Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in
Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED“ and in last week’s episode I answered another question from our readers and the question was
My Sister is Critically ill In the ICU and We are Worried Why the ICU Doctor Can’t Provide their Hospital Policy for DNR (Do Not Resuscitate)? Are They Hiding Anything from
Us?
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer questions from one of my clients Mikaela, as part of my 1:1 consulting and advocacy service! Mikaela’s sister is
ventilated in the ICU. Mikaela is asking about her sister’s survival chance after having a cardiac arrest in the ICU.
What is the Survival Chance of My Sister after a Cardiac Arrest in the ICU?
Dr. Marie: Hi, I’m Dr. Marie, and I am your sister’s cardiologist.
Mikaela: Hi Doctor.
Dr. Marie: How can I help you?
Mikaela: Just a few things to ask.. So with the heart, we had a few questions relating to her arrhythmia.
Dr. Marie: Yeah.
Mikaela: … most specifically. And what actually caused her heart attack in the first place, what are you doing to treat it currently, what is the condition overall of the heart at the moment, and just an understanding of long term, if there’s anything in
place for, should she recover from her neurological standpoint, where are we going to go forward with the long-term process for the heart and looking after that?
Dr. Marie: Yeah. Of course. I just need to know what are you up to actually with everything, because we haven’t spoken before and I know you’ve had discussions with ICU and maybe other neurologists. So I just need to find out what information or what sort of idea do you have about your sister.
Mikaela: It was just mostly on the neurological side to be honest-
Dr. Marie: Okay.
Mikaela: … that we spoke with the consultants, nothing regarding the heart. From what we’ve heard the heart is okay. There was, obviously, the arrhythmia that they had the issue with previously, but it’s not been irregular as of late.
Dr. Marie: Okay.
Mikaela: … and it’s been managed from my understanding. Only this morning, they told us last week or something they had treatment for the arrhythmia that was being caused, which was unknown of. We didn’t know anything about that.
So that was something new that we only found out this morning.
Dr. Marie: Okay.
Mikaela: What was the other thing? Sorry, my dad’s here as well.
Joseph: Yeah.
Mikaela: So we’re just thinking between us if there was anything else.
Joseph: Sorry, what’s the doctor’s name?
Mikaela: Oh her name is, Dr. Marie.
Joseph: Dr. Marie, yeah!
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Dr. Marie: Hi.
Joseph: Hi. So you know when she had the heart attack? So she was brought initially to this nearby hospital.
Dr. Marie: Yeah.
Joseph: … and we don’t know what was done there. And then she went onto the bigger hospital and we were told that she went into the … Is it the Cath Lab?
Mikaela: Cath lab
Dr. Marie: Cardiac cath lab
Joseph: Yeah. So I’d like to know what was actually done at those two places, really.
Dr. Marie: Yeah, so I think I’ll probably say things to you from the scratch, from the cardiologist’s perspective. So it seems that her heart stopped basically. So, she had what we call “out of hospital cardiac arrest”, which means the heart stopped. She had been resuscitated,
and she had 10 shocks, you know about this though?
Joseph: Yes.
Dr. Marie: Yeah. What we call downtime which means the time of resuscitation until her heart was resuscitated. This is estimated about 30 minutes, is that right?
Joseph: We are actually not sure if it is 30 minutes, but anyhow..
Dr. Marie: It’s a rough estimate anyway.
Joseph: Okay.
Bayomi (Doctor): By the time the paramedics arrive, CPR and shocks that she had, having 10 shocks already means that it’s been prolonged. She had prolonged resuscitation until her heart restarted again.
Mikaela: Until we got the pulse back, yeah.
Dr. Marie: Yeah, exactly. So, that was, we’re talking about 26, 27 days since that happened, is that right? So it’s like 27 days ago, is that right?
Mikaela: Yeah.
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Dr. Marie: Okay, that’s right. So normally patients who have out of hospital cardiac events, especially when the heart stops, they need to go to the cath lab most of the time.
Mikaela: Yeah.
Dr. Marie: The cath lab is basically where they have an angiogram to have a look at the coronary artery, the artery supplying the heart. So the most common cause for these kinds of cardiac arrest or the heart stopping is clots or thrombosis going in that stops the flow to the heart and that’s why the heart suffers. Less oxygen and then the heart stop. Is that clear?
Mikaela: Yeah, yeah, so it has a flutter of the heart, right? It doesn’t contract.
Dr. Marie: If it’s like a heart attack, what you’ve called a heart attack, but that’s the main issue, whether she had a heart attack or not. So she went to the cath lab and she had what we call an angiogram where they put tubes and they look at the coronary artery supplying the heart to see if there had been any narrowing or any clots. So the angiogram was completely normal. The consultant who did the procedure at that time thought,
it’s not a heart attack or basically it’s not an event, what we call ischemic event, where the heart actually suffers because of ischemia which means less blood supply to the heart, because her coronary arteries were normal. Because they couldn’t find out anything, the next thing in your diagnosis, if it’s not a heart attack causing this, what could it be? That’s what we call arrhythmia, where basically, the heart rate is not normal and the heart stopped because of abnormal rhythm. Is that
clear?
Mikaela: Yeah, yeah.
Dr. Marie: Yeah. What we call pulmonary arrhythmia which means an arrhythmia or abnormal heart beat which is non-origin, and that caused her heart to stop. Basically summarizing cath lab, she had an angiogram. It’s not a heart attack and her coronary arteries were normal. The likelihood is that she’s had an arrhythmia. Sometimes you’ll never know.
Mikaela: Because she wasn’t asleep when the event occurred.
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Dr. Marie: Okay, yeah. That makes sense. She had no chest pain as well before that, is that right?
Joseph: Right. So can I just butt in there?
Dr. Marie: Yeah.
Joseph: Because I keep on saying to the doctors, so I’ve been noticing for a couple of months prior to this that when she’s sleeping, she’s been snoring really loudly.
Dr. Marie: Yeah.
Joseph: And in between the snores, she’s not been breathing. And I’ve been nudging her and saying to her, “Hey, can you just breathe because I can’t hear you breathing.”
Dr. Marie: Yeah.
Joseph: And later on, I found out from my relatives and friends that it’s sleep apnea that she had.
Dr. Marie: Okay.
Joseph: So can sleep apnea cause the heart attack?
Dr. Marie: Again, we will not think of heart attack. This simplifies way of saying things, but this wasn’t a heart attack. From the cardiologist perspective, her coronary arteries were normal.
Mikaela: Sorry, it’s arrhythmia that caused the cardiac arrest.
Dr. Marie: Arrhythmia yeah, so I just don’t want you to get the wrong.
Joseph: Yeah.
Dr. Marie: I know when you speak with other doctors.
Joseph: Okay. So can the arrhythmia be caused by sleep apnea?
Dr. Marie: It’s difficult to say. I mean there are plenty of people that have sleep apnea. Sleep apnea would cause you to have apnea which means you stop breathing for a few seconds and then you continue to breathe again, mainly during sleep. Some people with sleep apnea, they have heart problems. I can’t really tell you what the cause of the arrhythmia is. It’s difficult. I know they have the documentation here that says her
old ECG, her heart tracing, showed something called left bundle which means she hasn’t got a normal ECG to start with.
Mikaela: When was that from?
Dr. Marie: Sorry?
Mikaela: When was that recorded from?
Dr. Marie: I’ll find out for you the exact date, but it’s been documented several times in the notes.
Mikaela: Okay, was that prior to this episode, previous in her lifetime?
Dr. Marie: Yeah, previous to the event, yeah. That was before.
Mikaela: I know she suffered from high blood pressure as well.
Dr. Marie: Thank you. It’s nothing to do with the blood pressure.
Mikaela: Okay.
Dr. Marie: I mean what we call left Bundle of His, so the heart has got different conduction systems by the heart. Some people got one of these conduction systems blocked. So there’s right and left bundle. So it’s all conductive fiber inside the heart and she had left bundle block. What we call left bundle branch block. It’s terminology that normally doesn’t mean anything, but I’m not sure why she’s had it or what circumstances, but
it’s documented that it’s an old left bundle which means there might be some evidence of heart race in the heart beat if it is in the past that she’s had them. I’m not sure what the context is. Something old anyway, prior to the event.
Mikaela: okay.
Dr. Marie: So, in normal scenarios, knowing that her coronary arteries are normal from the angiogram and we think it’s an arrhythmia, and not necessarily a heart attack. The next thing we do normally, is we do a cardiac MRI. So we put them through the MRI machine to look at the heart.
Mikaela: Yeah.
Dr. Marie: … in much more detail to look at what the cause behind the arrhythmia where you can see actually if there’s any abnormalities that’s causing this arrhythmia to happen.
Mikaela: Yeah.
Dr. Marie: Most of those patients end up, regardless what the cause of arrhythmia, with something called an ICD or (Implantable cardioverter defibrillator).
Mikaela: Yeah.
Dr. Marie: To prevent any sort of future event.
Mikaela: Yeah.
Dr. Marie: They normally, once they’re awake and back to cardio ward. Now because bringing her back recent patient lost long where it’s 30 minutes more or less has been long enough to cause some brain damage, what we call hypoxic brain injury. It’s an injury or an insult to the brain because of hypoxia which means low oxygen. We know from long resuscitation anything more than 10 minutes normally can cause the brain to suffer. She had a
CT scan of her head that shows evidence of this hypoxia in the brain. Then probably the neurologist will have explained that better to you than I do.
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Mikaela: Yeah, we’ll speak to the neurologist regarding that. Yeah, that’s fine.
Dr. Marie: Yeah. Then she’s had what we call an electroencephalogram of her brain to have a look at the waves of the brain, and the neurologist will look this EEG that showed there is actually evidence of the brain suffering
from this hypoxic brain injury. That’s why she’s not waking up. So you expect patients, from our experience, normally within a few days, they wake up. They start investigating why this happened. They need an ICD defibrillator. In this case, it’s been now, I think, as far as I can see from the documentation, it’s been 27 days in ICU, in intensive care. They are struggling to wake her up.
Mikaela: There’s been instances of her actually opening her eyes and such.
Dr. Marie: No, correct. No, I agree with you. I agree with you. I’ve seen her opening her eyes, and she has fluctuating consciousness.
Mikaela: Yeah, her GCS has been up and down.
Dr. Marie: Exactly, the highest I’ve seen is 8.
Mikaela: Yeah.
Dr. Marie: Some documentation and it’s been the last few days, as far as I can see from our systems, it’s been 4.
Mikaela: Which is, from our understanding if it is on an 8 scale, I mean give or take, it’s not consistent enough.
Dr. Marie: Yeah.
Mikaela: … that shows to me that there is some form of activity going on to where it may require. We don’t know much about the brain, compared to the next person.
Dr. Marie: Correct.
Mikaela: I think we just we’ve been fighting all this time just to say look, give her a chance. Let’s see what happens. I understand given the situation with COVID at the moment, but that’s not just an excuse to end her life because of COVID.
Dr. Marie: No, of course, no. I agree.
Mikaela: So-
Dr. Marie: Absolutely.
Mikaela: … end of the day, it’s my sister. So I just want to see she gets the best treatment and she goes all out with a fighting battle.
Dr. Marie: Correct, no, I agree with that completely.
Mikaela: The fact that we’re not able to be there as well just obviously it just makes it so much more difficult.
Dr. Marie: No, I understand, yeah.
Mikaela: If she needs that neurologic-
Dr. Marie: Have you-
Mikaela: Sorry.
Dr. Marie: Have you been able to visit her at all in the last few days?
Mikaela: We’ve escalated it internally to ridiculous lengths.
Dr. Marie: Okay.
Mikaela: … but like I said it’s just a lost cause. I mean with COVID taking most priority at the moment.
Dr. Marie: Yeah.
Mikaela: And end of life and palliative care patients, it’s just an absolute struggle.
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Dr. Marie: Yeah.
Mikaela: I mean we’re doing video calls where we can.
Dr. Marie: Yeah.
Mikaela: But that’s just not the same.
Dr. Marie: Okay.
Mikaela: She needs that physical touch, but like I said, the video calls that we have, there has been that eye opening and..
Dr. Marie: Yeah.
Mikaela: … the twitching and the moving and so forth.
Dr. Marie: Yeah.
Mikaela: Yeah, I mean-
Dr. Marie: I agree with you. There has been eye opening up. I’ve seen that myself, there has been an eye opening is, by its own, it doesn’t mean much but it means that it’s not completely flat as you said. She’s not completely all the time with GCS at 3 or 4. I agree with you. It’s really tough on you, as the family, for your dad, and all the family.
Mikaela: Absolutely, yeah, definitely.
Dr. Marie: Obviously, I can’t help with this because it’s completely beyond my power.
Mikaela: No, that’s fine doctor.
Dr. Marie: The ICU team will decide and you’ve probably been through this already, who comes.
Mikaela: Are you strictly impartial from the ICU team then in terms of your decisions? Or how?
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Dr. Marie: Yeah, so she remains under cardiology. What happens is she’s not intensive care, and she’s being seen every day by cardiology and intensive care doctor. So being in ICU doesn’t mean that she’s only in ICU. She needs a higher level of care while she’s in intensive care.
Mikaela: Yeah, yeah.
Dr. Marie: At the same time, there has been inputs from neurology. There has been daily inputs from cardiology, and daily inputs from, twice a day, from intensive care, because they do their rounds twice a day.
Mikaela: Yeah.
Dr. Marie: So there’s extensive documentation and you probably could imagine from intensive care twice a day about her care.
Mikaela: So, as the condition at the moment for her heart, how does that stand at the moment? So you’re saying that there wasn’t any underlying issues. There weren’t no blood clots. There weren’t any artery blockages of any sort.
Dr. Marie: Yeah. There’s none.
Mikaela: Because if you consider, obviously that the heart did stop, it would have got some sort of damage, no?
Dr. Marie: Yeah, correct, yeah. So, the reason that the heart stopped, there is a reason behind this. The most common cause is a heart attack. The second common cause is what we call arrhythmia or abnormal heart beat.
Mikaela: Yeah, yeah.
Dr. Marie: So the cath lab was the right thing to do. She went to cath lab. She had her angiogram to look at her coronary arteries. There was no clots or any blockage there.
Mikaela: Yeah.
Dr. Marie: The consultant ordered the procedures at time. It was completely normal coronary artery.
Mikaela: Yeah.
Dr. Marie: Okay.
Dr. Marie: Yeah, and the next line basically in the angiogram report was this is most likely an arrhythmogenic event, an arrhythmia that’s causing.
Mikaela: Then, I think after that, cooling was done, was it not?
Dr. Marie: Sorry, say again.
Mikaela: Cooling.
Dr. Marie: Yeah. They got to the stage of the cooling and then that’s something that we do.
Mikaela: To preserve the brain.
Dr. Marie: Yeah, so we don’t interfere with this. It’s beyond my..
Mikaela: Okay.
Dr. Marie: It’s not a heart problem.
Mikaela: Yeah, yeah, yeah.
Dr. Marie: It’s a protocol they have for every patient who comes around the hospital. We have cases like this almost every day.
Mikaela: Yeah.
Dr. Marie: The ICU team, they have their own protocol for cooling and stuff like that.
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Mikaela: Okay.
Dr. Marie: So, and I’m pretty sure that you’ve probably spoken, I’ve seen different discussion with ICU and yourself and your loved one. I’m pretty sure they explained things to you from their perspective.
Mikaela: Oh yeah, yeah, absolutely.
Dr. Marie: Yeah.
Mikaela: In terms of the arrhythmia as well that you were talking, I did mention previously about the medication that she was taking for it just to control it. She’s still on that now from my understanding per the conversation earlier.
Dr. Marie: Yeah.
Mikaela: Do you know in terms of what that is and what she’s on at the moment and what sort of dosage she’s on?
Dr. Marie: Yeah, correct. So she’s had a heart scan, an echocardiogram, to look for. One thing when you do the coronary arteries, you look for the artery supplying the heart.
Mikaela: Yeah.
Dr. Marie: The other thing you do, an echocardiogram which is the ultrasound scan of the heart to look at the structure of the heart, to look at the valves. The heart is a muscle.
Mikaela: Yeah.
Dr. Marie: Which is completely different than the angiogram.
Mikaela: Yeah, yeah.
Dr. Marie: Okay, so she had the echo back two to three weeks ago and that was reported as normal basically, a normal size of her right ventricle.
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Dr. Marie: Yeah, yeah, when she came in.
Mikaela: Okay.
Dr. Marie: Normally we do after the event.
Mikaela: Yeah.
Dr. Marie: There’s no valve issues which is good news, and her right ventricle is okay. Left ventricle is borderline normal.
Mikaela: Yeah.
Dr. Marie: In summary, from the heart scan, ultrasound scan, there was nothing really special. That all, again, make us think it could probably be arrhythmia because if the structure of the heart is normal, valve, muscle everything else and coronary artery supplying the heart, they were normal on the scan, on the angiogram.
Mikaela: So does that result in the contraction being normal as well then?
Dr. Marie: Exactly.
Mikaela: Okay.
Dr. Marie: Contraction is normal. So, again, back to square one. It’s most likely arrhythmia because you can’t see these small fibers that stop electricity of the heart.
Joseph: Yes.
Dr. Marie: To control whether there has been abnormality, and that’s why she went into cardiac arrest. As I said, normally these things are better seen on a cardiac MRI and after that, a defibrillator to prevent things happening in the future.
Mikaela: So they do an MRI of the heart?
Dr. Marie: They can’t do an MRI now until she’s awake.
The 1:1 consulting session will continue in next week’s episode.
