ROSC without defibrillation? ROSC with respiratory arrest?

Summit

Critical Crazy
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I'm trying unsuccessfuly to find some numbers on ROSC without defibrillation, preferably a dataset selected for primarily respiratory etiology and better yet out of hospital.

I haven't been successful in finding this type of research. Anyone know of any? Pretty much everything is for primary cardiac etiology and eventually there is electricity available.

Or....

Anyone care to speculate wildly on the utility of CPR without defib or drugs in otherwise healthy adult patients in out-of-hospital arrest due to hypoxia/asphyxia?
 

dutemplar

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I would speculate wildly that the majority of ROSCs with "just" CPR were poorly assessed and had pulses in the first case... It's theoretically possible, however unlikely to fix the underlying issues without electricity, medications, PCI, etc...

We had one the other night, unconscious unresponsive patient who miraculously regained ROSC and was fully conscious and highly agitated within one minute of CPR. Could be a miracle, or...
 
OP
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Summit

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dutemplar, my speculation agrees with yours, that poor assessment would explain a lot of supposed ROSC in that situation (not fully arrested).

My general thought would be very low numbers for ROSC in actual arrest because CPR only would be effective only if the patient was in some kind of Sinus PEA without appreciable contractility d/t hypoxia/acidemia that would be corrected by the CPR.

How often would that be the case? How much utility is CPR only in this hypoxia/acidemia asphyxia arrest? 0.1% ROSC? 1%? 10%?
 

VentMonkey

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dutemplar, my speculation agrees with yours, that poor assessment would explain a lot of supposed ROSC in that situation (not fully arrested).

My general thought would be very low numbers for ROSC in actual arrest because CPR only would be effective only if the patient was in some kind of Sinus PEA without appreciable contractility d/t hypoxia/acidemia that would be corrected by the CPR.

How often would that be the case? How much utility is CPR only in this hypoxia/acidemia asphyxia arrest? 0.1% ROSC? 1%? 10%?
Good questions, and I have no clue, lol.

The arrests that stick out in my mind that seem to "convert" rather quickly without defibrillation, and minimal CPR have been "fresh" hangings (traumatic asphyxias).

Here's an abstract that talks about care in (blunt) traumatic asphyxiation and it's care, though I don't think it's cardiac arrest specific, and I apologize if you've already perused it. Perhaps others will gain something from it though:

https://jmedicalcasereports.biomedcentral.com/articles/10.1186/1752-1947-6-257

So, now I wonder if there would be any correlation between what you're asking, and this patient subset in particular*.

*The patients I am referring to were/ are in fact clinically dead
 

EpiEMS

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Questions like this are why I absolutely love this site.

I'm trying unsuccessfuly to find some numbers on ROSC without defibrillation, preferably a dataset selected for primarily respiratory etiology and better yet out of hospital.

I haven't been successful in finding this type of research. Anyone know of any? Pretty much everything is for primary cardiac etiology and eventually there is electricity available.

Or....

Anyone care to speculate wildly on the utility of CPR without defib or drugs in otherwise healthy adult patients in out-of-hospital arrest due to hypoxia/asphyxia?
This is so good that I have to quote it. I can't find anything from a PubMed search either...

I would speculate wildly that the majority of ROSCs with "just" CPR were poorly assessed and had pulses in the first case... It's theoretically possible, however unlikely to fix the underlying issues without electricity, medications, PCI, etc...
I've seen non-ALS responders do CPR and put an AED on way too many people with pulses...so I tend to suspect that the ROSC with CPR-only may very well be correlated with poor assessments or difficult-to-assess patients. My anecdotal experience agrees with yours, though I am at a loss for actual evidence...

That being said, I want to caveat with this: A responder who cannot find a pulse is better off assuming that the patient is actually pulseless, because the harm of doing CPR is pretty minimal relative to the (potential) gains (see slide 11 here for why).
 

MonkeyArrow

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I actually had a case like this the other day. 90+ M cardiac arrest from SNF. Presented in monomorphic Vtach without pulses. Would resuscitate with high quality CPR, defib with no changes, spontaneously get rhythm conversion during CPR. See a good carotid, hypotensive, watch him brady back down over the next 2 minutes back into Vtach arrest. I think some of these patients do have some sort of Brady-PEA combination where they require chronotropes to sustain them. Of course, n=1 and I haven't found any studies specifically about this.
 

shelvpower

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Also had a successful resuscitation last week without defibrillation.

60 y/o female collapsed at the busy beach front (no bystander CPR, lifeguards places a 40% O2 mask on her though...) . Known CHF pt.
O/A pt was unresponsive, ECG confirmed very slow PEA. 10 minutes into resuscitation ECG showed asystole. After another 10 minutes we got ROSC (without defibrillation, only adrenaline) . Strong radial pulses @ 40-60bpm with a BP of 100/60 mmHg.

12 lead showed ST elevation in leads ll, lll, aVF and V4R.
Patient transported to closest appropriate facility. Unfortunately we were unable to stick around at hospital to see what treatment the patient was receiving.

Doctor informed us that the patient passed away the following day in CCU.

Sent from my SM-G930F using Tapatalk
 

StCEMT

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I'd guess that most stuff floating around is anecdotal, not sure that I've ever seen a study for it. Then again, I haven't ever really looked for this specifically, although I have dug around a bit on stuff talking about ditching epi or at least not dumping so much so fast.

For your asystole/PEA rhythms, I did find this. I haven't gone all the way through it and it doesn't specify any particular cause of arrest, but I will leave it here anyway just for the sake of keeping this going.
http://www.bmj.com/content/348/bmj.g3028?etoc

Speculation? Electricity is probably better with VF/VT, but I think there might be something to not dumping enough epi to bring a rock to life in general.
I actually had a case like this the other day. 90+ M cardiac arrest from SNF. Presented in monomorphic Vtach without pulses. Would resuscitate with high quality CPR, defib with no changes, spontaneously get rhythm conversion during CPR. See a good carotid, hypotensive, watch him brady back down over the next 2 minutes back into Vtach arrest. I think some of these patients do have some sort of Brady-PEA combination where they require chronotropes to sustain them. Of course, n=1 and I haven't found any studies specifically about this.
Did he end up getting any meds hanging since he was in and out of VT?
 

MonkeyArrow

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Did he end up getting any meds hanging since he was in and out of VT?
Not anything except for epi during the arrest periods. Honestly, starting him on a rapid bolus of amiodarone or lidocaine probably wouldn't have hurt, but if I recall correctly, the doc was trying to get the family member to confirm requests not to work him any further, so it wasn't really a try-hard case. Prepping an epi drip or even push-dose epi would have been a good option, I believe, in someone like him to try to bridge him to a more permanent solution right after ROSC before he could brady down again.
 

StCEMT

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Not anything except for epi during the arrest periods. Honestly, starting him on a rapid bolus of amiodarone or lidocaine probably wouldn't have hurt, but if I recall correctly, the doc was trying to get the family member to confirm requests not to work him any further, so it wasn't really a try-hard case. Prepping an epi drip or even push-dose epi would have been a good option, I believe, in someone like him to try to bridge him to a more permanent solution right after ROSC before he could brady down again.
What I was wondering was the potential of putting him on a LUCAS and once you had established that CPR would convert him, keep that push dose handy or hang dopamine along with Lidocaine to try to keep him from slipping back into VT. It worked very quickly last time we pushed a prefilled Lidocaine and maintained all the way to the hospital. That being said, I also didn't have a situation that had family trying to end resuscitation, so I can see where you're coming from.
 

VFlutter

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Self-terminating VT/VF is actually a thing. You occasionally see people who have loop recorders for syncope actually have episodic VT/VF that self-terminates without intervention. Not really sure of the mechanism. Saw a interesting case study in school of a younger female who was referred for a sleep study for possible seizures or narcolepsy but actually was having episodes of Torsades. I'll try to find the video.
 

VFlutter

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It is also a good learning point that people who abruptly arrest, seems to be more common in younger individuals, tend to have seizure like activity. Seen it a few times.
 

NomadicMedic

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It is also a good learning point that people who abruptly arrest, seems to be more common in younger individuals, tend to have seizure like activity. Seen it a few times.
All the more reason to bring your gear into the house on all seizure calls. I've walked into the dispatched as a SZ, is actually an arrest several times.
 

StCEMT

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All the more reason to bring your gear into the house on all seizure calls. I've walked into the dispatched as a SZ, is actually an arrest several times.
What's the relationships with seizures and arrests? I don't remember it being something we were told to keep in mind during school, but I have heard about it more lately and a buddy ran into this exact thing not too long ago.
 

NomadicMedic

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When the patient arrests and becomes hypoxic, they often display seizure like activity. The agonal respiration is often mistaken for the postictal state.
 

VFlutter

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I also think the abrupt cessation of cerebral blood flow plays a role as well for those who go into dysrhythmias. The one patient I had with sick sinus would puke, go asystolic, then seize for a few seconds before getting a rhythm back.
 

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