Resuscitation 50 (2001) 349–351

Case report

Prolonged resuscitation: a case report

Simon Cooper a,*, Peter Macnaughton b

a Departments of Resuscitation Training, Le�el 3, Derriford Hospital, Plymouth PL6 8DH, UKb Department of Intensi�e Care, Le�el 3, Derriford Hospital, Plymouth PL6 8DH, UK

Accepted 6 April 2001

Abstract

This report illustrates a case of prolonged resuscitation (without hypothermia) with a return of spontaneous circulation (ROSC)after 1 h of resuscitation in a hospital car park and emergency department. Coronary artery stenting was achieved 2 h and 45 minafter collapse. Following a 12-week stay in hospital the patient was discharged home making a full recovery within 12 months.Issues regarding prolonged resuscitation and the key predictors of survival are discussed. © 2001 Elsevier Science Ireland Ltd. Allrights reserved.

Keywords: Advanced life support (ALS); Basic life support (BLS); Cardiopulmonary resuscitation (CPR); Education; Emergency medical services;Emergency treatment

Resumo

Neste caso clınico descreve-se uma situacao de reanimacao prolongada (sem hipotermia) com retorna da circulacao espontaneaao fim de 1h de reanimacao no parque automovel de um hospital e no Departamento de emergencia. Foi colocado um sentcoronario 2h 45 min depois do colapso. Doente esteve internado 12 semanas, findas as quais teve alta hospitalar apos o querecuperou completamente ao fim de 12 meses. Discutem-se questoes relacionadas com a reanimacao prolongada e com os factoresde predicao de sobrevida. © 2001 Elsevier Science Ireland Ltd. All rights reserved.

Pala�ras cha�e: Suporte Avancado de Vida (SAV); Suporte Basic de Vida (SBV); Reanimacao cardio pulmonar (RCP); Formacao; Servicos deEmergencia Madica (SEM)

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1. Introduction

A number of reports [1–8] have shown that there arekey predictors of survival, one of which is the durationof a resuscitation attempt. From our own institutionCooper and Cade [8] demonstrated that some of thekey factors influencing immediate survival (survival for1 h) are the ‘primary arrhythmia’, ‘basic life support(BLS) within 3 min of an arrest’, ‘age less than 70years’, ‘primary mode of arrest (respiratory/cardiac)’and the ‘duration of the arrest’. Patients whose primary

arrhythmia was ventricular fibrillation (VF) or ventric-ular tachycardia (VT), as opposed to asystole or pulse-less electrical activity (PEA), were much more likely tosurvive. The duration of a resuscitation attempt was anessential factor; of those patients that initially surviveda resuscitation, 84%, 293/348 (P=0.001) were resusci-tated within the first 20 min. However, in updating thiswork we found that many of the patients who surviveresuscitation attempts of greater than 20 min are likelyto have had a return of spontaneous circulation(ROSC) at some time during the resuscitation. This issupported by the latest consensus opinion that if thereis a ROSC at any time during the resuscitation it maybe appropriate to consider extending the resuscitativeeffort [6].

* Corresponding author. Tel.: +44-1752-792851; fax: +44-1752-763796.

E-mail address: simon.cooper@phnt.swest.nhs.uk (S. Cooper).

0300-9572/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved.PII: S 0 3 0 0 -9572 (01 )00374 -4

S. Cooper, P. Macnaughton / Resuscitation 50 (2001) 349–351350

The criteria for terminating resuscitation efforts areclearly multi-factorial; however what is not entirelyclear is when a team should first consider discontinuinga resuscitation. A recent publication of internationalguidelines [6] makes the point that ‘in the absence ofmitigating factors, prolonged resuscitation efforts foradults and children are unlikely to be successful andcan be discontinued if there is no ROSC at any timeduring 30 min of cumulative ACLS’. However, a laterpaper within the same publication [9] suggests thatresuscitation efforts out-of-hospital should be discon-tinued, in the asystolic patient, after 10 min of basicand advanced life support (ALS). Preliminary work ofour own (being peer reviewed) from a 7 year study of1633 resuscitation attempts, demonstrates that 15 mininto a resuscitation (where there has been no ROSC) isan acceptable point at which to first consider termina-tion. For example, for a resuscitation duration ofgreater than 15 min, we found that 95% (17/340) ofpatients over 70 years of age whose primary arrhythmiawas asystole, did not survive 24 h following successfulresuscitation. In such circumstances, taking into ac-count the many other predictors of survival, it wouldappear reasonable to consider terminating resuscitationafter 15 min.

In contrast the following case report demonstratesthat where certain criteria are met prolonging resuscita-tion, with a high standard of post resuscitation care,can be highly successful.

2. Case report

At 18:00 h a 56-year-old male, with no previousmedical history, collapsed in a hospital car park. Hewas accompanied by hospital staff trained in ALS, whofound him to be pulseless. A precordial thump wasgiven with no response and cardiopulmonary resuscita-tion (CPR) was commenced immediately with mouth tomouth and chest compressions. A member of staffreturned to the hospital and summoned help at 18:04 h.The ambulance service were immediately contacted aswere the on call medical Registrar, Senior HouseOfficer and an armed forces medical assistant.

The medical team arrived on scene at 18:09 h withthe first emergency ambulance arriving at 18:12 h.Timings were accurately recorded by a security cameraon the site. At 18:14 h the first of two 200 J shocks weredelivered for VF, the patient’s rhythm changing toasystole. There had been some initial difficulties withmouth to mouth as the patients jaw had ‘locked’, somouth to nose was performed. Tracheal tube intuba-tion was successful on the second attempt, without drugintervention. Intra-venous cannulation was secured and1mg of adrenaline and 3 mg of atropine given. Treat-ment continued with further boluses of adrenaline fol-

lowed by a change of rhythm to pulseless electricalactivity (PEA). After approximately 20 min there was abrief ROSC with a tachycardia of 90–100 bpm, atwhich stage the patient was transferred to a waitingambulance at 18:26 h. On arrival at the Accident andEmergency (A&E) department (18:29 h) VF was againapparent and resuscitation was recommenced by a teamof experienced medical and nursing staff. Over the next30 min, BLS was continued with regular intravenousdoses of adrenaline and multiple shocks (15–20) forresistant VF. An arterial and subclavian central venousline were also inserted. After the administration of a 8mmol bolus of intravenous magnesium sulphate, defi-brillation was successful, with a return of spontaneouscardiac output at 19:00 h. Apart from one briefepisode, the patient had been without a spontaneouscardiac output for exactly 60 min.

In the immediate post resuscitation phase a 12 leadECG showed an extensive anterior myocardial infarc-tion. Controlled mechanical ventilation continued withfresh blood noted in the tracheal tube. Arterial bloodgases recorded a pH 7.10, pCO2 4.94 kPa, pO2 19.02kPa, HCO3-13 mmol/l, ABE-14 mmol/l and O2 satura-tion 97%. The cardiac rhythm remained unstable so abolus of 300 mg of amiodarone and a further 2 g ofmagnesium were given, whilst an adrenaline infusionwas commenced for persistent hypotension. By 19:45 hthe patient was stable on amiodarone and adrenaline

infusions with a heart rate and rhythm of 80–100 inatrial fibrillation and BP of 120/70 mmHg. Neurologi-cal assessment revealed that the pupils were equal andreacted to light with some spontaneous arm movement.The patient was then sedated and transferred to theCardiac Catheter Laboratory for emergency cardiaccatheterization. This revealed a proximal occlusion ofthe left anterior descending coronary artery which wassuccessfully stented 2 h and 45 min after the originalcollapse. A left ventricular angiogram showed extensiveantero-apical and distal inferior akinesia with a highend diastolic pressure of 40 mmHg. A heparin infusionwas commenced and antiplatelet therapy with abcix-imab, which inhibits platelet aggregation in stents. Thepatient was then transferred to the ICU.

The patient’s haemodynamic status rapidly im-proved, with inotropic support being discontinued after48 h. However, the subsequent ICU course was compli-cated by acute respiratory distress syndrome (ARDS),acute renal failure, rhabdomyolisis and poor neurologi-cal function. Treatment included prolonged ventilatorysupport, continuous renal support with haemofiltrationand a percutaneous tracheostomy. Renal function re-turned to normal and the patient was weaned offrespiratory support and discharged to the cardiac wardafter 21 days intensive care. At this stage the patientwas communicating appropriately apart from episodesof inappropriate disorientated jargon.

S. Cooper, P. Macnaughton / Resuscitation 50 (2001) 349–351 351

There followed a prolonged recovery phase in thecardiac ward and then in a rehabilitation unit. Hiscardiac function stabilised with an echocardiogram esti-mating the left ventricular ejection fraction at 50% andhis neurological function gradually improved as hebecame orientated to time and place, but with someimpairment of short and long term memory. Threemonths after admission he was discharged home withno cardiac symptoms and a complete neurological re-covery, except for a minor loss of short term memoryand some loss of his more sophisticated artistic andmusical attributes.

3. Discussion

Although duration of cardiac resuscitation is an im-portant predictive factor in determining outcome fol-lowing cardiac arrest, good outcome can occurfollowing prolonged resuscitation. Most other descrip-tions of full recovery, following prolonged cardiac ar-rest, have been described following hypothermia [10],poisoning [11], drug overdose and electrolyte abnormal-ities [6]. The factors that contributed to a good out-come in this case include: immediate and skilled basicand ALS [12], ventricular fibrillation as the primaryand persistent rhythm [1–8] and the absence of previ-ous medical disease [3] in a patient less than 70 years ofage [7,8]. In addition there was a brief ROSC at 20 minand a period of highly active and aggressive post-resus-citation care.

Magnesium (8 mmol I.V.) is recommended [13] as asafe and effective treatment for ventricular tach-yarrhythmias and refractory VF, with hypokalaemia(because hypokalaemia is often related to hypomagne-saemia). Magnesium is involved in energy generation inmuscle and reduces the sensitivity of the motor endplate. In this case it was the only antiarrhythmic givenduring resuscitation. It is difficult to say with certaintythat defibrillation was eventually successful due to itsadministration but its role in persistent tachyarrhthmiasis important.

In summary, successful outcome following prolongedcardiopulmonary arrest from ventricular fibrillation can

occur with prompt and skilled BLS. When making adecision to terminate a resuscitation attempt cliniciansshould consider, amongst others, the adequacy of basicand ALS, the primary mode of arrest, the initialrhythm, the patients age, pre-existing medical conditionand whether or not there was a ROSC during theresuscitation.

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