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Cardiac Arrest

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Title: Cardiac Arrest


1
Cardiac Arrest
September 2014 CME
2
Objectives
  • Identify the causes of cardiac arrest
  • Identify statistics related to sudden cardiac
    death
  • Differentiate between sudden cardiac death and
    cardiac arrest
  • Identify prehospital management for lethal
    cardiac arrythmias
  • Identify reversible conditions that may
    contribute to cardiac arrest

3
Objectives
  • Identify pathophysiological presentations of
    cardiac dysrhythmias
  • Review SMOs related to cardiac arrest
  • Review of the components of quality CPR
  • Discuss best practices in cardiac arrest
    management
  • Review prehospital use of induced hypothermia for
    ROSC patients

4
Cardiac Arrest
  • 424,000 people experience out-of-hospital cardiac
    arrest (OHCA) every year
  • 15-20 annual mortality related to cardiac arrest
  • 8-10 of all EMS-treated OHCA recover to resume
    normal lives

5
Sudden Cardiac Death vs. Cardiac Arrest
  • Sudden Cardiac Death Unexpected death from a
    cardiovascular cause in a person with or without
    preexisting heart disease (Circulation DOI
    10.1161/CIRCULATIONAHA.111.023838)

6
  • Cardiac Arrest Loss of cardiac function
    resultant of
  • Acute myocardial infarction, OR
  • Ischemia without infarction, OR
  • Structural alterations such as scar formation or
    ventricular dilation secondary to prior
    infarction or chronic ischemia

7
Whats the difference?
  • Its a matter of semantics
  • The SCD studies focus on mortality rates
  • Cardiac arrest statistics focus on outcomes i.e.
    survival rates
  • Prehospital providers need to look at the
    outcomes to determine our level of quality

8
Risk Factors of Cardiac Arrest
  • Coronary Heart Disease
  • Fibrous scar tissue formation on cardiac muscle
  • Direct effect on pump mechanism and electrical
    conduction pathways
  • Ischemia chronic or acute
  • Coronary artery blockages
  • Left ventricular dilation, myocardial stretch
  • Muscle walls are fatigued
  • Precursor to congestive heart failure

9
Risk Factors of Cardiac Arrest
  • Congestive Heart Failure
  • Altered calcium regulation
  • Decreased calcium less contractile force
  • Fibrous/Scar formation
  • Contractile force is inhibited by lack of
    elasticity of the cardiac muscle
  • Left ventricular dilation, myocardial stretch
  • Muscle walls are fatigued
  • Hypertrophy (left ventricular)
  • Increase in muscle mass, but the muscle does not
    increase its pumping ability
  • In pathological hypertrophy, the heart can
    increase its mass by up to 150.

10
Risk Factors of Cardiac Arrest
  • Shared Risk Factors
  • Age
  • From age 50 to 75 there is an 8x greater risk
  • Hypertension
  • Diabetes
  • Smoking
  • Obesity
  • Renal disease
  • Inflammation
  • GENETICS!!!!

11
Genetics and cardiac arrest
  • Cholesterol
  • Represents the strongest link genetically
  • Elevated LDL (the bad one)
  • Decreased HDL (the good one)
  • Increases the risk of cardiac arrest at younger
    ages!
  • Typically the sub-50 age group as early as the
    mid-20s!
  • Taken in through food (controllable)
  • Produced by the body (uncontrollable)
  • Up to 1000mg/day

12
Athletes and cardiac arrest
  • Physical activity can reduce the risk of cardiac
    arrestgenerally
  • Much media attention given to student athletes
    with pre-existing cardiac conditions
  • Helps raise awareness for early cardiac
    screenings

13
Pathology of Cardiac Arrest
  • Heart generally progresses through several
    cardiac rhythm disburbances

14
Cardiac ArrestLets Fix It!!
  • BLS before ALS!
  • Must assess before you treat
  • Whats the most important intervention to be
    performed in a cardiac arrest??????

15
  • CPR

16
CPR Chain of Survival
  1. Immediate recognition of cardiac arrest and
    activation of EMS
  2. Early CPR with emphasis on chest compression
  3. Rapid defibrillation
  4. Effective advanced life support
  5. Integrated post-cardiac arrest care

17
From the Cardiac Bible
  • Circulation Cardiovascular Quality and Outcomes
    (AHA Publication http//circoutcomes.ahajournals.
    org)
  • Summary Among patients with OHCA, survival
    from shockable arrhythmias (VT/fibrillation) has
    improved in recent years after the implementation
    of guidelines increasing the time devoted to
    chest compression during resuscitation. These
    changes include reducing the number of
    back-to-back rhythm analyses/shocks, eliminating
    rhythm and pulse checks after each shock, and
    increasing the ratio of chest compressions to
    ventilations.

18
Breaking it down
  • implementation of guidelines increasing the
    time devoted to chest compression during
    resuscitation.
  • Minimum 100 compressions per minute
  • Maximum 120 compressions per minute
  • Compression IS important, BUT, you must allow
    FULL RECOIL of the chest to allow the heart to
    refill with blood to circulate on the next
    compression

19
Good CPR
20
Breaking it down
  • implementation of guidelines increasing the
    time devoted to chest compression during
    resuscitation.
  • It takes 16 seconds worth of compressions to
    obtain enough vascular pressure for oxygen
    exchange to occur within the cells of vital
    organs
  • It only takes 3 seconds of no compressions to
    reduce that pressure back to 0!!!
  • Maintain your compressions while you ventilate

21
Not So Good CPR
22
Breaking it down
  • These changes include reducing the number of
    back-to-back rhythm analyses/shocks, eliminating
    rhythm and pulse checks after each shock, and
    increasing the ratio of chest compressions to
    ventilations.
  • Get on the chest and STAY ON THE CHEST even after
    defibrillation!
  • If rhythm converts to a viable one after
    defibrillation STAY ON THE CHEST for one minute
    before assessing a pulse
  • When using an AED only stop compressions when the
    machine tells you to
  • Ventilate once every 5-6 seconds, or once every
    20 compressionsNO MORE

23
Reality Check
  • Prehospital personnel are horrible at CPR
  • Why?
  • We worry about the next intervention
  • We do too much ALS before BLS
  • We spend to much time on ET/IV/IO insertions
  • We think we already know this!!!!

24
Low FrequencyHigh Intensity
  • Calendar year 2013
  • SCEMSS providers care for more than 30,000
    patients
  • 28 different agencies across almost 300 sq miles
  • Less than 500 documented, non-traumatic, cardiac
    arrest patients
  • Thats 1.6 of total call volume

25
  • How many of you could be experts at anything you
    only practice 1.6 of the time?

26
Improving CPR outcomes
  • Best Practices
  • The goal is to save lives
  • If the rhythm is shockable Stay and Play
  • If the rhythm is not-shockable Load and Go
  • Only move the patient if
  • Provider safety is at risk
  • The rhythm is not shockable

27
Improving CPR outcomes
  • Does this mean I may have to stay on scene for 20
    minutes doing care? Shouldnt I be getting this
    patient to the hospital?
  • So long as the rhythm is shockable, patient
    survival statistics prove 11 survivability by
    continuing aggressive CPR and defibrillation.
    This drops to less than 3 in non-shockable
    dysrhythmias
  • What you do in the field is nearly identical to
    what a physician will do in the hospital. So
    whats the hurry when positive patient outcome is
    the priority?

28
Improving CPR outcomes
  • Do unto others
  • Knowing what you know now
  • This V-Fib patient is your spouse, child, parent,
    sibling, best friend, etc

29
Are you still going to halt definitive
resuscitation to
  • Move them onto a board
  • Onto the cot
  • Pile the equipment up
  • Move through the hallway
  • Get down/up the stairs
  • Out to the ambulance
  • Into the ambulance
  • Restage your equipment
  • And finally resume quality CPR!!

30
So we have a survivor!
  • Induced Therapeutic Hypothermia (ROSC)
  • Region VII ALS SMOs, Code 11
  • Key points
  • Cardiac arrest not related to trauma, hemorrhage,
    or infection
  • Age gt16
  • Not currently pregnant
  • Patient is intubated and unresponsive
  • Initial temperature gt 34 degrees C (93.2 F)

31
Why ROSC?
  • American Heart Association
  • 2005 Updates
  • Therapeutic hypothermia demonstrates brain
    cooling in newborn asphyxia improves nuerological
    outcomes
  • 2010 Updates
  • Therapeutic hypothermia in adult cardiac arrest
    patients shows improved neurological outcome for
    those that are discharged from the hospital

32
Why ROSC?
  • 2010 Updates, contd

33
ROSC
  • 2010 AHA Outcomes
  • Cardiac arrest victims that receive therapeutic
    hypothermia show a 13 survival rate to discharge
  • ONLY 4 ARE NEUROLOGICALLY INTACT!

34
ROSC
  • SMO Algorithm
  • Return of spontaneous circulation
  • Initial temp gt 34 degrees Celcius
  • ET in place (NOT A KING AIRWAY DEVICE)
  • Confirm not responsive to verbal stimuli
  • Expose patient. Perform 12-lead EKG
  • Apply ice packs to groin and axilla
  • Cold saline bolus 30ml/kg, max 2L
  • Versed 0.15 mg/kg slow IV push, max 10 mg (for
    sedation/shivering) with repeat B/P

35
ROSC
36
ROSC
  • What current science says
  • A new study found that contrary to conventional
    belief, pre-hospital hypothermia had no effect on
    the rate of survival to hospital discharge or on
    neurological outcome among surviving cardiac
    arrest patients, either among patients with
    ventricular fibrillation (VF) or non-VF arrest.
  • Nuerology Today Volume 14(2), 16 January 2014,
    pp 1,9-9

37
ROSC
  • From the same study
  • However, the results from Dr. Kims trial were
    not simply that field cooling offered no
    advantage to patients. Instead, those patients
    randomized to prehospital cooling experienced
    re-arrest on the way to the hospital more often
    26 percent versus 21 percent as well as
    increased pulmonary edema and use of diuretics.

38
ROSC
  • The Decision is Yours
  • Choose wisely

39
Why Discuss Cardiac SMOs?
  • Well, because we are not always following them.
  • In November and December 2013, only 32 of
    eligible chest pain patients in SCEMSS received
    nitroglycerin.
  • Eligible means appropriate BP, cardiac
    signs/symptoms, etc.
  • In June 2014, only 25 of patients who got Nitro
    had their BP or pain level properly reassessed
    after administration.
  • 2014 to date, SCEMSS medics rarely utilized
    pacing for symptomatic bradycardia patients.
  • During most V-Fib calls in the 3rd and 4th
    Quarter 2013, patients never received lidocaine.

40
SMOs The Template of Care
  • Template?
  • Templates are used as the basis of creation.
    We act within our Medical Orders to the degree
    that it corresponds to how the patient presents
  • NOT Guidelines
  • Guidelines are a rule or instruction that shows
    or tells how something should be done
  • (http//www.merriam-webster.com/dictionary/guideli
    ne)

41
SMOs
  • We already know what to dowe just need to
    convince ourselves to do it!
  • Be Confident! Be Proud of Your Knowledge!
  • SCEMSS encourages providers to advocate for your
    patients
  • Use Medical Control to your advantageNOT as the
    Mother May I
  • Keep in mind that an order from medical control
    must be adhered to unless it directly compromises
    provider or patient safety!

42
Medical Control
Your Friend on the Other End!
43
Cardiac SMO Review
  • Lets review ALS cardiac SMOs. They are listed
    on the following slides.
  • As you go through them, discuss the notes on the
    slides, as well as any other medications or
    treatments you have questions about.
  • ILS/BLS providers your trimester test will not
    include ALS SMOs, but it will include questions
    on basic cardiac assessment.

44
Suspected Cardiac SMO
  • About Aspirin
  • We dont primarily give aspirin to cardiac
    patients for pain relief.
  • We give it because aspirins blood-thinning
    properties are linked to better outcomes for
    cardiac patients.
  • While aspirin can provide a small amount of pain
    relief, nitroglycerin and morphine are the true
    pain-fighters during a heart attack.

45
Aspirin Cautions
  • Typical
  • Known allergy or Hx GI bleeding
  • Atypical
  • USE OF BRILINTA
  • Do not administer ASA to ANY patient on this
    drug!!
  • Yes! This is as example of whyI have a list of
    medications coming with is not acceptable! You
    have to ask for current medications!

46
Brilinta
  • BRILINTA is used with aspirin to lower the chance
    of having a serious problem with heart or blood
    vessels such as heart attack, stroke, or blood
    clots
  • A dose of aspirin higher than  100 mg daily will
    affect how well BRILINTA works
  • Doses of ASA higher than 100mg can cause
    antagonist reactions including blood clot
    formation

47
Suspected Cardiac SMO
  • Some more points to ponder
  • The goal is zero pain. As long as its not
    contraindicated, nitroglycerin is one of the best
    ways to achieve that goal.
  • Blood pressure and 1-10 pain levels must be
    assessed before AND after each administration of
    nitroglycerin.
  • IV access is a good idea when giving nitro, in
    case BP suddenly bottoms out.
  • And an FYI
  • Especially in women and diabetics, weakness,
    n/v/d, or arm/jaw/back/shoulder pain may be the
    only symptom of a cardiac event. ALWAYS, do a
    12-lead.

48
NitroOrnot to Nitro
  • For use when
  • Suspected cardiac patient
  • Systolic BP gt 110 mmHg
  • NOT for use when
  • Patient is taking nitrates for erectile
    dysfunction
  • Systolic BP lt110
  • Patient presents with an Inferior Wall MI on
    12-lead EKG

49
WHOA!!!
  • Inferior wha? Of course I know what the
    Inferior Wall thing isIt says so on the
    printout!

Bazinga!
50
how Me the TEMI
  • Inferior wall STEMI
  • ST segment elevation is Leads II, III, and aVF
  • Inferior wall STEMI can effect both sides of the
    heart effecting afterload AND preload
  • Use of NTG may drastically reduce the patients
    blood pressure to the point of syncope

Lead II
Lead aVF
Lead III
51
Own the EKG
  • 12-lead EKGs know NOTHING about your patient!
    Especially, medical history and current
    medications.
  • 12-lead EKGs only interpret algorithms based on
    patients sex and age (if you have it entered on
    your monitor)
  • 12-lead EKGs are Unconfirmed
  • They rely on human interpretation of the
    information within them

52
Cardiogenic Shock SMO
  • Regarding Dopamine
  • We dont use it a lot, which can make us afraid
    to use it when its called for.
  • But for longer transports, or when waiting for a
    far-off mutual aid ambulance to arrive, Dopamine
    can save a life.
  • You cant shove fluid into a non-trauma patient
    forever without causing it to build up in lungs
    and elsewhere.
  • Dopamine increases cardiac output and blood
    pressure due to its positive inotropic (related
    to heart muscle) and chronotropic (related to
    heart rate) effects.

53
V-fib and pulseless V-tach
  • We are doing well as a system with immediately
    starting CPR, shocking, and giving Epinephrine.
  • Statistics show Lidocaine is not always
    administered per SMO requirements.
  • If the rhythm changes out of V-Fib/V-Tach too
    quickly to draw up lidocaine, thats fine.
  • If patient remains in V-Fib/V-Tach, then its
    time for an antiarrhythmic and Lido is what we
    have.

54
Tachycardias
  • If a patient with tachycardia is unstable (chest
    pain, SOB, low BP, altered mental status, shock)
    its time to cardiovert.
  • Dont delay cardioversion on an unstable patient
    while fishing for an IV.
  • If you DO have an IV, consider using Versed for
    mild sedation
  • Be sure to press sync before each attempt.
  • Some medics feel more comfortable with
    medications than cardioversion, but cardioverting
    your unstable tachycardic patient is going to
    help him/her more than medications.

55
PEA/Asystole
  • Search for the underlying causes
  • Hypovolemia
  • Hypoxia
  • Hypoglycemia
  • Hydrogen ions (acidosis)
  • Hypothermia
  • Hypo-/hyperkalemia
  • Tension pneumothorax
  • Tamponade
  • Thrombosis
  • Toxins
  • Definitely give CPR and Epinephrine. But also
    try a fluid bolus or a warm blanket. In the case
    of PEA, sometimes simple is better.

56
Bradycardia
  • DO YOUR 12-LEAD EKG FIRST!
  • SEARCH FOR STEMI AS AN UNDERLYING CAUSE
  • Only give atropine to the non-STEMI patient. Use
    of atropine in a STEMI may extend cardiac muscle
    damage
  • If atropine is indicated but not helping, and
    your patient is symptomatic, pace!
  • Consider versed, as pacing can be painful.
  • Set the heart rate at 70. Start the MA
    (milliamps) at zero and increase them until you
    feel a pulse and see a paced rhythm.
  • Pacing can be alarming if you havent done it
    before. The patients chest may twitch and
    bounce. Dont worry thats supposed to happen.
  • If pacing doesnt work or isnt available, you
    will have to consider dopamine to bring the heart
    rate up.

57
Pulmonary Edema/CHF
  • CPAP and Nitroglycerine are two tools that are
    not used as often as they should be.
  • CPAP offers quick relief once the patient becomes
    comfortable with the mask (which admittedly can
    take a minute or two).
  • Although it sounds counter-intuitive, Nitro WILL
    be more effective with SOB from pulmonary edema
    than a nebulizer. Thats why it comes before
    Albuterol in the SMO (if BP is high enough).
  • Also, be sure what you are hearing is a wheeze,
    not rales/crackles before you assume its COPD
    and skip the Nitro. In some cases, patients can
    even have both!

58
Cardiac SMOs Conclusion
  • Treating patients according to the SMOs and
    thoroughly documenting that treatment will allow
    us to continue to provide a high level of care.
  • If we dont appropriately use the ALS treatments
    we are given, we will lose them.
  • You wont get in trouble for deviating from an
    SMO if you consult with medical control first,
    then document your reasons why an intervention
    was not performed. We are healthcare
    professionals, not EMS robots.
  • If the treatment is listed on the SMO, is
    appropriate for the situation, and is something
    you are trained to do, there is no excuse NOT TO
    DO IT!

59
Cardiac Scenario
  • As a group determine how you would respond to
    this event.
  • Use the information provided as a template for
    your treatment.
  • Fill in the blank areas with your past
    experiences and you will find that there is more
    than one way to skin a cat.
  • Have fun and learn from eachother

60
Cardiac Scenario Review
  • You are called to a local high school for the
    football player that collapsed on the field at a
    Friday night game. You are greeted by a coach
    and an assistant trainer. As you observe the
    scene, you see a group of excited players
    surrounding their downed teammate. CPR is being
    performed by an off duty firefighter that was
    watching his son play, and the team trainer.
    Patient had just returned to the bench after a
    play, became syncopal, and was assisted to the
    ground without trauma. Helmet, jersey, and pads
    are removed. As you approach the patient, the
    attached AED unit blares out, Do not touch
    patientAnalyzingShock Advised.

61
  • What scene considerations are there?
  • What can you assume about the patients heart
    rhythm based on the AED assessment?

62
  • After a shock is delivered from the AED unit, you
    continue CPR and apply your cardiac monitor. You
    find the rhythm above.
  • What is it? Whats the next step?

63
  • You determine your patient needs an initial dose
    of Lidocaine in accordance with Region VII,
    SCEMSS SMOs.
  • Your patient is 17 years old and weighs 240 lbs.
  • What is your initial dose of Lidocaine?
  • Will the box above provide an adequate amount of
    medication for this patient?

64
  • Youve been on scene working this V-Vib patient
    for 12 minutes. Your next monitor check shows
    this rhythm.
  • In accordance with CPR best practices, you
    continue chest compressions for one minute,
    verify the rhythm is still present, and find your
    patient has a carotid pulse.
  • What do you do?

65
Scenario Outcome
  • You deliver your patient to the ED, still
    unresponsive to verbal stimuli but eyelids
    flutter on painful stimulation
  • Your patients vitals on arrival are
  • B/P 106/58
  • HR 70
  • SpO2 100
  • What do YOU think his outcome will be?

66
References
  • Deo, R., Albert, C. (2012). Epidemiology and
    Genetics of Sudden Cardiac Death. Circulation,
    125, 620-637.
  • Murugiah, K., Chen, S., Dharmarajan, K., Nuti,
    S., Wayda, B., Shojaee, A., et al. (2014). Most
    Important Outcomes Research Papers on Cardiac
    Arrest and Cardiopulmonary Resuscitation.
    Circulation Cardiovascular Quality and Outcomes,
    7, 335-345.
  • Nagao, K. (2012). Therapeutic hypothermia
    following resuscitation. Current Opinion in
    Critical Care, 18, 239-245.
  • Robinson, R. (2014). Why Neurointensivists Are
    Rethinking the Prehospital Hypothermia Protocol
    After Cardiac Arrest. Neurology Today, 14(2),
    1,9-9.
  • Stebbins, T., Salomone, J., Gratton, M.,
    Lindholm, D. (2011). Continous Chest Compression
    Protocol Improved Cardiac Arrest Survival Over
    Historical Cohort. Academy of Emergency Medicine,
    18(5), S147(380).
  • Wampler, D., Schwartz, D., Shumaker, J.,
    Bolleter, S., Beckett, R., Manifold, C. (2012).
    Paramedics successfully perform humeral EZ-IO
    intraosseos access in adult out-of-hospital
    cardiac arrest patients. American Journal of
    Emergency Medicine, 30, 1095-1099.
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