Neurologic recovery following prolonged out-of-hospital cardiac arrest with resuscitation guided by continuous capnography

Abstract

A 54-year-old man with no known cardiac disease collapsed outdoors in a small rural community. The cardiac arrest was witnessed, and immediate cardiopulmonary resuscitation was begun by a bystander and a trained first responder who was nearby. The patient was moved into a building across the street for continued resuscitation. First responders arrived with an automated external defibrillator, and ventricular fibrillation was documented. First responders delivered 6 defibrillation shocks, 4 of which transiently restored an organized electrocardiographic rhythm but with no pulse at any time. Additional emergency medical services personnel from nearby communities and an advanced life support (ALS) flight crew arrived. The flight crew initiated ALS care. The trachea was intubated, ventilation controlled, and end-tidal carbon dioxide tension continuously monitored. Antiarrhythmic and inotropic drugs were administered intravenously. An additional 6 shocks were delivered using the ALS defibrillator. End-tidal carbon dioxide measurements confirmed good pulmonary blood flow with chest compressions, and resuscitation was continued until a stable cardiac rhythm was restored after 96 minutes of pulselessness. The patient was transported by helicopter to the hospital. He was in cardiogenic shock but maintained a spontaneous circulation. Coronary angiography confirmed a left anterior descending coronary artery thrombotic occlusion that was treated successfully. After hospital admission, the patient required circulatory and ventilatory support and hemodialysis for acute renal failure. He experienced a complete neurologic recovery to his pre-cardiac arrest state. To our knowledge, this is the longest duration of pulselessness in an out-of-hospital arrest with a good outcome. Good pulmonary blood flow was documented throughout by end-tidal carbon dioxide measurements.

FIGURE 1.

Initial electrocardiogram (ECG) showing ventricular fibrillation and the first shock from the first responder automated external defibrillator. Ventricular fibrillation persisted after the shock.

FIGURE 2.

Electrocardiogram (ECG) showing ongoing ventricular fibrillation while cardiopulmonary resuscitation was in progress. The end-tidal carbon dioxide (CO₂) tension was 36 mm Hg.

FIGURE 3.

After the sixth shock from the advanced life support defibrillator, an electrocardiogram (ECG) showed return of an organized rhythm with an end-tidal carbon dioxide (CO₂) tension of 37 mm Hg.

FIGURE 4.

A 12-lead electrocardiogram obtained after admission of the patient to the emergency department.

FIGURE 5.

Left, Coronary angiogram obtained before intervention showing complete occlusion of the left anterior descending coronary artery. Right, Coronary angiogram obtained after intervention showing that the reopened left anterior descending coronary artery has excellent downstream flow.