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Cardiac Arrest Management for ALS Providers

Todd M. Cage MEd, NRP

Cardiac Arrest Management

Introduction

There is no event in medicine quite as dramatic as the resuscitation of a patient in cardio-pulmonary arrest. In order to achieve a successful outcome, skilled medical personnel must come together and function as a team.1 Although the process of resuscitation is highly protocolized and guided by the Emergency Cardiac Care (ECC) guidelines, many things can improve the success of the resuscitation team. This article will review background information on cardiac arrest and evaluate details that have been shown to improve success.

 

Pathophysiology

The term cardiac arrest is descriptive of the nature of the event, but it is not necessarily the cause of the event. Heart disease is estimated to be the primary cause of cardiac arrest ≈75% of the time in the Western world.2 Coronary artery disease (CAD) and ischemia account for 40–50% of the cardiac-related cases of cardiac arrest. Acute myocardial infarction (AMI or MI), primary ventricular fibrillation and congestive heart failure each account for 10–20% of cardiac-related cardiac arrest.

Other less common cardiac conditions include dilated cardiomyopathy (<10%), hypertropic cardiomyopathy (<5%), primary electrical diseases (<2%), valvular heart disease (<5%), and commotio cordis (<1%). Non-cardiac cases of cardiac arrest can include respiratory system issues, pulmonary embolism (PE), cancer, stroke/aneurism, overdose, sudden infant death, renal disease, and drowning.3-5

When evaluating survivors of cardiac arrest, cardiologists must use structural and electric testing to determine the presence of a variety of conditions (See Table 1, below.)

Table 1: Causes of Sudden Cardiac Arrest
Source: Simon, M. and Krahn, A.D. Sudden cardiac arrest without overt heart disease. Circulation. 2011;123:2994-3008.

Researchers who studied a small sample of in-hospital pulseless electrical activity (PEA) arrest found that hypoxia, MI, and PE were the most common reasons for PEA arrest but the underlying cause of arrest was managed in only 1 in 5 of the patients. Although correctly managing the causative condition was not an independent predictor of survival, an increase in 30-day survival did exist.6

Two studies evaluated the causes of out-of-hospital cardiac arrest where PEA was the initial rhythm.  The autopsy arm of a study from Finland found that 38% of PEA arrests were caused by AMI or other cardiac cause, with 28% caused by aortic dissection or rupture and 25% caused by PE.7 A study of North Carolina medical examiner data found that patients with witnessed cardiac arrest and PEA as the primary rhythm carry a high probability that the cause of the arrest is PE, second only to acute coronary syndrome.8

When the mechanical function of the heart stops, so does the perfusion of oxygenated blood to the body. The lack of blood flow results in ischemia to the entire body. Each organ system has a different tolerance to ischemia. Of chief concern is injury to the central nervous system, which begins within seven to 10 seconds of cardiac arrest. The lack of blood flow to the heart also causes necrosis of the myocytes of the heart.9

 

Epidemiology

The literature commonly cites 300,000 cardiac arrests per year in the U.S.10 This is an older number. The most current AHA statistics describe a lack of a nationwide data set that would accurately describe the problem of cardiac arrest. The AHA used census numbers and data from the ROC trial to extrapolate that 424,000 out-of-hospital cardiac arrests (OHCA) occur in the U.S. each year. Of these patients, approximately 60% are treated by EMS personnel and 23% have an initial rhythm of ventricular fibrillation (VF) or ventricular tachycardia (VT).11 The Japanese registry reports that in that country of about 128,000,000 people, 547,153 cardiac arrests occurred from 2005 to 2009.12

The recommended reporting structure for cardiac arrest data is the Utstein template. In this template, the patient is excluded from reporting if EMS personnel did not begin a resuscitation attempt. The template inquires whether the event was witnessed and if the witnesses performed CPR. Patients are then categorized by the initial presenting rhythm as shockable (e.g., ventricular fibrillation or pulseless ventricular tachycardia) or nonshockable (e.g., pulseless electrical activity or asystole). The occurrence of return of spontaneous circulation (ROSC) is also recorded, in addition to hospital discharge data.

The template also allows researchers to include follow-up data on short- and long-term neurological recovery. Neurological recovery is graded on a scale called Cerebral Performance Category (CPC).13,14 (See Table 2.)

Source: Cummins RO, Chamberlain DA, Abramson NS, et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: The Utstein Style. Circulation. 1991 Aug;84(2):960-75.

Ventricular fibrillation has been historically listed as the most common initial rhythm in out-of-hospital cardiac arrest. However, beginning in 2000, research began to report an increase in non-shockable rhythms as the primary presenting rhythm. The theory for the decline of VF is the success of pharmacological and device treatments targeted to patients with coronary artery disease. Examples of these treatments would be statin drugs, anti-hypertensive agents, and cardiac pacemakers and implanted defibrillators.15-17 However, the literature does not offer definitive reasoning for the somewhat sudden change.

 

Survival Rates

Survival from cardiac arrest is identified as a public health priority under the Healthy People 2020 goals of reducing death from. Survival rates for cardiac arrest vary dramatically by jurisdiction.18 Large metropolitan areas, such as Chicago and New York, often report older survival rates of 1.8–2.2%.19 The areas of Seattle/King County, Wash. and Rochester/Olmsted County, Minn. currently lead the nation in survival rates at or above 60% for VF cardiac arrest. Nationally, the survival to hospital discharge rate for adult patients assessed by EMS is 10.4%. Survival to hospital discharge is 28.4% if the initial rhythm is shockable and increased to 31.7% if bystander CPR was performed.11

The occurrence of ROSC in the field is associated with survival to hospital discharge. Patients transported to the hospital in cardiac arrest are highly unlikely to achieve ROSC.20 Public access defibrillation has increased survival rates in areas that generally suffer for difficult access for EMS provider. Equipping first responder agencies with AEDs has increased survival by ensuring one quickly arrives at the patient’s side after cardiac arrest occurs.21,22

An initial two-year study of AED use at Chicago area airports showed a survival rate of >60%.23 A multi-state study of casinos shows a 53% survival-to-hospital-discharge amongst patients who received a shock from a security officer.24 Exercise facilities, including golf courses, fitness centers, and recreation centers, are also common locations where public access AEDs have been placed.25

Although the AHA has recommended the chain of survival, researchers have actively evaluated retrospective cardiac arrest data to determine predictors for survival and the importance of system design.26 The CARES Registry used a composite model to evaluate bystander CPR, bystander AED, and response time less than four minutes. Their results found that each of those points have a statistically significant impact on survival in witnessed cardiac arrest.27 Data from King County shows a progressive increase in survival from unwitnessed arrest to witnessed arrest with the highest rate of survival in patients whose arrest was witnessed by EMS.28

 

Assessment

Assessment of the unresponsive patient who may be in cardiac arrest begins with assessing for responsiveness. The number of tasks that can be completed in the early stages of assessment and treatment depend on the number of providers present. It is likely that the team can do things simultaneously. For example, an early taking of patient history from family members and bystanders can yield important clues to the cause of the arrest. In addition, resources will often permit a search of the scene be performed while the resuscitation is happening. However, if you are a lone rescuer and the patient is unresponsive, quickly visualize for signs of life, such as whether the patient is breathing normally. If none is found, call for help.

The final assessment step is to check for a pulse at the carotid artery of the adult or child and the brachial artery of the infant. For healthcare providers, this pulse check should take no longer than 10 seconds. If no pulse is found or the rescuer is unsure, verbalize to the team that the patient is without a pulse. CPR should begin immediately while other equipment is being readied. A notification of a cardiac arrest patient should be made to any incoming resources and additional resources should be requested per system protocols.29

 

Location

Although cardiac arrest can occur anywhere, the location where treatment is actually rendered can be altered to improve the quality of resuscitation. An RCT showed that all aspects of resuscitation with manual compressions (i.e., compression rate, compression depth, and percentage of correct ventilations) were improved when the patient was on the floor rather than on the stretcher in a moving ambulance.30 Additional studies demonstrate similar concerns about the quality of CPR in a moving ambulance.31 Cloete et al compared the efforts of CPR in a standard hospital bed with the use of various “CPR boards.”

When CPR is conducted on a mattress, there is an inability of rescuers to compress at the recommended depth. Further, the use of a longer backboard increases both compression depth and back support.32 An earlier study found that the accuracy of CPR feedback provided by an accelerometer is maximized when the patient is on the floor. All CPR performed in a bed, regardless of the type of back support placed under the patient will overestimate compression quality.33

 

Treatment

The treatment of cardiac arrest is generally based on protocols that are derived from the International Liaison Committee on Resuscitation (ILCOR) Resuscitation Guidelines. The treatment of cardiac arrest is a bundle of care that includes both medications and procedures. Initial treatment of the cardiac arrest patient begins with prompt initiation of cardiopulmonary resuscitation (CPR). CPR is the mainstay in the treatment of the cardiac arrest patient. Other procedures are commonly employed during the management of cardiac arrest and will be discussed below.

 

High-Quality CPR

In the patient without a pulse, chest compressions are the key to maintaining perfusion of oxygenated blood to the tissues. Several human studies indicate that the chance for successful defibrillation with ROSC decreases in periods without chest compressions.34,35

According to the 2013 American Heart Association (AHA) Consensus Statement, “There are 5 critical components of high-quality CPR: minimize interruptions in chest compressions, provide compressions of adequate rate and depth, avoid leaning between compressions, and avoid excessive ventilation.”36  This statement has become the standard of care with the release of the 2015 Guidelines.126

In the patient with an unprotected airway, the AHA guidelines call for chest compressions and ventilations to be performed at a ratio of 30:2 with pauses in compressions being limited to 10 seconds. This comes to a total of five cycles of compressions and ventilations, which makes up the two minutes that resuscitation.37

 

Pharmacology

The pharmacology of cardiac arrest is the subject of extensive research and has changed over the history of resuscitation. The administration of a vasopressor, such as epinephrine, is the first line medication in all cardiac arrest patients. It is also important to note than in the presence of ventricular fibrillation or ventricular tachycardia, the guidelines call for the administration of the vasopressor to occur after the second shock.127

There is some evidence to suggest that early administration of epinephrine in the patient presenting with a non-shckable rhythm may be advantageous.128 If the patient is in a shockable rhythm that has been unchanged by defibrillation and the use of vasopressors, an antiarrhythmic is the next drug of choice. Amiodarone is the current drug of choice in the category; however, there may still be a role for lidocaine in the absence of amiodrane.

Additional medications may be added based on factors discovered during the assessment of the patient and vary based on the formulary and protocols of the respective ambulance service.38 Several studies conducted in the past 10 years compare some of the cardiac arrest medications with placebos.  Generally, these studies find greater ROSC with medications, however, survival to hospital discharge is similar in both groups.39-41 These studies and others were evaluated by ILCOR in determining the 2015 AHA Guidelines for CPR and ECC, but the evidence was insufficient to warrant major changes in practice at this time.127

 

Procedures

Prehospital medication has specific national and local protocols for the management of cardiac arrest.

 

Defibrillation

An AED or manual cardiac defibrillator should be attained and attached to the patient at the earliest possible time. Patients who are found in a shockable rhythm from ventricular fibrillation or ventricular tachycardia have their best chance of recovery when a shock is delivered early in the resuscitation effort. The purpose of defibrillation is to deliver an electric current across the heart that stops the heart from fibrillating. Defibrillation ensures the entire myocardium is depolarized, and the sinoatrial node once again becomes the dominant pacemaker.42,43  One recent study found that the highest rate of successful defibrillation with ROSC occurs in patients who receive the shock within two minutes of collapse.129  

Advances in the ability of AEDs and manual defibrillators to record to entire event for later review have opened up a new data source for cardiac arrest researchers. It is now possible to see on a frequent basis how the body responded to defibrillations and other therapies. Recurrent ventricular fibrillation occurs when the patient returns to VF following a successful defibrillation.  A study of first responder AED data showed that 73 out of 108 patients had at least one episode of recurrent VF prior to the arrival of ALS providers. This study defined a successful shock as the termination of VF for at least five seconds and found that 55% of recurrences occurred within 10 seconds of the resumption of chest compressions.44

Another research focus is refractory ventricular fibrillation, in which the patient remains in persistent VF despite treatment. Several researchers have used the cut point of 5 shocks, plus standard ACLS treatment as a point where double sequential external defibrillation (DSED) may be in order. The DSED process involves placing a second set of pads from a second defibrillator on the patient. The patient receives simultaneous defibrillations at the maximal emergency amount allowed by the machine. Research on DSED is limited to case study at this time because the rate of refractory VF is rare with an estimated occurrence of 0.5–0.6 per 100,000.45

 

Airway Management

Current resuscitation literature offers many different takes on airway management by prehospital providers and hospital providers as well. The management of the airway in cardiac arrest is a topic of study and controversy in the house of medicine. Some of the known complications of airway management include bleeding, bradycardia, hypotension, esophageal intubation, hypoxia, and vomiting.46 It is more than likely that there is no single solution to the management of the out of hospital cardiac arrest patient’s airway. A study from UK found that providers often use multiple airway methods during an arrest as the patient condition warrants.47

Passive airway management: One area of increased study is to allow spontaneous ventilations with compressions. The provider places a nonrebreather mask on the patient to deliver oxygen while continuous CPR is ongoing.48 A single retrospective study found an association with neurological recovery and passive airway management.49

Bag-valve mask ventilation: The bag-valve mask is the primary device used by healthcare workers to begin assisted ventilations. There is risk for hyperinflation and hyperventilation, as well as gastric insufflation.50,51 Some healthcare workers find it difficult to maintain an adequate seal and head tilt. The MOANS mnemonic, which represents mask, obesity, age, no teeth and stiff lungs, is used to evaluate the projected difficulty of BVM.52 The use of oral and nasal airways has been shown to improve neurological outcomes in cardiac arrest patients.53 Ideally BVM is a two-person procedure with one person doing a two-handed seal while a second rescuer squeezes the bag. A smaller study from Tokyo comparing patients who received BVM only with those who received some type of advanced airway found no statistical difference in ROSC or survival to hospital discharge.50 Sometimes BVM is the only method of airway management that is used. For example, a separate study on advanced airway management in Japan found that one-half of cardiac arrest patients are managed with a BVM only.54 A large-scale analysis of the Japanese Cardiac Arrest Registry found a more favorable neurological outcome in patients who received BVM as opposed to those who received an advanced airway. Survival rates in this study were 1.1% compared with 2.9%, with a higher number of patients also receiving BVM only.55

Supraglottic airway placement: The use of supraglottic airways (SGAs), such as the King Laryngeal Tube (King LT), has gained acceptance in recent years. These blind insertion devices have largely replaced the Combitube as the backup airway for ALS providers. The change was related to the speed and ease at which the device can be placed.56,57 SGA devices are at the scope of practice of the EMT in some jurisdictions and studies have shown that BLS providers are extremely successful in inserting these devices in a timely manner.58,59 There is also the possibility that SGA devices could be used as the primary device for advanced life support providers if the clinical situations warrants.60 Another advantage is that continuous chest compressions can begin increasing the chest compression fraction (CCF) over the use of the BVM.61 Supraglottic airways have even shown to reduce time with hands off the-chest when compared to endotracheal intubation.62 Because these were both manikin studies, the correlation to patient care is theoretical, however as stated earlier, increased CCF is an independent predictor of survival in OHCA patients.

Some in the anesthesia community are concerned about tongue engorgement if the device is left in place for more than two hours and how to best exchange the device for an endotracheal tube.63,64 Additionally, a single porcine study found that the supraglottic airway reduces cerebral blood flow when compared to an ET tube.65

Endotracheal intubation: Endotracheal intubation (ETI) has been part of the Advanced Life Support guidelines since their inception in 1974. As often taught today, the endotracheal tube isolates the airway, keeps it patent, prevents aspirations, and assures the delivery of oxygen to the lungs. Securing the airway also allows for continuous chest compressions. The placement of an endotracheal tube is not without difficulty or complication, and its use should be restricted to personnel who are highly trained, intubate frequently or are frequently retrained in the technique.38 The practice was officially added to the paramedic curriculum in 1985.66

The primary concern about ETI is the success rate of prehospital providers and reports of missed esophageal placement.46 ETI often forces interruption in chest compression, which has been shown to increase mortality.48 A secondary analysis of ROC data found that ETI patients had a higher rate of survival to hospital discharge than patients receiving an SGA.67 Similar results were reported in a Japanese study in which ETI resulted in greater likelihood of ROSC but also better neurological outcomes at one month. The overall survival rates in this study are low, but the authors indicate that all patients are transported because field termination is not allowed in Japan.54

Video laryngoscopes: Several types of video laryngoscopes are available to assist with intubation. In these devices, a video camera incorporated in the blade transmits an image of the airway to a screen. A prospective study of two common video laryngoscopes, the GlideScope from Washington-based Verathon Medical and the C-MAC from Germany-based Karl Storz, found similar success rates for both first-pass and overall success of intubation.68 A review of quality assurance data comparing C-MAC to direct laryngoscopy with a Macintosh blade found that overall success and better visualization of the airway were obtained with the C-MAC.69

End-tidal capnography: Failure of ET intubation, as well as tube displacement, has been reported in the literature.70 One method of determining the successful completion and maintenance of intubation is through the use of capnography, which involves monitoring the partial pressure of exhaled end-tidal carbon dioxide (EtCO2).71 One initial study showed the odds of unrecognized intubation were higher in the cohort that did not use continuous EtCO2, with the rate of unrecognized intubation in the EtCO2 group at 0%.72 Further research has shown that capnography results are important to cardiac arrest monitoring because they fall when the patient becomes pulseless and increase when ROSC occurs.73,74 Recent research has also provided some evidence that EtCO2 may be used as a predictor of survival from cardiac arrest; however, more research is needed to validate this work. Evidence suggests that an intial EtCO2 >10 and the ability to maintain EtCO2 above 20 during the arrest are significantly associated with ROSC.71,75

 

Compressions

Mechanical CPR devices: Data from research has caused concern for the capacity of human beings to perform manual CPR. Studies have indicated poor retention rates and poor quality of CPR.76-78 There is also concern about the ability of EMS systems to supply the human resources necessary to ensure fresh rescuers to perform CPR throughout a code. Additionally, research has shown that the quality of CPR in a moving ambulance is poor, as well as dangerous to the unrestrained provider in the event of a motor vehicle crash or evasive maneuvers.31,79,80 One novel study from Japan determined that the technique of CPR changes while standing in the ambulance because different muscles and joints are used.81 Air medical services have explored the use of mechanical CPR devices in helicopters to mitigate concerns about cabin size and crew safety.82 Several systems are exploring the use of or have implemented mechanical CPR devices to combat these concerns.83,84

Several mechanical CPR devices are available. The original mechanical CPR device, called the Thumper, was introduced by Michigan-based Michigan Instruments in the 1970s. This device used a piston powered by compressed air or oxygen to deliver chest compressions. The AutoPulse, produced by Massachusetts-based Zoll Medical Corp., uses a load-distributing, broad compression band that is applied across the entire anterior chest.85 The LUCAS_1 Chest Compression System, originally introduced by Sweden-based Lund University Cardiopulmonary Assist System and now owned by Physio-Control Inc., is a pneumatically powered device that delivers standardized chest compressions with active chest recoil via a piston and suction-cup mechanism.86

Data from the literature has caused concern over the length of time needed to apply the mechanical CPR device to the patient. Load-distributing-band type devices can be deployed within two minutes in a majority of situations, and the patient will benefit from the continuous chest compressions.85 A study using the LUCAS device found that the device could be placed with a median of 32 seconds of hands-off time, but the researchers cautioned that users do not perceive pauses in time accurately.87 A concern from a Swedish study was the inability of providers to determine whether the device was appropriately placed, increasing the risk of injury to the patient.88

The two initial studies on the load-distributing-band produced contradictory outcomes. A multi-center trial in North America was halted due to concerns about lower outcomes in the intervention group. Conversely a single-center trial found improved outcomes with the same intervention. Results from the international CIRC trial found no statistical difference between the manual CPR group and the intervention group.89

The LINC trial was a five-year, multi-center RCT from Europe that enrolled almost 2,600 patients. The patient demographics were surprisingly similar between the two groups—with no significant difference in ROSC, four-hour survival, or six-month survival.86 The primary benefit to mechanical CPR seems to be the ability to perform consistent chest compressions, minimizing hands-off time.90 Much like traditional CPR, mechanical CPR presents risk of injury to the patient. One case report found tension pneumothorax caused by broken ribs in an appropriately placed LUCAS device.91 A second report found the patient suffered trauma to the pancreas after receiving CPR from the LUCAS device. Although the cause is unknown, the authors speculate there was inadvertent movement of the device during the resuscitation.92 The results from the CIRC trial found no new injuries beyond traditional CPR but noted higher rates of rib fracture and subcutaneous emphysema with the use of the load-distributing band.89 Similarly, a review of patients from the LINC trial found an increased rate of rib fractures in the mechanical cardiopulmonary resuscitation (CPR) group.93  

The 2015 Guidelines reinforce the delivery of high-quality manual compressions as the standard of care.  Mechanical CPR devices that are either piston or load bearing may be used by trained providers where high quality CPR may be difficult to provide.  Such situations impacting prehospital providers include limited number of rescuers, prolonged CPR, during hypothermic cardiac arrest, and during transport.130

Impedance threshold devices (ITDs): The ITD is designed to enhance venous return and cardiac output during CPR by increasing the degree of negative intrathoracic pressure. The ITD is positioned between the port of the advanced airway and the bag valve mask. The ITD may also be used with a mask and BVM, but a seal must be maintained at all times using a two-handed seal.94 The device has been widely trialed, particularly in EMS systems participating in the ROC trial. A large RCT lasting almost two years and enrolling more than 8,700 patients found no difference in survival among patient treated with a real or sham ITD.95  Based on a review of the evidence, the 2015 guidelines indicate that the ITD should only be used in conjunction with Active Compression-Decompression CPR with properly trained providers.130

Active compression decompression (ACD) CPR: The purpose of ACD CPR is to actively decrease intrathoracic pressure during diastole with a suction-type device, thereby promoting venous return of blood to the heart.96 A multi-center trial comparing standard CPR to ACD-CPR with ITD showed a statistical significant increase in hospital discharge in the study group.94

Providing assistance to rescuers: Over time, studies have shown that rescuers have trouble performing skills to the standards of the guidelines. This is in part due to retention issues.97-101 Evidence shows the addition of audio prompts and feedback can help rescuers stay on task.102 Chiang and colleagues found that the addition of a metronome set at the rate of 100/minute and a siren that sounded every 20 seconds improved both hands-off time and the time to complete the intubation.103 Other studies have shown the ability to monitor changes through defibrillator records, although this is largely a quality assurance function.104

 

Teamwork and Leadership 

Care of the cardiac arrest patient is often undertaken by teams of rescuers, sometimes of varied skill levels. A team leader must be designated to coordinate the work of the team to ensure patient safety. A simulation study of experienced critical care clinicians showed that the absence of leadership and explicit task distribution were human factors associated with poor team performance in cardiac arrest management.105 Since the landmark To Err is Human report, there is a growing recognition in healthcare that the team leader, be it paramedic, nurse, or physician, is not an island.106 Crew resource management (CRM), which comes from the airline industry, is a model that promotes patient safety through teamwork and leadership skills. An RCT from Germany showed that the addition of CRM content to an ALS course increased team leader verbalization (TLV) and follower verbalization (FV) while reducing no-flow time (NFT).107 Many agencies are exploring the pit crew concept for cardiac arrest; however the results of those activities have not been published at this time.

 

Post-Resuscitation Care

The 2010 AHA Guidelines introduced a post cardiac arrest management algorithm identifying the usefulness of 12-lead ECG acquisition, transport to a percutaneous coronary intervention (PCI) capable center and the application of therapeutic hypothermia.28,108 These interventions are not new; however, these guidelines marked the beginning of a more formalized approach to post-resuscitation care. The Göteborg, Sweden EMS system compared patients from 1980–2002 with patients from 2002–2006. Rates of coronary artery bypass graft (CABG), PCI and hypothermia increased and were statistically significant to patient outcome. In this population, survival rates did not change, however, cerebral performance category (CPC) score on discharge did improve dramatically.109 Likewise, a retrospective study from South Korea found that patients who received active post-resuscitation care had improved outcomes over patients who received conservative care.110 The ROC group found similar results and also posited that hospitals treating a higher number of out-of-hospital cardiac arrest patients are more likely to initiate therapy and more favorable outcomes.111

 

Oxygen Titration

The administration of oxygen in cardiac arrest is an area of controversy and continued study. Research suggests that ventricular fibrillation, in particular, places significant oxygen demands on the myocardium.112 At the same time, a growing understanding of the deleterious effects of oxygen-free radicals created by hyperoxia causes questions about the delivery of oxygen.48 The guidelines indicate ensuring the patient’s oxygen saturation is ≥94%, but to begin reducing oxygen concentration (FiO2) to the minimum amount necessary to keep the patient at that level.108

 

Hypothermia

Therapeutic hypothermia was first proposed by Peter Safar, MD, in the 1950s who called it “suspended animation.” Initial attempts involved taking the patient to 30 degrees Celsius and were abandoned.112 The practice became technologically feasible in the late 1990s.113,114

In-hospital hypothermia can be induced by forced cold air, ice packs, and cooling blankets to bring the patient’s body temperature to 33 degrees Celsius. The patient is sedated, and the hypothermic state is generally maintained for 24 hours followed by a period of passive rewarming.115,116

The median day to awakening after cardiac arrest is day two.117 Hypothermia is used with success in patients whose presenting rhythm is shockable in nature. There is evidence to suggest hypothermia in patients who present with asystole or PEA is not associated with improved outcomes.118  Based on concerns about the neurological outcomes of patients who are not treated with hypothermia, the 2015 guidelines recommend that all patients who are comatose after ROSC receive hypothermia, regardless of the presenting rhythm.131

Although the majority of the treatment occurs in hospital, EMS systems initiate hypothermia with ice packs in axial regions or infusions of cold saline. Some evidence shows rapid infusions of cold saline by EMS personnel decreased the time to cool the patient by one hour, but they produced an increase in re-arrest and transient pulmonary edema without changing neurological outcome.119  Based on this and other studies, the 2015 guidelines advise against prehospital induction of hypothermia with cold saline.131

A recent randomized control trial finds no statistical significance in the outcome of patients who were induced to 36 degrees Celsius. The authors caution that further study is required to determine the best course of treatment for each patient.120 It is known that fever within 48 hours after ROSC is common. A study by Gephardt, et al, found that the occurrence of fever in a non-therapeutic hypothermia group was associated with death. Although fever can still occur in patients treated with therapeutic hypothermia, the treatment seems to decrease death.121

 

PCI and 12-lead ECG

An initial study of post-cardiac arrest survivors took all comers to the PCI suite, regardless of ECG findings. ST-elevation myocardial infarction (STEMI) was evident in 42% of the patients, with occlusion found in 48% of the patients. Regardless of the rhythm or the findings, the important finding of this study was that PCI in the recently resuscitated patient was safe and resulted in positive outcomes.122 Although most protocols would indicate PCI only in the presence of STEMI, this group validated their results over a decade after the initial study and found similar results.123 Since there is some concern about how the post-cardiac arrest state may alter the ECG, work continues to determine the best way to use the multi-lead electrocardiogram as a diagnostic tool.124

 

Blood Pressure Control

Obtaining baseline vitals when ROSC is achieved has long been part of patient care.  In 2015, the ILCOR writing group evaluated the impact of hypotension on patient outcomes.  Multiple studies were evaluated and were complicated by their design.  A single study evaluated prehospital data, specifically the first blood pressure on arrival at the Emergency Department.  The study found that patients who achieve ROSC after a VF/VT arrest and present to the ER with a systolic blood pressure <90 mm HG have a lower odds of survival than patients presenting with higher blood pressures.132  The 2015 recommendation is to avoid and immediately correct hypotension (systolic blood pressure less than 90 mm HG. MAP less than 65 mm Hg); however, specific values and the treatments that could be used to achieve those values (fluids, pressors, etc.) are left to local protocols.131

 

Termination of Efforts

Despite the best efforts of providers, many patients fail to achieve ROSC on scene.  In these cases prehospital providers must determine if it is appropriate to terminate the resuscitation or transport the patient to the hospital.  Although many new providers look for clear decision points such as a minimum time to work a code, these decisions are more nuanced.  The 2011 NAEMSP position statement Termination of Resuscitation (TOR) by EMS providers for patients in non-traumatic cardiopulmonary arrest indicated the following conditions that must be met prior to making this decision:

  • The arrest was not witnessed by an EMS provider;
  • There is no shockable rhythm identified by an automated external defibrillator (AED) or other electronic monitor, and
  • There is no return of spontaneous circulation prior to EMS transport.133

Two recent advances to the practice of medicine have brought new life into this discussion.  The first is the use of ECMO on patients in cardiac arrest, termed E-CPR.  In these cases, patients are transported to the hospital with CPR ongoing (preferably with automated CPR and mechanical ventilation).  In the ER, patients are placed on ECMO, which takes the place of circulation until the cause of the arrest can be corrected.  As the literature has yet to define the population that would benefit from this, the 2015 Guidelines indicate E-CPR can be used in settings where the therapy can be rapidly implemented.127

The second advance results from the increased use and understanding of ETCO2.  As noted earlier, continuous monitoring of ETCO2 with waveform capnography is a gold standard of airway management.  Several older studies with small samples have evaluated the relationship between ETCO2 and ROSC and we referenced in the Guidelines.  The consensus opinion is that the failure of an intubated patient to achieve ETCO2 of greater than 10 mmHg after 20 minutes of resuscitation is a factor that may be used to aid in the decision of when to terminate efforts.127  

 

Prevention

True cardiac arrests are likely caused by the blockage of an artery by plaque. In many patients, cardiac arrest is the first symptom of heart problems. This type of cardiac arrest is a cumulative problem. Steps can be taken to decrease the prevalence of the modifiable risk factors of heart disease. They include lowering blood pressure and cholesterol, controlling weight, increasing physical activity, reducing cigarette smoking and controlling diabetes. Taking any of these steps is also a method of reducing the incidence of cardiac arrest, as well as other potential health problems.11

Even with reduction of the incidence of cardiac arrest, increasing bystander CPR can help reduce the number of deaths from witnessed cardiac arrest. Many agencies and organizations support bystander CPR. For example, Healthy People 2020 advocates increasing the proportion of out-of-hospital cardiac arrests with appropriate bystander and EMS in its 18th Heart Disease and Stroke (HDS-18) objective.125 In the U.S. the AHA has been aligned with the promotion of bystander CPR since 1972. Its Hands-Only CPR page includes demos and videos, survivor stories, and even a musical playlist. And in the U.K., a London Ambulance Service study found that a focus on bystander CPR that including training of 30,000 people backed with a public education campaign produced an increase in the rates of bystander CPR and resulted in an increase in ROSC to the hospital. EMS agencies continue to explore outreach options for designed at increasing rates of bystander CPR.26

 

Conclusion

The resuscitation of the patient in cardiac arrest is one of the most dramatic events in medicine. The foundation of the resuscitation effort is a focus on high quality CPR and early defibrillation. In addition to clinical skills, knowledge of team leadership and team membership are important in the management of these patients.

Providers and local agencies can improve the success of the resuscitation team by having a detailed understanding of the anatomy and physiology of the cardiovascular system, the pathophysiology of cardiac arrest, and the prevalence of these incidents. Proper assessment of the patient, knowledge of best practices in treatment, pharmacology and procedures, can also increase the chances of a good outcome.

Combining those elements of team and individual success with prevention and community involvement through bystander CPR can help increase successful outcomes of our patients in cardiac arrest.

 

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Published: May 1, 2015
Revised: November 27, 2015