Pseudo PEA, Refractory VF- Challenging Cardiopulmonary Resuscitation: a case from ER

In this challenging cardiopulmonary resuscitation (CPR) case, a 45-year-old patient arrived at the emergency room following a collapse, having suffered an arrest 10 minutes prior. Upon admission, the patient was unresponsive with no central pulse and undetectable blood pressure. Following ACLS guidelines, the medical team initiated CPR, established an IV line, performed endotracheal intubation, and employed continuous monitoring.

The patient presented with ventricular fibrillation (VF), prompting successive shocks, and after two shocks, administration of Amidarone (300 mg, 150 mg), which initially appeared refractory. As the team adhered to hospital policy, the option of using a double-sequential defibrillator (DSD) was not pursued. Despite ongoing CPR and multiple interventions, the patient's condition persisted as VF.

At the 20-minute mark of CPR, a critical turning point emerged during an echo investigation, revealing a pseudo pulseless electrical activity (pseudo-PEA) due to visible cardiac activity on the monitor, detecting cardiac activity in the bedside echocardiogram but no central pulse. Recognizing this, the team adjusted their approach, continuing CPR, administering epinephrine every 4 minutes, and additional interventions including normal saline and norepinephrine.

After 40 intense minutes, a very weak pulse was detected, leading to the return of spontaneous circulation (ROSC). BP: 80/50, HR: 60, pupils normal size, and reactive.

• The medical team promptly consulted a cardiologist, suspecting ischemic heart disease. The patient was swiftly transported to the catheterization lab, revealing a significant blockage in LAD that was addressed with stent placement and Intra aortic balloon pump (IABP). Therapeutic hypothermia (TTM) was initiated, culminating in the patient's successful recovery.

This case underscores the complexity of resuscitation scenarios, emphasizing the importance of adaptability, continuous monitoring, and collaboration between medical disciplines. The unexpected pseudo-PEA highlights the significance of real-time assessments and adjustments during resuscitative efforts. The successful outcome underscores the resilience and commitment of the medical team in the face of a challenging resuscitation scenario.

Take-Home Points:

• Adaptability: Emphasizes the need for adaptable strategies during resuscitation.
• Continuous Monitoring: Highlights the importance of ongoing monitoring to detect unexpected developments.
• Collaboration: Underscores the significance of collaborative efforts between medical disciplines.
• Real-time Assessment: The pseudo-PEA incident stresses the need for real-time assessments and adjustments.
• Refrrectoy VF/VT: Double sequential defibrillation (DSED) for cardiac arrest with a refractory shockable rhythm after delivering 3 shocks. (ILCOR 2023)
• Resilience: The successful outcome showcases the resilience and commitment of the medical team in challenging scenarios.

https://youtu.be/0EpmiBA7j4E?si=RPQZukC19LMS1o91