Modern SCA Definition Sudden Cardiac Arrest: The Scourge Continues Ryan Schaefer RN, Electrophysiology & Project Adam Coordinator Sacred Heart Medical Center (1) Witnessed cardiac arrest; (2) within 1 hour after the onset of acute symptoms; or (3) unexpected, un-witnessed death in a patient known to have been well within the previous 24 hours. Note: The terms SCD (Sudden Cardiac Death) and SCA (Sudden Cardiac Arrest) and are both used in this slide set. What is Sudden Cardiac Arrest Sudden unexpected loss of heart function, breathing and consciousness, usually resulting in death Malfunction of the Hearts Electric system SCA Adults Not uncommon 1 in 1 per year Coronary artery disease Not the same as a Heart Attack SCA Incidence-the mystery Children and adolescents Less common than adults 1-2 in 1,-2, (vs. 1 in 1) per year Most etiologies are congenital A few are acquired AHA Heart and Stroke Facts 28 166, 325, MMWR ( Morbidity and Mortality Weekly reports) 46, Problem: Not a reportable disease for CDC Not categorized by national public health agencies 1
3, 25, 2, 15, 1, 5, Magnitude of Sudden Cardiac Arrest? (U.S. Deaths per year) The latest evidence-roc Trial Incidence of EMS-assessed SCA 95 / 1, Extrapolates to 295,/year in US EMS treats aprrox 6% of unexpected cardiac deaths Age > 2 36/1, to 81/1, Treat approx 74, - 174, per yr AIDS Breast Cancer Lung Cancer Stroke SCA Nichol, JAMA, 28 SCA facts SCA occurs abruptly and without warning The faces of sudden death 2/3 of SCA deaths occur without any prior indications of heart disease. SCA can happen to people of all ages and health conditions. Can occur in presumably healthy individuals- even athletes http://kenheart.org/html/memorials.html Cause of SCA 12% Other Cardiac Cause Underlying Arrhythmias of SCA VT 62% Torsades de Pointes 13% Bradycardia 17% Primary VF 8% 88% Arrhythmic Cause Albert CM. Circulation. 23;17:296-211. B Adapted from Bayes de Luna A. Am Heart J. 1989;117:151-159. ayés de Luna A. Am Heart J. 1989;117:151-159. 2
Latest evidence-roc trial V-fib as initial rhythm - 13.5% overall - 3% of those treated VF as initial arrest rhythm EMS-based studies: low and decreasing Annual Number of Patients Treated for Outof-Hospital VF, 197-2 in Seattle No. of Cases 4 35 3 25 2 15 1 5 197 1972 1974 1976 1978 198 1982 1984 1986 1988 199 1992 1994 1996 1998 2 Year Cobb L, Fahrenbruch CE, Olsufka M, Copass M. Changing Incidence of Out-of-Hospital Ventricular Fibrillation, 198-2. JAMA 288(23):38-313, 22. Survival Overall estimate for US is 6-7% Nichol (1999); Callaway (1997) Great variability in reported rates Regional differences probably exist All rhythms: 2-25% VF: 3-33% Pittsburgh 31% for witnessed VF Seattle 33% for OOH VF Rochester, MN 49% for OOH VF Different denominators All rhythms or just VF Witnessed Attempted resuscitations Different numerators ROSC, survival to admit, to discharge, neuro intact ROC Trial survival rates EMS assessed: 4.4% Varied by site: 1.1% - 8.1% EMS treated: 7.9% Varied by site: 3.% - 16.3% VF initial rhythm: 21.% Varied by site: 7.7% -39.9% Nichol, JAMA, 28 Strategies to improve survival Prevention is better than cure! Prevention Pre-resuscitation (Preparedness) Resuscitation Post-resuscitation 3
Prevention of Sudden Death Awareness Identify high risk patients Athletic pre-participation questionnaires Family history Warning signs and symptoms Risk stratification Early Referral to Electrophysiology Physician Prevention of Sudden Death Primary Identified as at risk of having a Cardiac Arrest Secondary -- having had a previous episode of Cardiac Arrest Implantable Cardioverter Defibrillator (ICD) Defibrillation therapy for SCA Painless termination of most arrhythmias with antitachycardia pacing (ATP) 98% effective for termination of VT/VF Used for Primary and Secondary prevention Major Clinical Studies Supporting ICD Guidelines Prior SCA, VT/VF AVID 1 HF, Low LVEF SCD-HeFT 2,3 COMPANION 4 1 The AVID Investigators. N Engl J Med. 1997;337:1576-1583. 2 Bardy GH, et al. N Engl J Med. 25;352:225-237. 3 Packer DL. Heart Rhythm. 25;2:S38-39. 4 Bristow MR, et al. N Engl J Med. 24;35:214-215. 5 Moss AJ, et al. N Engl J Med. 22;346:877-883. Prior Heart Attack, Low LVEF, HF MADIT-II 5 Relation of LVEF to Risk of SCA % of Sudden Cardiac Deaths 8 7 6 5 4 3 2 1 7.5% 5.1% -3% 31-4% 41-5% > 5% LVEF JJ, et al. J Am Coll Cardiol. 1997;3:15-155. 2.8% 1.4% Note: 56.5% of all SCA victims had an LVEF > 3%. Control Group Mortality % at 2 years SCD Rates in Heart Attack Patients with Low LVEF 3 2 1 28 14 2 1 18 7 32 28 16 16 TRACE CAPRICORN EMIAT MADIT MUSTT Inducible Total Mortality Arrhythmic Mortality 21 12 MUSTT Registry 19.8 9.4 MADIT II Total Mortality ~2-3%; SCD Accounts for ~5% of Total Deaths 4
In people who ve had a heart attack and have HF, SCD occurs at 4 times the rate of the general population. Prediction & Prevention Adabag AS, et al. JAMA. 28;3:222-229. Who is at Risk for SCA? A prior SCA Family history of SCA Congestive Heart Failure (CHF) Have had a Myocardial Infarction (MI) Ejection Fraction (EF) less than or equal to 35% Genetic, other causes Reduced Left Ventricle Ejection fraction remains the single most important risk factor for overall mortality and sudden cardiac death. Priori SG. Eur Heart J. 21:22;1374-145. Public unaware of risk factors Informed at risk patients more likely to initiate a discussion regarding SCA with primary Physician ICD s are 98% effective at protecting those at risk for SCA Over 8, people at risk for SCA remain unprotected Less then 35% of individuals who could benefit from an ICD have one Underserved Patient Populations The majority of hospitalized HF patients who qualified for ICD therapy did not receive it in a large AHAfunded study: --Hospitals were part of American Heart Association s Get With The Guidelines SM Heart Failure Quality Improvement Program 59,965 HF patients admitted to 217 US hospitals 13,34 HF patients (21.7%) with LVEF < 3% were considered eligible for ICDs Hernandez AF, et al. JAMA 27;298:1525-1532. 5
% of Eligible Patients Receive ICD Percentage of Eligible Patients Receiving ICD Therapy 7 6 5 4 3 2 1 35.4 % All Patients 28.2 29.8 % % Black Women White Women 33.4 % Black Men 43.6 % White Men Can t prevent all SCA, so must be prepared! Hernandez AF, et al. JAMA. 27;298:1525-1532. Pre-resuscitation phase Public awareness and education CPR and AED training Public access defibrillation programs On-site response plan Training of potential responders AED deployment and maintenance Emergency response readiness Enhanced 911 and Emergency Medical Dispatching First responders with AEDs Emergency medical services Resuscitation phase Immediate bystander action Call 911 (and on-site responders) CPR AED First responder/ EMS --Quality CPR --Timely defibrillation --Advanced life support (?) Survival for OOH-VF Cardiac-rehabilitation programs, electrophysiology laboratories 1 Automated External Defibrillators (AEDs) Survival (%) 8 6 4 PAD programs 2 Home, after EMS response to 911 request 1 2-7 8-15 Estimated Time from Collapse to Defibrillator Shock (minutes) Weaver WD et al. NEJM 22; 347:1223 This device enabled the concept of lay bystander defibrillation 6
What is an AED? Automated External Defibrillator Small, portable defibrillatordesigned for use by lay rescuers Analyzes victims heart rhythmwhen patches are attached Determines if shock is needed Simple, automatic- provides voice & visual prompts AEDs work Sensitivity of ECG analysis Rate of detection of shockable rhythms Over 8%; over 9% for coarse VF Most misses due to fine VF Efficacy of shock Termination of the arrhythmia 7-9% after one shock, 95-98% after 3 shocks Caution: various definitions used AEDs are safe High specificity Rate of detection of non-shockable rhythms At or near 1% in published studies Don t allow user to shock inappropriately Motion and artifact detection Most detect poor pad contact Excellent track record to date Urgency of Sudden Cardiac Arrest Resuscitation Success vs. Time % Success 1 9 8 7 6 5 4 3 2 1 Chance of success reduced 7-1% every minute Adapted from text: Cummins RO, 1998. Annals of Emergency Medicine. 18:1269-1275. 1 2 3 4 5 6 7 8 9 Time (minutes) Chicago Airports AEDs deployed 3 minutes apart 11/18 patients with VF alive and neurologically intact at one year 6/11 rescuers not trained in AED use Las Vegas Casinos Security guards trained in CPR and AED use 53% survival for VF 74% survival when shock within 3 minutes of collapse Caffrey SL et al. N Eng J Med 22;347. Valenzuela TD et al. N Eng J Med 2;343. 7
VF as initial arrest rhythm PAD-based studies: high and constant 1 8 6 4 2 VF Sites with AEDs had double the number of survivors than those without AEDs. Response plans in place at all sites. Casinos PAD Airlines Federal ROC report (AHA Nov 27) Review of ~1, cardiac arrests in ten large areas in US and Canada Bystander CPR 8% survival Bystander AED 33% survival WOW! AEDs do not save lives people using AEDs quickly and effectively saves lives! But only 3% had CPR and only 2.5% AED! Requires a well-planned program What about CPR? Immediate effective bystander CPR can double or triple a victims chance of survival Extends the time available for successful defibrillation and resuscitation Approx only 3% of people are trained in CPR On average only 27.4 % of out of hospital SCA victims receive bystander CPR 8
Why so few? Reluctant - fear of disease transmission Most common AIDS - difficulty learning and remembering - yuck factor Increase Bystander CPR 15% of people they would be willing to perform CPR w/ mouth to mouth 68% would be willing to perform chest compression only if it was on option Ventilations Do we really need them? History Been accepted for centuries as part of resuscitation Manual techniques of artificial respiration Most commonly used and accepted in early 19 s through 195 1744 miner overcome by smoke Various techniques over the years Becker, L. B. et al. Circulation 1997;96:212-2112 Survival with chest compression with and without assisted ventilation Survival rates in comparison of good quality chest-compressiononly CPR Becker, L. B. et al. Circulation 1997;96:212-2112 Becker, L. B. et al. Circulation 1997;96:212-2112 Copyright 1997 American Heart Association Copyright 1997 American Heart Association 9
Adverse Effects to Ventilations? Gastric insufflation or air into the stomach Pulmonary aspiration Higher level of CO2 may have a cardiodepressive effect Ventilations Takes away from compression time - delay up to 16 seconds - no circulatory support during 6% of resuscitation Hyper ventilation causes increased intra thoracic pressure decreasing venous return to the heart Chest compression alone CPR Bystander contacted 9-1-1 standard CPR (n=279) chest compression alone (n=241) 29/279 (1.4%) 35/241 (14.6%) p=.18 Ahlstrom et al, 2 28 call to action to help reduce barriers of performing cpr Sayre, Circulation, 28 Chest compression only Less intimidating Easily taught Easily remembered Easily preformed Adequately taught by dispatcher- delivered instruction More readily accepted by public If bystanders activate EMS and begin chest compressions more lives will be saved. Factors affecting survival EMS response time Especially if no bystander care Time to CPR Quality of CPR Time to defibrillation Timing of defibrillation Post-resuscitation care Hypothermia 1
The race to shock- First Responders Whether by land or sea, police or fire or QRS, EMS just can t get there fast enough. Firefighters Seattle (Weaver, NEJM, 1988) Police Rochester MN (White, Ann Emerg Med, 1996) Pittsburgh PA suburbs (Mosesso, Ann Emerg Med, 1998) SCA Chain of Survival Statistics Even in the best EMS/early defibrillation programs it is difficult to achieve high survival times due to many SCA events not being witnessed and the difficulty of reaching victims within 6-8 minutes. 48-58% SCA events are not witnessed 1,2 85% SCA events occur at home/non-public locations 1 Adequate rate Proper depth Full recoil Quality CPR: Compressions Continuous (very rare interruptions) 1 Nichol G, et al. JAMA. 28;3:1423-1431. 2 Chugh SS, et al. J Am Coll Cardiol. 24;44:1268-1275. Chest compression rates Chest compression rates by survival Number of 3 sec segments 3 25 2 15 1 5 n=1626 segments 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-1 1-11 11-12 R>12 Chest compression rate (min-1) Abella et al, 25 Number of 3 sec segments 21 18 15 12 9 6 3 p=.3 No ROSC ROSC Mean rate, ROSC group 9 ± 17 * Mean rate, no ROSC group 79 ± 18 * 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-1 1-11 11-12 >12 Chest compression rate (min -1 ) Abella et al, 25 11
Chest compression depth CPP, mm Hg 4 32 24 16 8 2 inches vs 1.5 inches 1 2 3 CPR duration, min ICCM, 25 Survival: 1% 15% Compression depth also associated with a higher rate of shock success S h o c k s u c c e s s 1% 9% 8% 7% 6% 5% 4% 3% 2% 1% % <26 26-38 39-5 >5 Compression depth in millimeters Recoil or chest wall decompression Complete chest wall recoil - improves hemodynamics - negative intrathoracic pressure - draws venous blood back to R heart -providing cardiac preload for next compression phase Incomplete chest wall recoil Relative decrease in negative intrathoracic pressure Positive intrathoracic pressure Results in significantly reduced coronary and cerebral perfusion pressures Interruption of compression = no flow time No Interruptions Blood pressure Blood pressure Time Time = chest compression Berg et al, 21 = chest compression Berg et al, 21 12
Ventricular Fibrillation and CPR Aortic pressure (purple) Interruptions of CC decreases survival Right atrial pressure (yellow Coronary perfusion pressure approaches zero within seconds after stopping chest compressions Coronary Perfusion Pressure (Ao diastolic - RA diastolic) Yu, Circulation, 22 CPR quality not so good Quality of CPR Rate of compressions were < 9 3% Depth of compression < 38 mm 4% Ventilations to high 6% Interuptions or no flow periods --approx half the time of no spontaneous circulation Complete Recoil/decompression 17% Wik, JAMA, 25 Abella, JAMA, 25 Poor Quality Contributing Chaotic scene Stressful Infrequent recertification Hand positioning technique Lack of reliable internal timing to pace compressions Fatigue Possible solutions Understand deficiencies Mechanical devices - Autopulse, Lucas Monitoring/Feedback devices -smart defibrillators and pads - CPR Ezy devices - end tidal Co2 monitors 13
What about Defibrillation? When to shock No more shock, shock, shock One shock at a time (Class IIa) Do CPR until ready to check rhythm and while defibrillator is charging. IMMEDIATELY follow each shock with CPR, beginning with compressions. Do NOT interrupt chest compressions to check rhythm or pulse until 5 cycles or 2 minutes of CPR are given. CPR before shock for prolonged VF? Several animal studies found shock less effective as VF duration lengthens CPR first may improve survival Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation 24% (155/639) 3% (142/478) p=.4 Defib first - AHA CPR (9 sec) first, then defib 42 months 36 months Cobb et al, 1999 Three phase model of SCA Electrical Circulatory Metabolic 1-4 min 4-1 min >1 min Wik L, et al. JAMA 23; 289:1389-95. Weisfeldt and Becker, JAMA, 22 14
When to shock Witnessed by on-site rescuer Shock as soon as defibrillator available Organization of VF decays over time after cardiac arrest Emergency responders After 9-18 seconds of CPR Can we be more precise more surgical? Sudden Cardiac Arrest Post resuscitation care Return of spontaneous circulation marks the start not the end of a successful resuscitation. The true end point is a fully conscious, neurologically intact patient with spontaneous cardiac rhythm BRAIN INJURY is the most common cause of death after initial resuscitation from sudden cardiac arrest Proportion of Patients Alive Acute Cardiopulmonary Disturbance (Dysrhythmia, Hypoxia, Pump Failure, Stunning) Brain Injury (Other Organs, Ischemic Neuronal Injury, MSOF) EMS Precipitating Disease (CAD, Arrhythmia, Cardiomyopathy) ED ICU Rehabilitation / Regeneration (Stimulation of Brain Recovery) Continuing Care HIPPA Collapse ROSC Admit to Hospital Discharge 6 months 12 months 15
Cardiac Arrest No Blood Flow Metabolic Chain of Events in Cardiac Arrest Cerebral Ischemia Free Radicals Cell Death and Cerebral injury Cell Damage CPR / Pulse O2 Reperfusion Induced Hypothermia (32-34º C) The Hypothermia after Cardiac Arrest Study Group N Engl J Med 22; 346 : 549-556 7 European EDs 275 VT/VF pts with ROSC Cooled to 32-34º C using an external cooling device +/- ice packs for 24 h Sedated with midazolam and fentanyl, paralysed with pancuronium 6 month follow-up % of patients 1% 8% 6% 4% 2% % Control 55% 39% Good Neuro Recovery Hypothermia 45% Survival 59% Induced Hypothermia (33º C) Bernard SA et al. N Engl J Med 22; 346 : 557-63 Consensus 25 Chain of Survival Australian study 73 OOH-CA pts Control with ROSC 1% Cooled to 33º C for 12 h % 8% 6% 26% of patients 4% 2% % p<.5 Survival Hypothermia 49% Cardiac Arrest Intra-arrest Abella, 24 Katz, 2 When to start cooling? Probably as soon as possible ROSC 1 2 3 4 5 6 7 8 Time Soon after ROSC Sterz, 1991 Kuboyama, 1993 HACA, 22 Pilot Randomized Trial of Prehospital Induction of Hypothermia in OOH-CA with Rapid Infusion of 4ºC Saline Kim et. al. Circ 27;115:364-37 7 paramedic units T 9 receiving hospitals e Adult, non-traumatic arrestm p All rhythms Esophageal temp >34C C h Intubated a n Unresponsive g IV access e Mean temp change= -1.2 ºC 1 1 2 <5 5 Control 2.1.1 ml 1.5 > 2 ml 1.8 16
EMS Initiated Cooling Pre-hospital cooling is feasible Core temp can be lowered -safely -easily -quickly Shortens time it takes to reach target temperature Serves as a reminder to emergency dept to continue hypothermia therapy Cooling techniques Internal cooling Ice cold IV fluid (4 degrees Celsius) Rate of 3ml/kg External Ice packs- head and torso Cooling blankets Protocol development Location Location Location Find a champion Review evidence Coordinate with receiving Hospital Develop criteria -inclusion/exclusion -indication to stop Pick a cooling method Educate Review quality assurance JAMA 28;3(12) SCA: a public health crisis 25 2 15 1 5 Annual incidence House fire Prostate cancer Breast cancer Car accidents Sudden cardiac arrest Survival higher in selected cities where Cardiac Arrest has been treated as a public health problem Proven Well designed strategies to increase public awareness Public access defibrillation programs Bystander CPR Identifying individuals at higher risk Advanced treatments in post-resuscitation Community campaign to strengthen the chain of survival 17
Community campaign Know your numbers Stakeholders develop trust and relationships Find the champions Not one recipe fits all communities Develop quality assurance program For more info: Sudden Cardiac Arrest Association www.suddencardiacarrest.org Heart Rhythm Society www.hrsonline.org American Heart Association www.americanheart.org Thank you for your attention! Secret Question Quality compressions include all of the following except? A. Adequate rate B. Proper depth with full recoil C. Continuous compressions D. Coordinate ventilations with compressions E. All of the above F. A, B and C only Questions? Contact: Carolyn Stovall 59-242-4263 1-866-63-433 stovalc@inhs.org Fax: 59-232-8168 18