1. 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

2. https://www. youtube. com/watch

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

4. 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

6. Sudden Cardiac Death (SCD)
Definition

7. 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.

9. 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

10. 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

12. Underlying Arrhythmia of Sudden Cardiac Arrest

13. 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 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

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

23. 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

24. 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.

25. 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

26. 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

27. 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

28. 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

29. 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)

30. 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 :

31. 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

42. Chain of Survival Early Recognition Early CPR Early AED
Improved Survival

43. 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.