- Email: [email protected]
High-tech arrest
BRIEF CLINICAL
part of the evaluation of all patients who present with variant angina. HARLAN M. KRUMHOLZ, M.D. ARY L. GOLDBERGER,M.D. Beth Israel Hospital Boston, Massachusetts 1. Miller D, Waters DD. Warnica W. Szlachcic J, Kreef J, Theroux P. Is variant angina the coronary manifestation of a generalized vasospastic disorder? N Engl J Med 1981; 304: 763-6. 2. Specchia G, de Servi F. Falcone C. et al. Significance of exercise-induced S-T segment elevation in patients without myocardial infarction. Circulation 1981; 63: 46-53. 3. Mauritson D, Peshock R, Winniford M, Stern L, Johnson S, Hillis L. Prinzmetal’s variant angina: is it transmitted genetically? Am Heart J 1983; 105: 1049. 4. Yoshino F. Sakuma N, Unoki T, et al. Variant angina in two brothers with left anterior descending coronary arterial spasm. Am J Cardiol 1989; 63: 379-80. 5. Madias J, O’Connor W. Variant angina in siblings with mild coronary artery disease. Am J Cardiol 1984; 53: 956-7. 6. Fournier J, Fernandez-Cortacero J, Granado C, Gascon D. Familial migraine and coronary artery spasm in two siblings. Clin Cardiol 1986; 9: 121-5. 7. Numano F. Nomura S, Yajima M, et al. Human leukocyte antigen in variant angina. Int J Cardiol 1987; 14: 47-53. Submitted
April 19, 1991, and accepted in revised form June 19, 1991
ACKNOWLEDGMENT: This work was supported in part by a grant from the G. Harold and Leila Y. Mathers Charitable Foundation and by the National Heart, Lung, and Blood Institute Grant ROl Hl42172 and Grant HL-07374. We thank Patricia Daly, M.D., and Lewis Landsberg, M.D., who participated in the patient’s care.
HIGH-TECHARREST The prognosis for the individual who sustains a cardiac arrest outside the hospital and is not resuscitated in the field remains dismal [1,2]. Despite major recent advances in our understanding of the pathophysiology of cardiac arrest, most physicians still approach cardiac arrests the same way they did in the 1970s: compressions, ventilation, and blind drug administration until the patient has remained pulseless for an extended time. Two new devices, disposable qualitative endtidal carbon dioxide (ETCOs) detectors and portable real-time ul-
trasound equipment, now allow physicians to make more rational decisions about the underlying etiology and prognosis in individuals who have a cardiac arrest. A 42-year-old man recovering from a thrombotic stroke had 6 weeks earlier developed sudden dyspnea and pleuritic chest pain. On arrival at the emergency department, he was tachypneic (78 breaths/minute) with tachycardia (126 beats/minute) and a blood pressure of 140/120 mm Hg. Hemoglobin saturation was 81% despite assisted ventilation with 100% oxygen. Orotracheal intubation was emergently performed. The qualitative ETCOa detector revealed the presence of CO2 on expiration. Streptokinase was administered but the patient became progressively hypoxic, ultimately resulting in ventricular fibrillation. After immediate defibrillation, an organized rhythm without pulses was noted at rates between 50 and 140/minute. During this period of electromechanical dissociation (EMD), the ETC02 detector indicated the absence of expired CO2 despite confirmation of correct endotracheal tube position by direct laryngoscopy. Bedside ultrasonography immediately performed in the emergency department confirmed the absence of any ventricular wall motion and the absence of pericardial tamponade. Resuscitation was terminated 16 minutes after initiation of thrombolysis. Disposable qualitative ETCOs detectors, which are small and inexpensive (Fenem Co., New York, NY), have been used mainly to document correct placement of an endotracheal tube. Detection of expired CO2 confirms that the tube is in communication with the pulmonary tree where COz is eliminated, thereby confirming intratracheal placement [3,4]. The device is connected between the adaptor on the endotracheal tube and the ventilation March
1992
The American
OBSERVATIONS
port of the manual ventilating bag. The COz-sensitive paper of the detector remains purple if less than 0.5% CO2 is detected and turns bright yellow on expiration if greater than 2.0% CO2 is expired (Figure 1). Detection of ETCOs is also dependent on the peripheral production of CO2 and its delivery to the lungs. After endotracheal tube insertion, failure to detect ETCOz implies: (1) incorrect tube placement in the esophagus, (2) the development of such profound circulatory impairment that pulmonary CO2 delivery has ceased, or (3) some form of interference with CO2 elimination (e.g., massive pulmonary embolism) [3,5]. In our patient, in whom correct tube placement was confirmed, the absence of ETCOz implied that massive pulmonary embolism and/or profound circulatory impairment was present. Such profound circulatory impairment in the setting of EMD is an indication of futility of further resuscitation efforts [5]. If return of ETCOs detection had occurred, this would have implied return of circulation or possibly successful thrombolysis of a massive pulmonary embolus. Small portable ultrasound machines are now available (weight 2.5 kg) (Scan-Mate Ultrasound Scanner, Damon Corp., Needham Heights, MA) and have sufficient scan quality to evaluate the presence of cardiac activity, the presence of pericardial effusion, and even the diameter of the abdominal aorta (all visible from a four-chamber subxiphoid approach). The subxiphoid approach can be rapidly and unobtrusively performed even while cardiopulmonary resuscitation is underway (Figure 2). In the setting of EMD, documenting the .presence or absence of pericardial fluid may guide treatment, and the absence of any myocardial contractility strongly implies fuJournal
of Medicine
Volume
92
335
Figure
1. Qualitative
ETCOZ
detector
with
color
tectors allow confirmation of intratracheal placement of an endotracheal tube when circulation is present. In addition, when tube position is confirmed, they may provide evidence of profound circulatory impairment with an extremely poor prognosis, or the presence of massive pulmonary embolism requiring immediate thrombolytic therapy or thoracotomy. Bedside ultrasonography not only rules out reversible causes of EMD (pericardial tamponade, ruptured abdominal aortic aneurysm, massive pulmonary embolism) but also, in the absence of any cardiac wall motion, implies a very poor prognosis for successful resuscitation. Use of this technology can help guide objective treatment in some cases and aid in the timing of termination of resuscitative efforts in others.
changes.
KEITH WRENN,M.D., F.A.C.P. STEVE WHITE,M.D. COREYM. SLOWS, M.D., F.A.c.E.P., F.A.C.P. University
of
Rochester Rochester,
Figure ulated
2. Cardiac arrest
using
imaging
with
a subxiphoid
a portable probe
real-time
ultrasound
scanner
during
sim-
position.
1. Bonnin MJ, Swor RA. Outcomes in unsuccessful field resuscitation attempts. Ann Emerg Med 1989; 18: 507-12. 2. Bonnin MJ, Pepe PE, Clark PS. Key role of prehospital resuscitation in survival from out-of-hospital cardiac arrest. Ann Emerg Med 1990: 19: 466. 3. Bhende MS, Thompson AE, Cook DR. Validity of a disposable end-tidal CO2 detector in verifying endotracheal tube position in infants and children. Ann Emerg Med 1990; 19: 483. 4. Ornato JP, Shipley JB. Racht EM, et al. Multicenter study of end-tidal carbon dioxide in the prehospital setting. Ann Emerg Med 1990; 19: 452. 5. Martin GB, Paridis NA, Rivers EP, Goetting MG, Appleton TJ, Nowak RM. End-tidal carbon dioxide and coronary perfusion pressure in human beings during standard CPR. Ann Emerg Med 1990; 19: 457. 6. Mayron R, Gaudio FE, Plummer D, Asinger R, Elsperger J. Echocardiography performed by emergency physicians: impact on diagnosis and therapy. Ann Emerg Med 1988; 17: 150-4. Submitted
tility of further resuscitative efforts [6]. ETCOz detectors and portable ultrasound machines can enable physicians to make rapid, ration-
336
March
1992
The American
Journal
al, inexpensive, noninvasive decisions about critical clinical variables during resuscitation from cardiac arrest, especially asystole or EMD. Qualitative ETC02 de-
of Medicine
Volume
92
School of Medicine New York
May 14. 1991, and accepted in revised form June 19, 1991
ACKNOWLEDGMENT: We are deeply indebted to Dr. Karl Schwarz and Dr. Richard Meltzer for the permanent loan of the Scan-Mate Ultrasound Scanner and for their instruction and support in its use.
part of the evaluation of all patients who present with variant angina. HARLAN M. KRUMHOLZ, M.D. ARY L. GOLDBERGER,M.D. Beth Israel Hospital Boston, Massachusetts 1. Miller D, Waters DD. Warnica W. Szlachcic J, Kreef J, Theroux P. Is variant angina the coronary manifestation of a generalized vasospastic disorder? N Engl J Med 1981; 304: 763-6. 2. Specchia G, de Servi F. Falcone C. et al. Significance of exercise-induced S-T segment elevation in patients without myocardial infarction. Circulation 1981; 63: 46-53. 3. Mauritson D, Peshock R, Winniford M, Stern L, Johnson S, Hillis L. Prinzmetal’s variant angina: is it transmitted genetically? Am Heart J 1983; 105: 1049. 4. Yoshino F. Sakuma N, Unoki T, et al. Variant angina in two brothers with left anterior descending coronary arterial spasm. Am J Cardiol 1989; 63: 379-80. 5. Madias J, O’Connor W. Variant angina in siblings with mild coronary artery disease. Am J Cardiol 1984; 53: 956-7. 6. Fournier J, Fernandez-Cortacero J, Granado C, Gascon D. Familial migraine and coronary artery spasm in two siblings. Clin Cardiol 1986; 9: 121-5. 7. Numano F. Nomura S, Yajima M, et al. Human leukocyte antigen in variant angina. Int J Cardiol 1987; 14: 47-53. Submitted
April 19, 1991, and accepted in revised form June 19, 1991
ACKNOWLEDGMENT: This work was supported in part by a grant from the G. Harold and Leila Y. Mathers Charitable Foundation and by the National Heart, Lung, and Blood Institute Grant ROl Hl42172 and Grant HL-07374. We thank Patricia Daly, M.D., and Lewis Landsberg, M.D., who participated in the patient’s care.
HIGH-TECHARREST The prognosis for the individual who sustains a cardiac arrest outside the hospital and is not resuscitated in the field remains dismal [1,2]. Despite major recent advances in our understanding of the pathophysiology of cardiac arrest, most physicians still approach cardiac arrests the same way they did in the 1970s: compressions, ventilation, and blind drug administration until the patient has remained pulseless for an extended time. Two new devices, disposable qualitative endtidal carbon dioxide (ETCOs) detectors and portable real-time ul-
trasound equipment, now allow physicians to make more rational decisions about the underlying etiology and prognosis in individuals who have a cardiac arrest. A 42-year-old man recovering from a thrombotic stroke had 6 weeks earlier developed sudden dyspnea and pleuritic chest pain. On arrival at the emergency department, he was tachypneic (78 breaths/minute) with tachycardia (126 beats/minute) and a blood pressure of 140/120 mm Hg. Hemoglobin saturation was 81% despite assisted ventilation with 100% oxygen. Orotracheal intubation was emergently performed. The qualitative ETCOa detector revealed the presence of CO2 on expiration. Streptokinase was administered but the patient became progressively hypoxic, ultimately resulting in ventricular fibrillation. After immediate defibrillation, an organized rhythm without pulses was noted at rates between 50 and 140/minute. During this period of electromechanical dissociation (EMD), the ETC02 detector indicated the absence of expired CO2 despite confirmation of correct endotracheal tube position by direct laryngoscopy. Bedside ultrasonography immediately performed in the emergency department confirmed the absence of any ventricular wall motion and the absence of pericardial tamponade. Resuscitation was terminated 16 minutes after initiation of thrombolysis. Disposable qualitative ETCOs detectors, which are small and inexpensive (Fenem Co., New York, NY), have been used mainly to document correct placement of an endotracheal tube. Detection of expired CO2 confirms that the tube is in communication with the pulmonary tree where COz is eliminated, thereby confirming intratracheal placement [3,4]. The device is connected between the adaptor on the endotracheal tube and the ventilation March
1992
The American
OBSERVATIONS
port of the manual ventilating bag. The COz-sensitive paper of the detector remains purple if less than 0.5% CO2 is detected and turns bright yellow on expiration if greater than 2.0% CO2 is expired (Figure 1). Detection of ETCOs is also dependent on the peripheral production of CO2 and its delivery to the lungs. After endotracheal tube insertion, failure to detect ETCOz implies: (1) incorrect tube placement in the esophagus, (2) the development of such profound circulatory impairment that pulmonary CO2 delivery has ceased, or (3) some form of interference with CO2 elimination (e.g., massive pulmonary embolism) [3,5]. In our patient, in whom correct tube placement was confirmed, the absence of ETCOz implied that massive pulmonary embolism and/or profound circulatory impairment was present. Such profound circulatory impairment in the setting of EMD is an indication of futility of further resuscitation efforts [5]. If return of ETCOs detection had occurred, this would have implied return of circulation or possibly successful thrombolysis of a massive pulmonary embolus. Small portable ultrasound machines are now available (weight 2.5 kg) (Scan-Mate Ultrasound Scanner, Damon Corp., Needham Heights, MA) and have sufficient scan quality to evaluate the presence of cardiac activity, the presence of pericardial effusion, and even the diameter of the abdominal aorta (all visible from a four-chamber subxiphoid approach). The subxiphoid approach can be rapidly and unobtrusively performed even while cardiopulmonary resuscitation is underway (Figure 2). In the setting of EMD, documenting the .presence or absence of pericardial fluid may guide treatment, and the absence of any myocardial contractility strongly implies fuJournal
of Medicine
Volume
92
335
Figure
1. Qualitative
ETCOZ
detector
with
color
tectors allow confirmation of intratracheal placement of an endotracheal tube when circulation is present. In addition, when tube position is confirmed, they may provide evidence of profound circulatory impairment with an extremely poor prognosis, or the presence of massive pulmonary embolism requiring immediate thrombolytic therapy or thoracotomy. Bedside ultrasonography not only rules out reversible causes of EMD (pericardial tamponade, ruptured abdominal aortic aneurysm, massive pulmonary embolism) but also, in the absence of any cardiac wall motion, implies a very poor prognosis for successful resuscitation. Use of this technology can help guide objective treatment in some cases and aid in the timing of termination of resuscitative efforts in others.
changes.
KEITH WRENN,M.D., F.A.C.P. STEVE WHITE,M.D. COREYM. SLOWS, M.D., F.A.c.E.P., F.A.C.P. University
of
Rochester Rochester,
Figure ulated
2. Cardiac arrest
using
imaging
with
a subxiphoid
a portable probe
real-time
ultrasound
scanner
during
sim-
position.
1. Bonnin MJ, Swor RA. Outcomes in unsuccessful field resuscitation attempts. Ann Emerg Med 1989; 18: 507-12. 2. Bonnin MJ, Pepe PE, Clark PS. Key role of prehospital resuscitation in survival from out-of-hospital cardiac arrest. Ann Emerg Med 1990: 19: 466. 3. Bhende MS, Thompson AE, Cook DR. Validity of a disposable end-tidal CO2 detector in verifying endotracheal tube position in infants and children. Ann Emerg Med 1990; 19: 483. 4. Ornato JP, Shipley JB. Racht EM, et al. Multicenter study of end-tidal carbon dioxide in the prehospital setting. Ann Emerg Med 1990; 19: 452. 5. Martin GB, Paridis NA, Rivers EP, Goetting MG, Appleton TJ, Nowak RM. End-tidal carbon dioxide and coronary perfusion pressure in human beings during standard CPR. Ann Emerg Med 1990; 19: 457. 6. Mayron R, Gaudio FE, Plummer D, Asinger R, Elsperger J. Echocardiography performed by emergency physicians: impact on diagnosis and therapy. Ann Emerg Med 1988; 17: 150-4. Submitted
tility of further resuscitative efforts [6]. ETCOz detectors and portable ultrasound machines can enable physicians to make rapid, ration-
336
March
1992
The American
Journal
al, inexpensive, noninvasive decisions about critical clinical variables during resuscitation from cardiac arrest, especially asystole or EMD. Qualitative ETC02 de-
of Medicine
Volume
92
School of Medicine New York
May 14. 1991, and accepted in revised form June 19, 1991
ACKNOWLEDGMENT: We are deeply indebted to Dr. Karl Schwarz and Dr. Richard Meltzer for the permanent loan of the Scan-Mate Ultrasound Scanner and for their instruction and support in its use.