March 2020

Clinical Question:

Is there a role for whole body CT (Pan Scan) in post ROSC patients following non-traumatic cardiac arrest?

Title of Paper:

Early whole-body CT for treatment guidance in patients with return of spontaneous circulation after cardiac arrest

Journal and Year:

Emergency Radiology. 2020.

Lead Author:

S. Viniol

Background:

– Most common causes of cardiac arrest are IHD followed by cardiomyopathies, inherited arrhythmia syndromes and valvular disease
– Plumbing > electrics and foundations
– We routinely perform CTB for these patients to exclude intracranial causes
– The [NEJM paper](https://www.nejm.org/doi/full/10.1056/NEJMoa1816897) in April 2019 showed no benefit in immediate over delayed angio for post ROSC patients without signs of STEMI
– The authors suggest pan-scan may identify a non-cardiac cause of cardiac arrest, or life-threatening complications of the CPR itself (such as tension pneumothorax, bleeding, haemopericardium)
– Current guidelines recommend focal CT in patients with high pre-test probability of pathology

Study Design:

– Retrospective, single centre study

Patients Studied:

– Non-traumatic In / Out OHCA with ROSC after CPR
– Included all patients who had WBCT protocol within 6 hours of arrest

What did they do?

– WBCT
– Non-enhanced CTB
CTA head to groin
CT venous phase abdomen

Summary of Results:

– 108 patients scanned over 12 months
– 8 Exclusions: 5 = delay in WBCT, 2 = trauma, 1 = incomplete scan
– 100 patients included:
– 27 female, 73 male
Most men ≥ 20 minutes CPR for ROSC (42.5%)
Most women ≤10 minutes for ROSC (44.4%)
– 88% OOHCA
– 80% of CA due to cardiac or lung disease
– WBCT took 4±2 minutes **once on table**

Pathologies

– Cranial pathologies – 15%
– 12% – early brain oedema
– All ≥ 20 minutes CPR
– All died during stay
– 3% – acute ischaemic stroke
– Heart/coronaries
– 38% – Myocardial hypoperfusion
– 66% (n=25) of those seen during cath
– 58% of study population got cathed
– Most patients had CAD
– 72% LAD
– 49% LCx
– 48% RCA
– Vessels
– 10% Peripheral PE
50% (5) also central
– 19% – High grade stenosis of supra-aortic branches
– 9% – Aneurysms
– 60% of those infrarenal AA
– 20% Aortic Arch
– 10% Thoracoabdominal Aorta
– 1% Bilateral internal iliacs
– 3% chronic dissection (of infrarenal abdominal aorta) with no complications
– Lungs
– 70% – lung opacities
– 60 consolidations
– 9 ground glass infiltrates
– 1 interstitial infiltrate
– 26% – pneumothorax
– 7.79% (n=2) tension ptx
– All associated with rib fractures
– 16% pulmonary contusion
– 20% malpositioned ETT
– Abdomen
– 10% – abdominal pathology
– 3 paralytic small bowel ileus
– 2 sub capsular splenic haematomas
– 1 duodenal perforation with free air and fluid
– 1 renal infarct
– 1 pyelonephritis
– MSK
– 93% – CPR related injury
– 88% – rib fractures w/ 78 of these bilateral, most serially
– 37% had >9 rib fractures
– 15% sternal fractures
– Mostly in men (80%)
– 18% – mediastinal haematomas
– 22% with sternal fracture
– 7% – mediastinal emphysema
– 14% – Thoracic wall haematomas – always with one or more rib fractures

Authors Conclusion:

Early WBCT is feasible in patients with CA and ROSC after CPR. Acute pathologies are not limited to the thorax but can also be found in the head and abdomen, which can be easily detected by QBCT. Extracardiac causes of CA are common and can be illustrated by WBCT. Therefore, a WBCT should be recommended in the post cardiac arrest care of patients with non-traumatic CA and ROSC after CPR.

Clinical Bottom Line:

If nothing else this paper shows how vicious CPR is. We’ve all felt the ribs give way but 37% had >9 rib fractures.

I’m not convinced the abdominal patholgies really add much, and it’s not clear how many of those would have been spotted anyway (with focused scanning based on clinical signs)

That being said – is there really much to lose from just adding a complete pan scan to the head and CTPA we’re inevitably moving towards doing anyway?

This month Chris and Becky are turning their eye to the latest on COVID-19.
The content of this podcast was recorded on 24th Feb 2020 which invariably will mean that things have progressed since then with a publishing date of March 2020. Please ensure you keep up to date and check here for the latest advice from the government.

Coronaviruses are large enveloped, positive strand RNA RNA viruses and they are not rare – they only hit the headlines it seems when a particularly virulent one with a high mortality hits the population.

These viruses are largely spread by respiratory droplets but have been detected in urine, faeces and other bodily fluids. It is worth noting that due to their structure (with a lipid envelope) they are pretty good at being killed by common disinfectants.

The UK govt has classified COVID-19 as a a high consequence infectious disease.

These are defined as diseases that are:

Acute infectious diseases
Have a high case fatality rate
No vaccine or treatment
They can be hard to detect and can be spread in the community or healthcare setting.

They need an enhanced system response to ensure safe management and reduce spread

Current recommendation (as of time of recording!!) is to take precautions in patients who within the 14 days before the onset of illness:
travel to China, Hong Kong, Japan, Macau, Malaysia, Republic of Korea, Singapore, Taiwan, or Thailand. This includes transit, for any length of time, in these countries (transit is important – we have swabbed people who were transiting through a couple of these places –even for a couple of hours)

OR

contact with confirmed cases of COVID-19

Clinical criteria:

severe acute respiratory infection requiring admission to hospital with clinical or radiological evidence of pneumonia or acute respiratory distress syndrome

OR

acute respiratory infection of any degree of severity, including at least one of shortness of breath (difficult breathing in children) or cough (with or without fever)

OR

fever with no other symptoms
Clinicians should be alert to the possibility of atypical presentations in patients who are immunocompromised
Current HCIDs

Contact Spread

• Argentine haemorrhagic fever
• Bolivian haemorrhagic fever
• Crimean Congo fever
• Ebola
• Lassa fever
• Lujo virus disease
• Marburg Virus disease
• Severe fever with thomboyctopenia syndrome (SFTS)

Airborne spread

• Andes virus infection
• Avian influenza A H7N9, H5N1, H5N6 and H7N7
• Middle eastern respiratory virus (MERS)
• Monkeypox
• Nipah virus
• SARS
• COVID-19
• Yersinia pestis