Cardiovascular Critical Care II
Patient Case
T.V. is a 72-year-old man with a history of chronic liver disease, hypoglycemia, and atrial fibrillation. He
was admitted to the medical intensive care unit (MICU) 2 days ago for sepsis requiring aggressive fluid
resuscitation and intravenous antibiotics. T.V. did not require vasopressors to treat his sepsis. On ICU day 3,
T.V. develops VF on telemetry, loses consciousness, and becomes pulseless; the MICU team is summoned
for a presumed VF cardiac arrest. Pads are placed on T.V. by the time the team arrives, and the rhythm is
confirmed to be VF. Which is the most accurate statement regarding defibrillation for T.V.?
response system, provide CPR, and deliver shock.
effective for pulseless VF.
definitive treatment of VF.
Airway control and ventilation
Background
During CPR, oxygen delivery to the heart and brain becomes more flow-dependent than arterial
ii.
Placement of an advanced airway in cardiac arrest should not delay CPR or defibrillation.
iii.
No studies address the optimal timing of advanced airway placement. The guiding general
concept is to place the advanced airway while minimizing interruptions to chest compressions.
iv.
Conflicting evidence exists for the urgent placement of an advanced airway.
| (a) | Study of IHCA has shown an increased 24-hour survival in patients with an advanced |
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airway placed within 5 minutes. No difference was found regarding ROSC (Resuscitation
2010;81:182-6); however, another study has shown a worse overall survival rate in cardiac
arrest patients who required intubation (Arch Intern Med 2001;161:1751-8).
| (b) | OHCA studies have shown that intubation in the rural and urban setting and, more |
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specifically, intubation within 13 minutes, is associated with better survival (Med J Aust
2006;185:135-9; Prehosp Emerg Care 2004;8:394-9).
| (c) | One large randomized controlled trial comparing endotracheal intubation to bag-mask |
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ventilation in OHCA found no difference in 28-day survival with favorable neurological
Oxygen during CPR
Unclear what the optimal concentration of inspired oxygen content should be during CPR, but
it is currently recommended that maximum (e.g., 100%) inspired oxygen be used to optimize
arterial oxyhemoglobin content and, subsequently, oxygen delivery (Circulation 2015;132(suppl
2):S315-S367).
ii.
In OHCA, patients with a higher Pao2 had higher survival to hospital admission but not
neurologically intact survival, which is likely a function of the underlying pathophysiology
iii.
Extended exposure to high oxygen concentrations carries the risk of toxicity, but this toxicity
has not been shown in the short-term setting of adult CPR (Resuscitation 1999;42:221-9).