Peri-arrest

[Nadine02]

Hello,

Now you probably might be thinking: "What the heck is a Pre-Health person doing in the physician forums?" But please hear me out..
The reason I'm posting this thread is because I have a question.

What is a peri-arrest?

I've searched on the Internet and so far I've found that it's an occurence either before or after a cardiac arrest and that it can be diagnosed with close monitoring of the patient.

However, what I can't find, and what really bugs me is WHAT a peri-arrest exactly is? How can you see that it's happening? Is there an arrythmia (spelling?) that can be seen on the monitor? A difference in breathing in the patient?
What are the symptoms?
And also, how can it be treated?

I realise these are a lot of questions and that you have busy lives, but I would be greatly appreciative if someone takes the time to answer these questions or point me to an article, site or book that can explain these questions to me.

Thank you in advance.
With kind regards,
Nadine

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[pseudoknot]

It's not a term with a formal definition. It just refers to the time when someone is deteriorating. It may only be apparent in retrospect. There is not a specific treatment, as it depends on why the patient is crashing.

 

[PMPMD]

It's not a term with a formal definition. It just refers to the time when someone is deteriorating. It may only be apparent in retrospect. There is not a specific treatment, as it depends on why the patient is crashing.

Exactly. I call it "pre-code" but same idea. I use it to refer to signs of impending cardiovascular collapse. i.e., derangements of vital signs that aren't responding to treatment and pointing towards someone requiring ACLS in the near future. For example, last night a pt had MAPs of 40s despite very high doses of pressors/inotropes and aggressive volume resuscitation. This was "peri-arrest" or "pre-code." Shortly thereafter, the MAPs continued to decline and pt arrested.

 

[PMPMD]

Hello,

Now you probably might be thinking: "What the heck is a Pre-Health person doing in the physician forums?" But please hear me out..
The reason I'm posting this thread is because I have a question.

What is a peri-arrest?

I've searched on the Internet and so far I've found that it's an occurence either before or after a cardiac arrest and that it can be diagnosed with close monitoring of the patient.

However, what I can't find, and what really bugs me is WHAT a peri-arrest exactly is? How can you see that it's happening? Is there an arrythmia (spelling?) that can be seen on the monitor? A difference in breathing in the patient?
What are the symptoms?
And also, how can it be treated?

I realise these are a lot of questions and that you have busy lives, but I would be greatly appreciative if someone takes the time to answer these questions or point me to an article, site or book that can explain these questions to me.

Thank you in advance.
With kind regards,
Nadine

Totally appropriate venue for your question.

Arrhythmia you were close. I usually say "dysrhythmia" because "arrhythmia" implies no rhythm but I'm OCD like that.

 

[Nadine02]

Totally appropriate venue for your question.

Arrhythmia you were close. I usually say "dysrhythmia" because "arrhythmia" implies no rhythm but I'm OCD like that.

Thank you both so much for your answer, PMPMD and pseudoknot. It does explain why I couldn't find anything about it.
Both your answer cleared it up quite a bit for me. It won't bug me anymore

And PMPMD, thanks for correcting my mistake. Never heard of dysrhythmia, I will look that up. I only had heard of arrythmia in my limited medical knowledge.

With kind regards,
Nadine

 

[CVRN]

This reminds me of a question that I've been wanting to ask on here if you don't mind i'll just add it on. I'm a CCU nurse as the name implies. I had a patient the other day that confused me a bit. The exact hx doesn't really change my question but here it is in a very quick nutshell: A 79 yo male is at home and seems fine, later to be found down by his wife. EMS arrives, pt is in asystole--> CPR-> shockable rhythms+ multiple shocks and finally get ROSC in ER. Pt has inferior ST elevation and goes to cath lab: chronic total RCA, severe LAD and Cx disease-> gets bare metal stents to the LAD and Cx but there's not obvious culprit. Pt is tubed and on multiple pressors by this point and still not doing well so an IABP is placed but afterwards, begins to deteriorate faster. Now he comes to me in CCU. Sats in the 80s, MAPs in the 50s despite obscene doses of every pressor. Now frank blood (definitely not frothy pink) is being suctioned from the ETT and sats and BP are dropping and he is obviously about to code (thus why the peri-arrest title reminded me of him). CXR shows very obvious opacity covering both upper lobes, no identifiable aortic arch, but clear lower lobes. The bloody sputum just continues to roll out the ETT. The pt ends up coding and dying. The docs thought this was probably aortic dissection which may explain why he got worse after the IABP. My question: how does aortic dissection cause this kind of pulmonary hemorrhage? When I search this topic I can find one case report of PEEP being used in aortic dissection with pulmonary hemorrhage to temporize until the pt could be placed on CPB but not much else. I would expect the bleeding to be in the mediastinum but I must be missing something regarding the anatomy. Anyone care to explain how or if this would be possible? Thanks

 

[pseudoknot]

My guess would be heart failure secondary to tamponade and aortic valvular insufficiency (which is how a dissection generally kills you) but I really don't know for sure.

 

[dotcb]

it's person who's about to die

 

[MrBeauregard]

This reminds me of a question that I've been wanting to ask on here if you don't mind i'll just add it on. I'm a CCU nurse as the name implies. I had a patient the other day that confused me a bit. The exact hx doesn't really change my question but here it is in a very quick nutshell: A 79 yo male is at home and seems fine, later to be found down by his wife. EMS arrives, pt is in asystole--> CPR-> shockable rhythms+ multiple shocks and finally get ROSC in ER. Pt has inferior ST elevation and goes to cath lab: chronic total RCA, severe LAD and Cx disease-> gets bare metal stents to the LAD and Cx but there's not obvious culprit. Pt is tubed and on multiple pressors by this point and still not doing well so an IABP is placed but afterwards, begins to deteriorate faster. Now he comes to me in CCU. Sats in the 80s, MAPs in the 50s despite obscene doses of every pressor. Now frank blood (definitely not frothy pink) is being suctioned from the ETT and sats and BP are dropping and he is obviously about to code (thus why the peri-arrest title reminded me of him). CXR shows very obvious opacity covering both upper lobes, no identifiable aortic arch, but clear lower lobes. The bloody sputum just continues to roll out the ETT. The pt ends up coding and dying. The docs thought this was probably aortic dissection which may explain why he got worse after the IABP. My question: how does aortic dissection cause this kind of pulmonary hemorrhage? When I search this topic I can find one case report of PEEP being used in aortic dissection with pulmonary hemorrhage to temporize until the pt could be placed on CPB but not much else. I would expect the bleeding to be in the mediastinum but I must be missing something regarding the anatomy. Anyone care to explain how or if this would be possible? Thanks

Cardiac tamponade frequently complicates proximal aortic dissection, as it may have in this case. Tamponade and acute heart failure leads to increased pulmonary venous pressure, transudation of fluid, pulmonary edema and ultimate cardiopulmonary collapse. I suppose that in this patient, or in any other with a similar condition, the rapid and overwhelming increase in pulmonary venous pressure resulted in venule/capillary rupture and thus pulmonary hemorrhage and frank blood seen in the ET tube.

I'm sure there are attendings on the forum can give a better explanation, but that's my thought as a student.

 

[pseudoknot]

Besides the tamponade, I forgot earlier about the STEMI you can get when you dissect past the coronaries. This would also worsen the heart failure, etc.

 

[souljah1]

Maybe he aspirated peri-CPR and then got a boatload of heparin and anti-platelet therapy and would up bleeding in the context of ALI. I do not think about heart failure causing frank hemoptysis. Also possible would be a traumatic intubation or suctioning while anticoagulated. The shock is not likely due to hemoptysis unless profound gas exchange abnormalities lead to acidemia.

 

[proman]

You wouldn't expect frank ETT blood from tamponade or dissected coronaries (MI & effusion is what's seen). Sounds like the aortic dissection is a presumptive (and probably wrong diagnosis). I also wouldn't expect a traumatic intubation to lead to frank blood and overly aggressive suctioning

Alveolar hemorrhage or bronchial artery laceration causes frank blood. So does pulmonary artery injury. Both can be caused by CPR (or a PA catheter like I did a few months ago). If there's massive blood coming out brachiocephalic-trachea fistula should also be on the list. The history seems most consistent with an ACS related code, and iatrogenic injury from CPR, especially in an subsequently anticoagulated patient.

 

[pseudoknot]

Well, this seems like splitting hairs. It is certainly possible to arrest from a dissection, leading to CPR and all the rest. And very acute heart failure can lead to hemoptysis, although it's not the most common thing in the world. We can't really know what happened with this person from the limited information provided.