Optimal Treatment for Post-Cardiac Arrest Patient

OK... it's been 2 weeks and it is time for another post.


Few days ago I had an interesting conversation with one of the cardiologist at one of the hospitals I'm working. The case was a 46-year-old post cardiac arrest patient. He had a witnessed collapse at home.  Paramedics arrived shortly after and began ACLS protocols. He was shocked seven times because of persistent VF and received five rounds of epinephrine with ROSC during transfer. Upon arrival his vitals were not terribly bad he was slightly hypotensive and tachycardic, but he's electrocardiogram didn't have ST elevation, but mild ST depressions in the inferior and lateral leads, so he didn't meet criteria to activate the cath lab as a code STEMI. However, this was a post arrest case and based on what I have seen in current literature, he has the best chances of surviving neurologically intact by combining hypothermia and catheterization. So I called the cardiologist on call and presented the case, and suggested that he should start making his way in while we start hypothermia and prepare him for cath. This conversation didn't go well at all. The cardiologist almost had a stroke while talking to me on the phone. He argued that there was no indication to go to the Cath Lab in a post cardiac arrest case without ST elevation in the ECG, and if someone agreed to cath this patient, it was the wrong thing to do and yara yara yard. - OK... no problem, thanks so much doc. Next; I called 2 different cardiologists with the same request. "Would you please take this young, post arrest, ST depression patient to cath? - The third cardiologist finally agreed, so we started cooling the patient and rushed to the cath lab before the cardiologist could change his decision... He found a 90% occluded LMCA. 

Unfortunately this is not an uncommon scenario. The cardiologists tend not to cath post-cardiac arrest patients without STEMIs because this group tends to do worse and it looks bad for their numbers. However... there is support for the cool and cath approach for NSTEMI post cardiac arrest patient in their own literature. Check this out, this is from the Journal of the American College of Cardiology, probably the most influential cardiology journal in the world, right up there with European Society of Cardiology and American Heart Association.

http://interventions.onlinejacc.org/article.aspx?articleid=1207384

These are the key points of this article

- The lack of ST elevation in the post arrest 12-lead ECG is not a reliable predictor for the absence of acute coronary disease. 

- The NNT with coronary angiography in a post-cardiac arrest patient after cardiac arrest to find an acute culprit lesion needing emergent revascularization among those without ST-segment elevation is, in fact, just 4 patients.

- "Resuscitated cardiac arrest victims without an obvious non- cardiac etiology should undergo emergency coronary angiography and, where indicated, percutaneous coronary intervention. If comatose, they should receive concurrent therapeutic hypothermia. Such an approach can double long-term survival rates among those successfully resuscitated after out-of-hospital cardiac arrest".

Therapeutic hypothermia and early catheterization with PCA when needed, is the best chance for a good outcome in post-cardiac arrest patients regardless of the initial ECG. If they argue otherwise, just refer them to their own journal. However, It will be wise to sit with the cardiologists at 3 pm, have a coffee and agree in a plan for these type of situations and have it all sorted out, so when the ambulance arrives at 3 am things are easier for everybody.

A nice review article with everything included: http://www.epmonthly.com/www.epmonthly.com/features/current-features/post-cardiac-arrest-care/?utm_source=EPI+Global+Briefing+0412+3-19-14&utm_campaign=Global+Briefing+3_27_14&utm_medium=email