PROLONGED CPR WITH RETURN OF CEREBRAL FUNCTION IN A PATIENT WITH ASYSTOLE AFTER ELECTROCONVULSIVE THERAPY
Perry Cole, M.D., Jerome H. Modell, M.D., Mark F. Trankina,
M.D., and Andrea Gabrielli, M.D.
University of Florida, Gainesville, Florida
An 82-year-old man with non-insulin dependent diabetes, an acute
urinary tract infection and complaints of mild shortness of
breath presented to psychiatry for treatment of major
depression. The patient noted no history of angina, myocardial
infarction, or congestive heart failure. An evaluation by a
cardiologist was obtained in anticipation of electroconvulsive
therapy (ECT). Both the electrocardiogram and echocardiographic
examinations were within normal limits. The cardiologist
recommended no further evaluation and to proceed with ECT.
Medications included glyburide for diabetes and ciprofloxacin
for his urinary tract infection.
Labetolol, 30 mg iv, was given to reduce postictal hypertension.
After preoxygenation with 100% O2, general anesthesia was
induced with methohexital, 30 mg iv. Succinylcholine, 60 mg iv,
was administered to reduce muscular response to ECT and
ventilation was controlled with 100 O2 both before and after the
ECT current was administered. Approximately two minutes after
the ECT current was delivered, this patient became pulseless and
asystole was displayed by EKG. The patient was intubated and
ventilation was provided manually with 100% oxygen. Chest
compressions were initiated within 30 seconds of the
disappearance of electrical activity on EKG and the pulse wave
on the oximeter. Epinephrine 1 mg was administered. During CPR,
the patient responded to simple commands with his eyelids and
hands. Femoral arterial and subclavian venous cannulation was
achieved. After transcutaneous pacing failed, transvenous
ventricular pacing provided a stable rhythm at a heart rate of
100 beats/minute 53 minutes after beginning CPR. When venous
pacing produced a stable rhythm, the patient became responsive
and oriented. Arterial blood gases demonstrated excellent
oxygenation and ventilation with normal acid base balance. The
patient was admitted to the MICU and, over the next 24 hours, a
tension pneumothorax and hemopericardium developed and were
treated. He continued to require various forms of ventilatory
and cardiovascular support and his mental depression worsened.
Heroic support was withdrawn two weeks after the initial arrest
and he expired.
Asystole in a witnessed arrest can be refractory to medical
intervention. This case shows that with adequate CPR as
demonstrated clinically and via laboratory values, a prolonged
course of CPR with salvage of cortical activity is possible.
