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Sunday, November 21, 2010

Bystander CPR Significantly Superior for Out Of Hospital Cardiac Arrests

Bystander chest compression-only CPR linked with survival benefit for cardiac arrest

Bobrow B. JAMA. 2010;304:1447-1454.

Cone D. JAMA. 2010;304:1493-1495.

The application of chest compression-only CPR by a layperson bystander was associated with increased survival in patients experiencing out-of-hospital cardiac arrest, results from a new analysis suggested.

Researchers observed 5,272 patients with out-of-hospital cardiac arrests during the 5-year follow-up period of the prospective, observational study. All patients were at least 18 years of age and had out-of-hospital cardiac arrests between 2005 and 2009. The relationship between layperson bystander administering CPR and survival to discharge was characterized using multivariable logistic regression analysis. The primary outcome was survival to hospital discharge, which was determined by a review of hospital records.

According to the results, 4,415 out-of-hospital cardiac arrests were reported and 779 were excluded from the analysis because the CPR was administered by a health care professional or were evaluated in a medical facility; this included 666 people who received conventional CPR, 849 who received compression-only CPR and 2,900 who received no bystander CPR.

Rates of survival to hospital discharge were higher in the compression-only group (13.3%; 95% CI, 11.0-15.6) when compared with the group with no bystander intervention (5.2%; 95% CI, 4.4-6.0) and the conventional CPR group (7.8%; 95% CI, 5.8-9.8). The researchers also reported an increase in layperson CPR from 2005 to 2009 (28.2% to 39.9%, P<.001), along with an increase in the proportion of compression-only CPR during the same time period (19.6% to 75.9%, P<.001). In increase in overall survival was also reported from 2005 to 2009 (3.7% to 9.8%, P<.001).

“Implementation of a 5-year, multifaceted, statewide public education campaign that officially endorsed and encouraged chest compression-only CPR was associated with a significant increase in the rate of bystander CPR for adults who experienced out-of-hospital cardiac arrest,” the researchers concluded. “Furthermore, chest compression-only CPR was independently associated with an increased rate of survival compared with no bystander CPR or conventional CPR.”

In an accompanying editorial, David C. Cone, MD, of Yale University School of Medicine in New Haven, Conn., said the findings regarding compression-only CPR were in line with those of previous trials that had suggested a theoretical advantage but did not offer much confirmatory data, adding that the results were encouraging, and no associations with neurologically impaired survival were reported.

“Taken together, these findings, along with the findings of the compression-only CPR trials and the findings reported by Bobrow et al suggesting a survival benefit, should encourage and justify continuing investigations involving compression-only CPR,” Cone wrote.

Saturday, November 20, 2010

Here's what hits the schools...

Abstract 12205: Saving Lives in Schools — School-based CPR-AED Programs: Awareness, Education, Planning and Partnerships

Stuart Berger; Robert Campbell; Jon Drezner; John Wilson; Allison Ellison; Maryanne Kessel; Debra Klich; Rebecca Neumann-Schwabe

Med College of Wisconsin, Milwaukee, WI; Emory Univ Med Sch, Atlanta, GA; Univ of Washington, Seattle, WA; Univ of Wisconsin, Madison, WI; Children's Healthcare of Atlanta, Atlanta, GA; Children's Hosp of Wisconsin, Milwaukee, WI; Children's Hopsital of Wisconsin, Milwaukee, WI; Children's Hosp of Wisconsin, Milwaukee, WI

Background: Sudden cardiac death (SCD) in the young is devastating. 20% of the U.S. adult and pediatric population spends time in schools each week, making schools a strategic location for secondary prevention through CPR-AED programs.

Purpose: We sought to describe the impact of school based CPR-AED programs.

Methods: Project ADAM (PA) (Milwaukee, WI) and Project SAVE (Atlanta, GA) are community programs designed to prevent SCD in schools. The goals are directed toward schools, including (1) education/awareness of signs, symptoms, treatment of SCA, (2) implementation of CPR-AED programs in schools (3) advocacy for students to learn CPR/AED use prior to graduation. SCA events are monitored at existing participating schools. A comprehensive program includes a coordinator, EMS, first responder team development/training, purchase/maintenance of AED(s) and an emergency response plan.

Results: WI: 850 schools have CPR-AED programs (35% of all WI schools). All schools in the Milwaukee Public School system have a program and 70% of high schools have programs. Across WI, in schools where an AED was deployed at the time of a SCA, there was a 36% rate of survival to hospital discharge. Since PA started, 11 "saves" are a result of school programs: 6 adults, 5 children/adolescents. GA: Project SAVE has provided CPR-AED program information to all 180 school districts in GA. 65% of all schools have AEDs and a HeartSafe program has been recognized in 728 schools (32% of schools). From Oct 2004 — May 2010:49 (26 students; 23 adults) SCA events have been reported in GA schools. Due to improved school AED and emergency response plans, 22 of the incidents have resulted in survival to hospital discharge (45% total survival rate, 10 students; 12 adults). Many student SCAs did not occur with high school sports (2 elementary, 6 middle, and 18 high school). Diagnoses in the child/adolescent survivor group include LQTS, CA from the opposite sinus of Valsalva, HCM, Kawasaki disease, aortic stenosis, WPW, commotio cordis and lightning strike.

Conclusions: Community programs designed to assist schools implement school CPR-AED programs are successful and lead to a high survival rate for SCA occurring in schools.

Author Disclosures: S. Berger: None. R. Campbell: None. J. Drezner: None. J. Wilson: None. A. Ellison: None. M. Kessel: None. D. Klich: None. R. Neumann-Schwabe: None.

Friday, November 19, 2010

The healing has begun

It's all about not interrupting chest compressions.

_________________

Prehospital Intubation Results in Worse Outcomes in Adult Cardiac Arrest Patients

Prehospital intubation was negatively associated with return of spontaneous circulation and survival to discharge.

Although studies in children suggest worse outcomes among those managed with prehospital intubation versus bag-valve-mask ventilation (JW Emerg Med Apr 1 2000), few studies have addressed this issue in adult patients with out-of-hospital cardiac arrest. In a retrospective study of data from an emergency medical services system in North Carolina for 1142 adult patients with cardiac arrest, researchers assessed the association between performance of prehospital endotracheal intubation and return of spontaneous circulation (ROSC) in the field and survival to discharge. The decision to attempt intubation was at the paramedics' discretion.

Intubation was not performed in 203 patients. In analysis that controlled for initial arrest rhythm, patients who were managed without any attempt at prehospital intubation were 2.3 times more likely to have ROSC in the field and 5.5 times more likely to be discharged from the hospital alive than patients who had one successful prehospital intubation attempt.

Comment: The 2010 American College of Cardiology/American Heart Association Advanced Cardiac Life Support guidelines emphasize chest compressions before airway management for all patients with cardiac arrest except newborns. Although these retrospective results could not determine cause and effect, the findings suggest that attempts at prehospital intubation are associated with worse outcomes in patients with out-of-hospital cardiac arrest. Interruption of chest compressions might contribute to the worse outcomes. Further study is warranted to determine whether prehospital intubation might cause more harm than good in adult patients with cardiac arrest.

Diane M. Birnbaumer, MD, FACEP

Published in Journal Watch Emergency Medicine November 19, 2010

CITATION(S):

Studnek JR et al. The association between prehospital endotracheal intubation attempts and survival to hospital discharge among out-of-hospital cardiac arrest patients. Acad Emerg Med 2010 Sep; 17:918.

Thursday, November 18, 2010

Another save...with comments

Here is a recent story about a successful cardiac arrest save. I've added some [comments within square brackets] to point out some really pertinent points.

Bob

Edwards hero saves heart attack victim with CPR


by Staff Sgt. Angelique Smythe
95th Air Base Wing Public Affairs


11/17/2010 - LANCASTER, Calif. -- With his own heart racing, he made every effort to keep the heart of the man lying lifeless on the ground beating.

Compression after compression. Breath after breath. Still, no change. [In this case - a witnessed adult arrest - no mouth-to-mouth is indicated. The odds of not dying or of not winding up with neurological damage is higher if you skip the breaths and thus avoid the interruptions.]This was nothing like the movies when a victim would simply return to life within a few seconds of receiving cardiopulmonary resuscitation.

He tried to block out the chaotic shouting of bystanders throwing out suggestions of things to do to save this man's life and the constant questioning from terrified family members. Is he all right? How's he doing? Is he responding? [This is a very accurate description of what goes on when a crowd gathers. All of a sudden everybody is an expert, and it's very distracting to the person performing CPR. Try to get one person to control the crowd.]

Minutes were slowly passing, but time was running out. He was starting to feel tired. Another man dropped to his knees to assist with compressions.

Finally, after what seemed like an eternity, paramedics arrived. But his job was not over yet.

"Who's doing the CPR?" they asked.

"I am," he said.

"Keep doing it."

Manuel Jaramillo, 95th Air Base Wing Environmental Restoration specialist, continued working to keep the oxygen flowing into this stranger's lungs as the paramedics worked hastily around him in preparation for defibrillation.

Mr. Jaramillo was in the middle of a softball game on a field in Lancaster, Calif., Aug. 15, when the pitcher of the opposing team suffered a massive heart attack.

Ron Welsh, a 30-year employee of Lockheed Martin in Palmdale, Calif., had just pitched the ball when he suddenly fell to the ground, suffered convulsions, then lied motionless on the field. People quickly surrounded him. No one understood what was going on. Everyone was in a state of panic.

Mr. Jaramillo rushed to the scene and noticed Mr. Welsh's skin was beginning to turn blue. He then noticed Mr. Welsh's wife, who had also been standing there in shock along with her son, Daniel Welsh.

"It's kind of awkward to approach someone like that," Mr. Jaramillo said. "I'm not one to just step up to the plate and say, 'let me be the hero.' I said, 'Ma'am, I'm CPR certified, if there's anything I can do, just let me know and I'll help you out.'"

She immediately pushed him to the ground.

"I started to check for a pulse, but I couldn't find a pulse on him," Mr. Jaramillo recalled. "People were starting to yell things like, 'do this; do that; you've got to check his pulse over here.' I tried to block it all out and continued doing what I was doing. It's kind of difficult to check someone's pulse when you've got everything racing like that. The only pulse I felt was my own." [Don't bother with checking the pulse. It's a waste of time, and someone who isn't really good at checking pulses or doing CPR can feel a pulse on a rock. The turning blue around the mouth tells you all you need to know in this case - what's needed are chest compressions, at least 2" deep, 100 times a minute.]

Mr. Jaramillo performed CPR for approximately 10 minutes. It had been nearly one year since he was trained on this very important life-saving skill, and he would be due for recertification within one week.

Mr. Jaramillo, a three-year employee of Edwards Air Force Base, Calif., said, "We need to be (CPR) certified for our jobs because we go to really remote locations (to monitor water.) So, if something were to happen to any of us, all of us are CPR certified."

When Gary Booker, Mr. Jaramillo's teammate and a property manager in Lancaster, noticed Mr. Jaramillo was becoming weary, he got down to perform compressions.

"When you're doing that and somebody kneels down next to you and decides to give you a hand, it makes a big difference," Mr. Jaramillo said. "You can ask anybody who performs CPR training and they'll tell you that you're going to get tired from doing it. It's not like you're going to do it and then they're just going to automatically wake up. Chances are you're just keeping the guy alive until professional help arrives. There wasn't much I could do except keep his heart pumping and blood flowing throughout his extremities." [What really counts is keeping the blood flowing through the brain and heart muscle.]

Mr. Booker said he remembered looking over and seeing the man on the ground.

"He looked as if he was having a hard time breathing," he said. "I didn't move at first. Manny definitely was the first one there, and he was there all the way throughout the whole thing."

While assisting Mr. Jaramillo with compressions, Mr. Booker could hear people praying. He saw the wife crying and her son standing over her shoulder saying, "Come on, dad."

Mr. Booker said his girlfriend, a healthcare professional, assisted by taking out the victim's dentures to provide more space for an airway. [That's not as silly as it sounds to some folks: A lot of time victims in this situation will have a swelling tongue. You need all the airway room you can get. The compression-only CPR is relying on residual oxygen in the blood, residual are in the lungs, and a non-inconsequential movement of air into and out of the lungs as the chest is compressed and then recoils.]

"Manny was the guy," he said. "I mean, I jumped in and helped out, but Manny was really solely responsible for helping in keeping that man alive. I'm just thankful for his quick actions and persistence and for staying with that man until paramedics took over."

Mr. Booker said he, too, is CPR certified which is very much necessary for a high school basketball coach. He's coached for six years in both northern and southern California.

"With the responsibility of coaching, or being in a gym filled with kids, you have to have (CPR) certification," he said. "It's really helpful to know what to do if something happens."

The paramedics shocked Mr. Welsh several times on the baseball field, but he did not become any better. They rushed him to the hospital where he was placed under a medically induced coma for the next two weeks.

Mr. Welsh's son, Daniel, said his father suddenly awoke just as the doctors were getting ready to tell his family that he probably would not make it.

"The doctors still can't believe he's alive," Daniel said.

Mr. Welsh's blocked artery was one which doctors usually refer to as the 'widow-maker' as its blockage can cause a massive heart attack which most often immediately leads to death.

"He was gone from us for a couple hours and had to be resuscitated, shocked and defibrillated a few times," Daniel said. "As a 25-year-old man, I never thought I'd have to watch my father die, which in all reality, is really what happened."

Each doctor the family came across throughout Mr. Welsh's month-long stay at the hospital told them that if it weren't for the two gentlemen who performed CPR, he would not have made it off of the baseball field, let alone his going home to them within a few weeks.

"(Manny) is an angel; he was sent from God to watch over my father," Daniel said. "The doctors said only three percent of people who get CPR outside of the hospital even make it to the hospital because people don't always do it correctly. It so happened that Manny and (Gary) knew what they were doing. They worked perfectly in unison as a team. I owe them my deepest gratitude."

Each week, Daniel called Mr. Jaramillo to keep him updated on Mr. Welsh's status. After his release from the hospital, for the first time since the incident, Mr. Welsh and his family attended another softball game in late September. He thanked everyone for their support and expressed his appreciation to the men who saved him.

It was then Mr. Jaramillo and Mr. Welsh were finally introduced to one another.

"The really cool thing is we ended up playing (Mr. Welsh's team) a few weeks later," Mr. Booker said. "It was at the same time on the same field as the previous game. Before the game, everyone recognized he was there. Our team went over to the bleachers, shook his hand and expressed how glad they were to see him back."

Mr. Welsh said he encourages everyone to learn CPR. Although he, himself, hasn't yet had CPR training, he said this will become one of his top priorities after full recovery.

"It saved my life, and I thank Manny everyday that he took this class," he said.

On Nov. 12, the two reunited again for a photo for this article and the Welsh family continuously expressed feelings of gratitude to Mr. Jaramillo.

Wednesday, November 17, 2010

Making it real

One of the problems encountered in trying to convince people that they ought to learn CPR is that many people think it's not relevant to them.

We keep looking for new ways to help people realize that cardiac arrests are realities that happen to people they know and that they might someday be the person who has the responsibility of keeping the heart and brain alive until the medics get there.

Here's one of the more recent suggestions.

"Write down a list of your family members, your friends, and your acquaintances. Divide the number of names on that list by 7 - that's the number of people on that list that will witness at least one sudden cardiac arrest in their lifetime.

"Now, look at that list of names. The odds are high that when you witness a sudden cardiac arrest, the victim will be someone from that list. When that happens, you will need to perform CPR and there has to be an AED nearby...or you will have to live with the remembrance that you could have made a large difference, if only you had invested an hour or so."

I'd really appreciate any suggestions you might have for how we can make this real to more people. bobt@slicc.org

Monday, November 15, 2010

Cardiac arrest recovery broadcast on PA system.

Who doesn't remember the roar of a loyal crowd at a high school football game? Cheerleaders with their multi-colored pom pom's, parents with homemade signs, athletic directors having heart attacks over the PA system. Wait, what?

Erasmus Hall HS athletic director Marshall Tames was broadcasting the play-by-play on a playoff game in Brooklyn when he suffered a near-fatal heart attack yesterday afternoon [see original story in NY Post.]. Faster than you can pull off a blitz, Tames went from calling punt returns to lying on the ground with no heartbeat, having stopped breathing. Speechless spectators listened as Tames was defibrillated on the spot, with everything overheard on the loudspeaker. Chris Miccio, who was keeping time for the game and first began CPR when Tames collapsed, said the people in the stands of the 2,000-seat at Midwood High's field were relieved when he responded quickly. "Somebody asked you what you did today. 'Oh, I worked a scoreboard at a football game and saved somebody's life,' " Miccio said. It's probably the craziest PA announcement we've heard of since Kenny Powers' curse-laden high school job acceptance speech.



Sunday, November 14, 2010

Systems Approach Improves Survival

Abstract 51: Implementation of the American Heart Association Guidelines With a Systems-Based Approach Improves Survival to Hospital Discharge Following Prehospital Cardiac Arrest

Michael Dailey; Jonathan Politis; Terry A Provo

Albany Med Cntr, Albany, NY; Town of Colonie EMS Dept, Latham, NY; Advanced Circulatory Systems, Roseville, MN

Intro: A systems-based approach to out-of-hospital cardiac arrest (OHCA) involves optimizing the care continuum beginning with public recognition and bystander CPR, and continuing through specialized post-resuscitation care at Level One Cardiac Arrest Centers (L1CACs).

Hypothesis: Implementing a systems-based approach to resuscitation care that includes the most highly recommended AHA resuscitation guidelines will improve survival.

Methods: Beginning in 2006, the Town of Colonie (NY) (population 80,000) EMS system began phasing in multiple recommended therapies from the 2005 AHA CPR guidelines including: 2006) new CPR guidelines and expanded bystander CPR Anytime training; 2007) use of an impedance threshold device and emphasis on, and more rapid deployment of, mechanical CPR; 2008) improvements in dispatch to reduce response times, two minutes of CPR prior to defibrillation, and delaying advanced airway placement and IV access in favor of a period of high quality CPR;and 2009) hospital therapeutic hypothermia for comatose resuscitated arrests. EMS shift commanders respond to all cardiac arrests to assure strict protocol compliance. Resuscitated arrests are transported to L1CACs capable of continuing therapeutic hypothermia. A Standard Chi-Square analysis was performed.

Results: Since 2005 {approx}200 people/year were trained in CPR, dispatch improvements reduced response times by one minute, and three L1CACs were established. Survival following OHCAimproved from 4% (3/75; 2005 historical control) to 22% (14/64) (p=0.0013) in 2009. Survivors from 2009 were neurologically intact.

Conclusion: When OHCA patients were treated with a systems-based approach intended to improve bystander CPR rates, rapidly defibrillate, optimize circulation during CPR, and preserve vital organ function following cardiac arrest, survival rates quadrupled compared to historical controls. This approach had dramatic effects on survival in this mid-size community.

Formula

Author Disclosures: M. Dailey: None. J. Politis: None. T.A. Provo: Employment; Significant; ACSI.

From Circulation, a peer-reviewed journal of the AHA