By: Andrew Steward, AAS, Paramedic
Cardiac arrest in the out-of-hospital setting is not an uncommon theme. More than 350,000 cardiac arrests were reported in 2016 alone. Sadly, a mere 12% of those patients survive nationwide (American Heart Association, 2015). This raises the question, why? As EMS practitioners we perform CPR, give all these wonderful drugs, and defibrillate—just for 12% to survive?
Over the last few cycles of the AHA/ECC guideline updates, you may have noticed a drop in the number of drugs ACLS recommends and an increased emphasis on high-quality CPR. These updates are based on a number of recently published medical studies.
- A study released in the Journal of the American College of Cardiology found that the links between epinephrine and good neurologic function post-resuscitation were vague at best (Dumas, et al., 2014).
- A study by the British Medical Journal found a decreased chance of survival in patients administered epinephrine in the out-of-hospital environment (Andersen, et al., 2016).
- A study published in the New England Journal of Medicine found very little evidence to support the effectiveness of the two major ACLS anti-dysthymia drugs, amiodarone and lidocaine, used in cases of cardiac arrest (Kudenchuk, et al., 2016).
So now what? Our cardiac arrest drug list has dwindled, and those few drugs left are being proven ineffective.
This brings us back to the increased emphasis on high-quality CPR. As advanced level providers, we need to keep our focus off all those fancy drugs and tools we carry, and instead focus on high-quality BLS, which has been proven time and time again to be the key to success for the patients. Many forms of CPR, from dispatch-assisted CPR to pit-crew CPR, have all demonstrated the many benefits of providing the right compression depth and rate as soon as the patient hits the ground (AHA/ECC, 2017) (Wesley & Wesley, 2016).
However, despite the proven benefits of high-quality CPR, the emphasis is often on getting the patient to the hospital as quickly as possible—but what is the cost of this load-and-drive theory? When we move patients out of their homes, we are often off their chest for more than 10 seconds at a time, which completely defeats the purpose of doing compressions at a rate of 100-120 per minute with less than 10 seconds off the chest. The science supporting the need to maintain that rate is abundant (American Heart Association, 2015). So when we move our patients and accept the load-and-go approach, what are we accomplishing? All that time off the chest may explain our 12% success rate.
EMS agencies are definitely conflicted on the question of whether to transport or to work the code on scene. With today’s emphasis on mechanical CPR devices, most agencies are back to transporting cardiac arrest patients early despite an unproven level of success that’s centered around expert opinion (Class IIb, LOE-C-EO) (Kern, 2017). The results seen in Europe with these devices is what makes them so timely in their development and push toward EMS.
The European TROICA study found that there was no survival benefit when thrombolytic tenecteplase (TNK) was given to a patient suffering from an out-of-hospital arrest (Crawford, 2017). However, patients in refractory VF/pVT are known to have a coronary blockage (Kern, 2017). The only treatment available to these patients in the out-of-hospital arena is to be reperfused. This reperfusion is achieved with a load-and-go methodology in the EMS arena, which includes mechanical CPR and transport to a facility able to perform PCI while also able to perform ECMO (Crawford, 2017). Two big studies have supported these results: the CHEER trial and the Minnesota Research Consortium. In both the CHEER trial and the Minnesota study, patients who received treatment similar to that provided in the TROICA study had a 45% survival rate—and of those surviving patients 94% of them were able to walk out of the hospital with good neurologic function (Kern, 2017).
Even though the hard data from the TROICA study is far from conclusive, transporting patients to PCI and ECMO capable centers while in arrest with mechanical CPR in place seems to be a way of the future. With proper mechanical CPR, high-quality CPR is achieved, and the safety of the crew is maintained while in transit—with better patient results than seen through the use of drugs. When this treatment is coupled with some early CPR and defibrillation, we may see a dramatic uplift in our statistics similar to those seen in both the CHEER and Minnesota studies.
- AHA/ECC. (2017, November 4). Highlights of the 2017 American Heart Association Focused Updates of Adult and Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality. Retrieved from ECC Guidelines – AHA: https://eccguidelines.heart.org/wp-content/uploads/2017/11/2017-Focused-Updates_Highlights.pdf
- American Heart Association. (2015). 2015 American Heart Association Guidelines Update for CPR and ECC. Hagerstown, MD: Lippincott Williams & Wilkins.
- American Heart Association. (2015, December 16). AHA Statistical Update – Heart Disease and Stroke Statistics – 2016 Update. Retrieved from Circulations – AHA Journals: http://circ.ahajournals.org/content/early/2015/12/16/CIR.0000000000000350
- Andersen, L. W., Kurth, T., Chase, M., Berg, K. M., Cocchi, M. N., Callaway, C., & Donnino, M. W. (2016, April 6). Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: propensity score matched analysis. British Medical Journal.
- Crawford, T. C. (2017, August 28). Coronary Disease in Out-of-Hospital Refractory Ventricular Fibrillation (A Summary). Retrieved from American College of Cardiology: http://www.acc.org/latest-in-cardiology/journal-scans/2017/08/28/09/51/coronary-artery-disease-in-patients-with-out-of-hospital-vf
- Dumas, F., Bougouin, W., Geri, G., Lamhaut, L., Bougle, A., Daviaud, F., . . . Cariou, A. (2014, December). Is Epinephrine During Cardiac Arrest Associated with Worse Outcomes in Resuscitated Patients? Journal of the American College of Cardiology, 64(22), 2360-2367.
- Kern, K. B. (2017, December). Trends & Changes in Cardiac Resuscitation. The Journal of Emergency Medical Services (JEMS).
- Kudenchuk, P. J., Brown, S. P., Daya, M., Rea, T., Nichol, G., Morrison, L. J., . . . Dorian, P. (2016, May 5). Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. New England Journal of Medicine, 1711-1722.
- Wesley, K., & Wesley, K. (2016, August 1). Pit Crew Approach to CPR has Higher Patient Survival Rates. The Journal of Emergency Medical Services (JEMS).
Andrew has more than 15 years of experience in emergency services. He holds numerous credentials in education in both the fire and EMS industries and also holds memberships with the NAEMT and NAEMSE. Andrew served as a Fire Lieutenant having oversight of training and has taught for a number of EMS programs having worked for busy 911 services in both suburban and urban areas as well as within a university-based critical care transport system. Andrew remains active in the industry still working on a regular basis as a paramedic for Harleysville Area EMS while also serving as the Director of Continuing Education for Medic-CE. He currently holds an Associate’s degree in Occupational Safety and Health from Columbia Southern University and is pursuing his Bachelor’s in Emergency Management with a minor in Homeland Security through Waldorf University.