thing over and over again and expecting different
results,” is particularly appropriate in this regard. 4
It’s time to begin to think differently. The key question is why are the standard treatments, including
defibrillation and ACLS therapies, not effective for
this particular patient? In adult out-of-hospital
refractory cardiac arrest, when the patient repeatedly reverts to, or stays in, v fib, the usual cause is
a catastrophic coronary issue, i.e., acute closure
of the left main coronary artery or its equivalent.
What’s needed in these cases is rapid reperfusion
of the occluded coronary, while providing some
systemic circulation to the central nervous sys-
tem and the myocardium. Following reperfusion,
defibrillation then has a real chance of success in
restoring spontaneous circulation.
A new paradigm for those with v fib refractory
out-of-hospital cardiac arrest is now on the horizon. Rather than the usual approach of “stay and
play, … and play, … and play some more,” a better
scenario appears to be to “load and go”—perhaps
better described as “scoop and treat on the way” to
the catheterization laboratory.
The concept is relatively simple. If an
acutely occluded coronary is preventing
any meaningful coronary blood flow
from reaching the myocardium, the
resultant ischemic myocardial milieu
is preventing establishment of a sustained perfusing rhythm. Continued efforts to
defibrillate will likely be futile until the occluded
coronary is reperfused and the milieu changed.
Acute reperfusion of an occluded coronary dur-
ing cardiac arrest is best accomplished by primary
angioplasty in the catheterization laboratory as
opposed to IV thrombolytics.
The European TROICA trial found no survival
benefit when TNK was administered to refractory
OHCA patients. Table 1, p. 4, summarizes both
patient demographics and treatment results from
this trial. The principal investigator suggested that
elimination of those with suspected pulmonary
emboli as the cause of their cardiac arrest may have
eliminated an important subgroup for whom such
a strategy might have been beneficial. 5
PCI for Reperfusion
Just as primary percutaneous coronary interven-
tion (PPCI) has become the preferred method of
reperfusion in ST-segment elevation myocardial
infarction (STEMI) patients, it also appears to be the
best option for successful reperfusion during car-
diac arrest, given the results of the TROICA study.
If timely reperfusion with PPCI is desirable for
those with refractory OHCA, the next pragmatic
question is how to get them to the hospital while
providing systemic circulatory support to their
brain and heart during transport? The answer:
mechanical chest compression devices.
According to the few studies that have looked
at their impact on resuscitation, such devices have
failed to improve overall outcomes when used rou-
tinely for all OHCA patients. 6, 7 Nevertheless, the
current cardiopulmonary guidelines recommend
their consideration in some special circumstances,
such as during transport when CPR is necessary.
The American Heart Association 2015 CPR and
ECC guidelines note, “The use of mechanical pis-
ton devices may be considered in specific settings
where the delivery of high-quality manual com-
pressions may be challenging or dangerous for the
Mechanical chest compression devices
improve the quality of CPR being
delivered and can help ensure the safety
of rescuers in a moving ambulance.
PHOTO COURTESY PH YSIO-CONTROL