Which Cardiac Arrest Patients are Taken to Hospital
Decided by Simple Tests for EMS
New guidelines identify which patients should be
brought to hospitals when emergency efforts to revive them aren’t
working
Sept. 24, 2008 - When someone’s heart suddenly
stops beating – a condition called cardiac arrest -- there’s a lot that
bystanders and ambulance crews can do to get it started again. But if
the victim doesn’t respond, when should such efforts stop? It is a
question of critical importance to senior citizens - the most likely
victims.
And, when should emergency crews rapidly transport
a patient to a hospital with lights and sirens on, potentially
endangering the lives of paramedics and other motorists and pedestrians
— even though the care provided by the emergency crew is the same as
what can be provided in the emergency department?
Currently, there’s no one “right” answer to these
questions, which arise in the majority of the cardiac arrests that
strike 166,000 Americans each year — and kill 93 percent of them.
As a result, emergency medical services crews and
hospital ER teams spend countless hours and healthcare resources on
patients who have no chance of making it home alive – at the expense of
other patients who need an ambulance or have spent hours in an ER
waiting room.
Now, a new study in the
Journal of the American Medical Associationshows that a
single standard guideline could help EMS and ER teams determine which
cardiac arrest victims might benefit from a trip to the hospital, while
at the same time reducing futile efforts on patients who have no chance
of surviving a cardiac arrest.
The study shows that EMS teams can use either a
simple five- or three-part rule to determine when they should
discontinue efforts to revive cardiac arrest patients on the scene where
their heart stopped beating.
The same rule will also tell them when they should
keep trying to resuscitate the patient while transporting him or her to
the nearest ER. The three-part rule may be sufficient to identify 99.8
percent of those who need to be transported to the hospital for further
care, the researchers say.
BLS Rule Decides Who Gets Rushed to
Hospital
The three-part rule, called a ‘basic life support’ or BLS rule,
calls for EMS teams to end their resuscitation efforts if a
cardiac arrest occurred - ●
before EMS arrived, ●
if no defibrillator was used, and ●
if the team can’t get the patient’s blood to begin
circulating again.
All three must apply for resuscitation efforts to be stopped.
Comilla Sasson, M.D., M.S., is the study’s lead author and a
Robert Wood Johnson Clinical Scholar at the
U-M Medical School. An emergency physician herself, she began the
study after many frustrating experiences in a Chicago ER where she had
to stop caring for other critically ill patients whenever a cardiac
arrest patient came in the door – no matter how futile it might be to
try to bring the patient back, and no matter how time-sensitive the
needs of the other patients in the ER.
EMS-treated cardiac arrest survival ranged from 3.0%
to 16.3%; ventricular fibrillation survival ranged from 7.7% to 39.9%
Link
to video in story
Sept. 24, 2008 – When hit with cardiac arrest your
chances of survival are five times greater in some cities than others,
which researchers say proves this often lethal event is treatable and
that quality EMS services may be under-appreciated.
Read
more...
Now at the U-M
Department of Emergency Medicine, Sasson teamed up with an Emory
University group that has been tracking cardiac arrest response. The
Emory effort, called
CARES, helps EMS crews and hospitals find ways to improve care.
“Many cardiac arrest patients are successfully
resuscitated at the scene, with the help of automated external
defibrillators and CPR, and the hospital is the right destination for
them,” Sasson says.
“The question has been what to do about patients
who fail to respond, despite the best efforts of an EMS team. This study
confirms previous findings, and shows that a standard rule could ensure
that the right patients get to the hospital while allowing us to use
scarce resources wisely.”
Sasson notes that many advanced EMS crews now have
nearly all the tools and training that ERs have for reviving cardiac
arrest patients, including artificial airways, heart-starting injectable
drugs and more. Many have radio contact with an emergency doctor at the
local medical control authority. In addition, automated external
defibrillators (AEDs) are now available in many public places for
bystanders to use to restart a stopped heart, in the crucial minutes
before an EMS team arrives.
But even still, some patients just don’t respond,
or their heartbeats are too erratic for the AED to determine that a
shock can be delivered. Then, the question for the EMS crew is whether
it’s worth the risk to the patient, the crew, and nearby motorists and
pedestrians to race to the hospital with sirens blaring and lights
flashing, and then to tie up the ER team to try to revive the patient.
In the new study, EMS crews pronounced 947 (17
percent) of the 5,505 patients dead at the scene between late 2005 and
early 2008. The other 4,558 were transported to one of 111 hospitals by
one of 19 EMS agencies. But only 7.1 percent of those transported
patients survived long enough to be discharged from the hospital alive.
Sasson and her colleagues, including Bryan McNally,
M.D., MPH, and Arthur Kellermann, M.D., MPH of Emory’s Department of
Emergency Medicine, analyzed the medical records from all 5,505
patients.
They ran statistical analyses to determine which
patients would have been transported, or survived, if EMS crews had
applied the three-part or five-part rule, both of which were developed
by a Canadian team as part of the Ontario Prehospital Advanced Life
Support study.
The BLS Rule
The three-part rule, called a ‘basic life support’
or BLS rule, calls for EMS teams to end their resuscitation efforts if a
cardiac arrest occurred before EMS arrived, if no defibrillator was used
(for instance, because there was none for a bystander to use, the EMS
crew didn’t have one, or an AED did not detect a shockable rhythm), and
if the team can’t get the patient’s blood to begin circulating again.
All three must apply for resuscitation efforts to be stopped.
If ambulance and fire crews had applied the
three-part rule, about 47 percent of all the cardiac arrest patients in
the study would not have met the criteria to be transported by ambulance
to the hospital.
This means that 2,592 patients would have been
pronounced dead at the scene – potentially saving 1,645 trips to the ER,
compared with what actually happened.
“Cardiocerebral Resuscitation will have a
world-wide impact.”
April 14, 2006 - Survival rates following the most
common form of cardiac arrest – a common killer of senior citizens -
increased three-fold when emergency medical personnel used a new form of
CPR developed at The University of Arizona Sarver Heart Center. The new
approach, called Cardiocerebral Resuscitation, is dramatically different
from guideline-directed CPR procedures.
The five-part rule, called the ‘advanced life
support’ or ALS rule, adds two more criteria to the list: the cardiac
arrest had no witnesses at all, and no bystander attempted to perform
CPR. If this more conservative rule had been applied to the 5,505
cardiac arrest victims in the study, 1,192 patients would have been
declared dead at the scene, saving 245 trips to the ER.
Then, the researchers looked at what actually
happened after the patients made it to the hospital, and compared it
with what might have happened if the two rules had been applied.
Only 70 patients who would have been declared dead
under the BLS rule survived the ER treatment and were admitted to the
hospital. But only five were discharged from the hospital alive, and
four of them were able to live a relatively normal life afterward.
Meanwhile, only 24 patients who would have been
declared dead under the more conservative ALS rule were able to be
resuscitated in the ER. None of them survived long enough to be sent
home from the hospital.
Read more from the American Heart Association below this report
● More about Cardiac Arrest
● More about CPR
In other words, the BLS rule misclassified only 0.2
percent of patients, and the ALS rule classified all patients correctly.
Either rule, the authors say, could be used – but the BLS rule would
save the most emergency medical resources while still meeting ethical
criteria for medical care.
“Through our study and others, the BLS rule has now
been applied to more than 10,000 patients in the U.S. and Canada, with
less than a 0.1 percent misclassification rate,” Sasson says.
“Currently, EMS systems vary widely in the care they deliver to cardiac
arrest patients.
To implement the BLS rule more widely would
standardize the care and transport of these patients, so that we can
reduce the risk of injuries or death to EMS personnel and the public in
high speed transports, decrease the pressure on our overcrowded ER’s,
allow our ER staff to focus on patients who can be treated, and open up
intensive care unit beds.”
In addition to Sasson, McNally and Kellerman, the
study’s authors are A.J. Hegg, M.D., a third-year Emergency Department
and Internal Medicine resident at Henry Ford Hospital in Detroit;
Michelle Macy, M.D., of the U-M Department of Emergency Medicine, and
Allison Park, MPH, of the CARES project. CARES stands for Cardiac Arrest
Registry to Enhance Survival. Reference: JAMA, Sept. 24, 2008, Vol. 300,
No. 12.
More About Cardiac Arrest
The American Heart Association urges the public
to be prepared for cardiac emergencies:
● Know the warning signs of cardiac arrest.
During cardiac arrest a victim loses consciousness, stops normal
breathing and loses pulse and blood pressure.
● Call 9-1-1 immediately to access the emergency
medical system if you see any cardiac arrest warning signs.
● Give cardiopulmonary resuscitation (CPR) to
help keep the cardiac arrest victim alive until emergency help arrives.
CPR keeps blood and oxygen flowing to the heart and brain until
defibrillation can be administered.
What is cardiac arrest?
Cardiac arrest is the sudden, abrupt loss of heart
function. The victim may or may not have diagnosed heart disease. It's
also called sudden cardiac arrest or unexpected cardiac arrest. Sudden
death (also called sudden cardiac death) occurs within minutes after
symptoms appear.
What causes cardiac arrest?
The most common underlying reason for patients to
die suddenly from cardiac arrest is coronary heart disease. Most cardiac
arrests that lead to sudden death occur when the electrical impulses in
the diseased heart become rapid (ventricular tachycardia) or chaotic
(ventricular fibrillation) or both. This irregular heart rhythm
(arrhythmia) causes the heart to suddenly stop beating. Some cardiac
arrests are due to extreme slowing of the heart. This is called
bradycardia.
Other factors besides heart disease and heart
attack can cause cardiac arrest. They include respiratory arrest,
electrocution, drowning, choking and trauma. Cardiac arrest can also
occur without any known cause.
Can cardiac arrest be reversed?
Brain death and permanent death start to occur in
just 4 to 6 minutes after someone experiences cardiac arrest. Cardiac
arrest can be reversed if it's treated within a few minutes with an
electric shock to the heart to restore a normal heartbeat. This process
is called defibrillation. A victim's chances of survival are reduced by
7 to 10 percent with every minute that passes without CPR and
defibrillation. Few attempts at resuscitation succeed after 10 minutes.
How many people survive cardiac arrest?
No statistics are available for the exact number of
cardiac arrests that occur each year. It's estimated that more than 95
percent of cardiac arrest victims die before reaching the hospital. In
cities where defibrillation is provided within 5 to 7 minutes, the
survival rate from sudden cardiac arrest is as high as 30–45 percent.
What can be done to increase the survival rate?
Early CPR and rapid defibrillation combined with
early advanced care can result in high long-term survival rates for
witnessed cardiac arrest. For instance, in June 1999, automated external
defibrillators (AEDs) were mounted 1 minute apart in plain view at
Chicago's O'Hare and Midway airports. In the first 10 months, 14 cardiac
arrests occurred, with 12 of the 14 victims in ventricular fibrillation.
Nine of the 14 victims (64 percent) were revived with an AED and had no
brain damage.
If bystander CPR was initiated more consistently,
if AEDs were more widely available, and if every community could achieve
a 20 percent cardiac arrest survival rate, an estimated 40,000 more
lives could be saved each year. Death from sudden cardiac arrest is not
inevitable. If more people react quickly by calling 9-1-1 and performing
CPR, more lives can be saved.
Unified national effort needed to save lives by
increasing use of CPR
American Heart Association scientific statement
Jan.
15, 2008 – A unified effort by the public, educators and policymakers is
needed to reduce deaths from sudden cardiac arrest by increasing the use
and effectiveness of cardiopulmonary resuscitation (CPR), according to a
new statement from the American Heart Association. The statement,
“Reducing barriers for implementation of bystander-initiated
cardiopulmonary resuscitation,” appears online in Circulation: Journal
of the American Heart Association.
“Bystander cardiopulmonary resuscitation rates are
woefully inadequate, resulting in an enormous missed opportunity to save
lives from cardiac arrest,” said Benjamin S. Abella, M.D., M.Phil.,
clinical research director for the Center for Resuscitation Science at
the University of Pennsylvania in Philadelphia, and lead author of the
statement.
Studies indicate that in many communities only 15
percent to 30 percent of out-of-hospital cardiac arrest victims receive
bystander CPR before emergency medical services (EMS) personnel arrive
at the scene. Considering that cardiac arrest survival falls an
estimated seven percent to 10 percent for every minute without CPR, the
low rate of bystander CPR has a big impact on outcomes, he explained.
Approximately 166,200 out-of-hospital sudden
cardiac arrest deaths occur annually in the United States. Sudden
cardiac arrest often results from an irregular heartbeat called
ventricular fibrillation (VF) which causes the heart to quiver so that
it cannot generate blood flow. Treatment of VF requires CPR to keep
blood moving through the body until the patient’s heart can be shocked
to terminate the VF and allow the heart’s pacemaker cells to establish a
normal rhythm.
In the last decade, automated external
defibrillators (AEDs), portable defibrillation machines, have become
increasingly common in public buildings such as casinos, airports and
schools. However, Abella said defibrillation is only one of the four
links in the Chain of Survival, a sequence of four actions that must
occur quickly to help ensure the best chances of survival.
The Chain of Survival requires: (1) early
recognition of the emergency and phoning 911 for EMS, (2) early
bystander CPR, (3) early delivery of a shock via a defibrillator if
indicated and (4) early advanced life support and post-resuscitation
care delivered by healthcare providers.
“Quick initiation of CPR, as well as providing high
quality CPR, is crucial to survival,” Abella said. “What’s needed is a
two-pronged approach: first, substantially increase the number of
bystanders trained in CPR who then provide CPR during an actual
emergency and second, improve the quality of training and actual CPR
performance through measures of its effectiveness.”
“In communities where widespread CPR training has
been provided, survival rates from witnessed sudden cardiac arrest
associated with VF have been reportedly as high as 49 percent to 74
percent,” Abella said. “Unfortunately, on average, approximately six
percent of out-of-hospital sudden cardiac arrest victims survive to
hospital discharge in the United States.”
The statement identifies specific potential
barriers to improving U.S. cardiac arrest survival rates including: fear
of infectious disease, fear of litigation and fear of poor performance,
all of which Abella said could be overcome with adequate education,
training and public awareness.
Specific recommendations in the statement include:
● Local, state and federal government agencies
should provide CPR education in such settings as school systems and
government-funded hospital and clinic systems.
● Communities should create and support
emergency dispatcher-assisted CPR training programs with an emphasis on
recognizing the symptoms of cardiac arrest.
● The public should understand that when
bystanders perform CPR immediately, the victim’s chance of surviving
cardiac arrest can double or triple at little risk to the rescuer.
● The public should be made aware of Good
Samaritan laws through CPR training materials and by including
information with community AEDs.
● Community lay rescuer and EMS programs should
include a process for continuous quality improvement that includes a
review of resuscitation efforts, quality of CPR and CPR instructions
provided to bystanders by dispatchers. CPR instructional programs
should always include an objective CPR quality assessment for
certification.
● Research funds should be targeted toward
improving methods of CPR education, skill retention and creative methods
to widen the scope of current CPR training and education.
Abella said creative approaches to CPR education
include initiatives such as the American Heart Association’s Family and
Friends CPR Anytime™, a 22-minute, individual training program that
provides an instructional video and an inflatable manikin, and other
approaches such as Internet-based instruction. Another idea is to
provide hospital-based training for family members of patients at risk
for cardiac arrest.
The statement also recommends directing research
dollars to learn more about ways to increase the use of bystander CPR.
“By broadening training and encouraging the public
to perform CPR, we believe we can save thousands of additional lives
each year in the United States,” Abella said.
Co-authors are: Tom P. Aufderheide, M.D.; Brian
Eigel, Ph.D.; Robert W. Hickey, M.D.; W.T. Longstreth, Jr., M.D.; Vinay
Nadkarni, M.D.; Graham Nichol, M.D.; Michael R. Sayre, M.D.; Claire E.
Sommargren, R.N., Ph.D.; and Mary Fran Hazinski, R.N., M.S.N.
Keep up with the latest news for senior citizens, baby
boomers
More About Cardiac Arrest
Jan.
15, 2008 – A unified effort by the public, educators and policymakers is
needed to reduce deaths from sudden cardiac arrest by increasing the use
and effectiveness of cardiopulmonary resuscitation (CPR), according to a
new statement from the American Heart Association. The statement,
“Reducing barriers for implementation of bystander-initiated
cardiopulmonary resuscitation,” appears online in Circulation: Journal
of the American Heart Association.