Cardiovascular: cardiac arrest and AEDs

Transcription

1 Emergency Medicine Cardiovascular: cardiac arrest and AEDs

2 Emergency Medicine Cardiovascular: cardiac arrest and AEDs 1 Stanley F. Malamed, DDS Dentist Anesthesiologist Emeritus Professor of Dentistry Ostrow School of Dentistry of USC Los Angeles, California, USA 2 malamed@usc.edu malamed@usc.edu malamed@usc.edu 3 4 Medical emergencies CAN and DO happen in the practice of dentistry

3 4,307 doctors in North America 94.9% have experienced at least one medical emergency in their office Average length of career 14.7 years 30,608 emergencies reported 7.1 emergencies per doctor during career 5 MALAMED SF, JADA 1993 Syncope 15,407 (50.3%) Mild allergy 2,583 (8.4%) Angina pectoris 2,552 (8.3%) 6 Postural hypotension 2,475 (8.1%) Seizure 1,595 (5.2%) Asthmatic attack 1,392 (4.5%) Hyperventilation 1,326 (4.3%) Epinephrine Rxn 913 (3.0%) Hypoglycemia 890 (2.9%) Cardiac arrest 331 (1.1%) Anaphylaxis 304 (1.0%) Myocardial infarction 289 (0.9%) L.A. Overdose 204 (0.7%) ALL patients (Adult, Pediatric, Geriatric) All ages N = 4, % 7 of medical emergencies (in dental offices) are related to stress and anxiety 8 Legal (moral) Obligation of the Doctor to the Victim

4 Try to keep the victim alive until they recover or until another - more qualified - individual assumes responsibility for treatment 9 10 PREPARATION for EMERGENCIES Dr. Dr. Stanley F. F. Malamed All Preparation of the Office & Staff Basic Life Support training 2. Preparation of Dental Office Staff Members 3. Emergency Assistance 4. Emergency Drugs & Equipment Preparation of the Office & Staff Basic Life Support 2. Basic Life Support 3. Basic Life Support 4. Basic Life Support 5. Basic Life Support 6. Basic Life Support 7. Basic Life Support 8. Office Emergency TEAM 9. Emergency Assistance 10. Emergency Drugs & Equipment All Rights 2013 Dr. Reserved Stanley F. Malamed

5 13 BASIC LIFE SUPPORT (CPR, Resuscitation, Reanimation) is THE single-most important step in the management of ALL medical emergencies All Rights 2013 Dr. Reserved Stanley F. Malamed Basic Life Support training 2. Preparation of Dental Office Staff Members 3. Emergency Assistance 4. Emergency Drugs & Equipment Basic Life Support training 2. Preparation of Dental Office Staff Members 3. Emergency Assistance 4. Emergency Drugs & Equipment Preparation of the Office & Staff Basic Life Support training 2. Preparation of Dental Office Staff Members 3. Emergency Assistance 4. Emergency Drugs & Equipment

6 Critical Drugs & Equipment 17 THE BASIC SEVEN (as per Malamed) 1. Epinephrine 2. Histamine-blocker 3. Bronchodilator 4. Nitroglycerin 5. Sugar 6. Aspirin 7. Oxygen 18 Automated External Defibrillator (AED) January /01/dentist_saves_patients_life_af.html EMERGENCY MANAGEMENT ALGORITHM 20 P - C - A - B - D Algorithm for ALL emergency management

7 P - C - A - B - D 21 P = Position Conscious = anything; Unconscious = supine C = Circulation Assess & chest compression if needed A = Airway Assess & maintain airway (head tilt-chin lift) if needed B = Breathing Assess & ventilate if needed D = Definitive Care... Diagnosis, Drugs, Defibrillation Preparation of the Office & Staff Basic Life Support training 2. Preparation of Dental Office Staff Members 3. Emergency Assistance 4. Emergency Drugs & Equipment Chest Pain 23 Chest Pain 2012 Dr. Stanley F. Malamed 24

8 Coronary Arteries 25 MYOCARDIUM 26 Blood flows through coronary arteries only during DIASTOLE, not systole Cardiac muscle extracts 60% to 80% of available O2 in blood; Skeletal muscle extracts 25% to 30% Coronary arteries dilate when myocardial workload increases 5% capillary 30% arterial 65% venous Syncope 15,407 (50.3%) Mild allergy 2,583 (8.4%) Angina pectoris 2,552 (8.3%) Postural hypotension 2,475 (8.1%) Seizure 1,595 (5.2%) Asthmatic attack 1,392 (4.5%) Hyperventilation 1,326 (4.3%) Epinephrine Rxn 913 (3.0%) Hypoglycemia 890 (2.9%) Cardiac arrest 331 (1.1%) Anaphylaxis 304 (1.0%) Myocardial infarction 289 (0.9%) L.A. Overdose 204 (0.7%) ALL patients (Adult, Pediatric, Geriatric) All ages N = 4, Let s look at CARDIOVASCULAR DISEASE

9 29 USA population: 327,768,011 (22 May, 2018) Statistics USA population: 327,768,011 (22 May, 2018) Median age: 38.1 years Life expectancy: 78.8 years Cardiovascular disease is, and has been for many years, the leading cause of death in the United States 30 Year #1 # Pneumonia & influenza Tuberculosis 1910 Heart disease Pneumonia 1920 Pneumonia & influenza Heart disease 1930 Heart disease Pneumonia & influenza 1940 Heart disease Malignant neoplasms 1950 Heart disease Malignant neoplasms 1960 Heart disease Malignant neoplasms 1970 Heart disease Malignant neoplasms 1980 Heart disease Malignant neoplasms 1990 Heart disease Malignant neoplasms 2000 Heart disease Malignant neoplasms 2010 Heart disease Malignant neoplasms 2015 Heart disease Malignant neoplasms 2015 statistics 2015 statistics 31 Number of deaths: 2,712,630 (2015) Number of deaths: 2,712,630 (2015) Heart disease 633,842 Cancer 595,930 Chronic lower respiratory diseases 346,571 CVA (stroke) 140,323 Alzheimer s disease 110,561 Diabetes 79,535 Influenza & pneumonia 57,062 Nephritis, nephrotic syndrome & nephrosis 49,959 Intentional self-harm (suicide) 44, Dr. Dr. Stanley F. F. Malamed All 32 Cardiovascular disease, listed as the underlying cause of death, accounts for nearly 801,000 deaths in the USA. About 1 in 3 deaths

10 33 2,200 a day Every 40 seconds an American dies from cardiovascular disease 34 About 790,000 people in the USA have heart attacks * each year * Heart attack is a lay term. The proper term is acute myocardial infarction Of these, about 114,000 will die* *Acute MI becomes sudden cardiac arrest 35 Of these 790,000 in the USA have AMIs annually. 580,000 are 1 st time MIs 210,000 recurrent MIs 36 The average age for 1st MI is 65.3 years for males, 71.8 years for females

11 % of out-of-hospital cardiac arrests (OHCA) occur in the victims home 19.8 % in public settings 10.6 % in nursing homes 38 So, what exactly IS CVD? 39 So, what exactly IS CVD? 40 Healthy coronary artery Progression of coronary artery disease

12 Coronary Artery Disease Plaque Muscular wall of artery 41 Lumen Red Blood Cells Plaque Plaque Angina Pectoris 42 Angina pectoris, commonly known as angina, is the sensation of chest pain, pressure, or squeezing, often due to ischemia of the heart muscle from obstruction or spasm of the coronary arteries. Angina Pectoris Anything increasing the workload of the heart can induce an anginal episode The 4 E s of angina Exertion Emotion Eating Extremely cold or hot weather 43 Transient Myocardial Ischemia = Angina Pectoris 44 Myocardium not receiving an adequate blood supply becomes ischemic, leading to the onset of anginal pain

13 Angina Pectoris... Management 45 P... Conscious = Comfortable (usually upright preferred) C... Assess... prn A... Assess... prn B... Assess... prn D... Nitroglycerin, O2 Nitroglycerin D... Determine cause, modify future treatment Dr. Dr. Stanley Stanley F. F. Malamed Malamed All Angina Pectoris 46 With rest or administration of nitroglycerin the myocardial workload decreases and the chest pain dissipates Dr. Dr. Stanley F. F. Malamed All Nitroglycerin 47 Nitroglycerin produces a 28 % increase in coronary artery lumenal diameter Angina pectoris and dentistry 48 The only time ANGINA should be considered as a diagnosis in acute chest pain is where the patient (victim) has a PREEXISTING HISTORY of ANGINA

14 Consider Myocardial Infarction: 49 ALWAYS when there is no prior history of cardiovascular disease Consider Myocardial Infarction 50 In anginal patient when: Pain worse than usual 3 doses of nitroglycerin fail to relieve discomfort doses every 5 minutes Nitroglycerin relieves pain, but pain returns. Acute Myocardial Infarction 51 Prolonged Myocardial Ischemia 52 RUPTURE of the PLAQUE into the lumen of the coronary artery terminates blood flow to an area of myocardium Dr. F. Malamed 2014 Dr. Dr. Stanley F. F. Malamed All

15 Prolonged Myocardial Ischemia = Myocardial Infarction 53 Prolonged myocardial ischemia leads to damage and then death (infarction) of myocardium 2014 Dr. Stanley F. Malamed All Reserved 54 Right Ventricle Left Ventricle Acute Coronary Syndrome 55 Narrowed Acute Myocardial Infarction Angina Pectoris Obstructed First Time Chest Pain P... C... A... B... D

16 Signs of a myocardial infarction ( heart attack ) 57 Acute Myocardial Infarction 58 SILENT MI Women (up to 50% of MIs) Elderly Diabetics Do not present with classic signs & symptoms Suspected MI... Management 59 P... Conscious = Comfortable (usually upright preferred) C... Assess... prn A... Assess... prn B... Assess... prn D... MONA - Nitroglycerin, O2 D... Activate EMS MONA Acronym for the PRE- HOSPITAL MANAGEMENT OF A SUSPECTED MYOCARDIAL INFARCTION 60 60

17 MONA Morphine 61 Oxygen Nitroglycerin Aspirin Prehospital management of suspected MI MONA = NONA 62 Morphine = N2O-O2 Oxygen Nitroglycerin Aspirin Prehospital management of suspected MI 62 Nitrous Oxide - Oxygen 50 % - 50 % 63 As analgesic as IV morphine Separates pain from suffering Sedative Relaxes scared patient 50 % O2 2.5 times ambient air Entonox Prehospital management of suspected MI 63 Aspirin in Myocardial Infarction mg. POWDERED, if available, with water 20 minute onset Prevents blood clot (thrombosis) from increasing in size Increases chances of primary balloon angioplasty being successful Prehospital management of suspected MI

18 Aspirin in Myocardial Infarction 65 Prevents blood clot (thrombosis) from increasing in size Increases chance of primary balloon angioplasty being successful Percutaneous coronary intervention (PCI) Acute Myocardial Infarction When cells are damaged, hypoxic or anoxic, they become hyperexcitable 66 Myocardium = DYSRHYTHMIAS Automaticity is the cardiac cell's ability to spontaneously generate an electrical impulse (depolarize). Cells that are dedicated to the purpose of generating an impulse to maintain a heart rate commensurate with the body's need are called pacemaker cells. AUTOMATICITY 67 Normal Sinus Rhythm - NSR 68 QRS QRS complex complex Ventricles Ventricles depolarize contract T wave Ventricles repolarize P wave Atria contract Atrial repolarization occurs during ventricular contraction

19 Premature Ventricular Complexes Monomorphic (Unifocal) 69 ALL PVC s look alike Area of ischemic myocardium Premature Ventricular Complexes Polymorphic (Multifocal) 70 PVC s vary in size & shape MORE CLINICALLY SIGNIFICANT! LVEF ranges from Premature Ventricular Contractions PVC s 71 Patient is CONSCIOUS 8 of 11 contractions (systoles) are normal, ejecting blood into the systemic circulation. Output of blood is 73 % of normal Premature Ventricular Contractions PVC s 72 Patient is CONSCIOUS yet demonstrating S&S of decreased blood flow to periphery: Cyanotic mucous membranes Ashen gray skin color Diaphoresis Generalized feeling of fatigue

20 Premature Ventricular Contractions PVC s 73 Premature ventricular contractions (PVCs) are considered a... PRE-FATAL DYSRHYTHMIA The doctor s goal in a medical emergency situation 74 Try to keep the victim alive until: (1) Recovery occurs or (2) Help arrives to take over management So, what exactly has been done prior to EMS arrival to PREVENT the occurrence of cardiac arrest? 75 NOTHING We have been LUCKY Ischemic myocardiam still exists; Victim is symptomatic; Dysrhythmias still occurring; But the pump - though damaged - is still pumping Acute Myocardial Infarction 76 Most OOH-CA are related to acute dysrhythmias (VF/ pulseless VT) Most occur during the 1 st hour after symptom onset 52% of MI mortality Cardiac Arrest 52% 19 pre-hospital 24 hrs, in-hospital 48 hrs, in-hospital 30 days 76 Deaths from MI 8 21

21 The significant mortality rate associated with MI is in part based on the average delay (4.9 hours) between the onset of signs and symptoms and intervention by the emergency medical system Dr. Stanley F. Malamed So, Ventricular what exactly fibrillation has is 15 been times done more prior likely to EMS to arrival occur in to the PREVENT 1 st hour after the the occurrence onset of signs of and cardiac symptoms arrest? than in the next 12 hours. NOTHING It develops in the first hour in approximately 36% of persons with acute MI. CARDIAC ARREST occurs when the heart ceases to PUMP BLOOD 79 In CARDIAC ARREST the heart, usually, is still BEATING It is no longer PUMPING There are 4 rhythms that constitute cardiac arrest 80 (1) (pulseless) Ventricular Tachycardia (2) Ventricular Fibrillation (coarse & fine) (3) Asystole (4) Pulseless Electrical Activity (PEA)

22 81 The sequence of death in SCA Ventricular Tachycardia VT VT with a pulse or pulseless VT The ischemic area of myocardium has taken control. ALL beats are PVCs 82 Cardiac Arrest Shockable rhythms 83 Ventricular Tachycardia Ventricular Fibrillation coarse & fine Cardiac Arrest Non-shockable rhythms 84 Asystole Pulseless Electrical Activity

23 85 The sequence NOT of death A in SCA SHOCKABLE RHYTHM Asystolic Cardiac Arrest What happens when the heart stops PUMPING blood? 86 Blood pressure falls to zero, (<60mmHg) Pulse is not palpable, Consciousness is lost, and Respirations cease. And the victim is... DEAD 87 UNCONSCIOUS NOT BREATHING clinically, DEAD NO PULSE Sudden Cardiac Arrest 88 In the absence of any treatment death is a certainty

24 Sudden Cardiac Arrest 89 Doing something gives the victim a chance at survival Our goal in resuscitation is to prevent the PERMANENT death of the victim. 90 Cells in the victims body will die when they use up all of the O2 available to them CELLULAR or BIOLOGICAL death occurs Biological death is irreversible The time between the occurrence of CLINICAL and BIOLOGICAL DEATH represents the period in which RESUSCITATION may be successful 91 Sternum 92 Heart Spinal column

25 Chronology of Sudden Cardiac Arrest 93 Time = up to 1 hour before SCA Signs & symptoms Time 0 Occurrence of sudden cardiac arrest Time = less than 10 seconds Time = 4 to 6 minutes Time = minutes Loss of consciousness Brain damage begins Biological (cellular) death Surviving Sudden Cardiac Arrest Brain cells (neurons) have a high metabolic rate. 94 A degree of permanent neurologic deficit can be expected when neurons are deprived of O2 for 4-6 minutes. Therapeutic Hypothermia to 93.2 F No BLS Delayed EMS, Delayed BLS & Defibrillation: 96 Death... or...

26 No BLS Delayed EMS, Delayed BLS & Defibrillation: 97 7 Minutes of Cerebral Anoxia Global Neurological Damage Begin brain damage <1 % survival Severe brain damage A very important fact about CPR (Basic Life Support): 98 Basic life support... Circulates oxygenated blood... Does NOT convert cardiac arrest into a functional rhythm (e.g. NSR) BLS simply increases the time during which the myocardium is still alive 99 NO CPR CPR Early BLS duration of VF (fine VF) + delayed defibrillation ~5 % survival Early BLS + early defibrillation (coarse VF) 100 ~20% survival

27 Early BLS + very early defibrillation (coarse VF) 101 Up to 74 % in some situations Neurological deficit unlikely EMS arrival Survival Rates 102 No CPR Delayed Defibrillation Defibrillation 0-2% survive Early CPR Delayed Defibrillation CPR Defibrillation 2-8% survive Early CPR Early Defibrillation CPR Defibrillation 20% survive CPR Defibrillation ACLS Early CPR Very early defib. Early ACLS up to 74% survive minutes BYSTANDER-INITIATED BLS The TIME from COLLAPSE to DEFIBRILLATION How critical is response time to survival? 103 In the absence of CPR, for every minute a victim is in cardiac arrest the chance of survival decreases by between 7 % and 10 % Survival to hospital discharge DTW ORD NYC LAX BHM SLC DFW ROC MEM TUC SFO FAT IAH MSP PIT PDX Iowa MIA MKE RST 7% 12% 15% Survival to Hospital Discharge 23% Eisenberg M. JAMA 300: , 2008 SEA % 62% 104

28 How critical is response time to survival? 105 With CPR initiated prior to EMS arrival, for every minute a victim is in cardiac arrest the chance of survival decreases by between 3 % to 4 % Survival to hospital discharge Bystander Initiated CPR 106 No Yes Day Survival from Cardiac Arrest Time (min) Saved YES Saved NO day survival day survival

29 How to use an AED 109 Simplistically, an AED is a battery operated computer which is capable of determining whether or not VF/VT is present. VF/VT present: SHOCK ADVISED How to use an AED 110 Any rhythm other than VF/VT PEA, asystole, NSR NO SHOCK ADVISED Check airway Check breathing Check pulse If no pulse, continue CPR AED accuracy in rhythm analysis 111 Atkins DL, Scott WA, Blaufox AD, Law IH, Dick M 2nd, Gehen F, Sobh J, Brewer JE Sensitivity and specificity of an automated external defibrillator algorithm designed for pediatric patients. Resuscitation 76(2): , shockable rhythms from 49 patients. Sensitivity: Coarse VF: 42 rhythms, 100% Sensitivity: Rapid VTach: 78 rhythms, 94% Combined sensitivity: 115/120, 96.0% 585 non-shockable rhythms from 155 patients. Sensitivity: NSR: 208 rhythms, 100% Sensitivity: Asystole: 29 rhythms, 100% Sensitivity: Supraventricular tachy: 161 rhythms, 99% Sensitivity: Other rhythms: 187 rhythms, 100% Combined sensitivity: 583/585, 99.7% Overall accuracy for shockable & non-shockable rhythms = 99% (702/709) 112 How to use an AED VF... chaotic, uncordinated quivering of myocardium Coarse VF

30 How an AED works AED delivers a biphasic (2 shocks) shock across the chest - through the myocardium - depolarizing all myocardial cells at the same time. 113 How an AED works 114 AED delivers a biphasic (2 shocks) shock across the chest - through the myocardium - depolarizing all myocardial cells at the same time, producing... ASYSTOLE Defibrillation Coarse VF Asystole 2012 Dr. Stanley F. Malamed 2018 All Rights Dr. Stanley Reserved F. Malamed How an AED works 115 Asystole NSR 2012 Dr. Stanley F. M All Rights Reserv Can the chest be compressed adequately with the victim in the dental chair? 116 YES Lepere AJ, Finn J, Jacobs I Efficacy of cardiopulmonary resuscitation performed in a dental chair J Australian Dental Association 48(4) , 2003 (December)

31 Time to delivery of an automated external defibrillator using a drone for simulated out-of-hospital cardiac arrests vs Emergency Medical Services 117 Median time from call to dispatch (drone launch)- DRONE = 3 seconds Median time from call to dispatch - AMBULANCE = 3 minutes Median time from dispatch to arrival - DRONE = 5.21 minutes Median time from dispatch to arrival - AMBULANCE = 22 minutes Claesson A, Backman A, Ringh M, Svensson L etal J Amer Med Assoc 317(22): , 2017 Time to delivery of an automated external defibrillator using a drone for simulated out-of-hospital cardiac arrests vs Emergency Medical Services 118 Claesson A, Backman A, Ringh M, Svensson L etal J Amer Med Assoc 317(22): , 2017 Rules to Remember 119 The very first step in management of all medical emergencies is BASIC LIFE SUPPORT, as needed Emergency Management 120 non-cardiac arrest P... position C... circulation A... airway B... breathing D... definitive care Drug therapy is ALWAYS secondary to basic life support Cardiac arrest P... position C... circulation A... airway B... breathing D... defibrillation

32 121 P - C - A - B - D Try to keep the victim alive malamed@usc.edu 123 THANK YOU for LISTENING! THANK YOU for LISTENING!