Alain Rozenberg

Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest ☆

OBJECTIVES The aim of the study was to assess the hemodynamic status of survivors of out-of-hospital cardiac arrest (OHCA). BACKGROUND The global prognosis after successfully resuscitated patients with OHCA remains poor. Clinical studies describing the hemodynamic status of survivors of OHCA and its impact on prognosis are lacking. METHODS Among 165 consecutive patients admitted after successful resuscitation from OHCA, 73 required invasive monitoring because of hemodynamic instability, defined as hypotension requiring vasoactive drugs, during the first 72 h. Clinical features and data from invasive monitoring were analyzed. RESULTS Hemodynamic instability occurred at a median time of 6.8 h (range 4.3 to 7.3) after OHCA. The initial cardiac index (CI) and filling pressures were low. Then, the CI rapidly increased 24 h after the onset of OHCA, independent of filling pressures and inotropic agents (2.05 [1.43 to 2.90] 8 h vs. 3.19 l/min per m(2) [2.67 to 4.20] 24 h after OHCA; p < 0.001). Despite a significant improvement in CI at 24 h, a superimposed vasodilation delayed the discontinuation of vasoactive drugs. No improvement in CI at 24 h was noted in 14 patients who subsequently died of multiorgan failure. Hemodynamic status was not predictive of the neurologic outcome. CONCLUSIONS In survivors of OHCA, hemodynamic instability requiring administration of vasoactive drugs is frequent and appears several hours after hospital admission. It is characterized by a low CI that is reversible in most cases within 24 h, suggesting post-resuscitation myocardial dysfunction. Early death by multiorgan failure is associated with a persistent low CI at 24 h.

End-tidal carbon dioxide during out-of-hospital cardiac arrest resuscitation : comparison of active compression-decompression and standard CPR

Abstract Study objectives: To compare the maximal end-tidal carbon dioxide pressure (ETCO 2 peak) values obtained during standard (S-CPR) and active compression-decompression CPR (ACD-CPR) during prolonged resuscitation in out-of-hospital cardiac arrest. Design: Prospective, randomized crossover study. Setting: City with a population of 3.5 million, served by an emergency medical service system providing advanced cardiac life support. Participants: Patients with nontraumatic out-of-hospital cardiac arrest. Interventions: Patients were randomly assigned to receive first, for a period of 3 minutes, either ACD-CPR or S-CPR; then the two methods were alternated. ETCO 2 was continuously monitored and computed. Measurements and Results: Sixteen patients (48±20 years old) were included; in 12, return of spontaneous circulation was achieved, and 5 were admitted alive to the hospital. A statistically significant increase in ETCO 2 peak was obtained with ACD-CPR (27.6±3 mm Hg) compared with S-CPR (15.6±2.2 mm Hg). No major adverse effect possibly related to ACD-CPR was observed. Conclusion: This prospective study suggests that ACD-CPR may improve cardiac output compared with S-CPR. [Orliaguet GA, Carli PA, Rozenberg A, Janniere D, Sauval P, Delpech P: End-tidal carbon dioxide during out-of-hospital cardiac arrest resuscitation: Comparison of active compression-decompression and standard CPR. Ann Emerg Med January 1995;25:48-51.]

Diagnosis and management of out-of-hospital cardiac arrest secondary to coronary artery spasm

OBJECTIVE The clinical features of coronary artery spasm as a cause of cardiac arrest were determined in a prospective study on out-of-hospital cardiac arrest (OHCA). METHODS Coronary angiography was performed at admission in 300 consecutive patients with no obvious non-cardiac cause of OHCA. In survivors with no or minimal coronary artery stenosis, a second angiography with provocation test and electrophysiological testing were performed at 1 month. RESULTS Spasm was demonstrated in ten patients. Diagnosis was based upon (1) spontaneous spasm on the admission angiogram (3 patients), (2) transient significative ST-segment elevation at follow-up in patients with no or non-significant coronary artery lesions (4 patients) and (3) spasm during the 1 month provocation test (3 patients). Six patients survived at 1 month; spasm occurred during a new provocation test in five despite treatment with high dosage calcium channel blockers leading to coronary stenting in two, an internal cardiovertor defibrillator in one, and increased drug therapy with prolonged hospitalization in the remainder. At a mean follow-up of 55+/-27 months, no recurrent cardiac arrest occurred. CONCLUSION Systematic coronary angiograms and provocation tests in survivors of OHCA allow prompt diagnosis of coronary artery spasm. Residual spasm despite treatment with calcium channel blockers is frequent. Therapy should therefore be guided by repetitive provocation tests, and seems to avoid recurrence of cardiac arrest.

End-tidal carbon dioxide during out-of-hospital cardiac arrest resuscitation: Comparison of active compression-decompression and standard CPR

STUDY OBJECTIVES To compare the maximal end-tidal carbon dioxide pressure (ETCO2 peak) values obtained during standard (S-CPR) and active compression-decompression CPR (ACD-CPR) during prolonged resuscitation in out-of-hospital cardiac arrest. DESIGN Prospective, randomized crossover study. SETTING City with a population of 3.5 million, served by an emergency medical service system providing advanced cardiac life support. PARTICIPANTS Patients with nontraumatic out-of-hospital cardiac arrest. INTERVENTIONS Patients were randomly assigned to receive first, for a period of 3 minutes, either ACD-CPR or S-CPR; then the two methods were alternated. ETCO2 was continuously monitored and computed. MEASUREMENTS AND RESULTS Sixteen patients (48 +/- 20 years old) were included; in 12, return of spontaneous circulation was achieved, and 5 were admitted alive to the hospital. A statistically significant increase in ETCO2 peak was obtained with ACD-CPR (27.6 +/- 3 mm Hg) compared with S-CPR (15.6 +/- 2.2 mm Hg). No major adverse effect possibly related to ACD-CPR was observed. CONCLUSION This prospective study suggests that ACD-CPR may improve cardiac output compared with S-CPR.