Robert A. Swor

Part 4: CPR Overview: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Cardiopulmonary resuscitation (CPR) is a series of lifesaving actions that improve the chance of survival following cardiac arrest.1 Although the optimal approach to CPR may vary, depending on the rescuer, the victim, and the available resources, the fundamental challenge remains: how to achieve early and effective CPR. Given this challenge, recognition of arrest and prompt action by the rescuer continue to be priorities for the 2010 AHA Guidelines for CPR and ECC. This chapter provides an overview of cardiac arrest epidemiology, the principles behind each link in the Chain of Survival, an overview of the core components of CPR (see Table 1), and the approaches of the 2010 AHA Guidelines for CPR and ECC to improving the quality of CPR. The goal of this chapter is to integrate resuscitation science with real-world practice in order to improve the outcomes of CPR. View this table: Table 1. Summary of Key BLS Components for Adults, Children and Infants Despite important advances in prevention, cardiac arrest remains a substantial public health problem and a leading cause of death in many parts of the world.2 Cardiac arrest occurs both in and out of the hospital. In the US and Canada, approximately 350 000 people/year (approximately half of them in-hospital) suffer a cardiac arrest and receive attempted resuscitation.3,–,7 This estimate does not include the substantial number of victims who suffer an arrest without attempted resuscitation. While attempted resuscitation is not always appropriate, there are many lives and life-years lost because appropriate resuscitation is not attempted. The estimated incidence of EMS-treated out-of-hospital cardiac arrest in the US and Canada is about 50 to 55/100 000 persons/year and approximately 25% of these present with pulseless ventricular arrhythmias.3,8 The estimated incidence of in-hospital cardiac arrest is 3 to 6/1000 admissions4,– …

Integration of pre-hospital electrocardiograms and ST-elevation myocardial infarction receiving center (SRC) networks: impact on Door-to-Balloon times across 10 independent regions.

OBJECTIVES The aim of this study was to evaluate the rate of timely reperfusion for ST-elevation myocardial infarction (STEMI) with primary percutaneous coronary intervention (PPCI) in regional STEMI Receiving Center (SRC) networks. BACKGROUND The American College of Cardiology Door-to-Balloon (D2B) Alliance target is a >75% rate of D2B <or=90 min. Independent initiatives nationwide have organized regional SRC networks that coordinate universal access to 9-1-1 with the pre-hospital electrocardiogram (PH-ECG) diagnosis of STEMI and immediate transport to a SRC (designated PPCI-capable hospital). METHODS A pooled analysis of 10 independent, prospective, observational registries involving 72 hospitals was performed. Data were collected on all consecutive patients with a PH-ECG diagnosis of STEMI. The D2B and emergency medical services (EMS)-to-balloon (E2B) times were recorded. RESULTS Paramedics transported 2,712 patients with a PH-ECG diagnosis of STEMI directly to the nearest SRC. A PPCI was performed in 2,053 patients (76%) with an 86% rate of D2B <or=90 min (95% confidence interval: 84.4% to 87.4%). Secondary analyses of this cohort demonstrated a 50% rate of D2B <or=60 min (n = 1,031), 25% rate of D2B <or=45 min (n = 517), and an 8% rate of D2B <or=30 min (n = 155). A tertiary analysis restricted to 762 of 2,053 (37%) cases demonstrated a 68% rate of E2B <or=90 min. CONCLUSIONS Ten independent regional SRC networks demonstrated a combined 86% rate of D2B <or=90 min, and each region individually surpassed the American College of Cardiology D2B Alliance benchmark. In areas with regional SRC networks, 9-1-1 provides entire communities with timely access to quality STEMI care.

Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial

BACKGROUND Active compression-decompression cardiopulmonary resuscitation (CPR) with decreased intrathoracic pressure in the decompression phase can lead to improved haemodynamics compared with standard CPR. We aimed to assess effectiveness and safety of this intervention on survival with favourable neurological function after out-of-hospital cardiac arrest. METHODS In our randomised trial of 46 emergency medical service agencies (serving 2·3 million people) in urban, suburban, and rural areas of the USA, we assessed outcomes for patients with out-of-hospital cardiac arrest according to Utstein guidelines. We provisionally enrolled patients to receive standard CPR or active compression-decompression CPR with augmented negative intrathoracic pressure (via an impedance-threshold device) with a computer-generated block randomisation weekly schedule in a one-to-one ratio. Adults (presumed age or age ≥18 years) who had a non-traumatic arrest of presumed cardiac cause and met initial and final selection criteria received designated CPR and were included in the final analyses. The primary endpoint was survival to hospital discharge with favourable neurological function (modified Rankin scale score of ≤3). All investigators apart from initial rescuers were masked to treatment group assignment. This trial is registered with ClinicalTrials.gov, number NCT00189423. FINDINGS 2470 provisionally enrolled patients were randomly allocated to treatment groups. 813 (68%) of 1201 patients assigned to the standard CPR group (controls) and 840 (66%) of 1269 assigned to intervention CPR received designated CPR and were included in the final analyses. 47 (6%) of 813 controls survived to hospital discharge with favourable neurological function compared with 75 (9%) of 840 patients in the intervention group (odds ratio 1·58, 95% CI 1·07-2·36; p=0·019]. 74 (9%) of 840 patients survived to 1 year in the intervention group compared with 48 (6%) of 813 controls (p=0·03), with equivalent cognitive skills, disability ratings, and emotional-psychological statuses in both groups. The overall major adverse event rate did not differ between groups, but more patients had pulmonary oedema in the intervention group (94 [11%] of 840) than did controls (62 [7%] of 813; p=0·015). INTERPRETATION On the basis of our findings showing increased effectiveness and generalisability of the study intervention, active compression-decompression CPR with augmentation of negative intrathoracic pressure should be considered as an alternative to standard CPR to increase long-term survival after cardiac arrest. FUNDING US National Institutes of Health grant R44-HL065851-03, Advanced Circulatory Systems.

Emergency Medical Service Dispatch Cardiopulmonary Resuscitation Prearrival Instructions to Improve Survival From Out-of-Hospital Cardiac Arrest A Scientific Statement From the American Heart Association

Each year, millions of people around the world experience out-of-hospital cardiac arrest (OHCA), a condition characterized by unexpected cardiovascular collapse.1,2 OHCA is a leading cause of death. The incidence of treated OHCA is ≈50 to 60 per 100 000 person-years and is comparable throughout many parts of the world. Resuscitation of these patients is challenging and requires a coordinated set of rescuer actions termed the “Chain of Survival.” The links in the Chain of Survival are immediate recognition of cardiac arrest and activation of the emergency response system, early cardiopulmonary resuscitation (CPR), rapid defibrillation, effective advanced life support, and integrated post–cardiac arrest care.3 These actions involve the participation of a spectrum of rescuers, including family members, bystanders, emergency medical service (EMS) dispatchers, pre–hospital care providers, and hospital-based personnel; each group of rescuers has specific motivations, responsibilities, and skills. Unfortunately, in most communities in the United States and Canada, only 5% to 10% of all OHCA patients in whom resuscitation is attempted survive to discharge from the hospital. In contrast, survival rates can approach 20% (50% for witnessed ventricular fibrillation) in communities where the Chain of Survival is strong.4 Efforts to improve survival from OHCA should be aimed at strengthening each link in the Chain of Survival. An important underpinning of successful resuscitation is the interdependence of each of these links. Specifically, the early links, those involving bystanders (immediate emergency activation and early bystander CPR), are essential for the effectiveness of subsequent links. Thus, efforts that can improve early recognition of OHCA and increase bystander CPR are likely to improve survival from OHCA. When a bystander calls the community emergency response number (eg, 911 in the United States) to request medical aid, the call creates an opportunity to improve both identification of OHCA and provision of …

Outcomes in Unsuccessful Field Resuscitation Attempts

To determine the outcomes of patients who did not regain vital signs after prehospital advanced cardiac life support, we studied adult patients who sustained nontraumatic out-of-hospital cardiac arrest. Our study consisted of a 20-month retrospective review of 244 charts beginning January 1986. Twelve patients were excluded for drug overdose, family request, or unavailable data. Of the remaining 232 patients, 51 had a rhythm and pulse on arrival at the emergency department. The record of each of the remaining 181 patients was analyzed for age, sex, location, witness, CPR initiator, advanced life support unit response time, initial field rhythm, and initial ECG rhythm. Outcome alternatives were dead in emergency department or hospital admission. All hospitalized patients were further evaluated for survival to discharge and neurologic status at discharge. Ten of the 181 patients (6%) who failed prehospital resuscitation survived to hospitalization, and one (0.6%) was discharged neurologically intact. Survival to hospital admission did not correlate with any of the variables studied except gender. The one patient who survived a failed prehospital resuscitation was not endotracheally intubated in the field. Our data support the practice of pronouncing adult nontraumatic cardiac arrest victims who fail to respond to advanced cardiac life support efforts in the field as dead at the scene.

Few emergency medical services patients with lower-extremity fractures receive prehospital analgesia

Previous literature has identified prehospital pain management as an important emergency medical services (EMS) function, and few patients transported by EMS with musculoskeletal injuries receive prehospital analgesia (PA). Objectives. 1) To describe the frequency with which EMS patients with lower-extremity and hip fracture receive prehospital and emergency department (ED) analgesia; 2) to describe EMS and patient factors that may affect administration of PA to these patients; and 3) to describe the time interval between EMS and ED medication administrations. Methods. This was a four-month (April to July 2000) retrospective study of patients with a final hospital diagnosis of hip or lower-extremity fracture who were transported by EMS to a single suburban community hospital. Data including patient demographics, fracture type, EMS response, and treatment characteristics were abstracted from review of EMS and ED records. Patients who had ankle fractures, had multiple traumatic injuries, were under the age of 18 years, or did not have fractures were excluded. Results. One hundred twenty-four patients met inclusion criteria. A basic life support (BLS)-only response was provided to 20 (16.0%). Another 38 (38.4%) received an advanced life support (ALS) response and were triaged to BLS transport. Of all the patients, 22 (18.3%) received PA. Patients who received PA were younger (64.0 vs. 77.3 years, p < 0.001) and more likely to have a lower-extremity fracture other than a hip fracture (31.8% vs. 10.7%, p < 0.004). Of all patients, 113 (91.1%) received ED analgesia. Patients received analgesia from EMS almost 2.0 hours sooner that in the ED (mean 28.4 ± 36 min vs. 146 ± 74 min after EMS scene arrival, p < 0.001). Conclusion. A minority of the study group received PA. Older patients and patients with hip fracture are less likely to receive PA. It is unclear whether current EMS system design may adversely impact administration of PA. Further work is needed to clarify whether patient need or EMS practice patterns result in low rates of PA.

Cardiac arrest in private locations: different strategies are needed to improve outcome☆

BACKGROUND A tremendous amount of public resources are focused on improving cardiac arrest (OHCA) survival in public places, yet most OHCAs occur in private residences. METHODS AND RESULTS A prospective, observational study of patients transported to seven urban and suburban hospitals and the individuals who called 911 at the time of a cardiac arrest (bystander) was performed. Bystanders (N=543) were interviewed via telephone beginning 2 weeks after the incident to obtain data regarding patient and bystander demographics, including cardiopulmonary resuscitation (CPR) training. Of all arrests 80.2% were in homes. Patients who arrested in public places were significantly younger (63.2 vs. 67.2, P<0.02), more often had an initial rhythm of VF (63.0 vs. 37.7%, P<0.001), were seen or heard to have collapsed by a bystander (74.8 vs. 48.1%, P<0.001), received bystander CPR (60.2 vs. 28.6%, P<0.001), and survived to DC (17.5 vs. 5.5%, P<0.001). Patients who arrested at home were older and had an older bystander (55.4 vs. 41.3, P<0.001). The bystander was less likely to be CPR trained (65.0 vs. 47.4%, P<0.001), less likely to be trained within the last 5 years (49.2 vs. 17.9, P<0.001), and less likely to perform CPR if trained (64.2 vs. 30.0%, P<0.001). Collapse to shock intervals for public versus home VF patients were not different. CONCLUSIONS Many important characteristics of cardiac arrest patients and the bystander differ in public versus private locations. Fundamentally different strategies are needed to improve survival from these events.

Multicenter prospective validation of prehospital clinical spinal clearance criteria.

BACKGROUND Spine immobilization is one of the most frequently performed prehospital procedures. If trauma patients without significant risk for spine injury complications can be identified, spine immobilization could be selectively performed. The purpose of this study was to evaluate five prehospital clinical criteria-altered mental status, neurologic deficit, spine pain or tenderness, evidence of intoxication, or suspected extremity fracture-the absence of which identify prehospital trauma patients without a significant spine injury. METHODS Prospectively collected emergency medical services data items included the above-listed criteria. Outcome data include spine fracture or cord injury, and also the level and management of injuries. RESULTS A total of 295 patients with spine injuries were present in 8,975 (3.3%) cases. Spine injury was identified by the prehospital criteria in 280 of 295 (94.9%) injured patients. The criteria missed 15 patients. Thirteen of 15 had stable injuries, the majority of which were stable compression or vertebral process injuries. The remaining two would have been captured by more accurate prehospital evaluation. CONCLUSION Absence of the study criteria may form the basis of a prehospital protocol that could be used to identify trauma patients who may safely have rigid spine immobilization withheld. Evaluation of such a protocol in practice should be performed.

Catechol O-Methyltransferase Haplotype Predicts Immediate Musculoskeletal Neck Pain and Psychological Symptoms After Motor Vehicle Collision

UNLABELLED Genetic variations in the catechol-O-methyltransferase (COMT) gene have been associated with experimental pain and risk of chronic pain development, but no studies have examined genetic predictors of neck pain intensity and other patient characteristics after motor vehicle collision (MVC). We evaluated the association between COMT genotype and acute neck pain intensity and other patient characteristics in 89 Caucasian individuals presenting to the emergency department (ED) after MVC. In the ED in the hours after MVC, individuals with a COMT pain vulnerable genotype were more likely to report moderate-to-severe musculoskeletal neck pain (76 versus 41%, RR = 2.11 (1.33-3.37)), moderate or severe headache (61 versus 33%, RR = 3.15 (1.05-9.42)), and moderate or severe dizziness (26 versus 12%, RR = 1.97 (1.19-3.21)). Individuals with a pain vulnerable genotype also experienced more dissociative symptoms in the ED, and estimated a longer time to physical recovery (median 14 versus 7 days, P = .002) and emotional recovery (median 8.5 versus 7 days, P = .038). These findings suggest that genetic variations affecting stress response system function influence the somatic and psychological response to MVC, and provide the first evidence of genetic risk for clinical symptoms after MVC. PERSPECTIVE The association of COMT genotype with pain symptoms, psychological symptoms, and recovery beliefs exemplifies the pleiotropic effects of stress-related genes, which may provide the biological substrate for the biopsychosocial model of post-MVC pain. The identification of genes associated with post-MVC symptoms may also provide new insights into pathophysiology.

Primary coronary angioplasty for acute myocardial infarction complicated by out-of-hospital cardiac arrest.

Abstract Our data indicate that reperfusion therapy with emergency catheterization, adjunctive hemodynamic support, and catheter-based mechanical reperfusion therapies is a therapeutic option in patients with out-of-hospital cardiac arrest surviving to emergency center admission, even in the presence of a depressed sensorium. We currently limit this therapy to patients with electrocardiographic evidence of transmural injury.