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