Statistical update from Circulation (updated September 2014). *emphasize the survival rate does not take into account neurological outcome, merely that the patient lived (no CPC score or quality of life determination).
Interventions for Cardiac Arrest
Name the two most important interventions that improve cardiac arrest patient survivability?
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Prompt questions here: Is it epinephrine? Chest compressions? Anti-dysrhythmics? Advanced airway placement? Defibrillation? *** Answers: Research supports the two treatments that maximize survival: High quality chest compressions and early defibrillation!
CARES 2013 Summary
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CARES – Cardiac Arrest Registry to Enhance Survival 2013 National Report – - 31, 127 cardiac arrests in the registry - 27.5 % pronounced in the field - 16.8% pronounced in the ED - 55.7% had resuscitation continued in the ED Overall survival: 27.5% to hospital admission 10.8% to hospital discharge 8.3% with a good or moderate neurological outcome
Cardiac Arrest Data From 3rd quarter 2014 in Riverside County
there were 525 patients with the primary impression of cardiac arrest.
An additional 21 patients had the
secondary impression of cardiac arrest.
Source: Healthems.com; MEDS Data Extractor
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If this 90 day period were to represent an average – there would be a little over 6 cardiac arrests per day in our service areas.
Phases of Cardiac Arrest Electrical phase (first 4 minutes of arrest)
Heart rhythm/conduction is likely to be chaotic and disorganized
Myocardium is relying on its internal myoglobin stores
Most effective treatment – early defibrillation Survival rates increase the earlier defibrillation is
completed.
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- pH is likely to be normal, most often acidosis is not yet a factor - Typical presenting rhythm in this case is VF/VT
Phases of Cardiac Arrest Circulatory Phase (approx. minute 4
through minute 10 of arrest) Decreased/exhausted myoglobin stores =
myocardial distress Treatment must focus on improving blood
flow to the heart (and arguably the brain for a good neurological outcome) Definitive treatment: consistent High quality
CPR
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Shift to anaerobic metabolism which means pH will begin to be impacted and acids will be building in bloodstream Myocardial ischemia possible/probable with time – will lead to myocardial infarction if not immediately and appropriately treated.
Phases of Cardiac Arrest Metabolic phase (approximately 10 minutes
into cardiac arrest) Severe hypoxemia, acidosis, inadequate
energy and likely myocardial damage Sodium/potassium pump fails
Myocardial and GI tract compromise
Current treatment initiatives focus on the first two phases of cardiac arrest; survival unlikely in this phase
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Myocardial ischemia and infarction are highly likely in this phase Sodium/potassium pump failure leads to uncontrolled sodium flow into cell from extracellular environment; water will follow leading to cellular swelling/rupture This same cellular swelling due to extracellular sodium shift causes the GI tract lining to degrade and lose its integrity. This eliminates the barrier between bacteria and system. these bacteria release chemicals that further depress myocardial function ROSC in this state can spread this acid build up, bacteria, free radicals and chemicals throughout the body causing reperfusion injury.
Cardiac Arrest Management Current Policies that oversee
management of the cardiac arrest patient: REMSA 4203 REMSA 4406 and 4407 (adult and neonatal) Performance Standards
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Performance Standards that may be utilized: Defibrillation Intraosseus infusion Calculation Chart Medication Administration
Cardiac Arrest Management Policy and Protocol Changes for the
following: REMSA 4203 REMSA 4406 and 4407
New directive to address REMSA strategy for team resuscitation concept Pit Crew CPR
Cardiac Arrest Management Overall EMS System Objective:
Increased patient survivability from out of hospital cardiac arrest with a cerebral performance score of 1 or 2. Modified Rankin Score has also been used to
measure neurological outcome
CPC Scale Cerebral Performance Categories (The lower the CPC score the better the neuro outcome)
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Discuss the cerebral performance categories scale (handout to students); define CPC of 1 or 2 CPC Score of 1 – a patient with minimal residual impact, able to resume their daily life with similar to same independence as pre-arrest. CPC Score of 2 associates a level of independence with the patient, though they will need a sheltered environment. CPC Score of 3 will leave the patient dependent on others for daily life, possibly with significant dementia as well. CPC Score of 4 is often correlated with a persistent vegetative or coma state, a patient remaining on life support
CPC Score and Modified Rankin Scale
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Highlight comparison to Modified Rankin Scale – hospitals report CPC score in CARES Registry Research is mixed as to whether these scores correlate – CPC has been researched and studies since early 1980’s’ Modified Rankin Scale takes into account structural function and independence/daily life. Both can be used in the hospital.
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Fabrice Muamba (age 25) a Bolton midfielder collapsed in cardiac arrest mid-game in March 2012. He was “effectively dead for 78 minutes” – found in VF cardiac arrest by medical team and was defibrillated 15 times. Discharged home with a CPC score of 1
How do we reach the objective? Additional focus on community based
education AED initiatives/legislation for schools/business
licenses Community CPR initiatives
Increased EMS focus on minimally interrupted CPR
Standards and training for an EMS System wide, team based resuscitation with defined roles/tasks
Consistent data collection and cQI
How do we obtain high quality CPR? At least 100 compressions/minute Complete chest recoil after each
compression Avoid hyperventilation with ventilations Interruptions in chest compressions are
less than 10 seconds Avoid rescuer fatigue–rotate every 2 min Team based approach (Pit Crew Model)
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Discuss what happens when the chest does not recoil with each compression: Inadequate cardiac refill which pushes out less blood flow with each compression = less blood flow to vital organs Discuss what happens with hyperventilation: Increase intrathoracic pressure which decreases preload and decreases cardiac fill/refill decreasing the amount of blood ejected from the heart with each compression. Interventions like vascular access and intubation (if needed) are done through compressions as much as possible, and interventions are prepared for ahead of time - Discuss how to avoid rescuer fatigue: rotate rescuers every 2 minutes, position rescuers to aid in their body mechanics (stools/rigid surfaces for compressions, etc).
How to measure high quality CPR? Diagnostic tools:
Capnography a distinct measure of pulmonary blood flow
Palpate distal pulses with chest compressions
Cardiac monitoring technology for depth/cadence and rate These tools can provide both visual and
auditory indicators
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Auditory indicators have shown to improve CPR pace and rhythm – counting/ metronomes/ cardiac monitor technology * Capnography waveforms and numbers should be continuously evaluated throughout CPR, and compressions monitored/adjusted as needed for rate/depth and consistency.
Perfusion Changes with interrupted CPR
Perfusion changes with uninterrupted CPR
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The more consistent the chest compressions are the more consistent the blood flow will be to the heart and brain – more consistent blood flow = greater chance of survival WITH an improved neurological outcome
2015 Policies for Resuscitation REMSA #4203
2015 Policies for Resuscitation Cardiac Arrest (REMSA 4406) / Neonatal
Resuscitation (REMSA 4407)
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Protocol Change states: “organize the resuscitation team and perform CPR according to current standards” Organize the resuscitation team = pit crew model Current standards for CPR = current AHA guidelines for CPR and ACLS/PALS
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Change in protocol: “Organize the resuscitation team and perform CPR according to current standards” Protocol will continue to emphasize excellent CPR and give strategies to ensure that excellence in CPR. H’s and T’s, standard medications still included.
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Change in protocol: “Organize the resuscitation team and perform CPR according to current standards” Protocol will continue to emphasize excellent CPR and give strategies to ensure that excellence in CPR. H’s and T’s, standard medications still included.
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Change in protocol: “As clinically indicated provide PPV, organize the resuscitation team and provide CPR to current standards” Protocol will continue to emphasize excellent CPR and give strategies to ensure that excellence in CPR. H’s and T’s, standard medications still included.
New Team Based Resuscitation Approach To minimize interruptions in chest
compressions responders will have assigned roles Choreographed approach with ALS or BLS
function built in Designated personnel for ALS and BLS
interventions Roles are predictable, have consistent skill
set for every resuscitation
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Roles/tasks do not change with first on scene responder or provider agency - Defined roles with set tasks – similar to NIMS/ICS or structure fire management, set approach with each incident once identified to maximize success for operations and patient outcomes.
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Handout diagram to students so they can reference as discussion continues – CCR (Cardio-cerebral resuscitation)
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Focus on Position 1 and Position 2 roles
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Discuss positions 3 and 4
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Discuss role of Position 5
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Discuss position 6 (when there are 6 providers, there will be a Pit Crew leader and an assistant to that person) if the 6th provider is a paramedic, then the additional paramedic can assist with contacting medical control, helping with assessment information and/or help out with additional setup/relief of other positions.
Pit Crew Applications Majority of responses have at least two
responders In cardiac arrest the first two responder
take Pit Crew positions 1 and 2 Compression leader (P1) Airway Leader (P2)
Additional responders will fill in positions as their scope of practice and time of arrival dictates
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Everything in the triangle is paramount – those positions are filled first every time!
Pit Crew Applications Focus is on minimally interrupted chest
compressions team members and team leaders should
be rotating in and out of roles as needed to maintain excellent, high quality CPR
Patient care continues on scene until determination is made by the team or medical control to discontinue efforts or transport
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Emphasize TEAM approach here – all members/leaders should be offering feedback/concerns (i.e. suspicious circumstances, scene safety issues, etc) - Patients should be worked on scene until ROSC is obtained – if ROSC is not obtained, and the parameters of REMSA policy #4203 apply then the appropriate steps with law enforcement and coroner notification and PCR completion should be done.
Pit Crew Applications Team members and leader anticipate
ROSC, monitor capnography changes continuously Capnography can spike dramatically or
increase consistently to preview ROSC Real Time indicator!!
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ROSC is temperamental in the first 5-10 minutes after it is achieved. Care for the heart
Pit Crew Application Examples 911 call for Unknown Medical Aid
Private residence BLS ambulance response
Patient pulseless and apneic
EMT #1 – Position 1 EMT #2 – calls for add’l
resources and takes Position 2
4 added responders arrive filter into Position 3, then 4 (if ALS),
then 5 and 6 last
CPR in Progress 4 team members
respond 2 ALS, 2 BLS; family doing CPR
EMT #1 – position 1 EMT #2 – position 2 PM #1 – position 3 PM #2 – position 4 2 additional team
members arrive (1 ALS, 1 BLS) EMT #3 rotates in to P3 PM #3 takes P5 and
transport is prepared
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Posters/other visual aids for pit crew model
Current Situation with Cardiac Arrest Management cQI Limited data collection for ultimate
patient outcomes Variable collection of data surrounding
cardiac arrest REMSA and providers audit the Utstein
criteria from data systems currently in use Transport providers data is integrated into
the CARES Registry and receiving centers enter the patient outcomes
cQI/Data Strategies for 2015 Increased access to the CARES registry
REMSA has access to portions Increased data sharing and reporting
Move to single data system cQI indicators for cardiac arrest to measured in
2015: How many cardiac arrests? How many transports? How many had ROSC? How many were discharged and what was their
CPC score?
Objectives Identify and discuss morbidity and
mortality of cardiac arrest Describe the phases of cardiac arrest Explain the cerebral performance
methods in each phase of arrest Discuss policy and protocol changes
affecting cardiac arrest
References Circulation January 2013 “AHA Statistical Update” CARES Registry: https://mycares.net/sitepages/reports.jsp Kellum et al. The American Journal of Medicine “Cardiocerebral
Resuscitation Improves Survival of Patients with Out-of-Hospital Cardiac Arrest” (2006) 119 pgs. 335-340. Elsevier
Mosier et al. “Cardiocerebral Resuscitation Is Associated With Improved Survival and Neurologic Outcome from Out-of-hospital Cardiac Arrest in Elders” Society for Academic Emergency Medicine (2010)
Bobrow & Aufderheide Emergency Medicine Reports Volume 12 Number 11 “Maximizing Survival from Out-of-Hospital Cardiac Arrest: Putting Effective Emergency Cardiac Care Into Practice” (May 2008)
Rittenberger et al. Resuscitation “Association between Cerebral Performance Category, Modified Rankin Scale, and Discharge Disposition after Cardiac Arrest”. (2011 August); 82(8): 1036–1040
