Dr. Benjamin Chadi, MD
OUR COMMITMENT
You can trust that your health and personal matters will be handled with professionalism, integrity, and the utmost respect. We try to provide availability including appointments on short notice and on time, to get you great results.
Dr. Benjamin Chadi, MD
OUR COMMITMENT
You can trust that your health and personal matters will be handled with professionalism, integrity, and the utmost respect. We try to provide availability including appointments on short notice and on time, to get you great results.
Benjamin Chadi, M.D., is Board Certified in Cardiovascular Diseases and in Internal Medicine. The doctor is a Fellow of the American College of Cardiology. He is currently a doctor affiliated with Beth Israel Hospital in manhattan, NY. The doctor did his Internal Medicine and Cardiology training at the University of Michigan Medical Center. The doctor got his medical degree from Stanford University (California).
Background
Clinical Interests
Non-invasive cardiac imaging, color doppler, management strategies in heart failure, coronary risk reduction and evaluation
Internal Medicine
Cardiovascular Disease
Cardiology
Research Interests
Non-invasive cardiac imaging
echocardiography
color doppler
stress-testing
management strategies in heart failure
coronary risk reduction and evaluation
Published Articles
Volume 84, Issue 5 May 2013 ISSN 0300-9572
Elsevier Journal – Letter to the Editor
Cardiac arrest: Vascular resuscitation by leg elevation
Sir,
Many factors may lead to cardiac arrest or affect the outcome of cardiopulmonary resuscitation (CPR). Resumption of normal hemodynamics depends on rapid restoration of proper oxygenation and cardiac pump function, focusing on a viable rhythm and adequate coronary and cerebral perfusion.1,2 Hypothermia, cold saline infusion, and correction of factors including cardiac preload and afterload may have an important role in the success of resuscitation.
The survival benefit of passive leg elevation (PLE) in addition to CPR in cardiac arrest has been recently reported.3 Here we report a case of out of hospital cardiac arrest that immediately and fully recovered with PLE, without requiring CPR, and discuss possible mechanisms of benefit.
One late afternoon at a large gathering everyone stood up. Soon there were calls for help. A 40-year-old man was found on the floor.
He was not breathing and was unresponsive. Two other doctors and I checked him serially but found no pulse. I checked his carotid for more than 30 s without feeling any pulse. About 3 min had passed since the call for help, and I was about to start CPR when I remembered that some people were fasting that day. I quickly lifted up his legs by putting my arm under his thighs. He was flaccid and his back came up off the ground, and the legs flew up into the air and then onto his abdomen. The legs were placed on top of a chair pulled from nearby. He immediately became pink in color, opened his eyes, and started breathing. Asked if he was fasting, he answered yes. Water was brought and he drank. He lay supine with his legs up for 10 min, then he sat and stood. When paramedics arrived (at about 15 min), he felt fine and refused to go. When evaluated the next day, an ear infection was diagnosed and he was given antibiotics.
The etiology of the cardiac arrest in this patient was likely
multifactorial including dehydration from fasting, orthostatic hypotension from rising quickly, and infection. Although there may have been a vasovagal component, such prolonged pulselessness and apnea and unresponsiveness are atypical for neurocardiogenic cause alone.4 In young patients or athletes these causes may be more likely than, or coexist with, ventricular arrhythmias or primary myocardial infarction. Limb elevation greatly aids resuscitation.
In one relatively simple and quick step it can suddenly
and significantly raise venous return and cardiac output. Using gravitational potential energy, PLE can provide about a 37 mmHg pressure gradient for a 0.5 m leg elevation, and 74 mmHg at the toes if elevated vertically 1 m above the ground (specific gravity of mercury 13.6).
Net limb arterial peripheral vascular resistance also increases significantly by the same gradient. By redirecting cardiac output away from the periphery, perfusion of critical central organs such as the heart, brain, and kidneys improves. The patient’s immediate response in skin color reflects this increased central blood volume.
Likely there was also a rapid reversal of the state of increased sympathetic tone and its own associated risks and consequences (e.g., arrhythmia, reflex hypervagotonia). That he opened his eyes before starting to breathe shows the importance of cerebral perfusion in driving respiration.
Amazing immediate and complete clinical improvement with
leg raising was noted in a case of out-of-hospital cardiac arrest. PLE seems an important initial resuscitation tool for arrest victims of any cause. Theoretically it may be beneficial in the treatment of shock5 and syncope. Likely mechanisms of benefit include that PLE simultaneously increases venous return and limb peripheral vascular resistance thereby greatly improving net critical organ perfusion and sympathetic and reflex parasympathetic tone, and that initially cardiac arrest may be precipitated by or confounded by a combination of causes such as dehydration, hypovolemia, orthostasis, vasovagal, and vasodilatation which may be unsuspected but would respond very well to PLE alone. The earlier in time begun, the more the number of limbs raised, and the higher the elevation, the greater the expected benefit.
Conflict of interest statement None.
References
1. Hazinski MF, Nolan JP, Billi JE, et al. Part 1: executive summary: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2010;122(Suppl. 2):S250–75.
2. Mottram AR, Page RL. Sudden cardiac death advances in resuscitation. Circulation2012;126:991–1002.
3. Axelsson C, Holmberg S, Karlsson T, et al. Passive leg raising during cardiopulmonary resuscitation in out-of hospital cardiac arrest—does it improve circulation and outcome? Resuscitation 2010;81:1615–20.
4. Moya A, Sutton R, Ammirati F, et al. Guideline for the diagnosis and management of syncope. Eur Heart J 2009;30:2631–71.
5. Chadi B. Shock. In: Rakel R, editor. Saunder’s manual of medical practice. 2nd ed. New York: WB Saunders Company; 2000. p. 291–5.
Benjamin H. Chadi∗ Beth Israel Medical Center, New York, NY, United States
∗ Correspondence address: 928 Broadway, Suite 805, New York, NY 10010, United States.
28 November 2012
Volume 84, Issue 5 May 2013 ISSN 0300-9572
Elsevier Journal – Response from the Editor
Reply letter: Passive leg elevation aids cardiopulmonary
resuscitation
Sir,
Thank you for your letter and your concerns. The re-discovery
of the importance of passive leg elevation (PLE) in treatment
of cardiopulmonary arrest especially in a hypovolemic patient
complements other techniques of cardiopulmonary resuscitation
(CPR).
Regarding the palpation of a pulse, according to the Eberle
article,1 for three independent observers to note a lack of pulse
would amount to a 91% likelihood of accuracy for laymen and 99.9% accuracy for 2nd year paramedics. Here, one doctor was an anesthesiologist and the author is a cardiologist. Furthermore, this patient was also apneic (observed by me for more than 1 min) and unresponsive. Therefore the lack of pulse was real.
The clinical decision-making process that was used in this case
follows.
First, the timing of his fall and unresponsiveness coincided with
when everyone stood up. This raised the suggestion of an orthostatic component.
Second, the setting was one where there was no food and no
suspicion of airway obstruction. From the time I first saw him lying
on the floor he was not breathing. Even when I was checking his
pulse I was really observing his chest closely for respiration.
Third, I was thinking that maybe he was vasovagal, but no pulse
was noted, and still no breathing. Therefore the diagnosis of arrest was most certainly true.
Fourth, I was about to start chest compressions (CC) but my
personal experience has been that of a poor outcome in hypovolemic or profoundly vasovagal individuals, even when CC was begun immediately. On the other hand my experience with vasovagal states has been that they respond well to leg elevation. When I realized that he could be fasting and dehydrated as well as orthostatic and vasovagal, I thought that leg elevation would aid CPR.
Leg raising takes less than 5 s of time so there was no delay in
the start of CPR. Correcting the reversible cause and hemodynamic optimization are part of the CPR protocol.2 PLE by the doctor was very rational and orthodox in this situation.
The surprise was the response: immediate and complete clinical
recovery. He spontaneously started to breathe and became alert
and responsive. It was later discovered that he also had an infection, and probable vasodilation, confounding his state. None of this was suspected previously. Based on these observations and since the underlying cause of arrest usually cannot be determined immediately, a rapid trial of PLE can now be recommended for initial use even by laymen in any shock or arrest situation: “Just lift the legs up and put them on a chair.”
The cardiovascular system is a circuit. CC will provide forward
cardiac output as long as there is a blood volume to be pumped. Positive pressure ventilation can be dangerous because it can decrease venous return and cardiac output.3 The outcome of CPR is dismal in hypovolemic patients.4 PLE can increase venous return and cardiac output.5 It may be able to pull a patient out of a downward spiral for enough time until the primary cause of hypovolemia or vasodilation is evaluated and treated.
In treating a patient, one must always think of a differential diagnosis and analyze the risks and benefits of different therapies. CPR is advocated for the initial treatment of any unresponsive patient who is not breathing.2 Such patients not necessarily have ventricular fibrillation but they may be severely hypovolemic, as in this case.
Since PLE is fast and without risk it should be performed initially.
Chest compression has known risks and takes effort so it should
follow if still needed. CPR has fair results for shockable rhythms.
PLE will likely benefit all causes. PLE is not a replacement for CPR,
but an addition or integral part of it and should be taught along
with it (v-CPR) (v for vascular). Statistics of survival with v-CPR vs.
CPR without PLE can be compared in a study or retrospectively if
desired to verify the improved outcome expected.
Conflict of interest statement
No conflicts of interest to declare.
References
1. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova I. Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation 1996;33:107–16.
2. Hazinski MF, Nolan JP, Billi JE, et al. Part 1: executive summary: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2010;122(Suppl. 2):S250–75.
3. Pepe PE, Roppolo LP, Fowler RL. The detrimental effects of ventilation during lowblood- flow states. Curr Opin Crit Care 2005;11:212–8.
4. Lockey D, Crewdson K, Davies G. Cardiac arrest: who are the survivors? Ann Emerg Med 2006;48:240–4.
5. Geerts BF, van den Bergh L, Stijnen T, Aarts LP, Jansen JR. Comprehensive review: is it better to use the Trendelenburg position or passive leg raising for the initial treatment of hypovolemia? J Clin Anesth 2012;24:668–74, http://dx.doi.org/10.1016/j.jclinane.2012.06.003.
Benjamin H. Chadi∗ Beth Israel Medical Center, New York, USA
5 February 2013