Strategies to Improve Cardiac Arrest Survival A Time to Act (2015) / Chapter Skim
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1 Introduction
1 Introduction
Pages 21-48
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From page 21... ...
In an instant, a person's pulse or blood pressure disappears, leading to a loss of consciousness and collapse, which is followed by death if treatment is not provided quickly. The risk of irreversible brain and organ injury and major disability increases the longer the delay in restoring a heart rhythm and blood flow.
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. Despite nearly 50 years of advocacy to improve cardiac arrest treatment, overall survival rates remain low, and disability with poor neurologic and functional outcome affect communities throughout the United States.
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to significantly improve survival and neurologic function following cardiac arrest. Within systems of care, continuous quality improvement initiatives that are based on process evaluation and observed outcomes can serve as a foundation for the development of more proactive and responsive care models, thus benefiting patients.
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COMMITTEE SCOPE OF WORK In 2013, the American College of Cardiology, the American Heart Association, the American Red Cross, the Centers for Disease Control and Prevention, the National Institutes of Health, and the U.S. Department of Veterans Affairs asked the Institute of Medicine (IOM)
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BOX 1-1 Statement of Task Treatment of Cardiac Arrest: Current Status and Future Directions The Institute of Medicine will conduct a study on the current status of, and future opportunities to improve, cardiac arrest outcomes in the United States. The study will examine current statistics and variability regarding survival rates from cardiac arrest in the United States and will assess the state of scientific evidence on existing lifesaving thera pies and public health strategies that could improve survival rates.
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Although both prevention and treatment of cardiac arrest are important to reduce the impact of cardiac arrest in the United States, the committee's scope of work was explicitly limited to an analysis of how to improve outcomes following cardiac arrest. Additionally, because of concerns about the quality and availability of evidence about cardiac arrest, in general, the committee limited its analysis of treatments up through hospital discharge and outcomes through 90-days post discharge, which excluded a detailed analysis of rehabilitation.
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From page 27... ...
Acute symptoms of a heart attack include chest pain, shortness of breath, sweatiness, and dizziness, but do not necessarily include the pattern of immediate loss of consciousness that characterizes a cardiac arrest. A heart attack, large or small, can affect the electrical signaling and cause a cardiac arrest.
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The distinction between cardiac arrest and heart attack is important because the goals and timing of treatment and the individuals qualified to perform specific treatments for these conditions are very different. The primary goals of cardiac arrest treatment are to facilitate return of spontaneous circulation (ROSC)
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c Male:female 3:2a,b; occurs in all ages, 2:1c; less likely to occur in incidence ratio although frequency in- people younger than 35 creases with increasing age years of age Immediate cause Cessation of mechanical Blockage or significant activity of the heart, caused narrowing of a coronary by a malfunction in the artery, causing tissue dam heart's electrical system age to an area of heart mus cle due to lack of oxygen Early warning Some patients may Patients may experience symptoms experience palpitations, chest pain or upper body dizziness, chest pain, or discomfort, unusual shortness of breath momen- fatigue, weakness, nausea, tarily before loss of shortness of breath; symp consciousness and collapse toms may occur days or weeks before Loss of pulse, Yes -- in all cases Heart attack may lead to blood pressure, cardiac arrest consciousness Breathing No, although gasping and Yes agonal breaths may be mis taken for normal breathing Cardiac rhythm Characterized by complete May be accompanied by lack of a heart rhythm or arrhythmias that do not one incapable of generating cause loss of mechanical a mechanical heart beat heart beats Risk factors/ Cardiac risk factors include Coronary artery disease, medical history coronary artery disease, congenital abnormalities in cardiomyopathy, myocar- vasculature of the dial infarction, valvular myocardium heart disease, congenital heart disease, and genetic syndromes continued
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From page 30... ...
The likelihood of irreversible brain injury resulting in brain death, coma, vegetative state, or significant neurologic disability increases with delay in ROSC. Alternatively, neurologic and organ ischemia are less likely with a heart attack unless blood pressure is severely decreased.
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In the context of OHCA, emergency medical systems professionals and/or bystanders may perform basic life support (BLS) , which includes recognition of cardiac arrest, activation of the emergency response system, and performance of CPR and defibrillation.
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32 STRATEGIES TO IMPROVE CARDIAC ARREST SURVIVAL TABLE 1-2 The Types and Characteristics of Primary Cardiac Arrest Arrhythmias Pulseless Pulseless Ventricular Ventricular Electrical Fibrillation Tachycardia Activity* Asystole Definition Uncoordinat- Organized The heart's Absence of ed electrical electrical electrical electrical activation of activation of activity is activity of the heart, result- heart, with present, often heart; no sig ing in loss of absent or slow and/or nal to initiate organized ineffective irregular, but contraction of contraction of contraction of the signal the ventriclesa the ventriclesa the ventricles, fails to initi due to rate or ate a mechan extent of ical response diseasea in the cells, resulting in no ventricle contractiona ECG Grossly irreg- Regular QRS Usually wide No electrical appearance ular electrical complexes, QRS com- activity -- flat pattern on usually wide plexes, often linea ECG, without and fasta slow and identifiable irregular;a QRS sometimes complexesa narrow QRS complexes Electrical Yes Yes Yes No activity Palpable No Usually not; No No pulse occasionally present but weak Responds to Yes (usually)
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From page 33... ...
NOTE: CA = cardiac arrest; ECG = electrocardiogram; IHCA = in-hospital cardiac arrest; OHCA = out-of-hospital cardiac arrest; QRS complexes = "the series of deflections in an electrocardiogram that represent electrical activity generated by ventricular depolarization prior to contraction of the ventricles" (MerriamWebster.com, 2015) ; VF = ventricular fibrillation.
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ain . NOTE: ACLS = advan cardiac life support; CPR = cardiopulmon resuscitatio nced e nary on.
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. Early Advanced Cardiac Life Support: Beyond CPR and defibrilla tion, paramedics may need to deliver early advanced care life support (e.g., drug therapies, airway management, and other intravenous treatment and monitoring)
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For example, the positive trends of cardiac arrest survival in selected communities may be a result of better feedback to EMS personnel, particularly in regard to meeting performance standards of care (Chan et al., 2014; McNally et al., 2011)
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The public also includes individuals who experience a cardiac arrest, friends, and families, along with individuals in industry, the workplace, schools, care facilities, and community organizations. EMS systems include 911 call takers, dispatchers, first responders, emergency medical technicians, and paramedics, who respond to cardiac arrests and transport patients to local hospitals and emergency medical facilities after initiating resuscitation treatment.
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may include rehabilitation services) respond to cardiac arrests, provide essential post-arrest care for patients, and facilitate critical care transitions between EMS systems and various departments within the hospitals.
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Reliable and accurate data are needed to empower states, local health departments, EMS systems, health care systems, and researchers to develop metrics, identify benchmarks, revise education and training materials, and implement best practices. Furthermore, increasing public awareness about disparities in care and opportunities to improve outcomes can lead to greater public engagement in education and training, larger advocacy networks, and stronger community leadership efforts related to cardiac arrest.
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. Continuous Quality Improvement Programs Widespread adoption of continuous quality improvement programs throughout the field of resuscitation would encourage data collection across all sites of care, enable comparisons within and between EMS and health care systems, and lead to the identification of best practices to improve population health and patient outcomes following cardiac arrest.
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From page 41... ...
Communities that have demonstrated higher cardiac arrest survival rates and favorable neurologic outcomes typically have strong civic, EMS, and health care system leaders, who establish accountability for these outcomes to their communities through increased public awareness efforts, widespread training in CPR and AED use, and sustained investment in outcome measurement, data reporting, and self-assessment. With appropriate leadership, effective treatments and strategies can be adopted in other communities to save thousands more lives across the country each year.
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From page 42... ...
Chapter 2 discusses the public health burden of cardiac arrest, summarizes available data registries for the evaluation of cardiac arrest, and suggests opportunities to improve cardiac arrest surveillance in the United States. Chapter 3 explores barriers to public engagement and education and training opportunities that encourage active response to cardiac arrest in the community.
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2010. Part 1: Executive summary: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
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P Edelson, for the American Heart Association Emergency Cardiovascular Care Committee; the Council of Cardiopulmonary, Critical Care, Perioperative and Resuscitation; the Council on Cardiovascular and
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A consensus statement from the international liaison committee on resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa) ; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council.
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From page 46... ...
2010. Part 9: Post-cardiac arrest care: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
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From page 47... ...
INTRODUCTION 47 June 30, 2015)
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