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Changes to CPR and Response to Cardiac Arrest with COVID-19

When it comes to survival of out of hospital cardiac arrest (OHCA), many advances have been made over the years, 1 early and high-quality chest compressions and defibrillation are key components of this. However, even prior to coronavirus and COVID-19, many bystanders are still hesitant to perform CPR for a variety of reasons; fear of litigation, fear of causing harm, or due to concerns about infectious disease transmission.2 In the new age of social distancing and a highly infectious disease causing stress on our world, the hesitancy may increase. In addition, many programs who have been key in providing education, such as CPR training, have come to a halt during this time.

CPR is generally considered an “aerosolized” procedure, 3 a procedure conveying high risk of transmission of disease via respiratory droplets. Resuscitation efforts in and out of hospital require multiple people in close proximity to each other to respond. In addition, COVID-19 has been reported to cause myocardial injury and ventricular arrhythmia that may predispose someone to cardiac arrest, 1 and despite a pandemic, sudden cardiac arrest and other causes of death do not decline. A concern rising in the medical community since shelter-in-place laws and changing stresses on our medical system, is a notable decrease in visits to the Emergency Departments for common complaints and concerns, such as chest pain, syncope and other things that may dispose someone to a cardiac arrest. We need to be aware of this happening in the community and the potential need for lay and EMS response in these situations.

Lay persons and dispatchers play a key role in survival efforts such as initiating CPR and early defibrillation. There has been documented success with telephone CPR and CPR guidance by dispatchers. An important component of ensuring the best survival of the community and those with COVID-19 or potential COVID-19 is communication and a well-developed community plan to ensure timely and quality resuscitation to patients while protecting rescuers. Recently, Circulation has released Interim Guidance and Advanced life Support in Adults, Children, and Neonates with Suspected or Confirmed COVID-19,1 a quick review is here. Resources from King County EMS in Washington are available for establishing a community response and plan here.

Overall, the common themes are aimed at adequate personal protective equipment (PPE), reducing the number of people responding to an event, and in the case of OHCA for lay people, focusing on hands-only CPR.

For lay persons, the majority of SCA occurs at home. The likelihood of already being exposed to a household contact is high and should be considered when responding to an arrest; for adults hands-only CPR with high-quality compressions is encouraged with early activation of EMS and defibrillation(not an aerosolizing procedure), if available. In the case of pediatric resuscitation, due to the high likelihood of respiratory arrest causing cardiac arrest, it is advised that if willing, after weighing the risk and benefit, that rescue breaths are provided along with compressions. You may use a cloth or mask covering over the victim’s mouth to help reduce transmission in the event it is not a household member.1

For EMS providers, dispatch is crucial in screening calls for any possible risk of exposure to COVID-19, based on symptoms in the victim or any recent contact or household members, and advising whether doing PPE is recommended to the EMS team.1 In Seattle, they have shown a very low rate of transmission to EMS providers when wearing the appropriate PPE.4

For in-hospital cardiac arrest, it is again important to reduce the personnel involved in the resuscitation, close the door when possible, and consider adding PPE to the code carts.  It is also important to use HEPA filters and closed circuit ventilation strategies when it comes to ventilation. The guidance also encourages early intubation by the provider with the highest qualification with the best chance for successful intubation, and use video laryngoscopy when able to minimize aerosolizing the virus while securing a closed circuit airway. The guidance also suggests that if patients are prone and intubated to perform CPR without moving the patient in the standard T7-10 vertebral bodies, however, if they are not intubated to attempt to place them supine and proceed with resuscitation.1

The article also discusses the importance of clarifying goals of care and advanced directives upon arrival, as well as proposes a careful evaluation in the cases of out of hospital cardiac arrest with inability to obtain ROSC, suggesting in some cases, this may be a reason to avoid transport to the hospital due to low likelihood of survival. However, it is important to take into consideration with the benefit, risk and ethics involved.1, 3

Another important update is in regards to maintenance of certification such as BLS/ACLS/PALS. As of March 13, the AHA has offered a 60 day extension for instructor cards and also recommends extension of provider cards for the same length, this allowance is open to be extended based on the evolving threat and CDC/public health recommendations, read the statement here. 5

Many people are looking for things to do in this time of sheltering in place, perhaps this could be an opportunity for education and learning on CPR and AED’s. There are many online resources available, and with the advent of telemedicine, zoom learning and video visits increasing, perhaps we could use this as an opportunity to increase our virtual presence for CPR education.

If you’re interested in some online resources, check out the ILHR website, or your local education center’s website.

  1. Edelson, Dana P, et al. “Interim Guidance for Life Support for COVID-19.” Circulation, ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.047463.
  2. Scquizzato, Tommaso, et al. “The Other Side of Novel Coronavirus Outbreak: Fear of Performing Cardiopulmonary Resuscitation.” Resuscitation, vol. 150, 2020, pp. 92–93., doi:10.1016/j.resuscitation.2020.03.019.
  3. Defilippis, Ersilia M., et al. “Cardiopulmonary Resuscitation During the COVID-19 Pandemic: A View from Trainees on the Frontline.” Circulation, Sept. 2020, doi:10.1161/circulationaha.120.047260.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

 

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We Need to Be Better About Recognizing Sudden Cardiac Arrest

“10-year-old dies of an apparent heart attack on Delta flight,” “High School Football Player Dies Suddenly,” “Teen Dies on the Court,”— these stories shock the community, cause people to ask questions, and are too soon forgotten. We need to be better about recognizing cardiac arrest in the young, and that starts with better cardiac arrest education. Many people do not realize the difference between cardiac arrest and myocardial infarction or “heart attack.” While a heart attack is often preceded by chest pain and other symptoms, cardiac arrest is usually not.

Sudden Cardiac Arrest (SCA) is a life-threatening emergency that occurs when the heart suddenly stops beating; 1 this can be due to a structural abnormality of the heart, a rhythm disturbance, or often an unknown cause.2 A heart attack usually has a different cause, occurring when the supply of blood to the heart becomes blocked, typically by a plaque or blood clot in an artery.3

Sudden Cardiac Death (SCD) is the leading cause of death in athletes during a sport.4 Delay in recognition leads to a rapid decline in survival, with a decline of survival by 10% for every 1-minute defibrillation is delayed.5 Studies show that survival can be improved if AED is applied and used within 3-5 minutes of arrest. Schools with on-site AED demonstrate survival from SCA as high as 71%.4 However, in order for proper AED use to occur the arrest must be recognized quickly.

What makes it hard to recognize sudden cardiac arrest?

  • Lack of Education on the subject— SCA is not on peoples’ radar for the young patient. Our brains are programmed to think about heart attacks involving older people clenching their chest, sweating, proclaiming pain, and not about SCA, which is much more silent. Anyone who suddenly collapses and is non-responsive to verbal stimuli should be treated as a sudden cardiac arrest until proven otherwise.5
  • SCA may present with seizure-like activity; in as many as 20% of SCA events, there will be myoclonic jerking activity such as shaking, quivering, or twitching.5 This activity may lead to observers mistaking the arrest for a seizure and not applying the right emergency protocol.
  • A victim of SCA may still be “breathing”; Agonal respirations/gasping appear like chest and abdominal movement. These breaths can be mistaken for breathing, but are ineffective to sustain life.4
  • Lack of AED’s or access to AED’s and Emergency Action Plans (EAP); some schools may not have AED’s, or they are locked after hours in an office or locations far from the athletic venue. Surveys have demonstrated that low socioeconomic status, schools with primarily black race, and rural schools are the most common barriers to AED use.6

Recently, the Parent Heart Watch has started a campaign to make the use of AED’s easier and to educate the public on their use with the campaign Call, Push, Shock. In addition, Dr. Jonathan Drezner and the NFL to educate the public on recognizing sudden cardiac arrest (Recognize, React, Rescue). These resources are helpful in sending a unified message to the public, providers and to everyone involved to help save lives.

What can we do to improve?

  • Early recognition and emergency activation – Suspect SCA in any collapsed or unresponsive athlete/person and call 911 immediately.
  • Access to early defibrillation – the goal is less than 3-5 minutes until the first shock.
  • Provide high-quality CPR and early access to advanced life support/EMS – Currently, the average time of EMS arrival is 6.1 minutes and can be longer in some communities.4 The more people trained and educated to start CPR while awaiting EMS, the better the outcomes.
  • Make sure all venues have EAP’s that encompass the above and more. An EAP should be established at any athletic venue and should be specific to the athletic venue. An effective EAP should encompass emergency communication (working with local EMS and having a detailed location/address of the venues available, including directions to access points from major roads), personnel, and equipment. They should be reviewed and practiced annually to ensure they work with mock SCA scenarios.
  • Continue to push for legislation to enforce the use of AED’s in schools. As of 2017, only 17 states required AED installation in schools, and only 5 of these offered funding for AED equipment.7

Want to learn more? Check out the Call, Push, Shock page to explore the mission and find local organizations— chances are there is a passionate person in your state or city who has been directly affected by SCA and could use your support and help!

 

Sources:

  1. “You Can Save A Life from Sudden Cardiac Arrest.” Call, callpushshock.org/.
  2. Harmon, Kimberly G. “Incidence and Etiology of Sudden Cardiac Death in Athletes.” IOC Manual of Sports Cardiology, 2016, pp. 63–73., doi:10.1002/9781119046899.ch7.
  3. “Heart Attack.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 30 May 2018, www.mayoclinic.org/diseases-conditions/heart-attack/symptoms-causes/syc-20373106.
  4. Toresdahl, Brett, et al. “Emergency Cardiac Care in the Athletic Setting: from Schools to the Olympics.” British Journal of Sports Medicine, vol. 46, no. Suppl 1, 2012, pp. i85–i89., doi:10.1136/bjsports-2012-091447.
  5. Drezner, Jonathan A., et al. “Inter Association Task Force Recommendations on Emergency Preparedness and Management of Sudden Cardiac Arrest in High School and College Athletic Programs: A Consensus Statement.” Prehospital Emergency Care, vol. 11, no. 3, 2007, pp. 253–271., doi: 10.1080/10903120701204839.Soun ds
  6. Saberian, Sepehr, et al. “Disparities Regarding Inadequate Automated External Defibrillator Training and Potential Barriers to Successful Cardiac Resuscitation in Public School Systems.” The American Journal of Cardiology, vol. 122, no. 9, 2018, pp. 1565–1569., doi:10.1016/j.amjcard.2018.07.015.
  7. Lou, Nicole. “Few States Require AEDs in Schools.” Medical News and Free CME Online, MedpageToday, 27 Mar. 2017, www.medpagetoday.com/cardiology/arrhythmias/64159.

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

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ECPR: What is it? And what do we know in 2020?

Despite advances in the resuscitation field, cardiac arrest, especially cardiac arrest in the setting of cardiogenic shock, continues to carry significant morbidity and mortality. This topic continues to challenge healthcare providers on ways to improve outcomes in patients with refractory cardiac arrest. Extra-Corporeal Membrane Oxygenation (ECMO) is a type of mechanical circulatory support device utilized for various conditions, including cardiogenic shock and multi-organ failure. I heard about ECPR recently, so I wanted to share what is out there, and potentially motivate colleagues and professionals to share their thoughts on this important topic.

What is ECPR?

ECPR (Extra-corporeal Cardio-Pulmonary Resuscitation) is the implementation of ECMO in selected patients with cardiac arrest, and may be considered when conventional CPR efforts fail in a setting with expeditious implementation and support.by skilled providers When/where does ECMO cannulation occur in these patients?

Patients with cardiac arrest and ongoing CPR are transported to the hospital while ongoing resuscitation efforts are being taken. ECMO potentially provides the circulatory and respiratory support these sick patients need until reversible conditions are addressed. ECMO cannulation usually occurs at the healthcare center, where skilled personnel and healthcare providers have expertise in ECMO. Figure 1 shows a simple illustration veno-arterial VA-ECMO utilized in ECPR.

Figure 1: Simple schematic illustration of veno-arterial VA-ECMO utilized in EPCR.

Figure 1: Simple schematic illustration of veno-arterial VA-ECMO utilized in EPCR.

What is the scientific evidence for the use of ECPR?

Unfortunately, there are no randomized controlled trials (RCTs) on the use of ECPR in cardiac arrest patients at this time. The evidence supporting ECPR comes from observational studies in the past two decades, in patients with out-of-hospital cardiac arrest, and studies looking at ECPR in in-hospital cardiac arrest. Many, but not all, of the observational studies showed overall favorable neurological outcomes in those who receive ECPR compared to conventional CPR. It is important to note, however, that these studies had variable inclusion criteria, and potential risk for confounding bias, making their validity and generalizability questionable.

Are there any AHA guidelines supporting the use of ECPR?

AHA 2019 Guidelines Updates:

Recommendations—Updated 2019

  • There is insufficient evidence to recommend the routine use of ECPR for patients with cardiac arrest.
  • ECPR may be considered for selected patients as rescue therapy when conventional CPR efforts are failing in settings in which it can be expeditiously implemented and supported by skilled providers (Class 2b; Level of Evidence C-LD).

Why is this important?

Some studies in the past 2 decades have shown that ECPR might be associated with favorable neurological outcomes compared to conventional CPR. It is known that neurological outcomes in cardiac arrest patients have a significant effect on morbidity and mortality. As such, although these are observational studies with limited evidence, they shed light on a potential therapy that could lead to better outcomes in this very sick population. Future studies, including RCTs, are much needed to assess the outcomes of ECPR and identify patients who would benefit the most from this potential therapy.

I would like to say special thank you to my friend and colleague, Dr Khaldia Khaled, for her help on this blog.

Reference

Panchal et al: 2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal Cardiopulmonary Resuscitation During Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019;140:e881–e894. DOI: 10.1161/CIR.0000000000000732.

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

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Addressing Women’s Cardiac Risk in Primary Care: Research & Practice

Last month, I wrote about my roles in research, practice, and education. This month, I’ll delve into how research and practice interface around a critical health issue: coronary heart disease in women.

A study recently published in JAHA suggests that both delay between symptom onset and hospital presentation and post-PCI coronary blood flow are independently associated with excess mortality in women1.

A key finding for clinical practice is that if delay between symptom onset and hospital presentation is less than two hours, that sex difference in mortality is not significant. One takeaway is that though it’s not the only factor, delay matters— and it’s something we can target now, in primary care (where I work) and in public health.

A key point for research is that PCI doesn’t seem to improve coronary blood flow in women as much as it does in men. What does this mean?  Here’s the rub: the whole paradigm of coronary heart disease— from defining acute coronary syndrome to medical management and PCI— is based on the flawed assumption that men and women are essentially the same (as Pande & Jacobs discuss in an accompanying editorial2).

Recall that women have historically been drastically underrepresented in heart disease research, so the foundational assumptions are based on men. Though the evidence is mounting on some of the mechanisms of sex differences— microvascular disease, endothelial dysfunction, MINOCA— this hasn’t yet resulted in meaningful differences in approach to ACS treatment. Before this study’s publication, it had not been clear whether women didn’t do as well post-PCI simply because they were less likely to get in in a timely fashion, or because it didn’t work as well for them. Now we have data suggesting that both are true. Are we using a hammer when we really need a screwdriver? There is an enormous need for research in this area designed with sex differences as a presupposition and with establishing effective treatments as the goal. It will be a long road and we won’t have “the answer” tomorrow.

So as a clinician, knowing that the data isn’t there yet to show us how to improve women’s outcomes in PCI, one of the best tools I have is education and communication with my patients and fellow clinicians around treatment delay. We’ve made great progress educating patients and providers about women’s risks of heart disease (thanks in large part to AHA’s Go Red for Women campaign). Yet women still have longer delays in accessing treatment and worse outcomes in ACS than their male counterpoints.

Since heart disease is the number one killer of U.S. women and men3, preventing and detecting it are high priorities for PCPs like me. Even though short appointments and competing priorities mean finding time for prevention and risk assessment is tricky, we need to do better in our discussions around cardiac risk. We’re doing well at initiating discussions around statin prescriptions and, to a lesser extent, lifestyle measures. We need to work on discussions about symptoms of ACS and response to symptoms.

What are you doing now to improve women’s cardiovascular outcomes? Will you commit to taking one of these steps?

References:

  1. Cenko E, van der Schaar M, Yoon J, Kedev S, Vavlukis M, Vasiljevic Z, Ašanin M, Miličić D, Manfrini O, Badimon L, Bugiardini R. Sex‐specific treatment effects after primary percutaneous intervention: A study on coronary blood flow and delay to hospital presentation. J Am Heart Assoc. 2019; 8:e011190. DOI: DOI: 10.1161/JAHA.118.011190.
  2. Pande, AN & Jacobs, A. Reperfusion and time to presentation in women: Too little too late. J Am Heart Assoc. 2019; 8. DOI: 10.1161/JAHA.118.011835
  3. Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L,Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O’Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics – 2019 update: a report from the American Heart Association [published online ahead of print January 31, 2019]. Circulation. doi: 10.1161/CIR.0000000000000659.
  4. Greenwood B, Carnahan S., & Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. PNAS August 21, 2018 115 (34) 8569-8574; published ahead of print August 6, 2018 DOI: 10.1073/pnas.1800097115

 

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Paradigm Shifts In Resuscitation

We go through a series of paradigm shifts during our childhood and development: the moments that change our outlook on the world around us and how we influence it.

  • “There’s a whole world outside of my home!”
  • “People can be really cruel!”
  • “Sharing is caring.”
  • “Chicken pox are contagious!”

Similar shifts occur in our development as physicians. I remember very distinctly the moment that the pathophysiology of heart failure finally just “clicked” in my mind.

A similar shift occurred as I reviewed a recent AHA news brief on survival in out-of-hospital cardiac arrest. Unconsciously, I had developed a thought-process around out-of-hospital cardiac arrest that was very skewed.

  • As a child, I thought of CPR as some sort of strange voodoo magic that only lifeguards and doctors could perform. It always worked and brought people back to life immediately with nothing but a residual cough (as they spit out water and seaweed, usually).
  • Then, as I trained to become a BLS instructor during medical school, I realized that anyone could do CPR, but it didn’t always work. There was no magic about it – it was pure science.
  • Through my years in medical school, residency, cardiology fellowship, and critical care fellowship, I saw patients who never recovered, or who had profoundly poor outcomes despite survival and I began to think of out-of-hospital cardiac arrest as sort of hopeless. Of course, there was the occasional patient who walked out of the ICU, but I felt like most of the time, if CPR was done outside the hospital, it was not going to end well.

However, after reading about the profound increase in survival and improved functional outcomes after bystanders used AEDs for patients with out-of-hospital cardiac arrest, I suddenly have much more hope. I look back on my own experiences and realize that those patients who did well were the ones who had immediate bystander CPR /- the AED, depending on the etiology of arrest. I think my learned pessimism made it more difficult for me to recognize this connection. But, studies like this show that the evolution in resuscitation science, public health and safety culture, and education can make huge differences in our world. It makes me more hopeful for the future and more thoughtful about ways that I can influence the health and safety of those around me. I think I’m more hopeful now that even small efforts towards improved public health, not just around resuscitation, but anything that makes a positive impact, are worthwhile.

David Werho Headshot

David K. Werho, MD is an Assistant Clinical Professor at the University of California San Diego and a Pediatric Cardiac Intensivist at Rady Children’s Hospital – San Diego.  His research focuses on pediatric cardiac ICU outcomes as well as interventions and curriculum development in medical education.  He tweets @DWerho and contributes to the Pediatric Cardiac Intensive Care Society Newsletter as editor and contributor.