A case of cardiac arrest

Dr.Rana Muhammad Habibullah

Intensive Care Medicine

Key content Cardiac arrest secondary to amitriptyline overdose

Management of amitriptyline overdose

Therapeutic hypothermia

Prognostication

Out of Hospital Cardiac Arrest

Witnessed Collapse

No standby CPR instantly

SCDF was called

SCDF arrived in 18 min

Found unresponsive, pulseless

CPR started

Defibrillator attached

ECG Tracing

Out of Hospital Cardiac Arrest

Shock delivered X 2 times

Pulse palpable

Transferred to ED with BMV

Intubated at ED

At EDParameters:

BP 79/52 mm (Hg)

HR 110 bpm

No spontaneous breathing

12 Lead ECG

Summary Survivor of cardiac arrest

Wide complex tachycardia with long QT

What might be cause Cardiac

Drugs

Electrolyte Imbalance

Case HistoryMr.X

53 years/Chinese/Male

Past Medical History

1.Depression

2.Benzodiazepine dependence

Social Issue Married with 3 children

Stays with wife and youngest son

Had behavioural issue and wife had Personal Protection Order

Breached PPO several occasion and had imprisonment

Current Admission Had conflict with wife

Became abusive and violent

Police was called by wife

Patient ingested more than 20 tablets

Police arrived

Patient collapsed while having argument with police

SCDF arrived in 18 minutes

VT arrest No H/O previous cardiac disease/risk factor/symptoms

Normal cardiac enzyme

Electrolytes normal

Diagnosed as VT arrest due to amitriptyline overdose

Issues Amitriptyline overdose

Survivor of cardiac arrest

Amitriptyline Pharmacokinetics:

-Highly lipid soluble

-Bioavailability 30-60%

-Highly protein bound

-Metabolised by liver

-Vd:5-10L/kg

-Half life 31-46 hours

Overdose:Effect CNS:

-drowsiness,coma,seizure,respiratory depression

Cardiovascular

-Tachycardia, Myocardial depression, wide QRS,Long QT,arrhythmia

Others:

Urinary retention, pupillary dilatation

Work up Routine Investigation

Drug screening test

ABG

ECG

ECG in TCA overdose Highly sensitive

Common-sinus tachycardia

Other feature: wide QRS,Long QT, increased PR interval, arrhythmia

Duration of QRS complex-correlates with complication, guide for treatment

R wave in aVr indicates susceptibility to seizure/arrhythmia

Treatment Vital support : ABC

Gastric Decontamination

Activated charcoal

IV sodium bicarbonate

Intralipid

Benzodiazepine for seizure

Treatment at ED IV fluid

IV sodium bicarbonate

Activated charcoal

Post Cardiac Arrest Care Supportive management

Therapeutic Hypothermia

Issues surrounding TH Toxic overdose

Arrhythmogenic drugs

Wide QRS+ Long QT

In ICUPupil :4 mm nonreactive

GCS:3/15

No spontaneous respiration

Gag reflex, cough reflex absent

Day 2

Wife raised concern about unnecessary prolongation of life

Prognostication

American Academy of Neurology guideline

ANN Guideline

Remember H’s and T’s-Cardiac arrest with toxic overdoseDR.RANA MUHAMMAD HABIBULLAH

INTENSIVE CARE MEDICINE

Prognostication Survivor of cardiac arrest

Amitriptyline overdose

Therapeutic hypothermia

Progress: Noted sluggish pupillary reaction D1(evening)

Noted gag reflex on D2

Noted Cough reflex D3

Noted spontaneous respiration D3

GCS was improving

Extubated on D6

Send to GW on D9