What about the "nearly arrest" patients?

What about the nearly
arrest patient?
Where evidence based medicine has yet to go but
where we often ﬁnd ourselves

SP-ER conference 9 Aug 2009
Suthaporn Lumlertgul M.D.
King Chulalongkorn Memorial hospital

Sunday, August 9, 2009

Reference:
Harvard Shock symposium


Objective

• Manage case that is nearly dead, guideline
yet go there
•


นาทีเฉียดตาย

•


Example case

• A 60 year old woman with complaint
lightheadness, chest tightness
• HR= 150/min, BP=200/110 RR=36/min O2
Sat 96% Temp=37.4


What are you examining in AF patient?


What are you examining in AF patient?

• A 60 year old
woman with
complaint
lightheadness,
chest tightness

• HR= 150/min,
BP=200/110

• RR=36/min O2
Sat 90%
Temp=37.4


Deﬁne Unstable

• Patients as those with ventricular rates 150,

• ongoing chest pain, or with evidence of critical
perfusion:

• systolic BP 90 mm Hg, heart failure, or reduced
consciousness.


Rapid AF

• AHA guideline for management of a patient
with hypotension and AF with RVR would
be cardioversion
• DC Cardioversion


Would you cardiovert
the patient?


Rhythm

Digoxin
Rate

Diltiazem/verapamil


Cardiovert

Rhythm

Digoxin
Rate

Diltiazem/verapamil


Cardiovert

Rhythm
Amiodarone

Digoxin
Rate

Diltiazem/verapamil


What are you using?
Amiodarone Diltiazem
Adenosine

Digoxin
Beta blocker


What are you using?

Digoxin

Beta blocker

5 min


What are you using?

Digoxin

Cardiovert

Beta blocker

5 min


What are you using?

Digoxin

Cardiovert

Diltiazem
Beta blocker

5 min


What are you using?

Amiodarone Digoxin

Cardiovert

Diltiazem
Beta blocker

5 min


Diltiazem

• Schreck et al compared the effectiveness of IV
Diltiazem receive
diltiazem with digoxin. In this open-label RCT,
consecutive patients with acute AF were assigned to more rapid rate
receive either diltiazem (0.25 mg/kg initial bolus
followed by 0.35 mg/kg 15 min after, and then an
control in 5 min
infusion of 10 to 20 mg/h to maintain a heart rate thank digoxin
100), digoxin (0.25-mg boluses at 0 and 30 min),
or both digoxin and diltiazem. Follow-up was for 180
min. Treatment with diltiazem achieved a rapid
reduction in ventricular rate compared to digoxin,
the results becoming statistically signiﬁcant by 5 min


Diltiazem

• Rate-limiting calcium channel antagonists have
therefore been shown to be effective in ventricular
rate reduction in acute AF. The major adverse event
reported from the RCTs was the precipitation of
symptomatic hypotension (18% of patients)


Amiodarone


Digoxin

• Double-blind RCT recruited 40 patients to receive either digoxin (total IVdose
of 1.25 mg in divided doses) or placebo.

• At 12 h posttherapy, there was no signiﬁcant difference between the rates of
conversion between the digoxin
• Ventricular rate reduction was 30 min


Maintain sinus Rate + anticoag

⇑Hemodynamic Avoid pro
Pro
⇓Thromboembolic arrhythmia

⇓Hemodynamic
Pro arrhythmic Bleeding
Con
Fatality Residual embolic


RV

LV

Loss of atrial kick sign?


•LV systolic function looks
depressed (subcostal long axis
view)

RV

LV



view)

RV •Reduce SV by reducing diastolic
time / by absence of atrial kick).

LV



view)


•In this patient with acute onset
of FA and subsequent
hypotension .

LV



view)


•In this patient with acute onset
of FA and subsequent
hypotension .

LV •After prompt cardioversion,
sinus rhythm is restored and LV
systolic function looks now much
better



What does it cause?


Loss of atrial kick

What does it cause?


Blood don’t go into
Loss of atrial kick
atrium

What does it cause?


Blood don’t go into
Loss of atrial kick It reﬂux into neck vein
atrium

What does it cause?


• Patient was administered Digoxin IV
• After not improving the clinical patient was
administered Diltiazem IV
• Patient has less lightheadesness but still
have chest tightness
• Heart rate was slower from 170 to 130/
min but BP still 200/100


• Patient was treated with Nicardipine IV
• He feel less lightheadeness still chest
discomfort
• Old ECG show no atrial ﬁbrillation


Take home message

• Remember for the unstable signs in limited
time Heart failure, poor perfusion
• How fast do you think the patient will
survive on this rhythm
• Pick the choice of treatment from that


Case II

• BP=110/60 HR=130 RR=20 T=37.3
• Complaint of chest tightness,


What would you do?

• Any reason to change rhythm?
• Dead now or later?
•


Case III

• A man with acute dyspnea come in ER with
expiratory wheezing and sound of
secretion, profound sweating
• Switching Taxi driver to passenger
• RR=35 PR=130/min BP=220/110 T=37
StO2=70%


What is your diagnosis?
Next Management?


What will you do in
this patient?

• Physical examinaiton
• Further investigation?
• Further Management


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What would you do in
this patient?
• Atropine
• Epinephrine
• Dopamine
• Transcutaneous pacing


เจ็บแปลบ ...

• The patient is so painful when you put on
pacemaker
• Will atropine cause more infarct?


Take home message

• Don’t be afraid to use adjuncts in life
threatening patients
• This is 2009, ER is all about proove it and
treat it.


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What about the "nearly arrest" patients?

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