Scientific Papers

Do we need standardized management after termination-of-resuscitation attempts? Autoresuscitation in a 67-year-old woman | Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

We report a case of prolonged CPR, TRA and delayed ROSC in the sense of autoresuscitation. The elapsed time between TRA and the recognition of ROSC was almost an hour. So far, this is the longest reported period of autoresuscitation with a positive patient outcome [6]. In contrast to our case report, a new review article by Zorko et al. showed that autoresuscitation was reported to occur between one and 20 min after circulatory arrest [12]. However, the timing of ROSC in our case remains unclear as the patient lacked continued monitoring.

The underlying medical reasons for the phenomenon of autoresuscitation are speculative and are based on case reports and a few systematic reviews. Hyperinflation of the lungs is a possible culprit that can lead to high intrathoracic pressure, caval and right heart compression and may hinder venous return to the heart [6, 13]. In our case, we did not use a mobile ventilator but delivered manual ventilations which could have led to higher tidal volumes and a higher ventilation rate than the proposed 10/Minute. It’s possible, that an associated auto-PEEP led to a delayed venous return, preventing the CPR drugs given per protocol to reach the site of action. The insertion of a gastric tube could have had a decompressing effect on the potentially high intrathoracic pressure but was not used in this case.

After abandoning further CPR, a final central pulse check was done by an emergency rescuer and the physician. ECG and capnography were removed within 5 min after TOR while leaving the endotracheal tube in situ. The tube could have worked as an airway-splinting and thus facilitated breathing.

We also mentioned the availability of an automated compression device (AutoPulse®), which was not used because of the manpower on site. Because of the shock refractory shockable rhythm transport to the cardiac center during CPR could have been a rational alternative. Shortly after telephone consultation with the anaesthesiologist on duty the decision was made to stay on site because of the change from shockable to non-shockable rhythm and the length of CPR. Our local regulations allow a very restrictive use of this automated CPR device due to skepticism regarding application security. In 2017 Koster et al. discussed the safety for mechanical chest compression devices and described a non-inferiority for the LUCAS® device whereas for the AutoPulse® severe or life-threatening damage could not be excluded. They also stated that there is an association between CPR duration and more bone and visceral damage. In our patient, only a fracture of the fifth rib on the right was revealed by CT scan. Finally, good quality manual chest compressions are not inferior to the use of automated CPR devices. [14, 15]

As mentioned in the case report section of the manuscript, the pulse checks were carried out manually due to the lack of a prehospital ultrasound device. It’s possible that the use of Point-of-Care Chest Ultrasound (PoCUS) could have shown remaining minimal cardiac activity and thus prompted ongoing clinical evaluation and continuation of monitoring. PoCUS may probably improve the recognition of persisting cardiac activity and is easy to learn [16]. On the other hand, ultrasound devices are not universally available, will need trained emergency service personnel and are not universally diagnostic because of anatomic reasons. But as PoCUS can be used for the detection of a variety of pathologies, it should be introduced in the standard equipment of emergency teams.

On the one hand existing literature recommends a minimum CPR length of 20 min, which in our case was much longer with a total of 60 min. On the other hand, the Swiss Academy of Medical Sciences proposes that after 20 min of ALS the chance of survival with good neurological outcome (CPC 1–2) drops to < 1% [17]. In contrast, our patient was discharged as a self-employed pedestrian with age-appropriate neurological performance despite the extended CPR length and the late clinical detection of ROSC.

In contrast to the extensively discussed ToR rules the ERC mentions autoresuscitation briefly in the context of uncontrolled organ donation after circulatory death and recommends a ´no touch` period to rule out its possibility [10]. Unfortunately, no further information is given about how long this period should be and what measures should be taken in order to not miss the occurrence of autoresuscitation. This reflects the complex and yet unclear situation regarding the correct procedure after TRA.

In emergency medicine we rely on various guidelines from different medical societies. There are recommendations how we should take care of patients who suffer from dyspnea, chest pain or even cardiac arrest. But until now we do not have a standardized approach when it comes to termination of resuscitative efforts. In this precarious situation the emergency personnel have to deal with different requirements all at once. A decision has to be made if there should follow a legal inspection of the body, relatives need to be taken care of or maybe the alert for the next rescue mission is coming in. And somewhere in between all of that we have to take care of the actual patient. Most of our medical tasks are complex, and so is death determination. In the clinical setting, especially before organ donation, two experienced physicians from different specializations are needed to accomplish this task [18].

It’s very likely, that a longer monitoring period and a standardized approach to TRA would have led to an earlier recognition of ROSC, faster treatment by specialists and less distress in affected emergency care givers.

The absence of a central pulse via manual pulse check and cardiac auscultation is an insecure tool to exclude minimal cardiac activity after TRA [19]. Therefore, we propose to monitor the patient via ECG and—if intubated—capnography. Any existing airway device should be disconnected from the ventilator or ventilation bag to enable escaping of trapped air. After at least 10 min the absence of brain stem reflexes should be checked. This includes the absence of light reactions to the pupils, corneal reflexes, reaction to painful stimuli, gag reflex and cough reflex. Additionally, patients with persistent gasping should remain under surveillance as long as gasping persists.

Finally, transport of a deceased patient should be undertaken after detection of indisputable signs of death, such as livores.

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