The incidence of pulmonary embolism in unexplained sudden cardiac arrest with pulseless electrical activity∗

doi:10.1016/S0002-9343(00)00511-8

The American Journal of Medicine

Volume 109, Issue 5, 1 October 2000, Pages 351-356

https://doi.org/10.1016/S0002-9343(00)00511-8 Get rights and content

Abstract

PURPOSE: The cause of many cases of sudden cardiac arrest from pulseless electrical activity is unknown. We hypothesized that pulmonary embolism was responsible for a substantial proportion of these cases and used transesophageal echocardiography to identify pulmonary embolism among patients with sudden cardiac arrest.

SUBJECTS AND METHODS: We performed a prospective study at a tertiary care, university-operated county hospital, with a level 1 trauma center. Consecutive patients (n = 36) who were admitted with (n = 20) or unexpectedly developed (n = 16) sudden cardiac arrest of unknown cause were studied with transesophageal echocardiography during cardiopulmonary resuscitation. We determined the presence of central pulmonary embolism, right ventricular enlargement, and other causes of sudden cardiac arrest (such as myocardial infarction and aortic dissection) using prospectively defined criteria.

RESULTS: Of the 25 patients with pulseless electrical activity as the initial event, 9 (36%) had pulmonary emboli (8 seen with transesophageal echocardiography and 1 diagnosed at autopsy) compared with none of the 11 patients with other rhythms, such as asystole or ventricular tachycardia or fibrillation (P = 0.02). Of the 8 patients who had pulmonary embolism diagnosed by transesophageal echocardiography, 2 survived to hospital discharge.

CONCLUSIONS: Mortality from massive pulmonary embolism is high, particularly if patients present with sudden cardiac arrest. Earlier diagnosis of pulmonary embolus may permit wider use of thrombolytic agents or other interventions and may potentially increase survival.

Section snippets

Material and methods

We performed emergency transesophageal echocardiography on 36 consecutive patients undergoing cardiopulmonary resuscitation for unexplained sudden cardiac arrest from July 1995 to June 1998 when it was requested by the treating physicians to assist in diagnosis. Studies were performed in the emergency room, intensive care units, or on the wards. The study was conducted at Harborview Medical Center, which is the level I trauma center and County Hospital (King County) for Washington as well as

Results

Based on review of paramedic reports and hospital code sheets, there were a total of 481 episodes of sudden cardiac arrest during the study period: 340 out of hospital and 141 in hospital. Of the out-of-hospital arrests, 129 were dead on arrival or died in the emergency room before hospital admission. The diagnosis—such as drug overdose, trauma, neurologic events, and known coronary artery disease—was known at the time of sudden cardiac arrest in 163 out-of-hospital cases. Of the remaining 48

Discussion

The major finding of this study is that pulmonary embolism was common (36%) among patients with unexplained sudden cardiac arrest who had pulseless electrical activity as the initial rhythm. This diagnosis can be made safely using transesophageal echocardiography, which unlike other diagnostic tests for pulmonary embolism can be performed in critically ill patients who are undergoing resuscitation (12). Although transthoracic echocardiography can show the indirect effects of large pulmonary

References (29)

N. Wittlich et al.
Detection of central pulmonary artery thromboemboli by transesophageal echocardiography in patients with severe pulmonary embolism
J Am Soc Echocardiogr
(1992)
W.F. Armstrong et al.
Spectrum of aortic dissection of the ascending aortaa transesophageal echocardiographic study
J Am Soc Echocardiogr
(1996)
R.F. Redberg et al.
Transesophageal echocardiography during cardiopulmonary resuscitation
Cardiol Clin
(1993)
W. Kasper et al.
Echocardiographic findings in patients with proved pulmonary embolism
Am Heart J
(1986)
B. Krivec et al.
Diagnosis and treatment of shock due to massive pulmonary embolism
Chest
(1997)
P.A. van der Wouw et al.
Diagnostic accuracy of transesophageal echocardiography during cardiopulmonary resuscitation
J Am Coll Cardiol
(1997)
P.A. Heidenreich et al.
Transesophageal echocardiography predicts mortality in critically ill patients with unexplained hypotension
J Am Coll Cardiol
(1995)
D.W. Sohn et al.
Role of transesophageal echocardiography in hemodynamically unstable patients
Mayo Clin Proc
(1995)
J.R. Gossage
Of emperors, emboli, and echocardiography
Chest
(1997)
A.L. Klein et al.
Visualization of acute pulmonary emboli by transesophageal echocardiography
J Am Soc Echo
(1990)

Y.H. Li et al.

Expanded indicationdiagnosis of pulmonary embolism by transesophageal echocardiography

Int J Cardiol

(1993)

D. Rittoo et al.

Role of transesophageal echocardiography in diagnosis and management of central pulmonary artery thromboembolism

Am J Cardiol

(1993)

W. Kasper et al.

Management strategies and determinants of outcome in acute major pulmonary embolismresults of a multicenter registry

J Am Coll Cardiol

(1997)

M.A. Kelley et al.

Diagnosing pulmonary embolismnew facts and strategies

Ann Intern Med

(1991)

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Implementation of an extracorporeal resuscitation (ECPR) program for out-of-hospital cardiac arrest in Stockholm, Sweden: Feasibility, safety, and outcome
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The aim of this study was to evaluate the implementation of a novel extra corporeal cardiopulmonary (ECPR) program in the greater Stockholm area with focus on feasibility, safety aspects and clinical outcomes.
Prospective observational study of ECPR program including patients with OHCA from January 2020 to December 2022, fulfilling ECPR criteria: age 18–65 years, initial shockable rhythm or pulseless electrical activity, witnessed arrest, bystander cardiopulmonary resuscitation and refractory arrest after three cycles of advance cardiac life support. The predefined time threshold from collapse to extracorporeal membrane oxygenation (ECMO) initiation was set at 60 min.
We included 95 patients. Of these, 22/95 (23%) had return of spontaneous circulation before ECMO initiation, 39/95 (41%) were excluded for ECMO and 34/95 (36%) had ECMO initiated out of which 23 patients were admitted alive to the ICU. ECMO-initiation within 60 min was met in 9%. In 6 patients vascular access was complicated, 2 patients had severe bleeding at access site requiring intervention. Survival to discharge among all cases was 25% (24/95). Among patients admitted to ICU on ECMO 39% (9/23) survived to discharge, of these 78% had cerebral performance category scale score 1–2 within 12 months. 8 out of 9 survivors had time from OHCA to ECMO-initiation >60 min.
The implementation of an ECPR protocol was feasible without any major, unexpected safety aspects but did not meet the intended target time intervals. Despite this, survival rates were similar to previous studies although most survivors had >60 min to ECMO-initiation.
Intra-arrest thrombolysis in acute pulmonary thromboembolism: Case report and review of the literature
2024, Acta Colombiana de Cuidado Intensivo
El tromboembolismo pulmonar (TEP) es una causa frecuente de paro cardiorrespiratorio, siendo este una entidad con tratamiento específico, el cual se debe instaurar incluso en casos con sospecha clínica alta sin diagnóstico confirmado. La trombólisis ha mostrado buenos resultados en diferentes desenlaces. Se presenta una paciente de 72 años, diabética, hipertensa, hipertiroidea, hospitalizada por una úlcera en miembro inferior infectada, quien presentó dificultad respiratoria con posterior falla ventilatoria, choque y paro cardiorespiratorio, por signos ecográficos se planteó diagnóstico de TEP y se realizó trombólisis intraparo, logrando con esto retorno a la circulación espontánea y resolución paulatina del choque. Se realiza una revisión a la literatura de la trombólisis intraparo, concluyendo que en el TEP gestionar el riesgo clínico es de vital importancia, pues aquellos con riesgo alto tienen mayores tasas de mortalidad y la instauración de medidas de reperfusión son indispensables; en paro cardiorespiratorio con alta sospecha de TEP, la ecografía es de valiosa utilidad para apoyar el diagnóstico, y la trombólisis intraparto tiene mayor tasa de retorno a la circulación espontánea e incluso de supervivencia.
Pulmonary thromboembolism is a frequent cause of cardiorespiratory arrest, this being an entity with specific treatment, which should be established even in cases with high clinical suspicion without confirmed diagnosis. Thrombolysis has shown good results in different outcomes. A 72-year-old diabetic, hypertensive, hyperthyroid patient is presented, hospitalized for an infected lower limb ulcer, who presented respiratory distress with subsequent ventilatory failure, shock and cardiorespiratory arrest, who was diagnosed with pulmonary thromboembolism due to ultrasound signs and was intra-arrest thrombolysis was performed, thereby achieving return to spontaneous circulation and gradual resolution of the shock. A review of the literature on intra-arrest thrombolysis is carried out, concluding that in pulmonary thromboembolism managing clinical risk is of vital importance, since those at high risk have higher mortality rates and the establishment of reperfusion measures are essential. In cardiorespiratory arrest with high suspicion of pulmonary thromboembolism, ultrasound is valuable to support the diagnosis and intrapartum thrombolysis has a higher rate of return to spontaneous circulation and even survival.
Managing Cardiac Arrest Using Ultrasound
2023, Annals of Emergency Medicine
Transoesophageal echocardiography in cardiac arrest: A systematic review
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Citation Excerpt :
Identification of aortic dissection on TEE may be helpful in both the identification of potentially salvageable patients as well as an adjunct in the decision to discontinue resuscitation in patients who are unlikely to be resuscitated, thus avoiding futile interventions. Several studies have included myocardial infarction as an identifiable cause of arrest.26,27,30–32 However, TEE can only identify wall motion abnormality in the presence of cardiac activity.
To identify, appraise and synthesize all available clinical evidence to evaluate the diagnostic role of transoesophageal echocardiography (TEE) during resuscitation of in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) in the identification of reversible causes of cardiac arrest and cardiac contractility.
We conducted a systematic review following PRISMA guidelines. Medline, EMBASE, Web of Science Core Collection, Proquest Dissertations, Open Grey, CDSR, Cochrane Central, Cochrane Clinical Answers, and the clinicaltrials.gov registry were searched for eligible studies. Studies involving adult patients, with non-traumatic cardiac arrest in whom TEE was used for intra-arrest evaluation, were included. Case studies and case series, animal studies, reviews, guidelines and editorials were excluded. The QUADAS-2 tool was used for quality assessment of all studies.
Eleven studies with a total of 358 patients were included. Four studies involved perioperative IHCA, three involved OHCA, and four were mixed population settings. Overall, the risk of bias in the selected studies was either high or unclear due to evidence or lack of information. In all 11 studies, TEE allowed the identification of reversible causes of arrest. We found significant heterogeneity in the criteria used to interpret findings, TEE protocol used, and timing of TEE.
Due to heterogeneity of studies, small sample size and inconsistent reference standard, the evidence for TEE in cardiac arrest resuscitation is of low certainty and is affected by a high risk of bias. Further studies are needed to better understand the true diagnostic accuracy of TEE in identifying reversible causes of arrest and cardiac contractility.
Impact of the modified SESAME ultrasound protocol implementation on patients with cardiac arrest in the emergency department
2021, American Journal of Emergency Medicine
Citation Excerpt :
During the pre-intervention period in our ED, there were few patients suspected of having a remediable cause of CA. To overcome the differences in the proportion of CA causes between past studies [17,27-34] and our ED's experience during the pre-intervention period, we wanted to introduce a systematic ultrasound protocol. Among the various protocols, the SESAME protocol was specifically introduced in March 2019 due to the ability to perform ultrasound exams during ongoing chest compressions and not only during the chest compression pause periods.
Point-of-care (POC) ultrasound protocols are commonly used for the initial management of patients with cardiac arrest in the emergency department (ED). However, there is little published evidence regarding any mortality benefit. We compared and studied the effect of implementation of the modified SESAME protocol in terms of clinical outcomes and resuscitation management.
This was a single-center retrospective observational study. We conducted a pre- and post-intervention study to evaluate changes in patient outcomes and management after educating emergency medicine residents and the faculty about the modified SESAME protocol. The pre-intervention period lasted from March 2018 to February 2019, and the post-intervention period lasted from May 2019 to April 2020. The modified SESAME protocol education was initiated in March 2019. Multivariate logistic regression analyses were performed to examine the associations between independent variables and outcomes.
A total of 334 patients were included in this study during a 24-month period. We found no significant differences between the two groups for the primary outcome of survival to hospital admission (pre-intervention group 28.9% versus post-intervention group 28.6%; P = 0.751), survival to hospital discharge (12.1% vs. 12.4%; P = 0.806), and good neurologic outcome at discharge (6.0% vs. 8.1%; P = 0.509). The proportion of resuscitation procedures of thrombolysis, emergency transfusion, tube thoracotomy, and pericardiocentesis during resuscitation increased from 0.6% in the pre-intervention period to 4.9% in the post-intervention period (P = 0.016).
We did not discover any significant survival benefits associated with the implementation of the modified SESAME protocol; however, early diagnosis of specific pathologies (pericardial effusion, possible pulmonary embolism, tension pneumothorax, and hypovolemia) and accordingly a direct increase in the resuscitation management were seen in this study. Future studies with larger sample sizes are required to examine the clinical outcomes as well as to identify the most effective POC ultrasonography protocols for non-traumatic cardiac arrests.
Focused cardiac ultrasound after return of spontaneous circulation in cardiac-arrest patients
2019, Resuscitation
Guidelines emphasize the clinician to consider the use of ultrasound to determine the cause of cardiac arrest. In this study we aimed to investigate how focused cardiac ultrasound (FOCUS) shortly after return of spontaneously circulation (ROSC) was associated with the use of further diagnostic measures and if the detection of pulmonary embolism, cardiac tamponade and acute myocardial infarction could be improved.
A retrospective, single-center, observational study at a tertiary hospital to evaluate FOCUS performed by cardiologists within 60 min after ROSC. Included were adult cardiac-arrest patients with ROSC, without restrictions in care. Excluded were patients with ECGs demonstrating ST elevation, patients with an obvious non-cardiac cause of cardiac arrest and patients where FOCUS was not performed.
Between January 2012 and December 2017, FOCUS was performed in 237 (182 OHCA and 55 IHCA) patients. FOCUS findings influenced management and led to further immediate diagnostic measures in 52 (21.9%) patients. Left-ventricular regional wall motion abnormalities influenced the decision to perform emergency coronary angiography in 17 (7.2%) patients, of which nine were treated with PCI. Right-ventricular dilatation and/or pressure overload influenced a decision to perform computerized tomography of the thorax in 21 (8.9%) patients, of which 11 were diagnosed with pulmonary embolism. Cardiac tamponade was found in three patients (1.2%).
The retrospective data on this cardiac-arrest population supports that ALS-conformed post-resuscitation care could include FOCUS as an adjunctive diagnostic measure shortly after ROSC.

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Clinical studyThe incidence of pulmonary embolism in unexplained sudden cardiac arrest with pulseless electrical activity∗

Abstract

Section snippets

Material and methods

Results

Discussion

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Cardiol Clin

Am Heart J

Chest

J Am Coll Cardiol

J Am Coll Cardiol

Mayo Clin Proc

Chest

J Am Soc Echo

Int J Cardiol

Am J Cardiol

J Am Coll Cardiol

Diagnosing pulmonary embolismnew facts and strategies

Ann Intern Med

Clinical study
The incidence of pulmonary embolism in unexplained sudden cardiac arrest with pulseless electrical activity∗