Background: Over the past few years there has been a shift in cardiac arrest from the mantra of ABC (Airway, Breathing, Circulation) to CAB (Circulation, Airway, Breathing). There has been increased emphasis on circulation and a de-emphasis of airway management in cardiac arrest. Physiologically, this makes sense as the only two interventions in cardiac arrest that have been shown to make a difference in neurological outcomes are early, high quality CPR and defibrillation. The reason for this is increased coronary and cerebral perfusion pressure, which improve oxygenation to ischemic tissue. The less ischemic cardiomyocytes are the more likely they will convert to a perfusing rhythm. Similarly, the less ischemic neurons are, the more likely we will have a better neurologic outcome for our patients. It has been fairly well established in the peer reviewed literature that advanced airway management in the prehospital setting is associated with decreased survival with good neurologic outcome. There is considerably less literature exploring this area in in-hospital cardiac arrest. Read more →
Tag Archive for: Cardiac Arrest
Cardiac Arrest, Return of Spontaneous Circulation (ROSC) With No ST-Segment Elevation on ECG. Now What?
Background: The American Heart Association/American College of Cardiology (AHA/ACC) give a Class I recommendation for activation of the cardiac catheterization lab in patients with out-of-hospital cardiac arrest (OHCA) whom ST-segment elevation myocardial infarction (STEMI) is present. The evidence for early cardiac catheterization in patients after cardiac arrest, with ROSC and no STEMI is a bit more controversial. The most recent 2015 AHA/ACC guidelines recommend, “it may be reasonable,” to perform an emergent cardiac catheterization in select patients without STEMI. Read more →
Post Written By: Sam Ghali (Twitter: @EM_RESUS)
In cardiac arrest care there has been a lot of focus over the years on limiting interruptions in chest compressions during CPR. In fact, this concept has become a major focus of the current AHA Guidelines. Why? Because we know interruptions are bad [1,2]. One particular aspect of CPR that has gotten a lot of attention in this regard is the peri-shock period. It has been well established that longer pre- and peri-shock pauses are independently associated with decreased chance of survival [3,4].
The Ontario Prehospital Advanced Life Support (OPALS) Study
Background: Sudden cardiac arrest is common and, obviously, very bad. In the US, there are about 500,000 cardiac arrests each year. About half of these cardiac arrests are OHCA and the survival rate is pretty poor. The most recent survival estimates put it at 7 – 9.5% in most communities. About 10-12 years ago, the American Heart Association built the 4-step “chain-of-survival.”
- Step One – Early access to emergency care
- Step Two – Early CPR
- Step Three – Early defibrillation
There is little debate about these three steps as the sum of the data supports that they lead to better outcomes.
The 4th step in the chain, however, is slightly more controversial; early advanced care. This basically means rapid access to ACLS type resuscitation skills (intubation and intravenous drug therapy). Despite it being the 4th step, ACLS has little evidence to defend it. Read more →
Background: Sudden cardiac arrest has very poor outcomes; less than 11% of patients in cardiac arrest in the Emergency Department survive to discharge from the hospital. The management of cardiac arrest is algorithmic because providers have limited tools at their disposal and limited knowledge of the patient’s past medical history. EKG is limited in its evaluation of cardiac function. Pulses are often difficult to palpate. The blood pressure cuff is often unreliable. As a result, there is a sense of futility when running resuscitations.
Transthoracic echocardiography (TTE) in the Emergency Department gave providers another tool to help guide management through direct visualization of cardiac activity, tamponade physiology, right heart strain, etc . It also offers prognostic value if there is no cardiac activity upon arrival to the Emergency Department on TTE, there is a near 0% chance of survival. However, TTE has its limitations: obesity, emphysema, poor windows, interrupts compressions, gel gets everywhere.
Transesophageal echocardiography (TEE) provides significant benefits when compared to TTE in the management of cardiac arrest in the emergency department. Read more →