Archives of Academic Emergency Medicine. 2022; 10(1): e40 CA S E RE P O RT Prolonged Resuscitation with Multiple Defibrillations; a Case Report Shaghayegh Rahmani1, Elham Mokhtari Amirmajdi2, Rana Kolahi Ahari3∗, Roohie Farzaneh4 1. Innovated Medical Research Center, Faculty of Medicine, Mashhad Branch, Islamic Azad University, Mashhad, Iran. 2. Department of Internal Medicine, Mashhad Branch, Islamic Azad University, Mashhad, Iran. 3. Faculty of Medicine, Mashhad Branch, Islamic Azad University, Mashhad, Iran. 4. Department of emergency medicine, Faculty of medicine, Mashhad university of medical sciences, Iran. Received: March 2022; Accepted: April 2022; Published online: 26 May 2022 Abstract: Although American Heart Association Guidelines (AHA) are practical and standardized in many aspects of car- diopulmonary resuscitation (CPR) performance, recommendations on when to terminate resuscitation are not fully understood and clear. There is not enough evidence about how long we can continue CPR in shockable rhythms and how many shocks can be delivered to patients, and if there is an end point for it or not. This is- sue is more challenging when we read papers published on survival rates and good functional and neurological outcomes after prolonged CPRs. Here, we demonstrate a case of cardiac arrest receiving CPR in the emergency room, for whom it was hard and challenging to make a decision on when to terminate the resuscitation attempts. Keywords: Cardiopulmonary Resuscitation; Electric Countershock; Heart Arrest Cite this article as: Rahmani S, Mokhtari Amirmajdi E, Kolahi Ahari R, Farzaneh R. Prolonged Resuscitation with Multiple Defibrillations; a Case Report. Arch Acad Emerg Med. 2022; 10(1): e40. https://doi.org/10.22037/aaem.v10i1.1583. 1. Introduction Cardiopulmonary resuscitation (CPR) consists of a group of life-saving interventions, which aid in oxygenation and circu- lation when cardiac arrest happens (1). Cardiac arrest onset is defined as absence of palpable central pulse, apnea, or un- responsiveness. When CPR performance is stopped for a pa- tient without the return of spontaneous circulation (ROSC), the patient is considered terminated (2, 3). Performing a high-quality CPR is a challenging issue. Although there are exact guidelines about its performance, some cases may be more complicated. There is no agreement on which patients need prolonged conventional CPR and which patients are not good candi- dates for it. In most cases, it varies across hospital proto- cols (3) and is based on subjective team decision (4). De- spite advancements in resuscitation, recent published data showed exceedingly poor outcomes for out- and in-hospital CPRs (5). The rate of survival with favorable neurologic out- ∗Corresponding Author: Rana Kolahi Ahari; Faculty of Medicine, Mashhad Branch, Islamic Azad University, Mashhad, Iran. Phone/Fax number: +989362943344, Email: kolahi.rana@gmail.com, ORCID: http://orcid.org/0000-0002-3681-7528. come is even lower (4). Although American Heart Association (AHA) Guidelines are practical and standardized in many aspects of CPR perfor- mance, recommendations on when to terminate resuscita- tion are not fully understood and clear. There is not enough evidence about how long we can continue CPR in shockable rhythms and how many shocks can be delivered to patients, and if there is an end point for it or not. This issue appears to be even more challenging when we read published pa- pers about survival rates and good functional and neurolog- ical outcomes after prolonged CPRs. Here, we demonstrate a case of cardiac arrest receiving CPR at the emergency de- partment, for whom it was hard and challenging to make a decision on when to terminate the resuscitation attempts. 2. Case presentation A 30-year-old male presented to the emergency department (ED) with cardiac arrest. He had had a seizure-like attack and cardiac arrest at home, no one performed basic life support for him. His family called emergency medical services (EMS), and within 5 minutes they reached the patient and advanced cardiac life support treatment, including endotracheal intu- bation and chest compressions based on AHA Guideline 2020 This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem S. Rahmani et al. 2 version, was initiated for him. The initial rhythm was not shockable. During CPR, auto- mated external defibrillator (AED) delivered two shocks. He also received 1 mg epinephrine. The patient was transferred to our emergency department, 22 Bahman Hospital, Mash- had, Iran, about 15 minutes after cardiac arrest. His first rhythm was asystole in hospital. CPR was continued. After two minutes, rhythm was checked. It was ventricular fib- rillation, he was defibrillated seventeen times, and received 1 mg epinephrine each three minutes, 300 mg intravenous (IV ) amiodarone, followed by 150 mg IV amiodarone. The emergency department cardiac arrest team, which was be- ing led by an emergency medicine specialist, continued with high quality CPR (our center does not have a cardiology unit). Other recommended medications that were used for this pa- tient included: 1 mg/kg of sodium bicarbonate and lido- caine, and 2 g of magnesium empirically. The laboratory test results such as hemoglobin, coagulation state, kidney func- tion test, and blood electrolytes were normal. About 10 min- utes after the last antiarrhythmic drug use, his rhythm was converted to sinus with a palpable carotid pulse. The qual- ity of CPR was monitored using the pressure of end-tidal CO2 (PetCO2). The return of spontaneous circulation (ROSC) was confirmed by increase in end tidal CO2, from around 20 mmHg to 50 mmHg. ED CPR lasted about 50 minutes, and the patient had re- ceived out-of-hospital CPR for 10 minutes. Patient’s rhythm was shockable during a long portion of CPR period. In the post-resuscitation period, liver function test (LFT) results was impaired, with a positive methadone test. He was trans- ferred to intensive care unit (ICU) but he was expired shortly thereafter. Other tests, such as ionogram, were normal. Tro- ponin was positive in first blood sample, unfortunately our hospital lab did not report it as a quantitative value. 3. Discussion We introduced a prolonged CPR case with shockable rhythm without underlying heart disease. The mentioned patient was young, with no cardiopulmonary complaints before ar- rest, and his post-ROSC electrocardiograph was normal si- nus rhythm with no ST segment changes. His past medi- cal history, physical examination, and preclinical evaluation showed no evidence regarding cardiologic problems what- soever. This case was confusing because of numerous de- fibrillations and use of variable antiarrhythmic agents dur- ing CPR. He had systole rhythm for only one cycle, it is as- sumed that this rhythm might have been fine ventricular fib- rillation (VF) that changed to ventricular tachycardia (VT) af- ter epinephrine administration. For our case, methadone toxicity might be an important un- derlying cause of arrhythmia, because such drugs can lead to prolonged QT interval. But in the electrocardiography (ECG) performed after ROSC, QT interval was normal. Bedsides, echocardiography, performed by an emergency medicine specialist, was also reported to be almost normal. So struc- tural and electrical abnormality can be ruled out in our pa- tient. So, the exact cause of this resistant arrhythmia is not fully determined. Generally, studies regarding the effect of duration of car- diopulmonary resuscitation on clinical outcome are few. A case study of prolonged resuscitation due to Torsade De Pointes with 99 defibrillations shows survival with good neu- rological outcome (5). Conformingly, Bingyu Ling et al. described a case who had developed cardiac arrest due to propafenone intoxica- tion and was successfully resuscitated after prolonged CPR without subsequent neurological complication (6). It seems that, intoxication might lead to cardiac arrest with shockable rhythm without basic cardiologic problems. Although our patient was a drug user (methadone), his family did not con- firm any overdose or suicidal effort. Urine analyses showed methadone, but we were not able to measure its concentra- tion level. Prolonged CPR is a decision for physician and its outcome depends on various factors, like CPR quality. We tried to im- prove in-hospital CPR quality with regular staff training pro- grams, selecting and announcing resuscitation code mem- bers daily, with defined positions for each of the six persons and assigning an emergency specialist or ICU physician as a CPR team director. The baseline status of the patient is another factor that would influence the duration of resusci- tation, including patient’s age and coexisting comorbidities. Our patient was young without underlying diseases. Due to the Corona virus pandemic and increasing risk of pulmonary thromboembolism (PTE), bedside echocardiog- raphy was performed by an emergency medicine specialist post-ROSC, but it revealed no evidence of PTE. We were un- able to find a reversible cause for cardiac arrest in our case. Sudden cardiac death in all age groups is estimated to be re- sponsible for 350000 deaths in the USA each year, and the survival rate is about 8% (7). The AHA’s advanced cardiac life support (ACLS) guideline recommends immediate initia- tion of high-quality CPR, early defibrillation, and the admin- istration of epinephrine and antiarrhythmic agents for the management of VF and pulseless VT (2). So, this should be a reminder for physicians to continue high quality CPR and shocking with less interruption in a specific group of cardiac arrest patients. But the maximum duration is still unclear. Another important aspect is the critical role of percutaneous coronary intervention (PCI) in post-cardiac arrest. Coronary angiography is recommended emergently for patients with suspected cardiac etiology of arrest and ST elevation on ECG, it is logical to transfer patients like ours to cardiology or an- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2022; 10(1): e40 giography units, since there was no evidence of heart disease in our patient but he had inexplicable rhythm during CPR with normal ionogram. 4. Conclusion The maximum duration of resuscitation attempts for incre- menting survival has not been established and it may vary from one patient to another. Considering the major factors that affect the outcomes of resuscitation, guidelines should better set clear and standard recommendations on optimal and most appropriate duration of CPR for patients with car- diac arrests and shockable rhythms. Further studies should be performed with regards to prolonged CPR, analyzing the different aspects relating to prolonged CPR and its outcomes. 5. Declarations 5.1. Acknowledgments We would like to express our special thanks to our patient’s relatives and our CPR team. 5.2. Authors’ contributions All authors discussed the results and contributed to the final manuscript. 5.3. Funding and supports We do not have a funding resource. 5.4. Conflict of interest The authors have no conflicts of interest. 5.5. Ethical considerations The authors adhered to confidentiality of patient’s pro- file and ethical consideration regarding the biomedical re- searches. References 1. Barker J, Koeckerling D, West R. A need for prone po- sition CPR guidance for intubated and non-intubated patients during the COVID-19 pandemic. Resuscitation. 2020;151:135-6. 2. Nolan JP, Monsieurs KG, Bossaert L, Bottiger BW, Greif R, Lott C, et al. European Resuscitation Council COVID-19 guidelines executive summary. 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