NAEMSP 2001 A NNUAL M EETING

Abstract

Recently, emphasis has been placed on the simultaneous implementation of resuscitation interventions currently recommended within the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). The rate of successful outcomes from out-of-hospital cardiac arrest remains relatively low in most U.S. communities. Accurate measures of these rates are difficult to determine because of ineffective reporting mechanisms. In many cases of acute myocardial infarction, the initial presentation of symptoms is quickly followed by sudden death. Little information exists regarding the system-of-care components most likely to result in successful outcomes. Inconsistent application of these components may be responsible in part for the variability of survival rates among communities. We present a case of acute myocardial infarction followed by sudden cardiac arrest benefiting from the application of coordinated, community-based systems of care.     

家属心肺复苏培训对提高心脏猝死高危患者存活率的影响

目的 探讨分析心脏猝死高危患者家属进行心肺复苏培训对提高患者存活率的影响。方法 选择重庆医科大学附属第二医院心内科住院部2012年2月至2016年6月收治的610名心脏猝死高危患者的家属为研究对象。利用随机抽签法将其分为两组,观察组305名患者家属接受系统的心肺复苏培训方案;对照组305名患者家属只接受床旁健康宣教及公休会等。分析两组患者心脏骤停后存活率及其家属对急救知识及技能的掌握情况。存活的定义为患者心脏骤停经复苏抢救,患者出现自主心搏、自主呼吸,且在高级生命支持下存活时间＞24 h。存活率=（心脏骤停后存活人数/心脏骤停事件总例数）×100%。结果 观察组患者家属对心脏猝死诱因、防治措施、心脏骤停判断等方面知识的掌握情况均好于对照组（P＜0.05）;观察组患者家属应急反应时间平均为（81.02±37.01）s,明显短于对照组（169.62±30.69）s;观察组患者家属护理满意度97.05%,明显优于对照组83.28%。随访1年,观察组患者存活率（88.51%）高于对照组（70.45%）,差异有统计学意义（P＜0.05）。结论 对心脏猝死高危患者家属进行心肺复苏培训,能够有效提高家属的急救水平及应急能力,利于提高患者存活率。     

Epidemiology of Ventricular Tachycardia/Ventricular Fibrillation and Sudden Cardiac Death

Despite the difficulties correlating pathological data with acute clinical events in the field of sudden cardiac death, information useful to both the clinician and the epidemiologist has developed. Sudden cardiac death may be defined broadly. These definitions have varied, but it is now generally recognized that sudden cardiac death should reflect a time span of less than one hour. The epidemiology of sudden cardiac death incorporates many factors, including age, heredity, gender, and race. Coronary risk factors and the history of prior coronary heart disease constitute additional points of importance. Finally, clinical characteristics of the cardiac arrest patient are variable. Improving outcome in prehospital cardiac arrest victims involves a multifactorial approach involving rescue personnel, resuscitation technology, and the participation of the public.     

Death and near death from cardiac arrest during the Boston Marathon

The Boston Marathon has been run for 115 years during which there were three sudden cardiac arrests. The most recent was a near death avoided by rapid cardiopulmonary resuscitation (CPR) and defibrillation. Awareness of the dangers of participating in a marathon, the risk factors associated with sudden death during competition, and the life-saving importance of rapid CPR and defibrillation are essential for participants and event organizers. Available records and reports of the three known cases of cardiac arrest during the Boston Marathon were examined. These cases were identified by representatives of the Boston Athletic Association, which has organized each marathon since its inception. Pertinent literature was reviewed and new information was obtained during interviews of witnesses and rescuers. The data were analyzed in search of shared risk factors for cardiac arrest, death, and the optimal requirements for survival. In 115 years, there were two cardiac deaths and one near death from cardiac arrest. A history of coronary artery disease, advanced age, and prolonged race time are risk factors for sudden cardiac arrest. Rapid application of CPR and defibrillation are essential for survival. Prevention or reduction of life-threatening cardiac incidents during marathon races might be achieved if participants of advanced age or with a history of coronary artery disease seek medical clearance prior to entering an event. Those with coronary risk factors should have a discussion with their physician. Availability of trained personnel and defibrillators are important considerations in marathon planning.     

Dying, sudden cardiac death and resuscitation technology

Many nurses will be familiar with the demanding role of caring for a patient who requires cardiopulmonary resuscitation following a sudden, life-threatening illness or event. This paper examines the phenomenon of sudden cardiac death and in particular, focuses on the medical-technical discourse of dying and death in the context of resuscitation for the victims of sudden cardiac arrest. The process of dying is distinguished from the end point of death by drawing upon biomedical determinants and definitions of death. Comparison is made between the use of resuscitation techniques in an attempt to reverse 'clinical death' and the notion of a 'natural death' that is proffered as a means to a 'good' or 'ideal' death. The humanistic versus technological imperative is further deliberated by examining the role of the emergency team in end of life care and includes consideration of the effects that medical dominance may have on the dying process. The practice of family witnessed resuscitation is recognised as one way in which a holistic approach to emergency resuscitative care may be achieved.     

心肺复苏家兔血浆ET、CGRP含量变化的研究

目的 研究血浆内皮素（ＥＴ）与降钙素基因相关肽（ＣＧＲＰ）在心脏骤停缺血／再灌注损伤前后含量变化规律及意义。方法 制作家兔心脏骤停缺血／再灌注模型。观察心肺复苏后各时相血浆ＥＴ、ＣＧＲＰ、血压及心电变化。结果 动物在心脏骤停及复苏即刻血浆ＥＴ含量明显变化（Ｐ〈０．０５），而血浆ＣＧＲＰ水平降低（Ｐ〈０．０５），复苏后０．５小时血浆ＥＴ明显升高（Ｐ〈０．０１），复苏后２小时血浆ＥＴ、ＣＧＲＰ均较复苏前有明显上升（Ｐ〈０．０５）。结论 在心脏骤停缺血／再灌注损伤过程中ＥＴ、ＣＧＲＰ水平变化及相关关系可能是一种调节机制并在病理生理过程中起重要作用。     

Sudden fatal cardiac arrest in a child with an unrecognized anterior mediastinal mass

We report a case of sudden fatal cardiac arrest in a 3-year-old boy. The arrest occurred when he was placed in the supine position by force for a venipuncture. Autopsy revealed a large anterior mediastinal mass. The death was attributed to the airway obstruction and cardiac compression by the mass. Postural change to supine position by force was believed to have triggered compression of the cardiopulmonary system by an unrecognized anterior mediastinal mass, resulting in cardiac arrest.     

Resuscitation by primary care doctors

BACKGROUND: Sudden cardiac arrest is a common mechanism of premature death in the community. Resuscitation is often possible, but no large study of resuscitation by doctors who practice there has been published. METHODS: General practitioners (GPs) equipped with defibrillators reported 555 patients with cardiac arrest in whom they attempted resuscitation. FINDINGS: Average age was 65.4, 75% male. Most arrests (49%) occurred at the patient's home but some (18%) occurred at or near the doctors' surgeries. Heart disease was responsible for 88% of the arrests: in these cases resuscitation to leave hospital alive was frequently successful (148 of 436 attempts, 34%). Success was rare (one of 59, <2%) when the arrest was due to non-cardiac disease. Resuscitation was most common when the first monitored rhythm was shockable (VF/VT) and defibrillated promptly: 144 out of 351 (41%) patients surviving. VF/VT was most common with early rhythm monitoring, particularly when the doctor was present (63% survival), or nearby (54%). When VF/VT complicated AMI, 72% of those defibrillated within 1min of onset survived. With delayed attendance, the frequency of VF/VT fell and asystole or Pulseless Electrical Activity (PEA) became more common. Survival after resuscitation was rare for patients presenting with these rhythms: five of 202 (2.5%). No such patient survived unless the rhythm could be converted to VF/VT with drugs or basic life support and subsequently shocked. CONCLUSION: Primary care doctors equipped with defibrillators attend patients with cardiac arrest under circumstances in which resuscitation is frequently successful. This presents a unique opportunity to reduce mortality from sudden cardiac arrest.     

院内猝死32例临床分析

目的：探讨猝死的病因、诱因及流行病学特征，为临床防治猝死提供依据。方法：回顾性分析32例猝死病例的临床资料。结果：32例中男性多见，无明显职业分布；基础疾病38％为心血管系统，其次为呼吸系统；仅28％有明确诱因，发作以夏冬季常见，24h中以凌晨和夜间多见。全部经心肺复苏，仅1人存活。结论：应针对猝死的特征进行一系列的干预．以积极防治猝死。     

Short-term health system costs of paediatric in-hospital acute life-threatening events including cardiac arrest

ObjectivesAcute life-threatening events in children are medical emergencies requiring immediate intervention. They can be due to cardiac arrest, respiratory arrest or another cause of sudden compromise for example, choking. Internationally, hospital systems are being introduced to reduce preventable acute life-threatening events and, despite having significant resource implications, have not yet been subject to economic analysis. This study presents the additional short-term health service costs of in-hospital acute life-threatening events to inform a cost-effectiveness analysis of prevention strategies.MethodologyPatient level costs (GB pounds, price year 2005), in excess of baseline costs, were collected from a short-term NHS perspective. The cost per survivor to hospital discharge included the cost of the cardiopulmonary resuscitation attempt, resuscitation preparedness, and the cost of in-hospital post-resuscitation care. Acute life-threatening events calls were classified into two groups: cardiac arrest, and respiratory arrest and other acute life threatening events. Outcomes from these groups were compared to a similar group of unplanned Paediatric Intensive Care (PIC) admissions. All survival and length of stay outcomes were calculated for the first episode.ResultsThe survival to hospital discharge was 64.4% (65/101), (95% Confidence Intervals 55.02, 73.70) for all acute life-threatening event calls, and 41.3% (12/29), (95% Confidence Intervals 23.45, 59.31) for cardiac arrest. The mean cost of the resuscitation attempt was £3664 for all acute life-threatening event calls, and £3884 for cardiac arrest. The annual cost of cardiopulmonary resuscitation preparedness was £181,565.The mean cost of the post-event length of stay in hospital was £22,562 for cardiac arrest, £26,335 for other acute life-threatening events, and £26,138 for urgent PIC admissions. The cost per survivor to hospital discharge was £53,289.ConclusionThe short-term costs of paediatric in-hospital acute life-threatening events, including cardiac arrest, from an NHS perspective, are more expensive than those reported for adults, but similar to other life saving treatments. This new information will serve to improve efficiency in the current resuscitation programme and contribute to cost-effectiveness analysis of prevention strategies.     

In-hospital cardiac arrest

In-hospital sudden cardiac arrest and resuscitation is distinct from out-of-hospital sudden cardiac arrest (OOHSCA) and warrants specific attention. Sudden cardiac arrest (SCA) is a manifestation of an underlying process rather than a disease itself. The complex, multiorgan system dysfunction common among the inpatient population can precipitate SCA by both similar and very different mechanisms than OOHSCA. The diagnostic and treatment algorithms of SCA remain largely the same between the inpatient and outpatient arenas. The application of complex diagnostic and therapeutic interventions is permissible, but such tools must not interrupt or delay the important basics of cardiac arrest management in the inpatient setting, including adequate chest compressions and timely defibrillation when appropriate.     

心肺复苏患者心肌损伤的临床研究

目的 探讨血清心肌肌钙蛋白T对复苏患者心肌损伤的临床价值。方法 对69例心跳、呼吸骤停的患者进行标准心肺复苏，观察心室颤动前和复苏后患者心肌肌钙蛋白T水平的变化。结果 复苏患者在恢复自主循环1h后，血清心肌肌钙蛋白T就明显升高，且升高水平与患者的病死率相对应。结论 复苏患者存在急性心肌损伤；心肌肌钙蛋白T浓度能客观地反映心肌受损状态。     

T ERMINATION OF R ESUSCITATION IN THE P REHOSPITAL S ETTING FOR A DULT P ATIENTS S UFFERING N ONTRAUMATIC C ARDIAC A RREST

The National Association of EMS Physicians (NAEMSP) supports out-of-hospital termination of resuscitation for adult, nontraumatic cardiac arrest patients who have not responded to full resuscitative efforts. The following factors should be considered in establishing termination of resuscitation protocols: 1) Termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical. 2) Unwitnessed cardiac arrest with delayed initiation of cardiopulmonary resuscitation (CPR) beyond 6 minutes and delayed defibrillation beyond 8 minutes has a poor prognosis. 3) In the absence of “do not resuscitate” or advanced directives, a full resuscitative effort including CPR, definitive airway management, medication administration, defibrillation if necessary, and at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines should be performed prior to declaring the patient dead. 4) A patient whose rhythm changes to, or remains in, ventricular fibrillation or ventricular tachycardia should have continued resuscitative efforts. Patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation. 5) Logistic factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. 6) Online medical direction should be established prior to termination of resuscitation. The decision to terminate efforts should be a consensus between the on-scene paramedic and the online physician. 7) The on-scene providers and family should have access to resources, such as clergy, crisis workers, and social workers. 8) Quality review is necessary to ensure appropriate application of the termination protocol, law enforcement notification, medical examiner or coroner involvement, and family counseling.     

The Role of Implantable Cardioverter Defibrillators in Non VT/VF Sudden Deaths

Implantable cardioverter defibrillator (ICD) therapy has been an impressive success in preventing sudden cardiac death (SCD). Electrocardiographic documentation of SCD in ICD patients has been rare, but usually arrhythmias other than ventricular tachycardia/ventricular fibrillation (VT/VF; asystole and electromechanical dissociation [EMD]) have been implicated. This raises the question whether backup bradycardia pacing can prevent deaths due to asystole and EMD in such patients. We studied the outcome of 88 patients with permanent bradycardia pacemakers and compared them to 500 consecutive nonpacemaker patient controls, sustaining out-of-hospital cardiac arrest and undergoing resuscitation by paramedics. Mean age of the pacemaker patients was 73.5 ± 10.3 years and 64% males, compared to mean age of 68.2 ± 6.7 years and 67% males in the control group. Overall success of resuscitation and survival rates were similar. When the documented rhythm was VT/VF or asystole there were no differences in resuscitation or survival rates for the pacemaker or nonpacemaker patients. However, resuscitation rate was significantly higher in pacemaker patients than nonpacemaker patients with EMD: 47% versus 20% ( P < 0.03). For EMD, survival rate for the pacemaker patients was 13% compared to 5% in the nonpacemaker patients, but this difference was not statistically significant. Backup bradycardia pacing in future generation devices may improve the outcome of non VT/VF sudden cardiac death in at least some of the ICD recipients.     

Characteristics and outcome of cardiorespiratory arrest in children

OBJECTIVE: To analyse the present day characteristics and outcome of cardio-respiratory arrest in children in Spain. DESIGN: An 18-month prospective, multicentre study analysing out-of-hospital and in-hospital cardio-respiratory arrest in children. Patients and methods: Two hundred and eighty-three children between 7 days and 17 years of age with cardio-respiratory arrest. Data were recorded according to the Utstein style. The outcome variables were the sustained return of spontaneous circulation (initial survival), and survival at 1 year (final survival). Three hundred and eleven cardio-respiratory arrest episodes, composed of 70 respiratory arrests and 241 cardiac arrests in 283 children were studied. Accidents were the most frequent cause of out-of-hospital arrest (40%), and cardiac disease was the leading cause (31%) of in-hospital arrest. Initial survival was 60.2% and 1 year survival was 33.2%. The final survival was higher in patients with respiratory arrest (70%) than in patients with cardiac arrest (21.1%) (P <0.0001). Although many individual factors correlated with mortality, multivariate logistic regression revealed that the best indicator of mortality was a duration of cardiopulmonary resuscitation of over 20 min (odds ratio: 10.35; 95% CI 4.59-23.32). CONCLUSIONS: In Spain, the present mortality from cardio-respiratory arrest in children remains high. Survival after respiratory arrest is significantly higher than after cardiac arrest. The duration of cardiopulmonary resuscitation attempt is the best indicator of mortality of cardio-respiratory arrest in children.     

Aetiology of unsuccessful prehospital witnessed cardiac arrest of unclear origin.

OBJECTIVES: To determine, by means of autopsy, the cause of death following unsuccessful cardiopulmonary resuscitation of patients with a witnessed prehospital cardiac arrest of unclear origin. METHOD: Observational study of all prehospital-witnessed cardiac arrest of unclear origin over a period of 19 months in the emergency medical service region of a tertiary care hospital. RESULTS: During the study period, 211 prehospital cardiopulmonary resuscitation attempts were recorded. In 144 study participants, cardiopulmonary resuscitation was not successful: there was no return of spontaneous circulation. Cardiac arrest of traumatic or other clear origin was not considered, nor were paediatric cases. Thirty out of the 114 remaining patients underwent an autopsy (26.3%). The main aetiology of cardiac arrest in this selected population was ischaemic heart disease in 16 out of 30 patients (53.3%) followed by pulmonary embolism in four patients (13.3%) and vascular disease other than coronary disease in two patients (6.7%). Other causes consisted of hypertrophic obstructive cardiomyopathy (one patient) (3.3%) and poisoning (one patient) (3.3%). The cause of death could not be identified in six cardiac arrest victims (20%). CONCLUSIONS: Ischaemic heart disease and pulmonary embolism account for 66.6% of all witnessed cardiac arrest with no return of spontaneous circulation.     

Lipid emulsion as rescue for local anesthetic-related cardiotoxicity.

Regional anesthesia techniques use local anesthetics to provide sensory and motor block for surgical intervention. Intravascular absorption of the local anesthetics may induce toxic effects, such as seizure activity or cardiac depression, leading to cardiac arrest. Standard, prolonged resuscitation efforts are not always successful in the event of local anesthetic cardiotoxicity. Research in animals, however, has shown that, with the administration of intravenous lipid emulsion, hemodynamic stability can be restored after local anesthetic-induced cardiac arrest. Recent case reports have detailed successful resuscitation from cardiac arrest in several patients with local anesthetic-induced cardiotoxicity.     

Termination of resuscitation in the prehospital setting for adult patients suffering nontraumatic cardiac arrest

The National Association of EMS Physicians (NAEMSP) supports out-of-hospital termination of resuscitation for adult, nontraumatic cardiac arrest patients who have not responded to full resuscitative efforts. The following factors should be considered in establishing termination of resuscitation protocols: 1) Termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical. 2) Unwitnessed cardiac arrest with delayed initiation of cardiopulmonary resuscitation (CPR) beyond 6 minutes and delayed defibrillation beyond 8 minutes has a poor prognosis. 3) In the absence of “do not resuscitate” or advanced directives, a full resuscitative effort including CPR, definitive airway management, medication administration, defibrillation if necessary, and at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines should be performed prior to declaring the patient dead. 4) A patient whose rhythm changes to, or remains in, ventricular fibrillation or ventricular tachycardia should have continued resuscitative efforts. Patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation. 5) Logistic factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. 6) Online medical direction should be established prior to termination of resuscitation. The decision to terminate efforts should be a consensus between the on-scene paramedic and the online physician. 7) The on-scene providers and family should have access to resources, such as clergy, crisis workers, and social workers. 8) Quality review is necessary to ensure appropriate application of the termination protocol, law enforcement notification, medical examiner or coroner involvement, and family counseling. PREHOSPITAL EMERGENCY CARE 2000;4:190-195     

Time-dependent interventions

The contribution by Pepe and colleagues provides additional evidence that initial defibrillation is not necessarily the optimal intervention for victims of cardiac arrest and especially when cardiac arrest has been untreated for more than 3 min. Precordial compression therefore remains the mainstay of basic life support cardiopulmonary resuscitation after sudden death. It is increasingly apparent that neither epinephrine whether in conventional or high doses nor vasopressin improve ultimate survival. To the contrary, there is evidence favoring β₁-adrenergic blockade.     

Time-dependent interventions

The contribution by Pepe and colleagues provides additional evidence that initial defibrillation is not necessarily the optimal intervention for victims of cardiac arrest and especially when cardiac arrest has been untreated for more than 3 min. Precordial compression therefore remains the mainstay of basic life support cardiopulmonary resuscitation after sudden death. It is increasingly apparent that neither epinephrine whether in conventional or high doses nor vasopressin improve ultimate survival. To the contrary, there is evidence favoring β₁-adrenergic blockade.