Case Report

Tight control of effectiveness of cardiac massage with Invasive blood pressure monitoring during cardiopulmonary resuscitation

Abstract

The continuity of chest compression is the main challenge in prehospital cardiopulmonary resuscitation in the field as well as during transport. Invasive blood pressure monitoring with visible pulse waves by means of an arterial line set prehospitally allows for tight control of the effectiveness of chest compressions as well as of the impact of the administered epinephrine and also captures beginning fatigue of the rescuers. In this case, maintaining unin- terrupted circulation through manual as well as Mechanical chest compressions continued until the successful percuta- neous coronary intervention saved the patients life without neurologic damage.

In the prehospital setting, the effectiveness of chest compressions is very difficult to objectify. Hemodynamic monitoring in the field is usually restricted to secondary signs such as end-tidal carbon dioxide monitoring, which provides semiquantitative information at best, or pulse oximetry, which is unreliable in the low output state. Other signs including cerebral reaction, breathing, and pupil reactivity to light occur with a delay of seconds or even minutes. Furthermore, helicopter transport of patients during resusci- tation poses a unique challenge to the transportation team to minimize interruptions in chest compressions. This case presents the continuous monitoring of the effectiveness of chest compressions using invasive blood pressure measure- ment by means of an arterial line that was inserted in the field. The local emergency physician-staffed rescue helicopter and the mobile intensive care unit, staffed with a highly skilled medical student comparable with an emergency medical technician of paramedic level, responded to a call of suspected cardiac arrest [1]. Both vehicles arrived at the scene 10 minutes after the initial call and found a 69-year-old man without vital signs, but no bystander cardiopulmonary resuscitation (CPR) had been attempted. Cardiac arrest was diagnosed, and chest compressions were commenced within 30 seconds. Electrocardiographic tracings revealed ventri-

cular fibrillation, and the patient received 4 defibrillation attempts at 360 J, which were unsuccessful. The trachea was intubated, the patient was mechanically ventilated with 100% oxygen, and intravenous access was established, through which a total of four 1-mg doses of epinephrine were administered. After 20 minutes of CPR, an arterial line was inserted into the right Radial artery to monitor the effective- ness of the chest compressions by an invasive blood pressure monitor, which is standard equipment of the mobile emergency care unit. Pulse waves were clearly visible, and blood pressure during ongoing chest compressions was 120/ 40 mm Hg. Also, an arterial blood gas analysis performed on-site showed a mild combined acidosis and relative hypoxemia (pH 7.21; PCO2, 48 mm Hg; base excess, -7.2; PO2, 89 mm Hg; SaO2, 94%), upon which Ventilation parameters were adjusted accordingly [2]. The invasive blood pressure monitoring allowed a targeted application of further epinephrine doses whenever blood pressure decreased and minimized the interruption of chest compres- sions. Throughout the CPR, the patient showed signs of cerebral function such as gasping, reflexive withdrawal movements of the extremities, and lacrimation. After 60 minutes, ventricular fibrillation still persisted despite the administration of 8 mg of epinephrine and 600 mg of amiodarone and infusion of magnesium and potassium. The cardiologic intervention center on duty was contacted, and a decision was made to attempt cardiac catheterization under CPR conditions. The patient was transferred to the helicopter and flown to the hospital. During helicopter transport, meticulous care was taken not to interrupt chest compres- sions, and systolic blood pressure was not allowed to fall below 100 mm Hg for more than a few seconds. During percutaneous coronary intervention, chest compressions were continued with a Lund University Cardiac Arrest System (Jolife, Lund, Sweden) chest compression device [3], and after 28 minutes, 1 hour, and 57 minutes after Cardiovascular collapse, an occlusion of the right coronary artery was identified and dilated. After one further defibrillation, a stable sinus rhythm was detected, and no further inotropic support was necessary. The patient remained in the cardiac intensive care unit for 1 week and was discharged from the hospital 2 weeks later without any neurologic deficit.

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746.e6 Case Report

This case of prolonged CPR underlines the paramount importance of chest compression in cardiac arrest [4-7]. Pauses during chest compressions have been demonstrated to have a detrimental effect on resuscitation outcome [8,9]. Another important factor contributing to poor CPR quality is rescuer fatigue [10]. Although hemodynamic monitoring by means of an arterial line is obligatory intrahospitally, it is rare in the field [11]. Even though arterial blood pressure does not adequately reflect actual cerebral perfusion, it is, at least for the time being, the best tool we have. We believe that in this case, the continuous hemodynamic monitoring, visualized using arterial blood pressure measurement, provided the motivation required for everybody to do their best and save the patient’s life. With regard to the decision to transport the patient to a catheter laboratory to allow targeted recanaliza- tion, it has been shown that primary percutaneous interven- tion is superior in cases of short delay [12]. To date, few cases have been reported demonstrating the successful use of continuous mechanical chest compression during percuta- neous coronary intervention [13]. Our case illustrates once again the chance of survival for a patient with out-of-hospital cardiac arrest and prolonged CPR. Havel et al [14] recently were able to demonstrate in a randomized crossover trial that effective closed chest compression can be applied during transport both in the moving ambulance and in the flying helicopter. The old paradigm of “no transport during CPR” may need to be revised.

We present a case of prolonged resuscitation after out-of- hospital cardiac arrest without neurologic sequelae. The patient was transported to a cardiologic intervention center by helicopter, and percutaneous coronary angioplasty was performed during resuscitation. An arterial line was inserted in the field and provided continuous hemodynamic monitor- ing from the scene until the successful recanalization.

Gerhard Prause MD Sylvia Archan MD Geza Gemes MD

Friedrich Kaltenbock MD

Department of Anesthesiology and Intensive Care Medicine

Medical University of Graz 8036 Graz, Austria

E-mail address: [email protected]

Ilja Smolnikov Medinizercorps of the Red Cross Graz Medical University of Graz

8036 Graz, Austria

Herwig Schuchlenz

Department of Internal Medicine

Hospital Graz-West Medical University of Graz 8036 Graz, Austria

Gernot Wildner MD

Department of Anesthesiology and Intensive Care Medicine

Medical University of Graz 8036 Graz, Austria

doi:10.1016/j.ajem.2009.09.035

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