Pulmonary Embolism Cardiac Arrest: Thrombolysis During Cardiopulmonary Resuscitation and Improved Survival

The Pharmacologic Management of Cardiac Arrest

The effectiveness of pharmacologic management of cardiac arrest patients is widely debated; however, several studies published in the past 5 years have begun to clarify some of these issues. This article covers the current state of evidence for the effectiveness of the vasopressor epinephrine and the combination of vasopressin-steroids-epinephrine and antiarrhythmic medications amiodarone and lidocaine and reviews the role of other medications such as calcium, sodium bicarbonate, magnesium, and atropine in cardiac arrest care. We additionally review the role of β-blockers for refractory pulseless ventricular tachycardia/ventricular fibrillation and thrombolytics in undifferentiated cardiac arrest and suspected fatal pulmonary embolism.

Intraoperative circulatory arrest secondary to high-risk pulmonary embolism. Case series and updated literature review

BACKGROUND

Intraoperative pulmonary embolism (PE) with cardiac arrest (CA) represents a critical and potentially fatal condition. Available treatments include systemic thrombolysis, catheter-based thrombus fragmentation or aspiration, and surgical embolectomy. However, limited studies are focused on the optimal treatment choice for this critical condition. We present a case series and an updated review of the management of intraoperative CA secondary to PE.

METHODS

A retrospective review of patients who developed high-risk intraoperative PE was performed between June 2012 and June 2022. For the updated review, a literature search on PubMed and Scopus was conducted which resulted in the inclusion of a total of 46 articles.

RESULTS

A total of 196 174 major non-cardiac surgeries were performed between 2012 and 2022. Eight cases of intraoperative CA secondary to high-risk PE were identified. We found a mortality rate of 75%. Anticoagulation therapy was administered to one patient (12.5%), while two patients (25%) underwent thrombolysis, and one case (12.5%) underwent mechanical thrombectomy combined with thrombus aspiration. Based on the literature review and our 10-year experience, we propose an algorithm for the management of intraoperative CA caused by PE.

CONCLUSION

The essential components for adequate management of intraoperative PE with CA include hemodynamic support, cardiopulmonary resuscitation, and the implementation of a primary perfusion intervention. The prompt identification of the criteria for each specific treatment modality, guided by the individual patient's characteristics, is necessary for an optimal approach.

The Pharmacologic Management of Cardiac Arrest

The effectiveness of pharmacologic management of cardiac arrest patients is widely debated; however, several studies published in the past 5 years have begun to clarify some of these issues. This article covers the current state of evidence for the effectiveness of the vasopressor epinephrine and the combination of vasopressin-steroids-epinephrine and antiarrhythmic medications amiodarone and lidocaine and reviews the role of other medications such as calcium, sodium bicarbonate, magnesium, and atropine in cardiac arrest care. We additionally review the role of β-blockers for refractory pulseless ventricular tachycardia/ventricular fibrillation and thrombolytics in undifferentiated cardiac arrest and suspected fatal pulmonary embolism.

Increased emergency cardiovascular events among under-40 population in Israel during vaccine rollout and third COVID-19 wave

Cardiovascular adverse conditions are caused by coronavirus disease 2019 (COVID-19) infections and reported as side-effects of the COVID-19 vaccines. Enriching current vaccine safety surveillance systems with additional data sources may improve the understanding of COVID-19 vaccine safety. Using a unique dataset from Israel National Emergency Medical Services (EMS) from 2019 to 2021, the study aims to evaluate the association between the volume of cardiac arrest and acute coronary syndrome EMS calls in the 16-39-year-old population with potential factors including COVID-19 infection and vaccination rates. An increase of over 25% was detected in both call types during January-May 2021, compared with the years 2019-2020. Using Negative Binomial regression models, the weekly emergency call counts were significantly associated with the rates of 1st and 2nd vaccine doses administered to this age group but were not with COVID-19 infection rates. While not establishing causal relationships, the findings raise concerns regarding vaccine-induced undetected severe cardiovascular side-effects and underscore the already established causal relationship between vaccines and myocarditis, a frequent cause of unexpected cardiac arrest in young individuals. Surveillance of potential vaccine side-effects and COVID-19 outcomes should incorporate EMS and other health data to identify public health trends (e.g., increased in EMS calls), and promptly investigate potential underlying causes.

Recommendations for treatment of critically ill patients with COVID-19 : Version 3 S1 guideline

Since December 2019 a novel coronavirus (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2) has rapidly spread around the world resulting in an acute respiratory illness pandemic. The immense challenges for clinicians and hospitals as well as the strain on many healthcare systems has been unprecedented.The majority of patients present with mild symptoms of coronavirus disease 2019 (COVID-19); however, 5-8% become critically ill and require intensive care treatment. Acute hypoxemic respiratory failure with severe dyspnea and an increased respiratory rate (>30/min) usually leads to intensive care unit (ICU) admission. At this point bilateral pulmonary infiltrates are typically seen. Patients often develop a severe acute respiratory distress syndrome (ARDS).So far, remdesivir and dexamethasone have shown clinical effectiveness in severe COVID-19 in hospitalized patients. The main goal of supportive treatment is to ascertain adequate oxygenation. Invasive mechanical ventilation and repeated prone positioning are key elements in treating severely hypoxemic COVID-19 patients.Strict adherence to basic infection control measures (including hand hygiene) and correct use of personal protection equipment (PPE) are essential in the care of patients. Procedures that lead to formation of aerosols should be carried out with utmost precaution and preparation.

A survey of cardiopulmonary resuscitation in COVID-19 patients

Background and Aims:

The novel coronavirus 2 (SARS-CoV-2) pandemic has placed severe resource constraints on hospitals. High mortality rates of the COVID-19 have overwhelmed the resuscitation services. The constant fear of virus infection during cardiopulmonary resuscitation (CPR) has placed severe restrictions on the resuscitation services. Reports of poor outcomes after CPR further dampened the spirits of CPR providers. Hence we surveyed CPR practices for COVID -19 patients across hospitals in India by health care providers.

Material and Methods:

An online survey using Google Forms was initiated to collect data on performance of CPR in diagnosed cases of COVID-19 after in-hospital cardiac arrest. The survey's web-link was publicized using social media, and participation sought of all personnel involved in CPR delivery in COVID-19 patients. The responses received were analyzed. The main outcome measured were determination of the percentage of COVID-19 patients discharged home who were administered CPR.

Results:

There were 248 responses from different parts of India. At the time of cardiac arrest, 194 victims had diffuse lung infiltrates, 22 had mild lung disease, while 32 had no documented lung lesion. Twenty-five victims had evidence of pulmonary embolism, 39 had cardiac involvement, and 3 had brain involvement. Return of spontaneous circulation (ROSC) was achieved in 59.27% of cases but ROSC sustained in only 22.59%. 7.25% of patients, who received CPR, could be discharged home.

Conclusion:

The survey has shown reasonable survival rates after CPR administration in COVID-19 patients suffering from IHCA. We should not ignore the need to maximize live outcomes after CPR, even in COVID-19 patients.

Thrombolysis of a massive intracardiac thrombus during resuscitation: documentation by transoesophageal echocardiography

Acute pulmonary embolism is a frequent potentially reversible cause of sudden cardiac arrest. The early diagnosis is challenging but essential for further treatment. New therapeutic options in resuscitation, such as extracorporeal resuscitation, are leading to frequent transports of patients to emergency rooms with ongoing resuscitation. A transoesophageal echo performed during resuscitation can give hints for reversible causes for the cardiac arrest. We present a case of a 40-year-old female patient who was transferred to our department with ongoing resuscitation and received a transoesophageal echo immediately on arrival. The examination showed a massive intracardiac thrombus. The subsequent thrombolysis and following resuscitation were observed and documented via transoesophageal echo.

[S2k Guideline - Recommendations for Inpatient Therapy of Patients with COVID-19]

Since December 2019, the novel coronavirus SARS-CoV-2 (Severe Acute Respiratory Syndrome - Corona Virus-2) has been spreading rapidly in the sense of a global pandemic. This poses significant challenges for clinicians and hospitals and is placing unprecedented strain on the healthcare systems of many countries. The majority of patients with Coronavirus Disease 2019 (COVID-19) present with only mild symptoms such as cough and fever. However, about 6 % require hospitalization. Early clarification of whether inpatient and, if necessary, intensive care treatment is medically appropriate and desired by the patient is of particular importance in the pandemic. Acute hypoxemic respiratory insufficiency with dyspnea and high respiratory rate (> 30/min) usually leads to admission to the intensive care unit. Often, bilateral pulmonary infiltrates/consolidations or even pulmonary emboli are already found on imaging. As the disease progresses, some of these patients develop acute respiratory distress syndrome (ARDS). Mortality reduction of available drug therapy in severe COVID-19 disease has only been demonstrated for dexamethasone in randomized controlled trials. The main goal of supportive therapy is to ensure adequate oxygenation. In this regard, invasive ventilation and repeated prone positioning are important elements in the treatment of severely hypoxemic COVID-19 patients. Strict adherence to basic hygiene, including hand hygiene, and the correct wearing of adequate personal protective equipment are essential when handling patients. Medically necessary actions on patients that could result in aerosol formation should be performed with extreme care and preparation.

[German recommendations for treatment of critically ill patients with COVID-19-version 3]

Seit Dezember 2019 verbreitet sich das neuartige Coronavirus SARS-CoV‑2 (Severe Acute Respiratory Syndrome – Corona Virus-2) rasch im Sinne einer weltweiten Pandemie. Dies stellt Kliniker und Krankenhäuser vor große Herausforderungen und belastet die Gesundheitssysteme vieler Länder in einem nie dagewesenen Ausmaß. Die Mehrheit der Patienten zeigt lediglich milde Symptome der sogenannten Coronavirus Disease 2019 (COVID-19). Dennoch benötigen etwa 5–8 % eine intensivmedizinische Behandlung. Die akute hypoxämische respiratorische Insuffizienz mit Dyspnoe und hoher Atemfrequenz (>30/Min) führt in der Regel zur Aufnahme auf die Intensivstation. Oft finden sich dann bereits bilaterale pulmonale Infiltrate/Konsolidierungen oder auch Lungenembolien in der Bildgebung. Im weiteren Verlauf entwickeln viele Patienten ein Acute Respiratory Distress Syndrome (ARDS). Eine klinische Wirksamkeit einer medikamentösen Therapie bei schwerer COVID-Erkrankung (hospitalisierte Patienten) ist bisher für Remdesivir und Dexamethason nachgewiesen. Das Hauptziel der supportiven Therapie ist es eine ausreichende Oxygenierung sicherzustellen. Die invasive Beatmung und wiederholte Bauchlagerung sind dabei wichtige Elemente in der Behandlung von schwer hypoxämischen COVID-19 Patienten. Die strikte Einhaltung der Basishygiene, einschließlich der Händehygiene, sowie das korrekte Tragen von adäquater persönlicher Schutzausrüstung sind im Umgang mit den Patienten unabdingbar. Prozeduren, die zur Aerosolbildung führen könnten, sollten falls nötig, mit äußerster Sorgfalt und Vorbereitung durchgeführt werden.

[German recommendations for treatment of critically ill patients with COVID-19-version 3 : S1-guideline]

Seit Dezember 2019 verbreitet sich das neuartige Coronavirus SARS-CoV‑2 (Severe Acute Respiratory Syndrome – Corona Virus-2) rasch im Sinne einer weltweiten Pandemie. Dies stellt Kliniker und Krankenhäuser vor große Herausforderungen und belastet die Gesundheitssysteme vieler Länder in einem nie dagewesenen Ausmaß. Die Mehrheit der Patienten zeigt lediglich milde Symptome der sogenannten Coronavirus Disease 2019 (COVID-19). Dennoch benötigen etwa 5–8 % eine intensivmedizinische Behandlung. Die akute hypoxämische respiratorische Insuffizienz mit Dyspnoe und hoher Atemfrequenz (>30/Min) führt in der Regel zur Aufnahme auf die Intensivstation. Oft finden sich dann bereits bilaterale pulmonale Infiltrate/Konsolidierungen oder auch Lungenembolien in der Bildgebung. Im weiteren Verlauf entwickeln viele Patienten ein Acute Respiratory Distress Syndrome (ARDS). Eine klinische Wirksamkeit einer medikamentösen Therapie bei schwerer COVID-Erkrankung (hospitalisierte Patienten) ist bisher für Remdesivir und Dexamethason nachgewiesen. Das Hauptziel der supportiven Therapie ist es eine ausreichende Oxygenierung sicherzustellen. Die invasive Beatmung und wiederholte Bauchlagerung sind dabei wichtige Elemente in der Behandlung von schwer hypoxämischen COVID-19 Patienten. Die strikte Einhaltung der Basishygiene, einschließlich der Händehygiene, sowie das korrekte Tragen von adäquater persönlicher Schutzausrüstung sind im Umgang mit den Patienten unabdingbar. Prozeduren, die zur Aerosolbildung führen könnten, sollten falls nötig, mit äußerster Sorgfalt und Vorbereitung durchgeführt werden.