Wang Lixiang: The three highs are heartbreaking, and the three preventions are the focus

In the face of the current peak of the COVID-19 epidemic, especially for the elderly, women and children with underlying diseases, the Omics variant is still lethal and can directly or indirectly damage the body's heart and lung organs and cause cardiac and respiratory arrest. Clinical data show that active prevention of high-risk factors that cause cardiac arrest is the key to minimizing the mortality rate - preventable death. Strengthening the "three-prevention" strategy of preventing primary factors, secondary factors, and inducing factors of cardiac arrest is an important part of reducing the mortality rate of COVID-19 patients.

1. Preventing high risk factors for primary cardiac arrest

Primary cardiac arrest refers to cardiac arrest caused by localized or diffuse acute or chronic lesions caused by the novel coronavirus infecting cardiovascular tissues and organs. It is more common in: ① Fulminant Myocarditis (FM), which is mainly characterized by rapid onset and extremely rapid progression of the disease. Patients quickly develop hemodynamic abnormalities, such as pump failure and circulatory failure, as well as severe arrhythmias, and may be accompanied by multiple organ failures such as respiratory failure and liver and kidney failure, with an extremely high early mortality rate. ② Thrombosis. After 2019-nCOV infects the human body, it causes immune imbalance and leads to cytokine storm syndrome, which in turn leads to abnormal coagulation function. COVID-19 patients may show thrombosis in multiple organs and parts. In addition to possible venous thromboembolism (VTE) and pulmonary thromboembolism (pulmonary thromboembolism), studies have found that about 50% of new crown patients have elevated D-dimer levels during disease progression, and this proportion is as high as 100% in deaths. ③ Myocardial infarction. Severe COVID-19 patients mainly present with hypoxemia, and critically ill patients often have coagulation disorders, which promote thrombosis and acute myocardial infarction (AMI). Studies have found that respiratory failure is the main cause of death in COVID-19 patients, followed by AMI.

Second, prevent the high risk factors of secondary cardiac arrest

Secondary cardiac arrest refers to the indirect cardiac arrest caused by the novel coronavirus infecting extra-cardiovascular tissues and organs, causing localized or diffuse acute or chronic lesions. It is more common in: ① Hypoxemia. The main site of damage to the new crown is the lung. All patients in the early cases had pneumonia, and about half of the patients had difficulty breathing. 61.1% of critically ill patients admitted to the ICU were diagnosed with acute respiratory distress syndrome (ARDS). ② Shock. Data show that the proportion of critically ill patients admitted to the ICU is as high as 30.6%. Critically ill patients cannot eat, resulting in insufficient capacity. Septic shock and viral myocardial damage caused by infection, coupled with DIC in the middle and late stages of the disease, are all possible causes of shock in patients. ③ Pulmonary embolism. Critically ill patients with new crowns have been bedridden for a long time and have combined coagulation abnormalities. They need to be highly vigilant about the risk of VTE. Clinical observations have found that nearly 20% of COVID-19 patients have abnormal coagulation function, and almost all severe and critical patients have coagulation disorders. Some COVID-19 patients suddenly deteriorate during the course of the disease, with significantly elevated D-dimers and even sudden death, which may be related to PTE after DVT detachment. ④ Stroke. The majority of COVID-19 patients are middle-aged and elderly, especially critically ill patients. They have abnormally elevated D-dimers and are more likely to have embolic vascular events. Many of these patients also have concurrent risk factors for cerebrovascular disease, and some patients may experience acute ischemic stroke.

Three high-risk factors for preventing sudden cardiac arrest

Induced cardiac arrest refers to the cardiac arrest caused by localized or diffuse acute or chronic lesions in the internal and external cardiovascular tissues and organs due to changes in the internal and external environment of the human body after infection with the new coronavirus. It is more common in: ① Water, electrolyte, and acid-base imbalance. Some COVID-19 patients have diarrhea symptoms. The use of antiviral drugs lopinavir/ritonavir can also cause diarrhea. Intestinal microecological disorders that occur during the disease process can also cause diarrhea, as well as abnormal renal function, the use of high-dose glucocorticoids, and patients' loss of appetite and reduced intake can all cause water, electrolyte, and acid-base imbalance. ② Tension pneumothorax. Mechanical ventilation is the main treatment measure for critically ill patients with new coronary pneumonia. Although protective ventilation strategies are emphasized, ARDS itself and ventilator barotrauma can easily lead to pneumothorax, especially for patients with COPD. Therefore, we should be highly vigilant about the possibility of this complication. ③ Drug toxicity. New coronary pneumonia is a new infectious disease caused by new coronary pneumonia infection. There is currently no specific drug for new coronary pneumonia that is widely recognized. The currently recommended antiviral drugs themselves have certain toxic side effects. Combined use can interact with each other and cause serious adverse reactions or events. ④ Psychological stress. In the modern medical era, the biomedical model has shifted to the bio-psycho-social medical model. People’s social attributes and social roles determine the complexity of their thoughts and psychology. Language, text, social environment, family and various accompanying conditions of stimulation, and the emotions brought about by them can affect the human heart and breathing, and even cause cardiac arrest.

Undoubtedly, guided by the life needs of COVID-19 patients, starting from the clinical solution to the critical problem of cardiac arrest, we should strive to explore the development and change patterns of cardiac arrest caused by the new coronavirus, improve the American Heart Association's "from rescue to rescue" survival chain model, and allow cardiopulmonary resuscitation to run through the entire cardiac arrest cycle. The Chinese-style survival cycle concept; especially considering COVID-19 cardiac arrest from the perspective of the entire cycle, moving the threshold for preventing cardiac arrest forward, and preventing the high-risk factors of primary COVID-19 cardiac arrest, preventing the high-risk factors of secondary COVID-19 cardiac arrest, and preventing the high-risk factors of induced COVID-19 cardiac arrest. The "three-prevention" strategy is an important measure to reduce the mortality rate of COVID-19 cardiac arrest.

References:

[1] Chinese Society of Research Hospitals Cardiopulmonary Resuscitation Committee. Expert consensus on cardiopulmonary resuscitation for patients with cardiac arrest associated with COVID-19[J]. Journal of PLA Medicine, 2020, 45(4): 345-359. DOI: 10.11855/j.issn.0577-7402.2020.04.02.

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[4] Wang Guiqiang, Wang Lixiang, Zhang Wenhong. Immunity is a good doctor[M]. Beijing: People's Medical Publishing House, 2020: 1-16.

[5] Li Xin, Liu Yahua, Wang Lixiang, "Chinese Cardiopulmonary Resuscitation Expert Consensus" - Clinical Operation Guidelines for Abdominal Compression Cardiopulmonary Resuscitation. Chinese Journal of Critical Care Medicine, April 2019, Vol. 31, No. 4