Prehospital Cardiac Arrest

For this episode, we bring in an expert and an esteemed guest to answer all of your burning questions about resuscitation of cardiac arrest. Part man, part mystery, but wholly dedicated to furthering excellence in out of hospital care: Dr. Walt Lubbers, MD.

Some background: Walt is an Emergency and Prehospital Medicine physician who holds board certification in both EM and EMS. He’s also an Assistant Professor of Emergency Medicine and Attending Physician at University of Kentucky Medical Center. If that wasn’t enough, he’s also the Medical Director of several EMS agencies throughout Central and Eastern Kentucky.


Three stages of cardiac arrest, generally:

  1. Electrical
  2. Circulatory
  3. Metabolic

Everyone’s heard of “High Performance” or “Pit-Crew” CPR, but what exactly does all of that mean? I mean, not everyone is King County right?

High performance CPR is nothing more than excellence in the foundational skills of resuscitation.

Use a metronome. CPR rate is tied to survival.

Achieving correct depth takes practice, and compressors need to switch frequently.
Everyone switches following two minutes of compressing. Minimize the time that hands are off the chest.

Pre-charge your monitor! Longer peri-shock and post-shock pauses are independently tied to a decrease in survival to hospital discharge. So minimize the pauses.

When should Mechanical CPR Devices be placed? (Where applicable).

Priorities:

  1. Shocks are king.
  2. If resource POOR, both compressors will be fatigued by 4 minutes. This is probably the best time to apply.
  3. If resource RICH, you can probably delay placement – if at all.

To the beat of a different drum: Rhythm management and Special Cases

PEA:

  1. Slow and Wide? Think tox, hyperK, or metabolic derangement.
  2. Narrow? Think “mechanical”. Tamponade, tension penumothorax, hypovolemia, and so on.

Torsades:

  1. Defibrillation and magnesium.

Refractory VF or VT:

  1. Change the vector. Anerolateral pad placement to anterior posterior.
  2. Maybe Double Sequential Defibrillation: maybe. This will also void your monitor warranty…
  3. Beta Blocker therapy.

Transporting Cardiac Arrest Patients and Scene Management

It is generally more favorable to meaningful patient outcomes to “work them where they fall”  in cardiac arrest patients.

Transporting a patient in cardiac arrest is a treatment like any other. It has risks, selective benefit, and should be considered with the clinical picture as a whole.

Transport situations to consider:

  1. Fire or cyanide exposure in lieu of a cyanokit or other antidote therapy.
  2. Obstetrics: viable, with the fundus at or above the level of the umbilicus.
  3. The witnessed trauma arrest, maybe.
  4. Artificial heart patient.

Timelines and flatlines: when is resuscitation futile?

The “standard” 20 minute time standard is arbitrary and should not be used in every cardiac arrest.

Some patients may benefit from prolonged resusciative efforts. Rigid adherence to strict time requirements may result in the termination of patients who may have otherwise survived with longer resuscitative efforts.

Patients presenting in VF or VT may benefit from prolonged resuscitation.

Patients in asystole or PEA after 20 minutes are generally considered futile. However, this is persistent asystole or PEA and not necessarily the VF or VT patient who converts into PEA at the 18 minute mark, for example. That patient is probably a candidate for prolonged resuscitation.


Airway Management and Cardiac Arrest

Don’t stop CPR to intubate or place an SGA.

Don’t hyperventilate.

Airway device placement should probably be deferred until later in the resuscitation in the majority of arrests.

The overall goal to to maintain an airway that can deliver effective ventilation/oxygenation without compromising the quality of CPR.


 

Podcast time…


 

 

References:

Benoit, J. L., Gerecht, R. B., Steuerwald, M. T., & McMullan, J. T. (2015). Endotracheal intubation versus supraglottic airway placement in out-of-hospital cardiac arrest: A meta-analysis. Resuscitation. https://doi.org/10.1016/j.resuscitation.2015.05.007

Hasegawa, K., Hiraide, A., Chang, Y., & Brown, D. F. M. (2013). Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA – Journal of the American Medical Association, 309(3), 257–266. https://doi.org/10.1001/jama.2012.187612

McMullan, J., Gerecht, R., Bonomo, J., Robb, R., McNally, B., Donnelly, J., & Wang, H. E. (2014). Airway management and out-of-hospital cardiac arrest outcome in the CARES registry. Resuscitation, 85(5), 617–622. https://doi.org/10.1016/j.resuscitation.2014.02.007

Yannopoulos, D., Matsuura, T., McKnite, S., Goodman, N., Idris, A., Tang, W., … Lurie, K. G. (2010). No assisted ventilation cardiopulmonary resuscitation and 24-hour neurological outcomes in a porcine model of cardiac arrest. Critical Care Medicine, 38(1), 254–260. https://doi.org/10.1097/CCM.0b013e3181b42f6c

Nagao, K., Nonogi, H., Yonemoto, N., Gaieski, D. F., Ito, N., Takayama, M., … Saku, K. (2016). Duration of prehospital resuscitation efforts after out-of-hospital cardiac arrest. Circulation, 133(14), 1386–1396. https://doi.org/10.1161/CIRCULATIONAHA.115.018788

Reynolds, J. C., Grunau, B. E., Rittenberger, J. C., Sawyer, K. N., Kurz, M. C., & Callaway, C. W. (2016). Association between Duration of Resuscitation and Favorable Outcome after Out-of-Hospital Cardiac Arrest: Implications for Prolonging or Terminating Resuscitation. Circulation, 134(25), 2084–2094. https://doi.org/10.1161/CIRCULATIONAHA.116.023309

Goto, Y., Maeda, T., & Nakatsu-Goto, Y. (2013). Neurological outcomes in patients transported to hospital without a prehospital return of spontaneous circulation after cardiac arrest. Critical Care, 17(6). https://doi.org/10.1186/cc13121

Zive, D., Koprowicz, K., Schmidt, T., Stiell, I., Sears, G., Van Ottingham, L., … Daya, M. (2011). Variation in out-of-hospital cardiac arrest resuscitation and transport practices in the Resuscitation Outcomes Consortium: ROC Epistry-Cardiac Arrest. Resuscitation, 82(3), 277–284. https://doi.org/10.1016/j.resuscitation.2010.10.022

Kim, T. H., Lee, E. J., Shin, S. Do, Ro, Y. S., Kim, Y. J., Ahn, K. O., … Lee, K. won. (2018). Neurological Favorable Outcomes Associated with EMS Compliance and On-Scene Resuscitation Time Protocol. Prehospital Emergency Care, 22(2), 214–221. https://doi.org/10.1080/10903127.2017.1367443

Shin, S. Do, Kitamura, T., Hwang, S. S., Kajino, K., Song, K. J., Ro, Y. S., … Iwami, T. (2014). Association between resuscitation time interval at the scene and neurological outcome after out-of-hospital cardiac arrest in two asian cities. Resuscitation, 85(2), 203–210. https://doi.org/10.1016/j.resuscitation.2013.10.021

Jiang, C., Jiang, S., Zhao, Y., Xu, B., & Zhou, X. L. (2015). Dominant hand position improves the quality of external chest compression: A manikin study based on 2010 CPR guidelines. Journal of Emergency Medicine, 48(4), 436–444. https://doi.org/10.1016/j.jemermed.2014.12.034

Olasveengen, T. M., Wik, L., & Steen, P. A. (2008). Quality of cardiopulmonary resuscitation before and during transport in out-of-hospital cardiac arrest. Resuscitation, 76(2), 185–190. https://doi.org/10.1016/j.resuscitation.2007.07.001

Cheskes, S., Common, M. R., Byers, P. A., Zhan, C., & Morrison, L. J. (2014). Compressions during defibrillator charging shortens shock pause duration and improves chest compression fraction during shockable out of hospital cardiac arrest. Resuscitation, 85(8), 1007–1011. https://doi.org/10.1016/j.resuscitation.2014.05.001

Cheskes, S., Schmicker, R. H., Christenson, J., Salcido, D. D., Rea, T., Powell, J., … Morrison, L. (2011). Perishock pause: An independent predictor of survival from out-of-hospital shockable cardiac arrest. Circulation, 124(1), 58–66. https://doi.org/10.1161/CIRCULATIONAHA.110.010736

Hong, D. Y., Park, S. O., Lee, K. R., Baek, K. J., & Shin, D. H. (2012). A different rescuer changing strategy between 30:2 cardiopulmonary resuscitation and hands-only cardiopulmonary resuscitation that considers rescuer factors: A randomised cross-over simulation study with a time-dependent analysis. Resuscitation, 83(3), 353–359. https://doi.org/10.1016/j.resuscitation.2011.11.006

Gianotto-Oliveira, R., Gianotto-Oliveira, G., Gonzalez, M., Quilici, A., Andrade, F., Vianna, C., & Timerman, S. (2015). Quality of continuous chest compressions performed for one or two minutes. Clinics, 70(3), 190–195. https://doi.org/10.6061/clinics/2015(03)07

Contri, E., Cornara, S., Somaschini, A., Dossena, C., Tonani, M., Epis, F., … Baldi, E. (2017). Complete chest recoil during laypersons’ CPR: Is it a matter of weight? American Journal of Emergency Medicine, 35(9), 1266–1268. https://doi.org/10.1016/j.ajem.2017.03.060

Yaru Zou, M., , Wen Shi, M., , Ying Zhu, M., , Ranjun Tao, M., , Ying Jiang, M., , Shanfeng Li, M., … , Jianjing Tong, M. information about the author M. J. T. (n.d.). Rate at 120/min provides qualified chest compression during cardiopulmonary resuscitation. The American Journal of Emergency Medicine.

Idris, A. H., Guffey, D., Pepe, P. E., Brown, S. P., Brooks, S. C., Callaway, C. W., … Aufderheide, T. P. (2015). Chest compression rates and survival following out-of-hospital cardiac arrest. Critical Care Medicine, 43(4), 840–848. https://doi.org/10.1097/CCM.0000000000000824

Curbside to Bedside

Curbside to Bedside is a blogcast created by front line EMS Clinicians to provide simple and relevant initial and continuing prehospital EMS education.

Leave a Reply

%d bloggers like this: