Question: VT/VF Arrest in patients who are unable to be stabilized

[RickyBob911]

New fellow with a question

By guidelines it appears that it is a Class 1b indication for coronary angiography in patients who have been resuscitated from sudden cardiac death or have sustained monomorphic or non sustained polymoprhic VT.

Specifically with regards to patients presenting electively for non cardiac surgery, who are presumed to have no known clinical significant coronary disease, who immediately postoperatively develop cardiac arrest from pulseless sustained VT or VF, where post resus EKG does not initially show STEMI.

It seems surgical and anesthesia providers rightly ask one question (albeit always hoping the answer is yes it), are you going to take such a patient for angiography emergently while they are unstable?, and lets say stat labs were done and do not show obvious inciting metabolic cause and subjectively intraoperative course was unremarkable vital signs wise.

My question is, if despite anesthesia's best efforts the patient cannot be stabilized electrically or hemodynamically except for maybe intermittent 5 minute periods where pulse is attained and rhythm is organized before coding again, what is the correct answer? Stabilize patient first for at least 20-30 minutes to allow a chance at reasonably safe transport to the lab? Or attempt to take the patient to the cath lab knowing full well he will likely code enroute in the hallway somewhere on the way to the lab, and possibly again before access is even achieved. Too unstable to transport to the lab?

With STEMI of course there may be more of a push but again too unstable to transport?

Thanks in advance for your input

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[Nephro critical care]

We use the LUCAS device for CPR and I know of a cardiac arrest pt with LAD occlusion ( I don't know if he was a STEMI or not ) who was kept on CPR through the whole cath/stent and was able to walk out of the hospital. I think total CPR time was 1 1/2 hrs. So the whole " too unstable to transport " argument may not be valid.

 

[nlax30]

A lot of other factors are considered in each case, but in general, a patient that suffers a VT/VF arrest, resuscitated, but then remains unstable I would take to the lab if there is any concern about it being due to an ACS/occlusive CAD.

If there's high enough concern about underlying coronary disease causing the arrest then you really aren't going to "stabilize" them until you can visualize their anatomy and fix the underlying problem.

Now obviously in a post-op patient there are a lot of specific questions where it's hard to make a general yes or no statement... such as how soon post-op, what kind of surgery was it, how high is suspicion for ACS, etc...

 

[RickyBob911]

Thank you! very helpful, definitely provides some framework for my thought process in these situations.

 

[go lakers]

New fellow with a question

By guidelines it appears that it is a Class 1b indication for coronary angiography in patients who have been resuscitated from sudden cardiac death or have sustained monomorphic or non sustained polymoprhic VT.

Specifically with regards to patients presenting electively for non cardiac surgery, who are presumed to have no known clinical significant coronary disease, who immediately postoperatively develop cardiac arrest from pulseless sustained VT or VF, where post resus EKG does not initially show STEMI.

It seems surgical and anesthesia providers rightly ask one question (albeit always hoping the answer is yes it), are you going to take such a patient for angiography emergently while they are unstable?, and lets say stat labs were done and do not show obvious inciting metabolic cause and subjectively intraoperative course was unremarkable vital signs wise.

My question is, if despite anesthesia's best efforts the patient cannot be stabilized electrically or hemodynamically except for maybe intermittent 5 minute periods where pulse is attained and rhythm is organized before coding again, what is the correct answer? Stabilize patient first for at least 20-30 minutes to allow a chance at reasonably safe transport to the lab? Or attempt to take the patient to the cath lab knowing full well he will likely code enroute in the hallway somewhere on the way to the lab, and possibly again before access is even achieved. Too unstable to transport to the lab?

With STEMI of course there may be more of a push but again too unstable to transport?

Thanks in advance for your input

In younger patients, VA-ECMO is an option here as well

 

[frosted2]

For what it is worth, where I am from (I work as a paramedic) we transport ALL cardiac arrests (aside from hospice codes without a DNR, peds, etc) to a PCI capable facility for the possibility of a cath.