New cardiac arrest procedure

By SHARON CHAYRA

VIEW ON HEALTH

The EMS division of Henderson Fire Department has changed they way they revive victims of sudden cardiac arrest, and if studies are any indication, others in Southern Nevada may follow their lead.

Division Chief of EMS for Henderson Fire Department, Scott Vivier helps lead the charge to ensure public safety with his department's EMS responders. Since 2009, Henderson Fire Department has been participating in a new way to teach and provide CPR. In fact, it's not technically CPR as it does not rely upon ventilations. This new technique is called CCR or cardio-cerebral resuscitation.

"This changes the focus of CPR and puts it on uninterrupted compressions by changing priority on ventilation," says Chief Vivier. "CCR is not consistent with current American Heart Association guidelines but studies in Tucson, Wisconsin and areas in North Carolina as well as peer-reviewed research have demonstrated the efficacy and science of CCR."

There are more than 3,000 certified emergency medical personnel in Southern Nevada, from basic EMT's to registered nurses who work on ambulances.There are a number of medical emergency response agencies too. Public providers in the greater Southern Nevada area include Clark County Fire Department, Las Vegas Fire and Rescue, Henderson Fire Department, North Las Vegas Fire Department and Boulder City Fire. Private ambulance companies include American Medical Response and Medic West. Together, they work cooperatively rendering emergency care when the 911 system is activated. Some of the cities also dispatch a police unit to an emergency medical call especially since many officers are trained and carry automatic external defibrillators or AED's. This training allows emergency responders to provide assistance to people suffering from cardiac arrest.

The upper chambers of the heart, or atria, power the heart and make it contract approximately100,000 times per day to keep you alive by pumping blood. Sudden cardiac arrest is defined as the unexpected loss of heart function, breathing and consciousness. Many things including heart disease, drug abuse and trauma can cause sudden cardiac arrest.

When cardiac arrest happens, cardiopulmonary resuscitation or CPR should be started immediately to ensure the best chance at survival. According to the American Heart Association, an estimated 40,000 more lives could be saved each year if bystander CPR and/or AED usage was initiated more consistently.

Nearly 450 people die each day in the U.S. of sudden cardiac arrest. Many times the bystanders who witness a person collapse don't know what to do. They are afraid they will hurt the victim or they feel nervous about doing traditional CPR with mouth-to-mouth breathing and chest compressions.

In a study of more than 17,000 bystander-witnessed cardiac arrests, researchers found CPR done by lay rescuers doubled the survival rate and CPR administered by health care professionals tripled the survival rate at one month when compared to no bystander CPR. It has been shown that "good" CPR is defined as providing a palpable pulse and chest rise with ventilation and has led to a 23 percent survival to hospital discharge.

According to a multi-center clinical study that included the UT Southwestern Medical Center, maximizing the proportion of time spent performing chest compressions during cardiopulmonary resuscitation substantially improved survival in patients who suffered cardiac arrest outside a hospital setting. One of the most important aspects of quality CPR is the proportion of time spent performing chest compressions, but EMS providers typically perform chest compressions only 50 percent of the total time spent on resuscitative efforts.

The studies lead to the straightforward conclusion that chest compression alone and with ventilation result in similar survival. Given that mouth-to-mouth rescue breathing is more difficult to perform and that many people find it distasteful, advocating continuous chest compression without ventilation by a bystander should increase the frequency of bystanders effectively performing CPR and therefore increase the chances of survival after cardiac arrest.

Previous animal studies have demonstrated that interruptions in chest compressions decrease coronary and cerebral blood flow. Based on further clinical and laboratory observations, the American Heart Association and the European Resuscitation Council Guidelines for Cardiopulmonary Resuscitation in 2005 recommended increasing the proportion of time spent delivering chest compressions.

The debate continues about the necessity of ventilation during CPR because of fear of contracting infectious diseases. Three questions are often considered: First, is ventilation necessary for the treatment of cardiac arrest? Second, is mouth-to-mouth ventilation any better than no ventilation at all? Third, are other techniques of ventilation as effective or more effective than mouth-to-mouth ventilation during basic life support CPR?

Although research is still inconclusive with regard to the need for ventilation during CPR, recent findings have clarified the effect of ventilation during low blood flow states and how ventilation influences resuscitation. Ventilation affects oxygenation, carbon dioxide elimination, and pH during times of low rates of blood flow. Ventilation may be unnecessary during the first few minutes of CPR.

The new CCR rules or protocols practiced in Henderson were granted by the Medical Advisory Board (MAB) of the Southern Nevada Health District, the agency that oversees all actively licensed emergency medical technicians in Southern Nevada. "The preliminary research was so compelling that it warranted a mid-cycle protocol change," says Chief Vivier. This means that the ability of EMS personnel to provide this new style was allowed as part of a trial provision. "While Henderson Fire Department as a whole pushed it, the community consensus has been overwhelming. It's strongly supported by the Medical Directors of all departments including Drs. Henderson, Slattery and Carrison," notes Vivier. Indeed as of September 1, 2010, CCR will become the standard of care for cardiac arrest when a patient meets criteria.

The question that many folks have is will CCR replace CPR? The short answer is no. The CCR protocol is provided when a person meets certain criteria.

"These new protocols simplify CPR protocols for civilians," says Vivier. "It goes away from memorizing numbers. Push hard, push fast because it's better for untrained persons to start CPR than for a trained person not to do CPR." In addition, 911 dispatchers in Henderson provide CCR pre-arrival instructions to callers. This means that even though the caller may have never been trained in CPR or CCR, they can still help the victim of a cardiac arrest until the EMS crew arrives. Seconds count in cases of cardiac arrest.

Because ventilation with exhaled gas contains as much as 4 percent carbon dioxide and less oxygen than air, it may have adverse effects during CPR. Spontaneous gasping may provide sufficient ventilation during CPR. Chest compression alone provides some pulmonary ventilation and gas exchange. Active chest compression-decompression may improve gas exchange better than does standard chest compression. Researchers also believe that this "passive" ventilation allows the body to better handle recovery.

As heart disease is the number one killer of people in the U.S., the manifestation of this disease is frequently cardiac arrest. In 2009, Henderson Fire responded to a more than 15,000 emergency medical calls and approximately three percent or 465 patients were in reported to be in cardiac arrest.

The obvious goal for a victim of cardiac arrest is survival and that means lungs that breathe and a heart that pumps. Vital organs such as the brain start dying within minutes of being deprived of oxygen. Providing chest compressions and/or assisted breathing mitigates damage until the heart can, hopefully, be restarted.

Chief Vivier emphasizes that successful resuscitative efforts are those that not only ensure survival but quality of life. "The cerebral performance category or CPC is a score given by hospitals to patients based on a patient's neurologic outcome. A grade of one is the best and that means the patient is discharged with no to mild neurologic symptoms. 'Normal.' Four means they're in a vegetative state." He further notes that demonstrable improvement has been seen since instituting the new CCR protocols.

Neurologic function is perhaps the best factor in determining the true success of medical interventions. As a 35-year paramedic and EMS Training Officer for the Clark County Fire Department, Don Abshier has run thousands of cardiac arrest calls. "There's no greater satisfaction than when a patient you worked on comes back to you to thank you personally for saving their life but it's really not the norm, particularly for older people. But for those that do survive, especially kids, it's really special and I can recall every one of these people."

Cardiac arrest outcomes are contingent on many factors but none is more important than CPR or CCR. Vivier indicates that CCR is used for all patients with presumed cardiac arrest. Patients who are in respiratory arrest or who have suffered a drug overdose are treated with conventional CPR as are pediatric drowning victims.

The improvement of emergency lifesaving has also taken on a highly promising element in Southern Nevada -- hypothermic treatment. Henderson Fire Department medics provide hypothermic treatment as do City of Las Vegas Fire Rescue medics but all departments will be on-board shortly.

Hypothermia is used only in patients 18 years and older who have regained spontaneous circulation post-cardiac arrest but are still unconscious. Used in conjunction with CCR, the victim's body temperature is lowered by the introduction of ice-cold intravenous saline fluid. By lowering a patient's core body temperature by 1 to 4 percent, the victim of a cardiac arrest benefits from the slowed metabolic status and thus, further cellular damage.

Vivier enthusiastically remarks, "Our outcome data runs behind because patients are in the hospital a long time but we have seven cases where crews did hypothermia. Out of those seven, four were discharged alive which is a rate of 57 percent. Not only that, but out of that 57 percent, two were discharged with a CPT of one so the numbers are very promising."

Cardiac arrest victims are taken to all area hospitals as all are equipped to treat these cases, however, hypothermic patients require a hospital whose staff has had specialty training. Currently, St. Rose DeLima, St. Rose Siena, Valley Hospital and UMC treat hypothermia patients.

People come from all over to enjoy a 24-hour lifestyle and it's not unusual for tourists to eat too much, drink too much, forget to sleep and even forget to take their medications. This can make the likelihood of them needing emergency medical care all the more likely. Fortunately, the area's resorts put a high priority of guest safety. Public and private agencies work hand-in-hand to shorten response times and allow for paramedic care. Area hospitals include regional trauma and burn centers, and many hospitals possess centers of excellence for stroke, pediatric and cardiac care. While no one plans for an emergency, it's nice to know southern Nevada's EMS agencies not only plan for such possibilities but set the example for the benefit of tourists and residents alike.