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Doctors awareness of spontaneous subarachnoid haemorrhage as a cause of cardiopulmonary arrest

2006; Elsevier BV; Volume: 71; Issue: 1 Linguagem: Inglês

10.1016/j.resuscitation.2006.06.027

1873-1570

Danilo Teixeira Noritomi, Roberto de Cleva, Idal Beer, Alexandre Garcia Dalbem, Alexandre Braga Libório, Norberto Anízio Ferreira Frota, Joaquim Gama‐Rodrigues,

Cardiac Arrest and Resuscitation

The true incidence of subarachnoid hemorrhage (SAH) as a cause of cardiopulmonary arrest (CPA) is difficult to determine, but it can be relatively common in some populations, especially in the young subgroups.1Shapiro S. Management of subarachnoid hemorrhage patients who presented with respiratory arrest resuscitated with bystander CPR.Stroke. 1996; 27: 1780-1782Crossref PubMed Scopus (27) Google Scholar, 2Bonita R. Thomson S. Subarachnoid hemorrhage: epidemiology, diagnosis, management, and outcome.Stroke. 1985; 16: 591-594Crossref PubMed Scopus (218) Google Scholar Here we report the results of a survey conducted among doctors, evaluating their suspicion of this diagnosis when presented with a real case-report.The following case report was sent to doctors, and they were asked which was the probable underlying diagnosis from a list of five options (non-mutually exclusive list). In addition to SAH, the list of possibilities included four usual CPA differential diagnosis: acute myocardial infarction (AMI); pulmonary embolism (PE); exogenous intoxication and hyperkalemia/acidosis.Doctors were also asked to indicate their professional level (medical resident or graduate specialist), medical specialty (medical or surgical), whether they had previously attended an ACLS course and how many CPA cases they had attended during the previous 12 months.All responders gave their informed consent.Case reportA 35-year-old woman presented to the medical Emergency room with cardiopulmonary arrest (CPA) in pulseless electrical activity (PEA). The patient had been working when she suddenly collapsed without any previous symptoms, a few minutes before being taken to the hospital. According to her family, she had no significant medical history and did not take any regular medication or illicit drugs.After 15 min of CPR, the patient achieved a spontaneous circulation with severe hypotension, requiring high doses of vasopressor drugs. The electrocardiogram was normal. Chest X-ray showed diffuse bilateral pulmonary infiltrates with normal cardiac image. Shortly after her arrival at the ICU, she underwent two new episodes of CPA (asystole and pulseless electrical activity) and was successfully resuscitated. During the insertion of a pulmonary artery catheter she presented the third CPA in ventricular fibrillation, which spontaneously reverted after quick removal of the catheter. A transthoracic echocardiogram was obtained, showing diffuse left ventricle hypokinesia (EF = 30%), predominantly in the septal and apical regions; the right ventricle was normal.Four hundred and twenty doctors were surveyed (380 by e-mail and 40 personally), and 160 (38%) questionnaires were returned. The majority of responders were young doctors. Seventy-six (48%) were still working as residents in internal medicine or surgery; 54 (33%) were residents in subspecialties and 26 (16%) were specialists. One hundred and nine (68%) were in medical and 51 (32%) in surgical specialties. On average, they reported to have attended 13.3 ± 1.23 CPA cases within the previous 12 months.Doctors gave a median number of two answers for the diagnosis, comprising a total of 303 positive answers. SAH was considered a possible diagnosis by only 25 (15%) of the responders. It was the least considered possibility for this case (Table 1). Interestingly, among the 10 responders who disregarded only one possibility, eight (80%) of them disregarded the SAH diagnosis.Table 1Diagnosis suspicionDiagnosisNumber of doctors (n = 160)Subarachnoid haemorrhage25 (15%)Electrolyte disturbances26 (16%)Pulmonary embolism49 (30%)Exogenous intoxication66 (41%)Myocardial infarction137 (85%) Open table in a new tab It has long been known that SAH can be responsible for many systemic changes, mainly in the cardiopulmonary system, including CPA.3Macrea L.M. Tramèr M.R. Walder B. Spontaneous subarachnoid hemorrhage and serious cardiopulmonary dysfunction—a systematic review.Resuscitation. 2005; 65: 139-148Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar The pathophysiology of CPA in SAH patients has been attributed to a sudden increase in intracranial pressure with brainstem herniation and respiratory arrest or to an excessive release of catecholamines leading to ventricular arrhythmias.4Tabbaa M.A. R-LMSBD: aneurysmal subarachnoid hemorrhage presenting as cardiorespiratory arrest.Arch Intern Med. 1987; 147: 1661-1662Crossref PubMed Scopus (16) Google Scholar The initially observed cardiac rhythm is usually pulseless electrical activity and asystole, being ventricular fibrillation in less than 10% of patients by the time cardiopulmonary resuscitation is started.5Kurkciyan I. Meron G. Sterz F. Domanovits H. Tobler K. Laggner A.N. et al.Spontaneous subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest.Resuscitation. 2001; 51: 27-32Abstract Full Text Full Text PDF PubMed Scopus (55) Google ScholarIt has been suggested that SAH is a relatively common cause of CPA among some population subgroups, mainly young patients (frequently females) without any previous medical history.5Kurkciyan I. Meron G. Sterz F. Domanovits H. Tobler K. Laggner A.N. et al.Spontaneous subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest.Resuscitation. 2001; 51: 27-32Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 6Schievink W.I. Wijdicks E.F. Parisi J.E. Piepgras D.G. Whisnant JP Sudden death from aneurysmal subarachnoid hemorrhage.Neurology. 1995; 45: 871-874Crossref PubMed Scopus (223) Google Scholar The clinical suspicion should be reinforced by the sudden onset of severe headache prior to cardiac arrest, pulmonary edema in the absence of a previous history of cardiac disease and absent brain stem reflexes on admission.4Tabbaa M.A. R-LMSBD: aneurysmal subarachnoid hemorrhage presenting as cardiorespiratory arrest.Arch Intern Med. 1987; 147: 1661-1662Crossref PubMed Scopus (16) Google Scholar Overall, we believe that the diagnosis should always be considered when the other diagnoses do not fit with the clinical condition. This was the cause in our case report. AMI or PE would be improbable with the absence of clinical prodrome, a normal ECG and the reported echocardiogram.It should be emphasised that the therapy for AMI and PE (the most frequent causes of CPA) is completely different from the appropriate one for SAH. Particularly, anticoagulation or systemic fibrinolysis can have catastrophic outcomes in SAH and may contribute to the reported poor survival for SAH after CPA.In conclusion, young doctors are not very aware of the possibility of the diagnosis of SAH within the context of CPA. We suggest that this diagnosis should be considered in CPA in young healthy patients. The true incidence of subarachnoid hemorrhage (SAH) as a cause of cardiopulmonary arrest (CPA) is difficult to determine, but it can be relatively common in some populations, especially in the young subgroups.1Shapiro S. Management of subarachnoid hemorrhage patients who presented with respiratory arrest resuscitated with bystander CPR.Stroke. 1996; 27: 1780-1782Crossref PubMed Scopus (27) Google Scholar, 2Bonita R. Thomson S. Subarachnoid hemorrhage: epidemiology, diagnosis, management, and outcome.Stroke. 1985; 16: 591-594Crossref PubMed Scopus (218) Google Scholar Here we report the results of a survey conducted among doctors, evaluating their suspicion of this diagnosis when presented with a real case-report. The following case report was sent to doctors, and they were asked which was the probable underlying diagnosis from a list of five options (non-mutually exclusive list). In addition to SAH, the list of possibilities included four usual CPA differential diagnosis: acute myocardial infarction (AMI); pulmonary embolism (PE); exogenous intoxication and hyperkalemia/acidosis. Doctors were also asked to indicate their professional level (medical resident or graduate specialist), medical specialty (medical or surgical), whether they had previously attended an ACLS course and how many CPA cases they had attended during the previous 12 months. All responders gave their informed consent. Case reportA 35-year-old woman presented to the medical Emergency room with cardiopulmonary arrest (CPA) in pulseless electrical activity (PEA). The patient had been working when she suddenly collapsed without any previous symptoms, a few minutes before being taken to the hospital. According to her family, she had no significant medical history and did not take any regular medication or illicit drugs.After 15 min of CPR, the patient achieved a spontaneous circulation with severe hypotension, requiring high doses of vasopressor drugs. The electrocardiogram was normal. Chest X-ray showed diffuse bilateral pulmonary infiltrates with normal cardiac image. Shortly after her arrival at the ICU, she underwent two new episodes of CPA (asystole and pulseless electrical activity) and was successfully resuscitated. During the insertion of a pulmonary artery catheter she presented the third CPA in ventricular fibrillation, which spontaneously reverted after quick removal of the catheter. A transthoracic echocardiogram was obtained, showing diffuse left ventricle hypokinesia (EF = 30%), predominantly in the septal and apical regions; the right ventricle was normal.Four hundred and twenty doctors were surveyed (380 by e-mail and 40 personally), and 160 (38%) questionnaires were returned. The majority of responders were young doctors. Seventy-six (48%) were still working as residents in internal medicine or surgery; 54 (33%) were residents in subspecialties and 26 (16%) were specialists. One hundred and nine (68%) were in medical and 51 (32%) in surgical specialties. On average, they reported to have attended 13.3 ± 1.23 CPA cases within the previous 12 months.Doctors gave a median number of two answers for the diagnosis, comprising a total of 303 positive answers. SAH was considered a possible diagnosis by only 25 (15%) of the responders. It was the least considered possibility for this case (Table 1). Interestingly, among the 10 responders who disregarded only one possibility, eight (80%) of them disregarded the SAH diagnosis.Table 1Diagnosis suspicionDiagnosisNumber of doctors (n = 160)Subarachnoid haemorrhage25 (15%)Electrolyte disturbances26 (16%)Pulmonary embolism49 (30%)Exogenous intoxication66 (41%)Myocardial infarction137 (85%) Open table in a new tab It has long been known that SAH can be responsible for many systemic changes, mainly in the cardiopulmonary system, including CPA.3Macrea L.M. Tramèr M.R. Walder B. Spontaneous subarachnoid hemorrhage and serious cardiopulmonary dysfunction—a systematic review.Resuscitation. 2005; 65: 139-148Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar The pathophysiology of CPA in SAH patients has been attributed to a sudden increase in intracranial pressure with brainstem herniation and respiratory arrest or to an excessive release of catecholamines leading to ventricular arrhythmias.4Tabbaa M.A. R-LMSBD: aneurysmal subarachnoid hemorrhage presenting as cardiorespiratory arrest.Arch Intern Med. 1987; 147: 1661-1662Crossref PubMed Scopus (16) Google Scholar The initially observed cardiac rhythm is usually pulseless electrical activity and asystole, being ventricular fibrillation in less than 10% of patients by the time cardiopulmonary resuscitation is started.5Kurkciyan I. Meron G. Sterz F. Domanovits H. Tobler K. Laggner A.N. et al.Spontaneous subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest.Resuscitation. 2001; 51: 27-32Abstract Full Text Full Text PDF PubMed Scopus (55) Google ScholarIt has been suggested that SAH is a relatively common cause of CPA among some population subgroups, mainly young patients (frequently females) without any previous medical history.5Kurkciyan I. Meron G. Sterz F. Domanovits H. Tobler K. Laggner A.N. et al.Spontaneous subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest.Resuscitation. 2001; 51: 27-32Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 6Schievink W.I. Wijdicks E.F. Parisi J.E. Piepgras D.G. Whisnant JP Sudden death from aneurysmal subarachnoid hemorrhage.Neurology. 1995; 45: 871-874Crossref PubMed Scopus (223) Google Scholar The clinical suspicion should be reinforced by the sudden onset of severe headache prior to cardiac arrest, pulmonary edema in the absence of a previous history of cardiac disease and absent brain stem reflexes on admission.4Tabbaa M.A. R-LMSBD: aneurysmal subarachnoid hemorrhage presenting as cardiorespiratory arrest.Arch Intern Med. 1987; 147: 1661-1662Crossref PubMed Scopus (16) Google Scholar Overall, we believe that the diagnosis should always be considered when the other diagnoses do not fit with the clinical condition. This was the cause in our case report. AMI or PE would be improbable with the absence of clinical prodrome, a normal ECG and the reported echocardiogram.It should be emphasised that the therapy for AMI and PE (the most frequent causes of CPA) is completely different from the appropriate one for SAH. Particularly, anticoagulation or systemic fibrinolysis can have catastrophic outcomes in SAH and may contribute to the reported poor survival for SAH after CPA.In conclusion, young doctors are not very aware of the possibility of the diagnosis of SAH within the context of CPA. We suggest that this diagnosis should be considered in CPA in young healthy patients. A 35-year-old woman presented to the medical Emergency room with cardiopulmonary arrest (CPA) in pulseless electrical activity (PEA). The patient had been working when she suddenly collapsed without any previous symptoms, a few minutes before being taken to the hospital. According to her family, she had no significant medical history and did not take any regular medication or illicit drugs. After 15 min of CPR, the patient achieved a spontaneous circulation with severe hypotension, requiring high doses of vasopressor drugs. The electrocardiogram was normal. Chest X-ray showed diffuse bilateral pulmonary infiltrates with normal cardiac image. Shortly after her arrival at the ICU, she underwent two new episodes of CPA (asystole and pulseless electrical activity) and was successfully resuscitated. During the insertion of a pulmonary artery catheter she presented the third CPA in ventricular fibrillation, which spontaneously reverted after quick removal of the catheter. A transthoracic echocardiogram was obtained, showing diffuse left ventricle hypokinesia (EF = 30%), predominantly in the septal and apical regions; the right ventricle was normal. Four hundred and twenty doctors were surveyed (380 by e-mail and 40 personally), and 160 (38%) questionnaires were returned. The majority of responders were young doctors. Seventy-six (48%) were still working as residents in internal medicine or surgery; 54 (33%) were residents in subspecialties and 26 (16%) were specialists. One hundred and nine (68%) were in medical and 51 (32%) in surgical specialties. On average, they reported to have attended 13.3 ± 1.23 CPA cases within the previous 12 months. Doctors gave a median number of two answers for the diagnosis, comprising a total of 303 positive answers. SAH was considered a possible diagnosis by only 25 (15%) of the responders. It was the least considered possibility for this case (Table 1). Interestingly, among the 10 responders who disregarded only one possibility, eight (80%) of them disregarded the SAH diagnosis. It has long been known that SAH can be responsible for many systemic changes, mainly in the cardiopulmonary system, including CPA.3Macrea L.M. Tramèr M.R. Walder B. Spontaneous subarachnoid hemorrhage and serious cardiopulmonary dysfunction—a systematic review.Resuscitation. 2005; 65: 139-148Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar The pathophysiology of CPA in SAH patients has been attributed to a sudden increase in intracranial pressure with brainstem herniation and respiratory arrest or to an excessive release of catecholamines leading to ventricular arrhythmias.4Tabbaa M.A. R-LMSBD: aneurysmal subarachnoid hemorrhage presenting as cardiorespiratory arrest.Arch Intern Med. 1987; 147: 1661-1662Crossref PubMed Scopus (16) Google Scholar The initially observed cardiac rhythm is usually pulseless electrical activity and asystole, being ventricular fibrillation in less than 10% of patients by the time cardiopulmonary resuscitation is started.5Kurkciyan I. Meron G. Sterz F. Domanovits H. Tobler K. Laggner A.N. et al.Spontaneous subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest.Resuscitation. 2001; 51: 27-32Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar It has been suggested that SAH is a relatively common cause of CPA among some population subgroups, mainly young patients (frequently females) without any previous medical history.5Kurkciyan I. Meron G. Sterz F. Domanovits H. Tobler K. Laggner A.N. et al.Spontaneous subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest.Resuscitation. 2001; 51: 27-32Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 6Schievink W.I. Wijdicks E.F. Parisi J.E. Piepgras D.G. Whisnant JP Sudden death from aneurysmal subarachnoid hemorrhage.Neurology. 1995; 45: 871-874Crossref PubMed Scopus (223) Google Scholar The clinical suspicion should be reinforced by the sudden onset of severe headache prior to cardiac arrest, pulmonary edema in the absence of a previous history of cardiac disease and absent brain stem reflexes on admission.4Tabbaa M.A. R-LMSBD: aneurysmal subarachnoid hemorrhage presenting as cardiorespiratory arrest.Arch Intern Med. 1987; 147: 1661-1662Crossref PubMed Scopus (16) Google Scholar Overall, we believe that the diagnosis should always be considered when the other diagnoses do not fit with the clinical condition. This was the cause in our case report. AMI or PE would be improbable with the absence of clinical prodrome, a normal ECG and the reported echocardiogram. It should be emphasised that the therapy for AMI and PE (the most frequent causes of CPA) is completely different from the appropriate one for SAH. Particularly, anticoagulation or systemic fibrinolysis can have catastrophic outcomes in SAH and may contribute to the reported poor survival for SAH after CPA. In conclusion, young doctors are not very aware of the possibility of the diagnosis of SAH within the context of CPA. We suggest that this diagnosis should be considered in CPA in young healthy patients. We thank Dr. Marcelo Park and Dr. Luciano Azevedo for allowing us to interview the doctors from their Internet group.