Advances in Cardiac Resuscitation in the Emergency Department -
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Publication Date: September 2022 (Volume 24, Number 9)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 09/01/2025.

Authors

Kamal Medlej, MD

Instructor, Division of Critical Care, Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA

Ivana Nikolic, MD

Instructor of Medicine, Division of Cardiovascular Medicine, Harvard Medical School; Massachusetts General Hospital, Boston, MA

Peer Reviewers

Patrick J. Maher, MD

Assistant Professor, Emergency and Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY

Christopher R. Tainter, MD, RDMS, FACEP, FCCM

Clinical Professor, Department of Anesthesiology, Division of Critical Care, University of California San Diego Health, San Diego, CA

Abstract

Cardiogenic shock, cardiac arrest, and circulatory failure are life-threatening, and recognizing the underlying etiology and initiating treatment to promote perfusion are key to managing these patients and improving outcomes. This issue reviews the current evidence on diagnosis and management of cardiogenic shock, including oxygen supplementation, red blood cell transfusion, vasopressors, and inotropes. A summary of the various mechanical circulatory support options, including inclusion/exclusion criteria and admission and inter-facility transfer guidance, is included. Special considerations regarding the resuscitation and management of patients with intracorporeal left ventricular assist devices who are experiencing circulatory failure are outlined, including testing, imaging, and treatment.

Case Presentations

CASE 1

An 82-year-old woman arrives to the ED by EMS with a complaint of dyspnea….

The EMS team informs you that the patient’s family called 911 because she has been increasingly tired and short of breath.
Her family states that she has a “weak heart,” and report a history of hypertension that is being treated with multiple agents.
In the ED she is somnolent, with cool and mottled extremities. Her heart rate is 45 beats/min; blood pressure, 114/71 mm Hg; and SpO2, 88%. Her ECG shows a junctional bradycardia with no ischemic changes. She has crackles diffusely through her lung fields with decreased air entry bilaterally on auscultation.
What is most concerning about this patient‘s presentation, and what is the most appropriate next step in her management?

CASE 2

A 54-year-old man is brought to your ED in cardiac arrest…

EMS informs you that the patient’s wife witnessed his collapse at home after he complained of chest pain, and that she immediately started chest compressions.
He was found by EMS to be in ventricular fibrillation, and advanced cardiovascular life support was initiated. He received a total of 3 shocks, 3 boluses of IV epinephrine, and 2 boluses of IV amiodarone.
In the ED, he remains in ventricular fibrillation, with a total down time of 20 minutes.
What other interventions can you attempt to restore perfusion?

CASE 3

You receive a pre-arrival call from a local EMS crew, who are bringing in a pulseless and unresponsive 61-year-old woman who has an left ventricular assist device…

They have not been able to measure her blood pressure, and were diverted to your facility instead of going to the local LVAD center, given proximity and concern for circulatory arrest.
On arrival to your ED, the patient is still nonresponsive.
What should your next steps be?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.