Morning Report

Morbidity & Mortality
Conference
Kate Grossman
Todd Barrett
12/16/10

Chief Complaint
• 21 yo F w/h/o SLE (s/p Autologous Stem Cell
Transplant in 2009) and ESRD on PD admitted to
General Medicine with chest pain, lower back pain,
abdominal pain, nausea and vomiting.

History of Present
Illness
• Chest pain – sharp, no radiation, left sided, x1 day,
non-exertional, non-pleuritic, no SOB, no fevers, no
cough
• Lower back pain x3 weeks, worsening, no sxs
concerning for cord compression
• N/V – chronic problem x1 year (since SCT), usually
has emesis 3-4 x/week, worse in last week, last few
days states is intolerant to PO fluids and solids
• Never previously worked up.

Past medical History
• SLE
• Lupus Nephritis ESRD
• Lupus Cerebritis h/o Seizures
• s/p Autologous SCT 8/09 no flares since
• ESRD
• Peritoneal Dialysis
• h/o Hemodialysis – L UE AV fistula
• HTN
• Right IJ Thrombus – 6/2010

Past Surgical History
• Appendectomy
• AV Fistula
• Multiple Central Lines
• Peritoneal Dialysis Catheter
placement
Social/Family
History
• No smoking
• No alcohol
• No illicits
• Incarcerated in past for “a
misunderstanding”
• Aunt w/SLE

Medications
• Prednisone 5mg po daily
• Plaquenil 200mg po bid
• Coumadin 5mg po daily
• Lisinopril 5mg po daily
• Amlodipine 10mg po daily
• Metoprolol 50mg po tid
• Lasix 80mg po daily
• Acyclovir 400mg po bid
• CellCept
Allergies
• Hydromorphone
• ? h/o HIT – was HIT
positive on past admission,
but SRA negative and repeat
HIT negative – still being
documented as having had
HIT.

Physical Exam
• 36.7, 99, 15, 175/119, 97% RA
• HEENT – PERRLA, no oral ulcers, no thrush, no LAD,
oropharynx clear, +moon facies
• CV – RRR, no M/R/G, no S3/S4, 2+ periph pulses
• Resp – dec. BS at left base
• GI – diffuse abd tenderness, no rebound, no guarding, PD
dressing C/D/I, +abd collateral vessels noted
• MSK – no LE edema, bony and soft tissue tenderness to palpation
(lower back>upper), no point tenderness
• Skin – no rashes, straiae over upper arms

4.5
N: 38%
L: 45%
M: 12%
11.1
220
CK 76 63 55
Trop

EKG

Gens Admission
• Thoughts on further work up? Further management?

Hospital Course
• 10/18/10 8pm – Seen in ED
• 10/19/10 am – admitted to general medicine Taken to
floor at 2:20pm
• 10/19/10 3:20pm – Peritoneal Dialysis started
• Peritoneal Fluid sent for Culture, Cell count, Gram Stain
• Culture negative
• 20 WBC
• 10/19/10 6:42pm – patient ruled out w/3 sets negative
enzymes, no EKG changes, symptoms resolved.
• Decided to keep patient in-house until morning so she can be
seen by Rheumatology
• Patient eating dinner

Hospital Course (cont)
• 10/19/10 7:05pm – pt unresponsive
and pulseless - Dr. Cart called

Dr. Cart Called
• Upon presentation the patient was
unresponsive, pulseless, partially connected
to the floor cardiac monitor
• Per report the patient was alert and
responsive 5 minutes before being found
unconscious
• Patient was connected to the peritoneal
dialysis machine and nursing staff did not
know how to disconnect it.

Dr. Cart Called
• Initial rhythm was identified as Vfib
• CPR started
• Pads from Dr. Cart Pack were connected
and shock was delivered.
• Leads kept being removed from the patient
and rhythm was monitored on floor pack

Dr. Cart
• Patient was intubated and end tidal CO2 was >25
in following 2 minutes. Leads were connected.
• Pt identified as having lupus and on dialysis.
• Epi x 2, Magnesium, Calcium, and Bicarb were
given over the course of 4 minutes.
• EKG from admit showed prolonged QT
• Surgery inserted right femoral central line

Dr. Cart
• Patient had spontaneous return to circulation
• There were spontaneous movements noted and
sedation was ordered for the patient
• Code labs started to arrive…

Ventricular Fibrillation
Differential
Viskin, S and Belhassen, B, American Heart Journal, Sept. 1990, 260-271
• Myocardial Ischemia
• Electrolyte abnormalities including hyperkalemia and
hypomag
• Prolonged QT
• Structural valvular disease
• Reentrant loops including Wolf Parkinson White syndrome
• Brugada Syndrome
• Myocarditis
• Overdose of cardiac toxic medications
• Trauma

Disposition
• Patient was hospitalized with multiple chronic
medical conditions and the MICU senior was
present at the code, so the decision was made to
admit the patient to the medical ICU with the
presumed cause of the arrest to be long QT with
electolyte abnormalites.

Role of Cardiac Cath in In
Hospital Vfib Arrest
• American College of Cardiology guidelines for
non-STEMI do not address post-arrest survivors.
• ACLS does not include any recommendations for
post Vfib or Vtach arrest to receive urgent cardiac
catheterization
• Some recent evidence indicates cardiac
catheterization in underutilized and may improve
survival.
• No randomized controlled trials are present for
in hospital arrest

Cardiac catheterizations are under utilized after in-hospital
cardiac arrest.
R. M. Merchant et al.
Journal of Resuscitation (2008) 79, 398-403
• 1035 inpatient cardiac arrests were analyzed
• 427 had return of spontaneous circulation
• 110 initial rhythm was Vfib
• 80 did not receive early cardiac catheterization
• 30 received early catheterization
• Early catheterization was defined as a cath within 24
hours of arrest
• Average age was approximately 65

Cath Group
• 13/30 = 43% had STEMI or new LBBB on EKG
• All of these patients had clinically significant CAD and
92% had successful PCI
• 17/30 = 57% went to cath lab without STEMI or LBBB
• Of these patients 6 (35%) had obstructive CAD requiring
intervention

Outcomes
Outcomes and Limitations
• Patients receiving cardiac catheterization were more likely to survive that those who
did not receive catheterization
• No cath survival = 54%
• Cath survival = 80%
Limitations
• This was a retrospective chart review with no discussion about clinical reasoning for
decisions
• Small patient numbers and the average age was 67 (who went to cath)
• It is unknown if the people receiving PCI needed urgent intervention or if similar
outcomes would have resulted with a diagnostic cath at a future date

Niemann, JT. et al. Is all ventricular fibrillation the same? A
comparison of ischemically induced with electrically induced
ventricular fibrillation in a porcine cardiac arrest and
resuscitation model. Critical Care Medicine. 2007 May; 35(5); 1356-61
• The purpose: Determine if ischemic induction of ventricular fibrillation in
swine followed by standard ACLS would result in short term outcomes
similar to out of hospital arrest outcomes
• 40 domestic swine of both genders
• No difference in number of shocks required to to initially terminate rhythm
• electric 1.9 and ischemic 2.4
• Total shocks for spontaneous circulation
• electric 2.4 and ischemic 9.4 p

MICU Transfer
• Transferred to MICU intubated.

MICU Differential Dx
• Arrhythmia - Prolonged QT, Hypokalemia, Reglan, Zofran,
Plaquenil
• PE - ? Hypercoaguable w/recent R IJ Thrombus, ?HIT, but
was therapeutic on Coumadin
• Ischemia – main risk factor – h/o SLE
• Intracerebral bleed – decerebrate posturing after code
• Seizure d/o – h/o seizures, ?sz activity in ER nursing note
• Sepsis – dialysis pt, on prednisone and plaquenil – from UTI
vs bacteremia vs peritonitis

First 12 hrs in MICU
• Hypotensive initially – 90s/60s improved with 1L
IVF bolus, lightening of sedation, and stress dose
steroids.
• h/o Pleural Effusion – w/hypotension considered
Pericardial Effusion Bedside Resident Echo (from
Echo study) – no pericardial effusion w/good gross
function
• Concern for Ischemia – very rapid ROSC, post-code
enzymes sent, EKG showed sinus tach
CK 94 139 178
MB-RI --- 3.5 2.2
Troponin T 0.5 1.37 0.9

First 12 hrs in MICU
(cont)
• S/p V-Fib Arrest – discussed cooling pt – but moving
all extremities and responsive once settled in D3.
• Hyperreflexic w/muscle fasciculations (left UE and
LE> right) with decerebrate posturing Ativan given
x2, STAT bedside Head CT (no bleed, no edema),
Neuro evaluated, Keppra started
• Concern for peritonitis initially w/hypotension
Broad spectrum antibiotics initiated w/plan for IJ line
for CVP monitoring and SvO2

Therapeutic Hypothermia
Nolan, JP et al. Therapeutic Hypothermia After Cardiac
Arrest International Liaison Committee on Resuscitation,
Circulation Supplement 2003
• ILCOR recommendations
• Unconscious adult patients with spontaneous circulation after out of
hospital arrest should be cooled to 32-34 degrees C for 12-24 hours when
the initial rhythm is Vfib. Level I evidence
• Such cooling may also be beneficial for other rhythms or in-hospital
arrest. Level 4 evidence
• OUR PATIENT HAD SPONTANEOUS MOVEMENT

Hypothermia Exclusion
Criteria
• Severe cardiogenic shock
• Life-threatening arrhythmias
• Pregnant patients
• primary coagulopathy
• Thombolytics are NOT exclusion criteria. They were all
included in the European trials

Central
Line
Placement

Blood Gas
• 7.45/34/196/24/97.5%

Blood gases
Line R Radial
Art Line
R IJ (?) TLC Venous Stick
pH 7.48 7.45 7.4
pCO2 30 34 38
pO2 305 196 53
HCO3 22 24 24
SO2 98% 97.5% 87%

Cardiac Cath
• Left main - large caliber vessel which gives off the LAD and
LCx arteries without significant disease.
• Left anterior descending artery - large caliber vessel which
gives off diagonal and septal perforator branches
without significant disease.
• Left circumflex - dominant vessel whichgives off several
obtuse marginal branches and a posterior descending artery
without significant disease.
• Right coronary artery - small nondominant vessel which
gives off very small acute marginal branches without
significant disease.

LVEDP 13 mmHg.

Indications foR ICD

InDications for ICD
Therapy
• Class I Recommendation - Cardiac arrest due to
ventricular fibrillation (VF) or VT not due to a transient
or reversible cause. (Level of Evidence: A)
• Class IIb Recommendation – Familial or inherited
conditions with a high risk for life-threatening ventricular
tachyarrhythmias such as long-QT syndrome or
hypertrophic cardiomyopathy. (Level of Evidence: B)
• Class III Recommendation - Ventricular tachyarrhythmias
due to a transient or reversible disorder (eg, AMI, electrolyte
imbalance, drugs, or trauma) when correction of the
disorder is considered feasible and likely to substantially
reduce the risk of recurrent arrhythmia. (Level of Evidence:
B)
Circulation: ACC/AHA/NASPE 2002 Guideline Update for Implantation
of Cardiac Pacemakers and Antiarrhythmia Devices.
ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of
Cardiac Rhythm Abnormalities: Executive Summary

Support for icd
• Survivors of ventricular
tachyarrhythmias due to a transient or
reversible disorder have a high recurrence
rate of lethal cardiac events.
Resuscitation. Vol 54. Issue 3. 237-243.

Our patient
• Discharged home with f/u w/EP.
• Since V-Fib arrest thought 2/2 Hypokalemia
(reversible) – set up for outpatient EP study and ICD
Placement.

References
• Merchant, Abella, et al. Cardiac Catheterization is underutilized after in-hospital
cardiac arrest. Resuscitation. 2008. Vol 79: 398-403
• Nadkarni, Larkin et al. First Documented Rhythm and Clinical Outcome from inhospital
cardiac arrest among children and adults. JAMA. 2006. 295:50-57.
• Brembilla-Perrot, Miljoen, et al. Causes and Prognosis of Cardiac Arrest in a
population admitted to a general hospital; a diagnostic and therapeutic problem.
Resuscitation 2003. Vol 58: 319-327.
• AVID Investigators, Wyse, Friedman et al. Life-Threatening ventricular arrhythmias due
to transient or correctable causes: high risk for death in follow-up. Journal of American
College of Cardiology. 2001. Vol 38: 1718-1724.
• ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers
and Antiarrhythmia Devices: Summary Article. Circulation. 2002. Vol 106: 2145.
• ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm
Abnormalities: Executive Summary. Journal of American College of Cardiology. 2008.
Vol 51: 2085-2105.