An intra-arrest, secondary transfer of a patient for primary percutaneous coronary intervention case report

Introduction

In-hospital cardiac arrest (IHCA) is associated with a 30-day mortality as high as 85% whilst out-of-hospital cardiac (OOHCA) arrest is worse still, with a mortality averaging 92–95% (1). When return of spontaneous circulation (ROSC) has not been achieved during an OOHCA, pre-hospital practitioners may conduct a primary transfer to the emergency department with cardiopulmonary resuscitation (CPR) ongoing. Survival in these situations is very poor with reported rates ranging from 1.7% to 4% (2,3). What is not commonly reported in the literature is the incidence of, or survival after, a secondary interhospital transfer with CPR ongoing.

Whilst ROSC can be achieved in around 30% of the OOHCA and around 53% of the IHCA (4), the chance of survival and a favourable neurological outcome are still lower. Cardiac arrest in the emergency department does, however, represent a subset of IHCA with slightly more favourable outcome with a survival to discharge rate of 35%, three-quarters of whom will have a good neurological outcome (5). Many factors including age, initial rhythm and time to CPR contribute to the likely outcome (6), but one of the key predictors of survival and good neurological outcome is the duration of the resuscitation (7). One study suggests that after 21 to 25 minutes of CPR the chance of a positive neurological outcome is significantly reduced, and there was <1% chance of a favourable neurological outcome after 54 minutes for a shockable arrest and 28 minutes for a non-shockable arrest (8).

The case presented below demonstrates a successful resuscitation in a patient with two predictors of poor outcome: interhospital transfer and a prolonged resuscitation. We present this case in accordance with the CARE reporting checklist (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-33/rc).

Case presentation

A fit, 57-year-old Caucasian man with a background hypertension and cigarette smoking presented to the emergency department with a two-day history of chest pain. Prior to this he had been diagnosed with coronavirus disease 2019 (COVID-19) ten days earlier; COVID symptoms were mild and he had not required any treatment. Shortly after arrival, at 08:05, he suffered a witnessed cardiac arrest in the waiting room and CPR was started immediately. Initial rhythm showed ventricular fibrillation (VF) and he was managed with defibrillation, 1 mg adrenaline on alternate cycles, and 300 + 150 mg of amiodarone administered as per Adult Life Support (ALS) guidelines (9). Shortly after the commencement of manual CPR he was established on mechanical chest compressions (LUCAS, Stryker Medical, Portage, USA). He was then intubated; the first attempt was abandoned as he was able to resist mouth opening and insertion of the laryngoscope. A second attempt was successful with 2 mg of midazolam and 80 mg of rocuronium. Prior to intubation it was noted that his pupils were 3 mm and reactive. Following intubation, he was commenced on a ketamine infusion and his end-tidal carbon dioxide (EtCO₂) was monitored with a value at least 3 kPa for the duration of the arrest. An intra-arrest focused echocardiogram (ECHO) was performed to exclude pericardial effusion. The most likely cause of arrest was thought to be myocardial infarction or pulmonary embolus so he was thrombolysed with 50 mg of alteplase at 08:20 and a repeat dose of 50 mg given 20 minutes later. At 08:42, after thirty-seven minutes in arrest, ROSC was achieved and a 12-lead electrocardiography (ECG) (Figure 1) demonstrated a large anterior ST-elevation myocardial infarction (STEMI).

Figure 1 The patient’s ECG recorded after the first ROSC demonstrating an anterior ST-segment elevation myocardial infarction. ECG, electrocardiography; ROSC, return of spontaneous circulation.

He was discussed with the local percutaneous coronary intervention (PCI) centre, a tertiary cardiothoracic unit, which accepted him for rescue PCI once stable but at 09:03 he arrested again. The rhythm was VF and after four minutes of advanced life support ROSC was achieved. Preparations were made for transfer including insertion of invasive blood pressure monitoring and a central venous catheter. His electrolytes were deranged so his potassium, magnesium and calcium were corrected along with an amiodarone maintenance infusion. He was not requiring any vasopressor or inotropic support at this stage. It was felt that the most expedient way to facilitate transfer would be with a local critical care team and paramedic ambulance, however, the local ambulance service were extremely stretched so as it became apparent that there was going to be a significant delay the regional critical care transfer team were contacted. The East of England Adult Critical Care Transfer Service (ACCTS) were dispatched but shortly after this the patient’s rhythm began to change with an increasing frequency of ventricular ectopics which eventually deteriorated into a further VF arrest at 10:08. CPR was re-established with the LUCAS and a 100 mg lidocaine bolus was given and an infusion commenced on advice from the consultant cardiologist. He also received 200 mL of 8.4% sodium bicarbonate. During this third arrest the pupils remained reactive, EtCO₂ above 3kPa and pH above 7.2 and so the case was rediscussed with the local PCI centre to inform them of the new arrest and to confirm that they were willing to receive the patient in cardiac arrest. A discussion was had with the family explaining that the chances of survival were minimal and even if he were to survive he had a high chance of neurological deficit. Despite this the family wanted to go ahead with the transfer and the clinical team agreed given the good prognostic factors.

The transfer team arrived at the patient at 10:59. CPR was still in progress and the patient had now been in arrest for fifty-one minutes with a cumulative total arrest time of ninety-two minutes. The consultant from ACCTS contacted the local primary percutaneous coronary intervention (PPCI) centre again to confirm they were still happy to receive the patient, and as they were, preparation was made to package the patient for transfer, a process that meant changing the monitors and infusions for those compatible with the transfer team equipment. By this point the patient had received in total 750 mg amiodarone (in boluses of 300, 150, 150 and 150 mg) with 900 mg bag running over 24 hours, the ongoing lidocaine infusion and adrenaline boluses of 1 mg every 3–5 minutes as per the ALS algorithm. He had also received 2,000 mL of Hartmann’s solution and was on a midazolam infusion of 5 mg/hr, a ketamine infusion of 50 mg/hr and a noradrenaline infusion of 0.15 mcg/kg/min with an arterial and central line in situ. The rapid primary examination showed that the patient had bilateral course crepitations in the chest with evidence of pulmonary oedema in the breathing circuit and a deep-seated LUCAS suction cup mark on the chest from such prolonged CPR. The EtCO₂ at this stage was 3.7 kPa and pupils were still reactive.

During the organisation of, and the packaging for transfer, attempts were made by the ACCTS consultant to establish ROSC and optimise the patient for safe transfer. This included a suggestion that the pads be changed from the standard position to anterior-posterior (AP) and that the boluses of adrenaline be held in case this was precipitating further VF storms. The midazolam and ketamine infusions were also stopped in order to try to improve the haemodynamics as there was no evidence of awareness at this stage. With the pads in the AP position, it was noted that post-shock there was now success in temporarily breaking the VF and producing a brief period of ROSC of approximately 10 seconds before the patient was relapsing back into VF. There were a few episodes where ROSC was achieved for almost one minute but not sustained. ABG performed prior to transfer showed: pH 7.353, pCO₂ 6.4 kPa, pO₂ 6.83 kPa with an FiO₂ of 1.0. The transfer team departed the hospital at 11:58 via road with mechanical CPR ongoing. The total duration of CPR at this stage was 110 minutes for this episode and 151 minutes cumulatively. Enroute, the patient was being defibrillated every two minutes, but adrenaline continued to be withheld. A discussion occurred again between the ACCTS transferring consultant and the cardiology consultant at the PCI centre with regards to whether ongoing shocks should be continued based on the non-sustained effects, but it was agreed to continue trying to break the recurrent VF episodes, if possible, through this approach. A further 200 mL 8.4% sodium bicarbonate was given enroute alongside the amiodarone and lidocaine infusions.

At 12:22 a sustained ROSC was finally achieved and an adrenaline bolus of 200 mcg was given and a noradrenaline infusion titrated up to 0.3 mcg/kg/min to maintain a MAP of 80–90 mmHg to maximise coronary perfusion. The duration of CPR at this stage was 134 minutes for this episode and 175 minutes cumulatively. At 12:26 pupils were checked for response and on opening the patient’s eyes it was noted that he started to blink and was able to obey the command to squeeze his hand, so sedation was restarted with a 2 mg midazolam and 30 mg ketamine bolus. Infusions of midazolam and alfentanil were started for maintenance for the remainder of the journey.

The ACCTS team arrived at the PCI centre at 12:45 where the patient had a witnessed episode of pulsed VT during offloading. He was successfully cardioverted with one synchronised shock delivered immediately. The patient was in the cardiac catheterisation suite by 12:52 and shortly after handover had another VF arrest so PCI was started with ongoing CPR. A timeline of the arrest is illustrated in Figure 2.

Figure 2 Timeline of events from the point of first cardiac arrest until arrival at the PPCI centre. Figure illustrated by Toby Hoskins. PPCI, primary percutaneous coronary intervention; CVC, central venous catheter; ROSC, return of spontaneous circulation; CPR, cardiopulmonary resuscitation; LAD, left anterior descending artery; PCI, percutaneous coronary intervention.

The patient ultimately received PCI to the left anterior descending artery. Following PPCI the patient was commenced on aspirin and ticagrelor and was taken, ventilated, to intensive care unit (ICU). His stay was then complicated by in-stent stenosis, managed with drug-eluting balloon dilation, and femoral artery pseudoaneurysm. He remained ventilated and on haemofiltration for an acute kidney injury. Over the next two days he had three more sudden cardiac arrests on the ICU and was successfully resuscitated each time. The patient was finally repatriated nine days later back to the parent hospital. On return he had an ongoing troponin rise with ECG changes but this settled and an ECHO demonstrated an ejection fraction of 44% with some regional wall motion abnormalities. Computed tomography (CT) of the head showed a right thalamic infarct. There were initial concerns about the likelihood of neurological recovery but the patient made steady forward progress and reached the point of physiological stability where a sedation hold could be considered.

Attempts were made to extubate the patient, but he did not tolerate a sedation hold becoming very hypertensive and not following commands. He underwent tracheostomy on day 17 post-arrest and sedation was fully stopped on day 21. On assessment of his neurology, he was able to obey commands and respond meaningfully to his wife’s questions. By day 26 he was fully alert, able to tolerate a speaking valve well enough to talk to his sons and make jokes at the expense of the ICU staff! He was able to move all his limbs and whilst he still had a significant ICU acquired weakness his prospect of a near-full neurological recovery was now felt likely, and indeed on day thirty post-arrest the patient was discharged from ICU and subsequently went home on day forty-one.

Further patient follow-up showed that he had fully recovered functionally and had no ongoing neurological deficit other than a slight focusing issue with the right eye, giving him a modified Rankin Score of 1. He has subsequently returned to a fully independent and active lifestyle with his family. In a phone interview with him he stated the following: ‘I don’t remember anything that happened that day or much of my stay on the intensive care unit. I am very grateful for the treatment I received, it not only saved my life but enabled me to get back to a job I love full time. I attend the gym at least twice a week and am on very limited medication. Living my best life and very happy.’

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Sudden cardiac arrest is a known complication of STEMI. The gold-standard treatment for STEMI is PPCI (10), and its successful use during cardiac arrest has been described (11). The British Cardiac Intervention Society has recommendations for volume of PPCI performed (12) and as such these services have become centralised. It is, therefore, inevitable that patients who may benefit from intra-arrest PCI suffer their arrest at a facility that does not provide this service. In these scenarios thrombolysis may be considered but (10), as with the case presented above, it is not always successful. The two remaining options are to perform a secondary, intra-arrest transfer or terminate resuscitation efforts.

Transfer of a mechanically ventilated patient requiring critical care intervention is resource-intensive and high risk, even more so if the patient is in arrest. It is, however, possible as demonstrated by this case. To maximise resources and the benefit to a patient, careful selection is required to identify those with a reasonable chance of survival. This can be difficult during the process of a cardiac arrest.

There is no agreed upon duration of CPR, and indeed the Resuscitation Council state that duration of resuscitation alone should not be a factor in stopping CPR (13). There has even been a case report of good neurological outcome after six hours of CPR, but this were associated with deep hypothermia (14). Despite this it is well documented that prolonged CPR reduces the likelihood of a favourable neurological outcome (7,8). In this particular case, the decision to continue resuscitation and proceed with a secondary transfer was due to the presence of positive indicators.

In a review of 82 case reports, Youness et al. identified several predictors of possible good outcome after prolonged resuscitation: young age, myocardial infarction, reversible cause and effective resuscitation started without delay (15). In addition to this, patients with a shockable rhythm are more likely to have a favourable neurological outcome after prolonged CPR (8). In the above case, many of the same positive features were present: a shockable rhythm throughout, the identification of a reversible cause, immediate commencement of chest compression and high-quality CPR as evidenced by reactive pupils and a good EtCO₂. Positive prognostic indicators have been summarised in Table 1.

Another factor that may have had an impact in the neurological outcome of the patient is the brief periods of non-sustained ROSC during preparation for transfer and therefore slight reduction in the ischaemic insult. These brief periods were noted after the pads were reconfigured to the AP position. A study conducted by Cheskes et al. demonstrated that in cases of refractory VF arrest, AP positioning increased survival to discharge compared to standard defibrillation (16).

Conclusions

The authors believe that this case demonstrates that secondary, intra-arrest transfer of a patient for PCI can be successful. It is necessary to look at all the patient factors, not just duration of arrest, when making the decision to continue resuscitation and perform a transfer. None of these positive features alone would have been enough to predict a successful outcome but the presence of so many of these convinced the authors to persist.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-33/rc

Peer Review File: Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-33/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-33/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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