Out-Of-Hospital Management and Outcomes of Sudden Cardiac Death Abdelouahab BELLOU, MD, PhD Professor of Internal Medicine, Emergency Medicine, Therapeutics. Past President of the European Society for Emergency Medicine. BIDMC, Harvard Medical School, Boston, USA. Faculty of Medicine and University Hospital Emergency Department of Rennes, France.
Pathophysiology of Cardiac Arrest
Electrical 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. Metabolic Phase Greater than ten minutes following arrest, cardiac cells swell, rupture, and die.
Sudden Cardiac Death (SCD) Definition
Sudden Cardiac Death A Major Public Health Problem 1/2 of all cardiac deaths 1/7 of all deaths
Sudden Cardiac Arrest is one of the Leading Causes of Death in the U.S. 300,000 250,000 200,000 150,000 100,000 50,000 0 AIDS Breast Cancer Lung Cancer Stroke SCA Source: Statistical Abstract of the U.S. 1998, Hoover s Business Press, 118 th Edition
High Risk Groups for SCD Population Size SCD Percent / Year Total SCD / Year High Coronary Risk Post M I Heart Failure/ E F < 35%) Syncope / Heart Disease Previous VF / VT 0 1 2 5 10 20 (millions) 0 1 2 5 10 20 50 (percent) 0 50 100 200 300 (thousands) Adapted from Myerburg
Underlying Arrhythmia of Sudden Cardiac Arrest Primary VF 8% Torsades de Pointes 13% VT 62% Bradycardia 17%
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
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
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 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 100 90 80 70 60 50 40 30 20 10 Chances of success reduced 7-10% each minute 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 0 1 2 3 4 5 6 7 8 9 Cummins RO. Ann Emer Med. 1989. 18:1269-1275
Probability of Survival REACT: Cardiac Care 0.6 0.5 1 Minutes, Collapse to CPR 0.4 0.3 5 0.2 0.1 10 From Estimating Effectiveness of Cardiac Arrest Interventions: A Logistic Regression Survival Model, TD Valenzuela et. al., Circulation 1997; 96:3308 0 0 2 4 6 8 10 12 14 16 18 20 Collapse to Defibrillation Interval (minutes) 15
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.
Cochrane Database Syst Rev. 2014 Sep 12;9:CD009803. doi: 10.1002/14651858.CD009803.pub2. Cardiopulmonary resuscitation (CPR) plus delayed defibrillation versus immediate defibrillation for out-of-hospital cardiac arrest. Huang Y et al. AUTHORS' CONCLUSIONS: Owing to the low quality of available evidence, we have been unable to determine conclusively whether immediate defibrillation and one and one-half to three minutes of CPR as initial therapy before defibrillation have similar effects on rates of return of spontaneous circulation, survival to discharge or neurological insult.we have also been unable to conclude whether either treatment approach provides a degree of superiority in OHCA.We propose that this is an area that needs further rigorous research through additional highquality RCTs, including larger sample sizes and proper subgroup analysis.