The Vitals: Priorities in Cardiac Arrest Part 1

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Picture of Shyam Murali
Shyam Murali
Fellow in Trauma and Surgical Critical Care - University of Pennsylvania, Senior Editor - CriticalCareNow.com, Writer - RebelEM.com, Saxophonist, EDM remixer, husband, puppy father, and new human father

The Pre-brief

Recently I gave a lecture to our interns about the basic approach to cardiac arrest. This was the result of that lecture…

I want to break down this chicken scratch into more understandable terms and will start today by discussing priorities in cardiac arrest. Much of this is dependent on your personal practice, so we would love to hear from you in the comments about how you like to do things.

Before your patient arrives to the emergency department, it is crucial to gather your team and brief them: assign roles, verbalize any known information about the patient, and give them a rough plan of the first few minutes of resuscitation. At a minimum, consider having the following roles assigned:

  • team leader
  • at least one designated chest compressor
  • airway operator (does not need to be able to intubate; just needs to be trained in basic airway maneuvers) 
  • IV or IO placer and medications manager (also switches with chest compressor at appropriate intervals)
  • vitals, monitor, and defibrillator manager (can also switch with compressor, but more challenging because defibrillation and compressor swaps will usually take place at the same time, i.e. during rhythm/pulse checks)
  • recorder/timer

Discuss all the information you currently know about the patient with the rest of the team. Establish and communicate a tentative plan with your team for the first few minutes of the resuscitation, with the understanding that it may change the minute your patient is wheeled through the door. This allows the team to have a shared mental model, so it can operate as one unit during the first part of the patient’s care. Tell your team ahead of time if you are considering advanced CPR practices such as pre-charging the defibrillator, infusing epinephrine instead of using bolus doses, dual sequential defibrillation, or using ETCO2 to determine ROSC or futility.

For in-hospital cardiac arrests (IHCA), you may only have enough time to assign roles and verbalize a brief plan, but this should occur only after Priority #1 and Priority #2 have been addressed. Controlling the room and sending out people who don’t need to be there will greatly improve the flow of the rest of the resuscitation.

PRIORITY #1: HIGH-QUALITY CHEST COMPRESSIONS

The one intervention that has consistently been shown to improve outcomes is early, high-quality chest compressions (HQ CC) with minimal interruptions.1,2,3,4 This seems to be the best kept secret in all of medicine that only the true resuscitationists (ED and ICU nurses included) know. Paramedics, nursing assistants, and even cardiologists will frequently stop compressions for a variety of reasons (e.g. they want to help someone place patches on the chest, they thought they heard someone tell them to stop, etc.). It is your responsibility, as the resuscitationist, to ensure that HQ CC continue with minimal interruptions.

To master the art of improving the chest compression fraction, find ways to decrease pauses in compressions. Consider telling the compressor to only stop when the team leader tells them to, not when the recorder/timer calls “Pulse check!” This way, you can ensure somebody has a finger on an artery to check a pulse before compressions stop, thus minimizing the time it takes to identify that there is no pulse and resume CPR. You can also use this delay to ensure that an ultrasound probe is in the appropriate position to view the heart during the pulse check. Remember, there is no harm to doing a few more chest compressions before stopping for a rhythm/pulse check. Consider pre-charging the defibrillator before your pulse check so that you can avoid a second pause in compressions for delivery of the shock.

From ALiEM.com
Unless your ETCO2 is improving or the patient shows signs of consciousness, do not stop compressions to check for a pulse in between the 2-minute pulse checks. Every pause requires a few extra compressions to build up the necessary pressure for organ perfusion, so do your best to maximize your chest compression fraction.5
From RebelEM.com

Airway management during cardiac arrest is a highly controversial topic and requires a post unto itself. While we will cover it in a future Vitals post here on CCN, check out my emDocs.net post on this subject in the meantime. Bottom line: don’t let airway management get in the way of HQ CC.

PRIORITY #2: EARLY DEFIBRILLATION WHEN APPROPRIATE

The second most important intervention you can provide for your patient is early defibrillation when indicated. While chest compressions are usually just a bridge to therapy, defibrillation is the only definitive treatment for ventricular fibrillation and ventricular tachycardia. Defibrillation sends an electrical current through the heart muscle cells, momentarily interrupting the abnormal electrical energy and allowing the intrinsic rhythm to resume. Numerous studies have shown that survival rates and survival with good neurologic function have increased over time as public access to and education about AEDs has increased.1,3,6,7 Researchers have also shown that delays in time to defibrillation is associated with worse outcomes.8 Interestingly, out-of-hospital cardiac arrest (OHCA) patients who had an initial non-shockable rhythm but converted to a shockable rhythm during resuscitation, had over a three-fold increase in survival rates and higher rates of good neurological outcomes.9

PUTTING PRIORITY #1 AND #2 TOGETHER

HQ CC and rapid defibrillation are so important that they are both on the AHA Chain of Survival for OHCA.
Once your patient arrives, stop EMS before they give you the full report, but ask for two very important things:
  1. time since last pulse check
  2. time since last defibrillation (if any)
Without getting a full history from EMS, which might delay important interventions, these pieces of information give you an idea of how long you have before a pulse check or defibrillation. You can then decide which to do first based on how much time you have: 1) stop compressions and perform a rhythm/pulse check while the patient is on the EMS stretcher, or 2) transfer the patient from the EMS stretcher first while compressions continue. In certain cases, patients may have a mechanical CPR device (LUCASTM, AutoPulseTM, LifeBandTM) in place; until you have complete control of the room, it might be best to leave these devices in place. They have been shown to be reasonably equivalent to manual CPR in a number of randomized trials and meta-analyses.10,11,12,13 The hands-free benefit of these devices cannot be underestimated, especially in hospitals with fewer staff. Another upside to these machines is that you can deliver shocks while compressions are still ongoing.14 That being said, we cannot yet recommend placing patients on mechanical CPR devices routinely, because none of the studies truly showed any benefit in patient-oriented outcomes. Furthermore, the systematic review portion of a cluster randomized trial by Gates et al. published in 2017 did show a tiny signal of lower survival with CPC 1 or 2 (adjusted OR 0.72, 95% CI 0.52 to 0.99).15

The Debrief

In summary, Priority #1 is high-quality chest compressions with minimal interruptions. Do everything you can to maximize compression fraction. Priority #2 is early defibrillation when appropriate; this is the definitive therapy for VFib/VTach. In future posts, we will conquer the next priorities in cardiac arrest (history, IV/IO access, medications, airway management, etc.). Stay tuned!

References

  1. Nakahara S, Tomio J, Ichikawa M, et al. Association of Bystander Interventions With Neurologically Intact Survival Among Patients With Bystander-Witnessed Out-of-Hospital Cardiac Arrest in Japan. JAMA. 2015;314(3):247-254. doi:10.1001/jama.2015.8068. PMID: 26197185.
  2. Cunningham LM, Mattu A, O’Connor RE, Brady WJ. Cardiopulmonary resuscitation for cardiac arrest: the importance of uninterrupted chest compressions in cardiac arrest resuscitation. Am J Emerg Med. 2012;30(8):1630-1638. doi:10.1016/j.ajem.2012.02.015. PMID: 22633716.
  3. Buick JE, Drennan IR, Scales DC, et al. Improving Temporal Trends in Survival and Neurological Outcomes After Out-of-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes. 2018;11(1):e003561. doi:10.1161/CIRCOUTCOMES.117.003561. PMID: 29317455.
  4. Wallace SK, Abella BS, Becker LB. Quantifying the effect of cardiopulmonary resuscitation quality on cardiac arrest outcome: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2013;6(2):148-156. doi:10.1161/CIRCOUTCOMES.111.000041. PMID: 23481533.
  5. Berg RA, Sanders AB, Kern KB, et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation. 2001;104(20):2465-2470. doi:10.1161/hc4501.098926. PMID: 11705826.
  6. Drennan IR, Lin S, Thorpe KE, Morrison LJ. The effect of time to defibrillation and targeted temperature management on functional survival after out-of-hospital cardiac arrest. Resuscitation. 2014;85(11):1623-1628. doi:10.1016/j.resuscitation.2014.07.010. PMID: 25107539.
  7. Kiyohara K, Nishiyama C, Kitamura T, et al. The association between public access defibrillation and outcome in witnessed out-of-hospital cardiac arrest with shockable rhythm. Resuscitation. 2019;140:93-97. doi:10.1016/j.resuscitation.2019.05.017. PMID: 31129227.
  8. Chan PS, Krumholz HM, Nichol G, Nallamothu BK; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17. doi:10.1056/NEJMoa0706467. PMID: 18172170.
  9. Han KS, Lee SW, Lee EJ, Kim SJ. Prognostic Value of the Conversion to a Shockable Rhythm in Out-of-Hospital Cardiac Arrest Patients with Initial Non-Shockable Rhythm. J Clin Med. 2019;8(5):644. Published 2019 May 9. doi:10.3390/jcm8050644. PMID: 31075958.
  10. Wik L, Olsen JA, Persse D, et al. Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial [published correction appears in Resuscitation. 2014 Sep;85(9):1306]. Resuscitation. 2014;85(6):741-748. doi:10.1016/j.resuscitation.2014.03.005. PMID: 24642406.
  11. Rubertsson S, Lindgren E, Smekal D, et al. Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA. 2014;311(1):53-61. doi:10.1001/jama.2013.282538. PMID: 24240611.
  12. Gates S, Quinn T, Deakin CD, Blair L, Couper K, Perkins GD. Mechanical chest compression for out of hospital cardiac arrest: Systematic review and meta-analysis. Resuscitation. 2015;94:91-97. doi:10.1016/j.resuscitation.2015.07.002. PMID: 26190673.
  13. Bonnes JL, Brouwer MA, Navarese EP, et al. Manual Cardiopulmonary Resuscitation Versus CPR Including a Mechanical Chest Compression Device in Out-of-Hospital Cardiac Arrest: A Comprehensive Meta-analysis From Randomized and Observational Studies. Ann Emerg Med. 2016;67(3):349-360.e3. doi:10.1016/j.annemergmed.2015.09.023. PMID: 26607332.
  14. Esibov A, Banville I, Chapman FW, Boomars R, Box M, Rubertsson S. Mechanical chest compressions improved aspects of CPR in the LINC trial. Resuscitation. 2015;91:116-121. doi:10.1016/j.resuscitation.2015.02.028. PMID: 25766094.
  15. Gates S, Lall R, Quinn T, et al. Prehospital randomised assessment of a mechanical compression device in out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised trial and economic evaluation. Health Technol Assess. 2017;21(11):1-176. doi:10.3310/hta21110. PMID: 28393757.

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