A 44-year-old man presented to the emergency department with chest pain for 3 days and collapsed while undergoing triage.
The patient was found to be pulseless; he was immediately placed on a stretcher, ACLS was initiated, and he was wheeled into the resuscitation room with compressions in progress. The patient was placed on the monitor, with end-tidal CO2 measuring at 15mmHg. He was given 1 dose of epinephrine, and at the initial pulse check, was found to be in pulseless ventricular fibrillation (VF).
The patient was defibrillated at 200 joules (J) and placed on a mechanical CPR machine. During mechanical compressions, the patient woke up, stated he was okay, and started fighting with staff and the machine. Staff paused for pulse check and the patient again became unresponsive, was in VFib, and ACLS was continued. The patient again returned fighting staff during compressions and was unable to be verbally de-escalated. The patient was given 150mg ketamine intravenous for sedation while preparing for intubation. He was defibrillated 3 more times prior to obtaining return of spontaneous circulation (ROSC). During this time, the patient was placed on dual pads for dual defibrillation, and advanced cardiovascular life support (ACLS) was continued.
After the patient was intubated successfully with rocuronium and etomidate, ketamine was started for post-intubation sedation. The patient was dual-defibrillated 3 more times until initial ROSC was obtained. At that time cardiology was at bedside, an ECG demonstrated STEMI in V1-V3, and the decision was made to transfer to a tertiary site with STEMI lab, cardiothoracic surgery, and extracorporeal membrane oxygenation (ECMO).
Minutes after acceptance to a tertiary care center, the patient again went into pulseless VF, and ACLS was reinitiated. ROSC was again obtained after a total of 75 minutes and included 15 defibrillations (at least 5 dual defibrillators) and a total of 13 mg epinephrine, 8mg magnesium, 450 mg amiodarone, 200mg lidocaine HCl, 1g calcium chloride, and 3 amps of sodium bicarbonate.
The patient was transferred to a tertiary care site via ambulance along with two senior residents and an attending physician on board in case there was a need for prolonged CPR (due to the distance of the facility and unpredictable traffic of New York City). No interventions were required en route. The patient was taken immediately to the catheterization lab, impella placed, and was found to have a 100% occlusion of the left anterior descending artery that responded to mechanical thrombectomy and stenting. The patient had post-perfusion runs of VFib and defibrillated successfully. At this time, the patient was hemodynamically stable on vasopressors and did not require ECMO. That evening, the patient was weaned from sedation and was able to follow commands in his native language and acknowledge his family members in his room.
Discussion
Ventricular fibrillation is the most common cause of sudden cardiac death (SCD), usually preceded by 48 to 72 hours of symptoms prior to occurrence.3 VF is a manifestation of ischemia, thus more likely in patients with a history of heart failure or cardiovascular event. The definitive treatment for VF is defibrillation at 120-200 J, many times requiring dual defibrillators, as it has a higher success rate.4 VF is usually a short-lived arrhythmia and results in SCD, unless met with chest compressions within 3 minutes of arrest to maintain myocardial perfusion. Mechanical compression devices have shown better survival rates in prolonged resuscitations, but worse survival when thrombolytics were used.5 A study from Milwaukee in 1983 demonstrated a 46% survival rate to discharge in VFib arrest patients with a mean time of resuscitation of 12.6 minutes.6 Reports demonstrate resuscitations can be successful after multiple hours, and even days. One case report demonstrated a patient was able to sustain shock-resistant VF for 10 days, as he had cardiac perfusion via LVAD.7
Once the patient has been resuscitated to sinus rhythm, reperfusion therapy must occur to maintain myocardial perfusion. If cardiogenic shock is present, an assistive device must be placed. Several devices exist to aid in circulatory support and allow the patient time to recover to have further intervention. These options include Impella, ECMO, intra-aortic balloon pump, Centrimag, and TandemHeart. Each device differs in its capabilities, time to placement, time allowed to be in place, and complications profile.
Importance of Awareness
VF arrests can occur after days of symptoms and proceed into a ventricular storm. This may require prolonged resuscitation with defibrillators, the definitive therapy of VF. Early dual sequence defibrillation has been shown to increase outcomes, while treating other underlying causes. These patients may require intubation for further sedation, if this occurs, propofol will help reduce the sympathetic storm. Patients that regain ROSC after VF arrest may need emergent cardiac intervention due to its high association with ischemia. If your facility does not have catheterization abilities, it may require transfer to a tertiary care center to include interventional cardiology, cardiothoracic surgery, and ECMO capabilities. Be considerate in placement of IV lines using mostly large bore peripherals, as large veins and arteries should be saved for cardiac intervention including impella, ECMO, and stenting.
References
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