The Cardiac Arrest Survivor

This hot case typically takes one of two possible courses. Its either an attempt to work out what has caused this cardiac arrest, or what the prognosis is likely to be.

Important prognostic features include the following:

  • Initial rhythm
  • Quality of CPR (in or out of hospital)
  • Time to ROSC
  • Treatability of the cause of arrest
  • Presence of poor prognostic features (eg. old age, multiple comorbidities, persisting coma at 72 hours, presence of early myoclonus)
  • Performance in the various tests (eg. N20 SSEPs).

Previous hot cases with this sort of theme to them can be found below.

Examination of the Cardiac Arrest Survivor

The standard introduction

  • The examiner will give you a history.

The prelude to the dance

  • Wash hands.
  • Gown and glove.
  • Ask, if relevant:
    • "Can I turn on all the lights?"
    • "Are there any movement restrictions? Can I sit them up, or roll them on their side?"
    • "Is there a language barrier?"
  • Introduce yourself: “Hi Mr or Mrs Bloggs, I’m Dr So-and-so. I’m going to examine you.”

The Monitors

  • Rhythm - specifically, look for abnormalities associated with hypothermia
  • Rate
  • Morphology: QRS width, ST segment changes
  • MAP and abnormal morphology of the arterial waveform
  • CVP and abnormal morphology of the CVP waveform
  • Ancillary waveforms eg. the PA catheter waveform
  • Oxygen saturation measurement, and the quality of the waveform
  • End-tidal CO2 waveform and level

A pacing box?

  • Pacing mode
  • Set rate

Sensitivity and pacing threshold may not be relevant.

The Ventilator

One can ask the examiners the following questions:

  • How are we oxygenating this patient?
  • How are we ventilating this patient?
 

One should ask about the following parameters:

  • FIO2
  • PEEP
  • Peak pressure
  • Plateau pressure
  • Tidal volume and minute volume

One should ask to look at the pressure-volume loops.

It would be useful to note whether the patient is triggering the ventilator.

Urine catheter

  • Unusual colour
  • Anuria
  • Polyuria of hypothermia, or of DI.

Drains (surgical, intercostal, etc)

There may be surgical drains (what is in them? How much of it?). Asking how much has been coming out may be relevant.

The pleural catheters are also interesting. One should make a mental note of whether the ICCs are on free drainage or on suction. The content of these drains could be informative, especially if one notices blood or chyle. Haemothorax may have been caused by vigorous CPR efforts.

Dialysis

A CVVHDF or SLEDD process may be in progress. The savvy candidate may wish to ask the following questions:

  • Which modality is being used?
  • What is the dose of dialysis?
  • What is the rate of fluid removal?
  • How is the circuit anticoagulated?
  • How long has this filter lasted?

These questions may go unanswered. The CRRT machine is a good marker of poor prognosis. Either the patient already has end-stage renal failure, or they are suffering multi-organ system failure in the wake of their prolonged downtime.

IABP / ECMO

The patient you are examining may have some sort of extra gadget hooked up. If ECMO is in progress, one may wish to ask about the following parameters:

  • VA or VV?
  • Flow rate
  • Fresh gas flow
  • Any recent problems with the circuit

If IABP counterpulsation is in progress, it raises additional questions. One may wish to ask the examiners whether one may be able to switch it to 1:2, to assess the efficacy of augmentation.

The IABP also alerts one to the possibility that the patient has had a VF arrest following a STEMI, and have now been revascularised.

Infusions

This stage is critically important. The drug and fluid infusions which are currently in progress give a clue as to what problem is currently being addressed.

Important infusions not to miss:

  • Vasopressors
  • Inotropes
  • Paralysis agents

If the patient is paralysed, ask the examiners to perform a train of four. You will be denied; the examiners will probably just tell you the results.

EVD

One should observe the following features of an EVD:

  • Set height
  • Whether it is open or closed
  • The CSF colour - eg. is it full of blood?

The cardiac arrest survivor does not routinely score an EVD. Its presense suggests that an intracranial catastrophe may have been responsible for the arrest; typically a massive SAH is one such catastrophe.

Active cooling

One should note the temperature.

A patient cooled to 33° is not going to be a fruitful neurological examinee.


The physical examination

Expose and observe

Ideally, one should get the patient sitting up to 30-45°. This may not be possible. However, one should still ask for it.

Ideally, the patient should be exposed from the waist up. Peel back the cooling blanket, if one is allowed to do so. The candidate can then stand back and look for anything externally obvious:

  • Skin colour, eg. jaundice or the discolouration of chronic renal failure
  • Muscle wasting, obesity
  • The evidence of trauma, wound dressings, etc
  • The pattern of breathing (eg. whether there is a characteristic chest flail)

GCS

Performing the GCS should be the first step, unless you notice that a neuromuscular junction blocker is among the infusions. The level of consciousness then determines how you go about examining the rest of the patient. Again, the process of cooling may render this step redundant.

A traditionalist, who is examining Mr Bloggs, would approach the GCS in the following manner:

  • Grab hold of both of the patient's hands.
  • "Mr Bloggs!" One pauses to observe for eye opening.
  • "Can you squeeze my hands?"
  • If hand squeezing and eye opening is not observed, one administers a painful nail bed stimulus to both hands, to observe the response to pain.

Hands, nail signs, pulse and the arterial line.

One has just performed a GCS assessment; one is still holding the hands.

Now, time to look at them more closely.

First, one should spent a second assessing whether they are warm or cold.

Then, one can focus on the nails. Nail signs are numerous and deserve their own page.

In brief, the nail signs one could look for are as follows:

Look for the presence of any sort of characteristic deformities, eg. assymetrical wasting of the small muscles, or the joint changes of rheumatoid arthritis.

Assess the pulse. While one still has both of the patient's hands, one ought to try to compare the radial pulses.

Arms

Tone of the upper limbs

Move up from the hands. While you are still holding the hands, you can perform a sort of gross examination of tone by pronating and supinating the wrists, and by flexing and extending the elbows.

Asterixis

In the conscious patient, it may be possible to assess asterixis by asking the patient to hold both their arms up with the wrists dorsiflexed. The presence of asterixis late in the recovery phase of cardiac arrest may suggest that a severe ischaemic liver injury has occurred. More likely, the patient will be too comatose to perform this trick.

Cubital fossa

Examine the cubital fossa for

  • Peripheral lines
  • Evidence of multiple venepunctures
  • Lymph nodes
  • Brachial pulse
  • The presence of an obvious AV fistula

One should then palpate the axillary lymph nodes.

The Neck

  • Inspect any central lines
  • Look again at the CVP

Palpate the neck:

  • Trachea: is it midline? Is there a new tracheostomy there?
  • Thyroid gland
  • Cervical lymph nodes
  • Carotid pulse - one side at a time!
  • Submandibular lymph nodes
  • Pre- and post-auricular lymph nodes

Pupils and the higher cranial nerves

The examination of the face and head is always affected by the level of consciousness, which is in turn related to the core temperature and the level of sedation.

The cardiac arrest survivor, unless extremely lucky, will be totally comatose, with few cranial nerve signs. The awake uncooled cardiac arrest survivor may have signs.

Thus, this section can be divided into three broad groups:

The paralysed hypothermic patient The unconscious nortmothermic patient The awake post-arrest patient

Visual acuity

A Snellen chart is ideal, but probably will not be available.

The extubated patient should be able to read the time on the clock in the room.

One performs this test with each eye individually.

This tests CN II.

Light reflex

Ask the examiners to dim the room lights.

Open both eyes. Each eye is exposed to light. The opposite pupil should constrict consensually.

This tests CN II (afferent) and CN III (efferent).

Corneal reflex

The cornea (not the sclera) is touched lightly with a moistened corner of a piece of gauze.

A normal reflex is to blink.

This tests CN V (afferent) and CN VII (efferent)

Eye movements

The conscious patient will be able to follow the tip of the candidate's finger.

The pattern of movements should be tracing the six cardinal points: superior left, inferior left, superior center, inferior center, superior right, inferior right.

This tests CNs II, IV and VI.

Facial pain sensation

Typically, this is performed by putting some pressure on the superior orbital notch.

The patient should either open their eyes or localise.

This tests CN V.

Facial movements

The conscious patient will be able to perform a series of grimaces to assess the bilateral motor control of facial muscles:

  • Raise eyebrows to wrinkle forehead
  • Squint eyes to assess periorbital muscles
  • Bare teeth to assess nasolabial muscles
  • Blow out cheeks

Oculocephalic reflex

In the comatose patient, as the head is moved from left to right, the eyes should move in the opposite direction. A fixed unchanging gaze is a negative test; the reflex is not working.

This tests CNs III, IV, VI, and most importantly VIII.

Cold caloric reflex

Cold water is funneled into the patient's ear. A positive reflex consists of the eyes turning towards the chilled ear. This is a more potent stimulus for CN VIII than the oculocephalic reflex.

Airway and the lower cranial nerves

Now that one has finished with the upper cranial nerves, one can move on to the mouth, airway, and swallowing apparatus.

Gag reflex

The Yankeur sucker is used to probe the posterior pharynx, on both sides. A gag reaction should result from this.

This collectively tests CN X and IX.

Cough reflex

While on the subject of CN X, one may test the cough reflex by suctioning the trachea.

This tests CN X.

This is also a convenient time to ask about the volume and character of the secretions.

Tongue movements

The conscious patient is asked to protrude their tongue, and move it from side to side.

This tests CN XII.

Uvula deviation

The uvula deviates away from the lesion.

This tests CN X and IX.

Shoulder shrug

The conscious patient is asked to shrug their shoulders against resistance.

This tests CN XI.

During the cranial nerve examination, one will inevitably end up tripping over the endotracheal tube. One should note whether there is anything unusual there; for instance, is there a dual-lumen tube, or a bronchial blocker?

Chest palpation, percussion and auscultation

Palpation:

One puts both their hands on the chest to assess the symmetry of chest expansion.

During this part of the examination, one should make a point of looking for rib fractures. These will affect ventilator weaning, and are an important factor to mention when discussing the long-term outlook.

Percussion:

One might wish to percuss the chest.

Changes in percussion resonance may be worth commenting on.

Auscultation:

One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible. The money is in the bases.

Specifically, one is looking for evidence of pneumothorax or aspiration pneumonia, both of which may be complicating recovery from this arrest.

Palpation and auscultation of the praecordium

Palpation:

The clever candidate will make a big show of palpating both the apex and the right sternal edge.

Auscultation:

One should auscultate in the following sequence:

  • Apex
  • Left sternal edge, lower
  • Left sternal edge, upper
  • Right sternal edge, lower
  • Left sternal edge, upper
  • Both carotids

The various clicks and murmurs one encounters are discussed elsewhere.

Abdominal palpation, percussion and auscultation

For this, one should ask to lay the patient flat.

Abdominal observation

  • Take a moment to behold the abdomen. One may ask the examiners to look under any surgical dressings; one is likely to be denied this part of the examination (they will tell you the wound looks clean and dry).
  • One is specifically looking for the deep purple of hepatic laceration haematoma, or evidence of gastric repair.

Abdominal palpation

  • All quadrants should be palpated.
  • Then, feel for the liver edge; observe respiratory excursion
  • Then, feel for the spleen.
  • Then, try to ballot the kidneys. Enquire about renal tenderness.

Abdominal percussion

  • This can double as a test for peritonism.
  • If there is some suspicion of ascites, one may ask to roll the patient, so shifting dullness can be better appreciated. The examiners may not permit this test.

Abdominal auscultation

  • One should spend a good length of time on this, if one suspects bowel obstruction or ileus.

Examination of the pelvis and groins

The pelvic content would have been palpated during the abdominal examination.

The more important part of this examination is the groin.

At this stage, the patient should be re-draped - cover them from the waist up, and uncover their legs.

Observation and palpation of the pelvis:

  • There may be a rash of thrush, or a groin haematoma, or an external fixation device.
  • The posterior pelvis and sacrum should ideally be palpated for pitting oedema.

Examination of the lines

  • One should take notice of anything going into or coming out of the femoral vessels.
  • There may be a vascath, a PiCCO catheter or some sort of angiography sheath. These are important clues. Did this patient get an angiogram?

Examination of the genitals and rectum

  • A complete examination would call for the palpation of the testes, and a comment on their size. However, this may not be practical.
  • One should take note of any sort of waste management devices, eg. rectal tube, SPC or IDC.
  • One should definitely ask about performing a PR.
  • If one is forbidden from performing the PR, one should ask about the following features:
    • Anal sphincter tone
    • Size and quality of the prostate
    • Presence of melaena or hard stool

Once one is finished with the pelvis, one should cover it again, so that only the legs are sticking out.

Examination of the lower limbs

One should ask to remove TEDs and compression stockings.

  • One should observe whether the lower limbs are mottled, and whether they are of the same size (assymetrical swelling leads one to suspect lymphoedema or DVT)
  • One should palpate the larger muscles.
  • One should appreciate the temperature difference between the limbs, which could be important in the assessment of peripheral vascular disease.
  • Pitting oedema should be palpated.

Leg muscle tone

The best way to test muscle tone is by holding the knee. Roll the knee gently to distract the patient; then try to lift it off the bed. In the presence of increased tone, the leg will remain straight and the whole thing will lift up; with normal or decreased tone, only the knee will bend

Calf tenderness

In the conscious patient, one might be able to assess whether a gentle calf squeeze produces the characteristic pain which suggests a DVT may be present.

This brings one to the feet, and to the beginning of the neurological examination.

Feet and the Babinsky reflex

The feet would have already been palpated to assess their temperature, and to look for pitting oedema.

Observation of the feet

One should look specifically for changes suggestive of chronic diabetic foot disease, or chronically poor vascular supply.

Palpation of the feet

This should consist of palpating the dorsalis pedis and posterior tibial pulse.

Babinsky reflex

One should test the Babinsky bilaterally.

Clonus

One should attempt to assess clonus in both feet.

Power in the lower and upper limbs

The conscious post-arrest patient may allow the candidate to perform a proper neurological exam.

However, the patient most likely to be selected for this hot case will likely be in a deep coma.

Power of the muscle groups may be tested in the following sequence:

  • Ankle dorsi and plantarflexion
  • Knee flexion and extension
  • Hip flexion, extension, adduction and abduction.
  • Hand grip
  • Wrist dorsiflexion/palmarflexion
  • Elbow flexion/extension
  • Shoulder adduction / abduction

Reflex testing

Now that one is back to the upper limb, one may as well start their reflex tests there.

The reflexes may be tested in the following order:

  • Brachioradialis
  • Biceps
  • Triceps
  • Knee jerk
  • Ankle jerk

The measured observations

Ask to see the obs chart. If it is not allowed, ask for the following:

  • Trends of blood pressure and heart rate
  • Temperature
  • Drain output
  • Urine output

One may also wish do demonstrate an interest in the trends of any sort of advanced haemodynamic monitoring, eg. cardiac index as measured by PAC or PiCCO

The laboratory investigations

One needs to show an interest in the following labs:

  • ABG
  • Routine bloods
  • Urinalysis
  • Culture results
  • CK, troponin, LFTs, pancreatic enzymes, inflammatory markers... generally speaking, features of multi-organ system failure

Imaging and other investigations

One should always ask for the following:

  • ECG
  • CXR

You sometimes want to see the following:

  • Results of the coronary angiogram
  • CSF analysis
  • CT or MRI results
  • Results of recent SSEPs
  • Results of the EEG
  • Results of four-vessel angiography

 

Case presentation and discussion: when you have a good idea of what is going on

"Mr Bloggs has suffered a cardiac arrest, which was probably caused by [insert clever diagnosis here]."

"I have come to this conclusion on the basis of the following findings: [insert clinical findings here]"

"I would like to confirm my diagnosis with the following investigations: [insert appropriate investigations]"

"The current management issues are as follows: [a brief list of management priorities]"

"I would approach the management of these issues in the following manner: [list of management strategies; it helps to organise this into an A,B,C,D,E approach if one has a complex multisystem problem to manage]"

"Given the current progress, I suspect Mr Bloggs' prognosis is [guarded, very poor, or reasonably good]"

Case presentation and discussion: when you don't have a clue

”Mr Bloggs has suffered a cardiac arrest."

"I have been unable to arrive at a specific cause for this on my limited examination." Or: "With the available data, I am unable to make a confident statement about Mr Bloggs' prognosis".

"The possible aetiologies responsible for this arrest could include [list of differentials]"

"I have identified clinical findings which support some of these differentials: namely, [insert list of findings]."

"Furthermore, I note the following organ failures: [list organ problems]."

"In order to aid prognostication, I would like to perform the following investigations: [list of investigations]"

"In view of the organ system dysfunction, I would offer the following supportive therapies:[list of supportive measures]"

"Additionally, I would like to enlist the help of the following specialties [insert list of consults], for whom I will have the following specific requests/questions: [what questions will you ask these specialist teams]"

Number of previous hot cases in this topic: 20

2015, Paper 2

Unspecified hospital in Adelaide

58-year-old male, day 3 ICU, who had undergone thoracic surgery three days earlier and suffered an intraoperative arrest.

Candidates were directed to examine the patient and discuss a management plan.

Discussion points included the causes of intra operative arrest and the complications of pneumonectomy.

Unspecified hospital in Adelaide

44-year-old male admitted to ICU 2 weeks earlier having been found collapsed in the dialysis unit car park with a GCS 3, heart rate 30 bpm and temp 41.7oC. CPR was started in the ambulance with ROSC in ED 10 minutes later following treatment for K+ 8.1 mmol/L. Background included IDDM and end-stage kidney disease on haemodialysis 3x /week. Clinical findings included GCS 4 with roving eye movements, increased tone with extensor response to pain and upgoing plantar reflexes and the presence of an A-V fistula in his forearm.

Candidates were directed to examine him with a view to assessing his neurological prognosis and possible causes of the cardiac arrest

Discussion points included management of the initial arrest, neurological prognostication, pros and cons of tracheostomy and family discussion re prognosis

2015, Paper 1

Unspecified hospital in Melbourne

50-year-old male, day 7 ICU, admitted following out-of-hospital VF cardiac arrest secondary to STEMI, requiring multi-system support with VA ECMO, mechanical ventilation, vasopressor and inotropic support and CRRT. Candidates were asked to assess him with a view to making a plan for that day and projecting forward for the subsequent few days.

Unspecified hospital in Melbourne

35 - year - old male, day 1 ICU, admitted following attempted suicide by hanging. He required 5 min CPR at the scene and GCS was 3/15 on presentation to hospital. Background included a history of IV drug use and alcohol abuse.
Candidates were asked to assess him , say which investigations they would perform and to give a management plan for the next 72 hours .

Unspecified hospital in Melbourne

A 63 - year - old man admitted 24 hours previously following an out of hospital cardiac arrest. Relevant background history included hypertension, Type 2 diabetes and rheumatic fever. He was in cardiogenic shock requiring inotropic support and IABP with clonus on neurological exam. Candidates were asked to examine him and outline their management plan.

Unspecified hospital in Melbourne

81 - year - old female who had suffered a cardiac arrest following an acute coronary syndrome, which was complicated by a stroke. The patient had undergone percutaneous intervention (PCI) and had an intra - aortic balloon pump in place. Candidates were directed to assess the patient’s progress and formulate a management plan .

2013, paper 2

Liverpool Hospital

  • 59-year-old female, day 5 in ICU, post in-hospital PEA arrest of unknown cause with a background of insulin-dependent diabetes and chronic renal failure. Clinical findings included a pansystolic murmur, peripheral oedema, left pleural effusion, hepatomegaly and Charcot's joints. Candidates were told that she had been admitted to hospital for insertion of a permacath for dialysis and subsequently had a PEA arrest in the ward. Candidates were asked to examine her and establish likely causes for the arrest. Other discussion points included interpretation of investigations and indications for dialysis.
2012, Paper 2

Royal Melbourne Hospital

  • 47-year-old man, day 4 in ICU following an out of hospital cardiac arrest. Clinical findings included GCS E3M6VT, dysconjugate gaze, hyporeflexia and ankle clonus, systolic murmur and renal replacement therapy. Candidates were asked to assess him from a neurological point of view. Discussion points included the neurological prognosis and the possible causes of the renal failure
2012, Paper 1

Royal Brisbane Hospital

  • 65-year-old man post cardiac arrest on induction of anaesthesia for amputation of an infected foot. Candidates were asked to assess him and determine his prognosis.

Prince Charles Hospital

  • 42-year-old female day 10 post out of hospital cardiac arrest with hypoxic-ischaemic encephalopathy. Candidates were asked to assess her neurological state, formulate a management plan, discuss a differential diagnosis for the clinical signs and interpret the CT brain and CXR.

Prince Charles Hospital

  • 43-year-old male post attempted hanging with GCS 3, myoclonus, unreactive pupils and absent oculocephalic reflexes. Candidates were asked to assess the patient and to formulate a management plan.
2011, Paper 2

Royal North Shore Hospital

  • 64-year-old male day 5 ICU following out of hospital VF arrest, revascularised, treated with hypothermia
2011, Paper 1

Westmead Hospital

  • 58-year-old male one week post VF arrest secondary to blocked LAD with some neurological recovery but recent deterioration with acute pulmonary oedema. Other issues included acute kidney injury.

Westmead Hospital

  • 35-year-old male with out of hospital VF arrest admitted to ICU with cardiogenic shock following emergency coronary angiography and failed PTCA. Current issues included hypoxia, cardiogenic shock, sepsis, acute kidney injury and uncertain neurological recovery.
2010, Paper 1

Alfred Hospital

  • A 60 year old lady readmitted to ICU post cardiac arrest due to a PE after an AVR and a CABG and had been discharged to the ward. Candidates were asked to examine the patient and have an approach towards differential diagnosis of cardiac arrest post surgery and have management plan about PE post cardiac surgery.

Alfred Hospital

  • A young man who had suffered a cardiac arrest during a rugby match and had suffered hypoxic cerebral injury. Candidates were asked to assess neurology and discuss prognosis
2009, paper 1

Royal Brisbane Hospital

  • A 50 year old man who collapsed at a bus stop and was in a cardiac arrest when paramedics
    arrived.  Asses for possible causes of cardiac arrest

    Issues
    °  Causes of cardiac arrest
    °  Management post cardiac arrest
    °  C-spine clearance
    °  Complications of cardiac arrest

    Areas of weakness identified by examiners: 

    °  Missed Codman catheter
    °  Missed toxicology as a possible cause of arrest
    °  Poor exam technique
    °  Focussed only on the cardiac causes
2008, Paper 2

Unspecified hospital

  • 65 year old male, 1 day in ICU post resuscitated cardiac arrest and candidates asked to assess neurology, discuss prognostication and management plan over the next few days. Active hypothermia, IABP, no corneals, gag or cough reflexes

Unspecified hospital

  • A 64 yr old man with cardiogenic shock following a cardiac arrest. Findings included a dilated L.pupil, raised A-a gradient, CRRT and a broad complex rhythm

Unspecified hospital

  • 62 year old male, 5 days in ICU post resuscitated cardiac arrest and candidates asked to assess neurology, discuss prognostication and management plan over the next few days