Advances in Cardiac Resuscitation in the Emergency Department

Table of Contents

 

About This Issue

Cardiogenic shock and cardiac arrest can occur as a result of many different pathologies, and management of an ED patient with inadequate perfusion due to low cardiac output will depend on the etiology. This issue reviews these etiologies and summarizes management according to the best available evidence. Management of patients with mechanical circulatory support devices (such as left ventricular assist devices [LVADs]) is also discussed, along with criteria for referral for other support devices, such as ECMO, ECPR, and REBOA.

What are the physical examination features of cardiogenic shock in patients with heart failure, coronary artery disease/cardiac surgery, or pregnancy?

How is pulse pressure measured in a patient who has an LVAD and no detectable pulse?

What are the distinct SPO₂ waveforms and ECG patterns seen in patients with LVADs?

What laboratory tests are needed for patients with heart failure versus those with LVADs?

Are imaging studies useful?

How is oxygen delivery (DO₂) assessed?

When should oxygen supplementation and red blood cell transfusion be used to improve oxygenation?

How and when should vasopressors, vasodilators, and inotropes be used?

When should you refer a patient for mechanical circulatory support?

What is the recommended process for resuscitation of a patient with an LVAD?

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
7. Circulatory Failure in Patients With Left Ventricular Assist Devices
8. Differential Diagnosis
9. Prehospital Care
   1. Prehospital Management of Patients With Left Ventricular Assist Devices
10. Emergency Department Evaluation
    1. History
       1. History for Patients With Left Ventricular Assist Devices
    2. Physical Examination
       1. Physical Examination of Patients With Left Ventricular Assist Devices
11. Diagnostic Studies
    1. Electrocardiogram
       1. Electrocardiogram in Patients With Left Ventricular Assist Devices
    2. Laboratory Testing
       1. Laboratory Testing in Patients With Left Ventricular Assist Devices
    3. Imaging Studies
       1. Imaging Studies for Patients With Left Ventricular Assist Devices
12. Treatment
    1. Oxygen Supplementation
    2. Transfusion of Red Blood Cells
    3. Vasopressors
    4. Vasodilators
    5. Inotropes
    6. Mechanical Circulatory Support
       1. Resuscitation of Patients With Left Ventricular Assist Devices
13. Special Circumstances and Populations
    1. Cardiogenic Shock Secondary to COVID-19
    2. Cardiogenic Shock and Cardiac Arrest in the Pregnant Patient
    3. Accidental Hypothermia
    4. Toxin-Induced Cardiogenic Shock
14. Controversies and Cutting Edge
    1. Epinephrine for Out-of-Hospital Cardiac Arrest
    2. Esmolol for Refractory Ventricular Fibrillation
    3. Double Sequential External Defibrillation for Refractory Ventricular Tachycardia and Ventricular Fibrillation
    4. Resuscitative Endovascular Balloon Occlusion of the Aorta for Nontraumatic Cardiac Arrest
15. Disposition
    1. Hospital Admission
    2. Inter-Facility Transfer
16. Summary
17. Time and Cost-Effective Strategies
18. Risk Management Pitfalls for Cardiac Resuscitation in the Emergency Department
19. 5 Things That Will Change Your Practice
20. Case Conclusions
21. Clinical Pathways
    1. Clinical Pathway for Management of Cardiogenic Shock in the Emergency Department
    2. Clinical Pathway for Management of a Patient With an LVAD in Whom Circulatory Failure is Suspected
22. Tables and Figures
23. References

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

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?

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?

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?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathways

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

7. * Yannopoulos D, Bartos J, Raveendran G, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet. 2020;396(10265):1807-1816. (Prospective; 36 patients) DOI: 10.1016/S0140-6736(20)32338-2

11. * van Diepen S, Katz JN, Albert NM, et al. Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association. Circulation. 2017;136(16):e232-e268. (Scientific statement) DOI: 10.1161/CIR.0000000000000525

12. * Menon V, Slater JN, White HD, et al. Acute myocardial infarction complicated by systemic hypoperfusion without hypotension: report of the SHOCK trial registry. Am J Med. 2000;108(5):374-380. (Prospective registry study; 992 patients) DOI: 10.1016/s0002-9343(00)00310-7

16. * De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362(9):779-789. (Prospective; 1679 patients) DOI: 10.1056/NEJMoa0907118

32. * Lamontagne F, Richards-Belle A, Thomas K, et al. Effect of reduced exposure to vasopressors on 90-day mortality in older critically ill patients with vasodilatory hypotension: a randomized clinical trial. JAMA. 2020;323(10):938-949. (Prospective; 2598 patients) DOI: 10.1001/jama.2020.0930

35. * Rui Q, Jiang Y, Chen M, et al. Dopamine versus norepinephrine in the treatment of cardiogenic shock: a PRISMA-compliant meta-analysis. Medicine (Baltimore). 2017;96(43):e8402. (Meta-analysis; 9 studies, 510 patients) DOI: 10.1097/MD.0000000000008402

41. * Léopold V, Gayat E, Pirracchio R, et al. Epinephrine and short-term survival in cardiogenic shock: an individual data meta-analysis of 2583 patients. Intensive Care Med. 2018;44(6):847-856. (Meta-analysis; 16 cohorts, 2583 patients)

42. Richardson AS, Schmidt M, Bailey M, et al. ECMO cardio-pulmonary resuscitation (ECPR), trends in survival from an international multicentre cohort study over 12 years. Resuscitation. 2017;112:34-40. (Retrospective; 1796 patients) DOI: 10.1016/j.resuscitation.2016.12.009

56. * Perkins GD, Ji C, Deakin CD, et al. A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med. 2018;379(8):711-721. (Prospective; 8014 patients) DOI: 10.1056/NEJMoa1806842

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Keywords: cardiogenic, shock, cardiac, perfusion, ECMO, LVAD, assist, cardiopulmonary, resuscitation, heart failure, MAP, norepinephrine, inotrope, pregnant, hypothermia