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Senior Citizen Health & Medicine
Very Low Survival after Out-of-Hospital Cardiac
Arrest Improved by New Resuscitation
 MICR emphasizes minimal interruption of chest
compressions
March 11, 2008 – Those experiencing a cardiac
arrest outside of a hospital have a scant chance of survival, despite
massive efforts in cardiopulmonary resuscitation (CPR) training and
efforts to place more automated external defibrillators in public
places. A new study, however, finds hope in minimally interrupted
cardiac resuscitation (MICR), which emphasizes minimal interruption of
chest compressions during a rescue attempt.
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Health & Medicine |
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The new study has found that those receiving MICR
were more likely to survive than those patients who received standard
treatments, according to a study in the March 12 issue of the Journal of
the American Medical Association.
Out-of-hospital cardiac arrest is a major public
health problem and a leading cause of death.
The American Heart Association says, “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.”
“Although early defibrillation with automated
external defibrillators improves survival, early defibrillation is rare
and few patients with out-of-hospital cardiac arrest survive," according
to this report.
"In 2004, the average survival of patients with
out-of-hospital cardiac arrest was 3 percent in the state of Arizona.”
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Early story of what is now called MICR |
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More Lives Saved from Cardiac Arrest with New CPR
“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.
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MICR, previously referred to as cardiocerebral
resuscitation, is a new approach to out-of-hospital cardiac arrest for
emergency medical services (EMS) personnel.
MICR focuses on maximizing blood flow to the heart
and brain through a series of coordinated interventions, and includes
● an initial series of 200 uninterrupted chest compressions,
● rhythm analysis with a single shock,
● 200 immediate post-shock chest compressions before pulse check or
rhythm re-analysis,
● early administration of epinephrine (adrenaline, used to stimulate
the heart), and
● delayed endotracheal intubation (placement of a flexible plastic
tube into the trachea for the purpose of ventilating the lungs).
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Read more from the American Heart Association below this report
● More about Cardiac Arrest
● More about CPR |
Bentley J. Bobrow, M.D., of Mayo Clinic,
Scottsdale, Ariz., and colleagues investigated whether MICR would
improve survival from out-of-hospital cardiac arrest.
Patients with out-of-hospital cardiac arrests in
two metropolitan cities in Arizona before and after MICR training of
fire department emergency medical personnel were assessed.
In a second
analysis of protocol compliance, patients from the two metropolitan
cities and 60 additional fire departments in Arizona who actually
received MICR were compared with patients who did not receive MICR but
received standard advanced life support.
Study Results
Among the 886 patients with cardiac arrest in the
two metropolitan cities, survival-to-hospital discharge increased from 4
of 218 patients (1.8 percent) in the before MICR training group to 36 of
668 patients (5.4 percent) in the after MICR training group.
In the subgroup of 174 patients with a witnessed
cardiac arrest and ventricular fibrillation (chaotic, irregular heart
rhythm that results in little or no circulation but that may respond to
defibrillation), survival increased from 2 of 43 patients (4.7 percent)
in the before MICR training group to 23 of 131 patients (17.6 percent)
in the after MICR training group.
For the protocol compliance analysis, overall
survival-to-hospital discharge occurred in 69 of 1,799 patients (3.8
percent) who did not receive MICR and in 60 of 661 (9.1 percent) who
received MICR.
Survival with witnessed ventricular fibrillation
and cardiac arrest occurred in 46 of 387 patients (11.9 percent) who did
not receive MICR and in 40 of 141 patients (28.4 percent) who received
MICR.
“Why should MICR be associated with improved
outcomes after out-of-hospital cardiac arrest? One major contributor to
the poor survival rates of patients with out-of-hospital cardiac arrest
is prolonged inadequate myocardial and cerebral perfusion,” the authors
write.
“During resuscitation efforts, the forward blood
flow produced by chest compressions is so marginal that any interruption
of chest compressions is extremely [harmful], especially for favorable
neurological outcomes. Excessive interruptions of chest compressions by
pre-hospital personnel are common. Therefore, MICR emphasizes
uninterrupted chest compressions.
“In this study, survival-to-hospital discharge of
patients with an out-of-hospital cardiac arrest improved significantly
after implementation of MICR as an alternate EMS protocol. These
findings require confirmation in randomized trials.”
Editorial: progress in resuscitation — an
evolution, not a revolution
In an accompanying editorial, Mary Ann Peberdy,
M.D., and Joseph P. Ornato, M.D., of Virginia Commonwealth University,
Richmond, comment on the findings of Bobrow and colleagues.
“Although the concept of MICR needs further
scientific evaluation, perhaps in the form of a randomized, controlled,
clinical trial with precise documentation of protocol compliance, these
details are likely not important factors to the numerous additional
survivors who are back home with their families after the implementation
of this new protocol.
“Progress in improving survival after cardiac
arrest is most commonly made by a gradual evolution of science and its
translation into clinical medicine rather than single, earth-shattering
revolutions. This study ... represents confirmation that the quality of
CPR, particularly the need for minimally interrupted chest compression
and the lesser importance of positive pressure ventilation [receiving
oxygen under pressure by a mechanical respirator], is a meaningful
development in the evolution of resuscitation science.”
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.
>>
Go to this American Heart Association presentation on Cardiac Arrest
Related AHA publications:
>>
Heart and Stroke Facts
>>
Heart Disease and Stroke Statistics Update
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.
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