepicardial fatty infiltration of the left ventricle lateral wall. Genetic testing detected a variant of uncertain significance in the ANK2 gene. The diagnosis of arrhythmogenic left ventricular myocardiopathy did not fulfill all the current diagnostic criteria, but it is a very likely diagnosis. An implantable cardioverter-defibrillator was placed. The patient was discharged without physical or cognitive impairment.
Assuntos
Cardiomiopatias , Reanimação Cardiopulmonar , Disfunção Cognitiva , Parada Cardíaca , Masculino , Humanos , Adulto Jovem , Adulto , Serviço Hospitalar de EmergênciaRESUMO
BACKGROUND: The effects of adrenaline on cerebral blood vessels during cardiopulmonary resuscitation (CPR) are not well understood. We developed an extracorporeal CPR model that maintains constant low systemic blood flow while allowing adrenaline-associated effects on cerebral vasculature to be assessed at different mean arterial pressure (MAP) levels independently of the effects on systemic blood flow. METHODS: After eight minutes of cardiac arrest, low-flow extracorporeal life support (ECLS) (30 ml/kg/min) was started in fourteen pigs. After ten minutes, continuous adrenaline administration was started to achieve MAP values of 40 (n = 7) or 60 mmHg (n = 7). Measurements included intracranial pressure (ICP), cerebral perfusion pressure (CePP), laser-Doppler-derived regional cerebral blood flow (CBF), cerebral regional oxygen saturation (rSO2), brain tissue oxygen tension (PbtO2) and extracellular cerebral metabolites assessed by cerebral microdialysis. RESULTS: During ECLS without adrenaline, regional CBF increased by only 5% (25th to 75th percentile: -3 to 14; p = 0.2642) and PbtO2 by 6% (0-15; p = 0.0073) despite a significant increase in MAP to 28 mmHg (25-30; p < 0.0001) and CePP to 10 mmHg (8-13; p < 0.0001). Accordingly, cerebral microdialysis parameters showed a profound hypoxic-ischemic pattern. Adrenaline administration significantly improved regional CBF to 29 ± 14% (p = 0.0098) and 61 ± 25% (p < 0.001) and PbtO2 to 15 ± 11% and 130 ± 82% (both p < 0.001) of baseline in the MAP 40 mmHg and MAP 60 mmHg groups, respectively. Importantly, MAP of 60 mmHg was associated with metabolic improvement. CONCLUSION: This study shows that adrenaline administration during constant low systemic blood flow increases CePP, regional CBF, cerebral oxygenation and cerebral metabolism.
Assuntos
Reanimação Cardiopulmonar , Parada Cardíaca , Animais , Gasometria , Circulação Cerebrovascular , Epinefrina , Parada Cardíaca/terapia , Fluxo Sanguíneo Regional , SuínosRESUMO
OBJECTIVE: To investigate the relationship between hypotension and neurologic outcome in adults with return of spontaneous circulation after out-of-hospital cardiac arrest. METHODS: Blood pressure and medication data were extracted from adult patients who had ROSC after OHCA in Alameda County and matched with neurologic outcome using the CARES database from January 1, 2018 through July 1, 2019. We used univariate logistic regression with p ≤ 0.2 followed by multivariate logistic regression and reported an odds ratio with 95% confidence intervals. RESULTS: Among the 781 adult patients who had ROSC after OHCA, 107 (13.7%) were noted to be hypotensive and 61 (57% of the hypotensive group) received vasopressors. Patients with a final prehospital blood pressure recording of <90 mmHg were more likely to have a poor neurologic outcome (adjusted odds ratio 2.13, adj p = 0.048). About twice as many patients who were not hypotensive had a good neurologic outcome compared to hypotensive patients who had a good neurologic outcome (23% to 10.3%). Additionally, patients who were hypotensive and did not receive vasopressors had a similar neurologic outcome compared to patients who did receive vasopressors. CONCLUSION: Prehospital post-ROSC hypotension was associated with worse neurologic outcome and giving hypotensive patients vasopressors may not improve neurologic outcome in the prehospital setting.
Assuntos
Pressão Sanguínea , Malformações do Sistema Nervoso/etiologia , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Retorno da Circulação Espontânea/fisiologia , Idoso , Idoso de 80 Anos ou mais , California/epidemiologia , Correlação de Dados , Feminino , Parada Cardíaca/complicações , Parada Cardíaca/epidemiologia , Parada Cardíaca/fisiopatologia , Humanos , Hipóxia Encefálica/complicações , Hipóxia Encefálica/etiologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Avaliação de Resultados em Cuidados de Saúde/métodosRESUMO
BACKGROUND: The influence of adrenaline during cardiopulmonary resuscitation (CPR) on the neurological outcome of cardiac arrest survivors is unclear. As little is known about the pathophysiological effects of adrenaline on cerebral oxygen delivery and cerebral metabolism we investigated its effects on parameters of cerebral oxygenation and cerebral metabolism in a pig model of CPR. METHODS: Fourteen pigs were anesthetized, intubated and instrumented. After 5 min of cardiac arrest CPR was started and continued for 15 min. Animals were randomized to receive bolus injections of either 15 or 30 µg/kg adrenaline every 5 min after commencement of CPR. RESULTS: Measurements included mean arterial pressure (MAP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), cerebral regional oxygen saturation (rSO2), brain tissue oxygen tension (PbtO2), arterial and cerebral venous blood gases and cerebral microdialysis parameters, e.g. lactate/pyruvate ratio. Adrenaline induced a significant increase in MAP and CPP in all pigs. However, increases in MAP and CPP were short-lasting and tended to decrease with repetitive bolus administration. There was no statistical difference in any parameter of cerebral oxygenation or metabolism between study groups. CONCLUSIONS: Both adrenaline doses resulted in short-lasting CPP peaks which did not translate into improved cerebral tissue oxygen tension and metabolism. Further studies are needed to determine whether other dosing regimens targeting a sustained increase in CPP, may lead to improved brain oxygenation and metabolism, thereby improving neurological outcome of cardiac arrest patients.
Assuntos
Reanimação Cardiopulmonar , Parada Cardíaca , Animais , Gasometria , Circulação Cerebrovascular , Epinefrina , Parada Cardíaca/tratamento farmacológico , Humanos , SuínosRESUMO
BACKGROUND: Recent studies have shown that during cardiopulmonary resuscitation (CPR) head-up position (HUP) as compared to standard supine position (SUP) decreases intracranial pressure (ICP) and increases cerebral perfusion pressure (CPP). The impact of this manoeuvre on brain oxygenation and metabolism is not clear. We therefore investigated HUP as compared to SUP during basic life support (BLS) CPR for their effect on brain oxygenation and metabolism. METHODS: Twenty pigs were anaesthetized and instrumented. After 8â¯min of cardiac arrest (CA) pigs were randomized to either HUP or SUP and resuscitated mechanically for 20â¯min. Mean arterial pressure (MAP), ICP, CPP, cerebral regional oxygen saturation (rSO2) and brain tissue oxygen tension (PbtO2) were measured at baseline, after CA and every 5â¯min during CPR. Cerebral venous oxygen saturation (ScvO2) was measured at baseline, after CA and after 20â¯min of CPR. Cerebral microdialysis parameters, e.g. lactate/pyruvate ratio (L/P ratio) were taken at baseline and the end of the experiment. RESULTS: ICP was significantly lower in HUP compared to SUP animals after 5â¯min (18.0⯱â¯4.5 vs. 24.1⯱â¯5.2â¯mmHg; pâ¯=â¯0.033) and 20â¯min (12.0⯱â¯3.4 vs. 17.8⯱â¯4.3â¯mmHg; pâ¯=â¯0.023) of CPR. Accordingly, CPP was significantly higher in the HUP group after 5â¯min (11.2⯱â¯9.5 vs. 1.0⯱â¯9.2â¯mmHg; pâ¯=â¯0.045) and 20â¯min (3.4⯱â¯6.4 vs. -3.8⯱â¯2.8â¯mmHg; pâ¯=â¯0.023) of CPR. However, no difference was found in rSO2, PbtO2, ScvO2 and L/P ratio between groups after 20â¯min of CPR. CONCLUSION: In this animal model of BLS CPR, HUP as compared to SUP did not improve cerebral oxygenation or metabolism.
Assuntos
Reanimação Cardiopulmonar/métodos , Circulação Cerebrovascular/fisiologia , Parada Cardíaca/terapia , Pressão Intracraniana/fisiologia , Animais , Gasometria , Modelos Animais de Doenças , Parada Cardíaca/sangue , Parada Cardíaca/mortalidade , Distribuição Aleatória , Decúbito Dorsal/fisiologia , SuínosRESUMO
Massive pulmonary embolism is associated with mortality rates exceeding 50%. Current practice guidelines include the immediate administration of thrombolytic therapy in the absence of contraindications. However, thrombolysis for pulmonary embolism is said to be absolutely contraindicated in the presence of recent hemorrhagic stroke and other conditions. The current contraindications to thrombolytic therapy have been extrapolated from data on acute coronary syndrome and are not specific for venous thromboembolic disease. Some investigators have proposed that the current contraindications be viewed as relative, rather than absolute, in cases of high-risk pulmonary embolism. We present the case of a 60-year-old woman in whom massive pulmonary embolism led to cardiac arrest with pulseless electrical activity. Eight weeks earlier, she had sustained a hemorrhagic cerebrovascular accident-a classic absolute contraindication to thrombolytic therapy. Despite this practice guideline, we administered tissue plasminogen activator systemically in order to save the patient's life. This therapy did not evoke intracranial bleeding, and the patient was eventually discharged from the hospital. Until guidelines specific to venous thromboembolic disease are developed, we think that the current contraindications to thrombolysis should be considered on an individual basis in patients who are at high risk of death from massive pulmonary embolism.