Pre-Hospital CPR and Life Support for Sudden Cardiac Death Abdelouahab BELLOU, MD, MSc, PhD Professor of Therapeutics and Emergency Medicine Past President of the European Society for Emergency Medicine. Associate Professor of Emergency Medicine, Harvard Medical School Director of Quality & Safety, Administration & Leadership, International Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, USA

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Pathophysiology of Cardiac Arrest Point to Emphasize The phases of cardiac arrest are electrical, circulatory, and metabolic. 3

Electrical Phase Circulatory Phase Metabolic Phase Less than four minutes following arrest, the cardiac muscle uses its sugar/oxygen stores. Circulatory Phase From four to ten minutes following arrest, the cardiac muscle switches to anaerobic metabolism. Talking Points The electrical phase begins immediately upon cardiac arrest and ends four minutes afterward. The heart still has a good supply of oxygen and glucose, and aerobic metabolism is maintained with continued energy production for cell function. The circulatory phase begins at four minutes and lasts through ten minutes following the cardiac arrest. During this phase, the oxygen stores have been exhausted, and the myocardial cells shift from aerobic to anaerobic metabolism. The metabolic phase begins ten minutes after cardiac arrest. At this point the heart is oxygen- and glucose-starved and has a large amount of acid buildup. The tissues are very ischemic and may begin to die. Resuscitation during this phase does not typically produce very favorable results. Discussion Question How can cardiac arrest patients benefit from CPR prior to defibrillation in the circulatory phase of cardiac arrest? Metabolic Phase Greater than ten minutes following arrest, cardiac cells swell, rupture, and die. 4

Sudden Cardiac Death (SCD) Definition

Sudden Cardiac Death A Major Public Health Problem 1/2 of all cardiac deaths 1/7 of all deaths Defined by the American Heart Association as cardiac death occurring within one hour of the onset of symptoms, sudden cardiac death is a major public health problem. According to AHA statistics, sudden death is responsible for half of all cardiac deaths and one seventh of all deaths of Americans. It causes almost as many deaths as all cancers combined.

Sudden Cardiac Arrest is one of the Leading Causes of Death in the U.S. Source: Statistical Abstract of the U.S. 1998, Hoover’s Business Press, 118th Edition

High Risk Groups for SCD High Coronary Risk Post M I Heart Failure/ E F < 35%) Previous VF / VT Syncope / Heart Disease 100 200 300 50 (thousands) (millions) Population Size 10 20 1 2 5 SCD Percent / Year Total SCD / Year (percent) Adapted from Myerburg

Underlying Arrhythmia of Sudden Cardiac Arrest

What do we know about SCD in Athletes? 12-15 million young (<30 years) competitive athletes in the US Estimated incidence of sudden cardiac death at 2.1 per 100 000 athletes per year Estimated 200 athletes in the US die per year of sudden cardiac death Sudden death of the young athletes is mostly unexpected, dramatic, tragic and carries huge emotional impact on the society

REACT Recognize Evaluate Activate EMS Cardiac Care Transport Target goal of <3 minutes from time of collapse to first shock is strongly recommended

Recognition of SCA  SCA should be suspected in any victim who is collapsed and unresponsive SCA should be suspected in any non- traumatic collapse Brief seizure-like activity is common after collapse from SCA Seizure = SCA until proven otherwise Occasional gasping is not normal breathing… think SCA

REACT: Recognize “Agonal Respirations” When heart stops beating with SCA the breathing center in the brain is still alive for a couple of minutes and will cause the victim to take a few abnormal breaths, or agonal respirations These abnormal breaths associated in dying may appear as snoring, gasping, or snorting and will disappear in a couple of minutes. Do not let abnormal breathing stop you from starting CPR.

CPR should be implemented while waiting for an AED REACT: Cardiac Care CPR should be implemented while waiting for an AED AED should be applied as soon as possible and turned on for rhythm analysis in any collapsed and unresponsive victim 25

REACT: Cardiac Care 2010 CPR Guidelines “Push hard and fast” depth of compression at least 2” rate of at least 100 to 120 compressions per minute Allow full chest recoil 30:2 compression to breath ratio Start with CPR if downtime is unknown or greater than 4-5 minutes If downtime < than 4-5 minutes, use AED

Automated Chest Compression Devices Load-distributing band CPR device Mechanical piston CPR device Point to Emphasize Be familiar with any mechanical CPR or circulation-enhancing devices used by your system. Teaching Tip Show any mechanical CPR devices or circulation-enhancing devices used in your local EMS system. Discussion Question What are the advantages and disadvantages of adjunctive equipment used for CPR? 27

Automated External Defibrillator AED Automatically analyzes the patient’s heart rhythm Determines whether a shock is needed Uses voice and screen prompts to guide the rescuer through the process

Ventricular Fibrillation (VF) What VF looks like on an EKG Shock “converts” VF to better rhythm Defibrillation (electrical shock) is the primary solution (cannot be used in other lethal heart rhythms)

REACT: Cardiac Care Single greatest determinate of survival following SCA is the time from collapse to defibrillation, with survival rates declining 7-10% per minute for every minute defibrillation is delayed Survival rates as high 49 to 75% with CPR plus defibrillation within 3-5 minutes of collapse 10 20 30 40 50 60 70 80 90 100 1 2 3 4 5 6 7 8 9 Chances of success reduced 7-10% each minute Cummins RO. Annals Emer Med. 1989. 18:1269-1275

REACT: Cardiac Care Probability of Survival 0.6 1 Minutes, Collapse to CPR 0.5 0.4 Probability of Survival 0.3 5 0.2 10 0.1 15 From “Estimating Effectiveness of Cardiac Arrest Interventions: A Logistic Regression Survival Model,” TD Valenzuela et. al., Circulation 1997; 96:3308 2 4 6 8 10 12 14 16 18 20 Collapse to Defibrillation Interval (minutes) 31

Chain of Survival Early Recognition Early CPR Early AED Improved Survival

Quality Improvement Elements of a Resuscitation System. Travers A H et al. Circulation. 2010;122:S676-S684 Copyright © American Heart Association, Inc. All rights reserved.