cpr – The Early Career Voice

Moving from ‘Luck of the Draw’ to making BLS and Defibrillator availability basic

January 6, 2022January 6, 2022 Olubadewa Fatunde, MD MPH

The AHA ReSS council had a fascinating 2021 meeting, including trials making us reassess the optimal temperature for patients following cardiac arrest (TTM2) and those investigating the potential new application of existing meds repurposed to cardiac arrest (e.g. Tocilizumab [IL-6 inhibitor] to reduce cytokine storm post-arrest, LPC-DHA to improve mitochondrial function). What really put these clinical trials into perspective was the plenary session, featuring actual survivors of sudden cardiac arrest discuss their experiences with the frustrating lack of established resources as they journey to find the new normal for their lives.

Perhaps the most memorable part of AHA 2021 was the harrowing account of Dr. Kevin Volpp, a cardiology and behavioral economics researcher at the University of Pennsylvania, reflect on his own sudden cardiac death experience. The morning of July 9, 2021 started as just a regular day. Volpp traveled to Cincinnati, Ohio to watch his daughter, Anna, play in a squash tournament. While dining with Anna, her Coach (Gina Stoker), and her Coach’s boyfriend (John White) the night before, Volpp suddenly became unresponsive, slumping his chair into the arms of White. Coach Stoker called 911. White, who is himself a squash coach at Drexel University, laid Volpp flat, could not find a pulse, and initiated bystander CPR. EMS arrived four minutes later. Ultimately, he received 14 minutes of CPR with three shocks from the automated external defibrillations before his circulation was restored. He was rushed to University of Cincinnati Hospital, where he was found to have a 99% blockage in his LAD artery, which was opened and stented (1).

Volpp, who had a strong family history of premature heart attacks, had been undergoing primary prevention measures including CAC screening, medications, and well exceeding the AHA’s minimum recommendation for weekly exercise, as he was training with Anna for an Ironman 70.3 triathlon (1). Sudden cardiac death does not always occur in those with a strong family history with plaque in their arteries. During his 3^rd year of internal medicine residency, Dr. Anezi Uzendu suffered cardiac arrest while he was playing basketball, with no prior family history. Fortunately, through high quality CPR and persistent resuscitation (receiving a total of 13 defibrillation attempts before he was revived!)(2), he eventually recovered and completed both general and interventional cardiology fellowships.

Ultimately, the prompt recognition and initiation of the cardiac chain of survival that allowed Drs. Volpp and Uzendu to have good outcomes. Coach White credited Drexel University’s requirement that Coaches keep their training in Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) active (1). BLS is the use of high-quality chest compressions (2 inches deep at 100-120 beats per minute) to maintain adequate circulation to the brain, before additional help can arrive to provide higher level of care (ACLS). Out of hospital cardiac arrest and recovery is far from normal across the country, occurring in less than 8% of individuals (3). Acknowledging the critical nature of illnesses causing cardiac arrest, why do so few survive? Low rates of education and implementation of bystander CPR and AEDs, two of the most important interventions linked to improving survival by as much as 3-fold (3). These interventions are not independent, as defibrillator effectiveness increases, with increasing quality of CPR (optimal depth & speed) administered (4). In 2014, Dr. Monique Anderson and colleagues at Duke University found that, only 1.29-4.07% of the US population is certified in BLS—a shockingly low statistic for the number one cause of death in America (heart disease) (3, 5). Unfortunately, disparities are more likely in racial minority, older, rural, and Southern communities (5). Dr. Maryam Naim and colleagues found similar disparities in a pediatric population (6). Not surprisingly, average rates of bystander in America CPR are only 38.2% (7), with significant geographic variation (10-65%) (8) and lower rates of proper technique (compression depth of 2 inches and pace of 100-120 beats per minute (9). These findings are compounded by the fact that almost 90% of cardiac arrests occur in or near the home (10).

What’s the best method of increasing this? Anywhere from 71.5% to 85.3% of American high school seniors have their driver’s license (11). Many obtain this through taking driver’s education class in school. One long term solution would be providing BLS courses to all high schoolers, with the option to advance to ACLS certification for those interested. While logistics can be debated, this would increase the proportion of individuals ready to perform by stander CPR from the 70% of Americans who don’t feel prepared (10) to adequately administer CPR. For adults, there are many available BLS courses available. The AHA Knowledge Booster App is a fun and interactive resource for those who want to learn more, but don’t know where to start. There are several Spotify playlists of songs with a tempo of 100-120bpm (12-14), but “Staying Alive,” by the Bee gees seems to be the most enduring. Dr. Uzendu founded an organization—Make BLS Basic—that focuses on increasing bystander CPR rates in minority communities (15).

Increasing bystander CPR rates is only half of the prehospital equation. When bystanders perform CPR and use a defibrillator, the survival to hospital discharge approaches 50-60%, with improved survival and neurological outcome with earlier defibrillation of shockable rhythms (3). The meager rates of Automated External Defibrillator (AED) availability in public spaces are similarly shocking. In a Cleveland Clinic survey, only 27% of Americans reported an AED in their workplace. After his experience, Volpp posed the question, should national chains be required to install AEDs, given that most adults spend 15-20 (pre-pandemic) minutes a day in a restaurants or bar (1). To be sure, AEDs require maintenance (replacement of defibrillator pads & batteries) and untrained lay providers may struggle to use them effectively (3). Several cost-effectiveness analyses have found a benefit of widespread dissemination of public AEDs (16-18), though not all are as optimistic (19, 20). AED Laws vary by state (21); there has also been federal legislation (22). The Sudden Cardiac Arrest Foundation states a goal of having an AED accessible within 90 seconds of any public area that people congregate (e.g. schools, state & federal buildings, casinos, etc.). We are far from this important goal.

I think the ultimate questions are: Should one’s survival following cardiac arrest depend on being with the right person at the right time or where you live, shop, eat, or pursue leisure? Will we accept the status quo? How can we improve rates of bystander CPR and AED availability to give everyone an equitable chance at surviving these life-threatening events, and a new lease on life? How can we better support SCA survivors during their recovery? Looking forward to answering these questions at future meetings.

References:

Avril T. “A Penn professor’s heart stopped at restaurant that had no defibrillator. Few are equipped with the lifesaving devices.” Philadelphia Inquirer. 2021. https://www.inquirer.com/health/aed-defibrillator-restaurant-cardiac-arrest-20211213.html
Uzendu A. From “delivered to the cath lab alive” to Interventional Cardiologist on call in 5 years. God is good. #CPRSavesLives. In: @DrUzendu, editor. 2021. https://twitter.com/DrUzendu/status/1465120531317989382
Brady WJ, Mattu A, Slovis CM. Lay Responder Care for an Adult with Out-of-Hospital Cardiac Arrest. N Engl J Med. 2019;381(23):2242-51.
Edelson DP, Abella BS, Kramer-Johansen J, Wik L, Myklebust H, Barry AM, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation. 2006;71(2):137-45.
Anderson ML, Cox M, Al-Khatib SM, Nichol G, Thomas KL, Chan PS, et al. Rates of cardiopulmonary resuscitation training in the United States. JAMA Intern Med. 2014;174(2):194-201.
Naim MY, Griffis HM, Burke RV, McNally BF, Song L, Berg RA, et al. Race/Ethnicity and Neighborhood Characteristics Are Associated With Bystander Cardiopulmonary Resuscitation in Pediatric Out-of-Hospital Cardiac Arrest in the United States: A Study From CARES. J Am Heart Assoc. 2019;8(14):e012637.
Promotion OoDPaH. Increase the rate of bystander CPR for non-traumatic cardiac arrests — PREP‑01. In: Promotion OoDPaH, editor.: Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-data/browse-objectives/emergency-preparedness/increase-rate-bystander-cpr-non-traumatic-cardiac-arrests-prep-01/data
Brown LE, Halperin H. CPR Training in the United States: The Need for a New Gold Standard (and the Gold to Create It). Circ Res. 2018;123(8):950-2.
New Cleveland Clinic Survey: Only Half Of Americans Say They Know CPR [press release]. Newsroom: Cleveland Clinic, February 1, 2018 2018. https://newsroom.clevelandclinic.org/2018/02/01/new-cleveland-clinic-survey-only-half-of-americans-say-they-know-cpr/
CPRBlog [Internet]. www.heart.org: American Heart Association. [cited 2021]. https://cprblog.heart.org/cpr-statistics/
Ranzetta T. Question of the Day: What percent of high school seniors have a driver’s license? : Next Gen Personal Finance; 2019 [Budgeting]. Available from: https://www.ngpf.org/blog/budgeting/question-of-the-day-what-percent-of-high-school-seniors-have-a-drivers-license/.
American Heart Association. Hands-Only CPR’s ‘Keep The Beat’ 100BPM Playlist: Spotify; 2015. https://open.spotify.com/playlist/18uMyHJHboUUCCwbtwdj3k
nyphospital. Songs to do CPR to: Spotify. https://open.spotify.com/playlist/7oJx24EcRU7fIVoTdqKscK
seigfriedb. CPR playlist (110 bpm). https://open.spotify.com/playlist/67BxVmgXqjr2lQqXKsyLxw: Spotify.
Uzendu A. Make BLS Basic http://www.makeblsbasic.org2019 [Available from: http://www.makeblsbasic.org.
Andersen LW, Holmberg MJ, Granfeldt A, James LP, Caulley L. Cost-effectiveness of public automated external defibrillators. Resuscitation. 2019;138:250-8.
Nichol G, Huszti E, Birnbaum A, Mahoney B, Weisfeldt M, Travers A, et al. Cost-effectiveness of lay responder defibrillation for out-of-hospital cardiac arrest. Ann Emerg Med. 2009;54(2):226-35.e1-2.
Weisfeldt ML, Sitlani CM, Ornato JP, Rea T, Aufderheide TP, Davis D, et al. Survival after application of automatic external defibrillators before arrival of the emergency medical system: evaluation in the resuscitation outcomes consortium population of 21 million. J Am Coll Cardiol. 2010;55(16):1713-20.
Atkins DL. Realistic expectations for public access defibrillation programs. Curr Opin Crit Care. 2010;16(3):191-5.
Pell JP, Walker A, Cobbe SM. Cost-effectiveness of automated external defibrillators in public places: con. Curr Opin Cardiol. 2007;22(1):5-10.
Roszak AR. CPR / AED Laws: Sudden Cardiac Arrest Foundation; [Available from: https://www.sca-aware.org/about-sudden-cardiac-arrest/cpr-aed-laws.
State Laws on Cardiac Arrest and Defibrillators National Conference of State Legislatures [cited 22 Dencee. Available from: https://www.ncsl.org/research/health/laws-on-cardiac-arrest-and-defibrillators-aeds.aspx.

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How will COVID-19 Affect Return to High School Sports and ECG Screening?

August 19, 2020August 19, 2020 Alyssa Vermeulen, DO, FAAP

August is traditionally very busy month in the pediatric cardiology office; visits for “sports clearance” flood the schedule due to something picked up on a high school sports physical such as chest pain. Most of these will be non-cardiac and receive reassurance; however, the cardiac causes in the pediatric population can be quite distressing. With the current COVID-19 pandemic we are seeing many cardiac effects of the virus— myocardial inflammation, dysfunction and coronary artery dilation or MIS-C (multisystem inflammatory syndrome in children). There has also been a reported increase in out of hospital cardiac arrest in the adult population, which could be attributed to those afraid to seek care, but none the less, a concern.

Cardiac effects play an important part in the recent discussions on return to school, as eventually return to school will mean return to school sports. Sports cardiologists have been following this closely and have been working to establish a safe way for return to sports in competitive athletes who have had COVID-19¹(click here for recommendations and see flowchart below), which may include extensive cardiac testing of those who had symptomatic COVID-19, most of which is based on the return to play myocarditis guidelines.² These important decisions require individualization, knowledge of risk and what is happening in the community.

So what does this mean for the high school athletes? There is no doubt that exercise is great for everyone, especially with the rising obesity and the sedentary lifestyle. Organized sports participation has shown to have a positive impact on mental and physical health that extends beyond childhood.³ Many have raised concerns about the development and health of children by not attending school, along with decrease in social interaction and activity from organized sports during the stay-at-home orders and while we work to defeat COVID-19 spread.

Prior to the pandemic, the question of universal ECG testing for high school athletes always started a conversation, but could that change? Critics say that the false positives create distress and extra healthcare cost, that follow up is problematic and that it has not been shown to change outcomes. Others argue saving one child from the devastating event of collapsing and dying on the field is worth it, and a recent study showed ECG with H&P is more likely to detect a condition associated with sudden cardiac arrest (SCA) than H&P alone, and also improved cost efficiency when interpreted in the right hands.⁴ All agree it is important to have a good plan in place for SCA at all sporting events, including an emergency response plan in place specific to cardiac arrest.

With so many affected by the virus, at varying severity, I can’t help but wonder if this will change the way we assess our young athletes for participation in sports when it is safe to do so. While healthcare costs are always a problem, with a new virus and unclear long-term outcomes, we must be conservative. Perhaps this may provide an opportunity to learn more about ECG screening, as we will likely see a larger amount of patients who have had COVID-19 coming to our offices for clearance. This may provide an opportunity to gather evidence on the continued debate of whether ECG screening is effective.

Until we know more, what we do know is it is safer to be conservative, to assess benefit and risk and provide appropriate counseling to families on signs and symptoms of SCA. We also must continue to reassess and stay up-to-date on new knowledge and testing related to COVID-19 recovery and sports. Most importantly, it is important that we continue to advocate for heart safe schools which include having AEDs, training in CPR, and emergency response plans related to Sudden Cardiac Arrest. With more kids participating in school from home, this could be a great opportunity to engage the whole family in CPR and AED education to improve the safety and survival of our communities and at home.

References

Phelan, Dermot, et al. “A Game Plan for the Resumption of Sport and Exercise After Coronavirus Disease 2019 (COVID-19) Infection.” JAMA Cardiology, 2020, doi:10.1001/jamacardio.2020.2136.
Maron, Barry J., et al. “Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task  Force 3: Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy and Other Cardiomyopathies, and Myocarditis.” Journal of the American College of Cardiology, vol. 66, no. 21, 2015, pp. 2362–2371., doi:10.1016/j.jacc.2015.09.035.
Logan, Kelsey, and Steven Cuff. “Organized Sports for Children, Preadolescents, and Adolescents.” Pediatrics, vol. 143, no. 6, 2019, doi:10.1542/peds.2019-0997.
Harmon, Kimberly G, and Jonathan A Drezner. “Comparison of Cardiovascular Screening in College Athletes” Heart Rhythm, 2020, www.heartrhythmjournal.com/article/S1547-5271(20)30406-9/pdf.

How is the AHA leading the way in Cardiopulmonary resuscitation (CPR)?

August 18, 2020August 18, 2020 Lina Ya'qoub, MD

In writing this last post as a junior blogger, I decided to highlight the tremendous efforts by the American Heart Association (AHA) to improve cardiovascular care in the field of cardiac arrest and cardiopulmonary resuscitation (CPR). As we know, the AHA is a worldwide leader in first aid, CPR, and Automated External Defibrillator (AED) training – educating millions of people globally in CPR every year. Here, I will share some fun facts about CPR, and you can refer to the AHA website for further details about this important topic.

Important CPR statistics

Majority of cardiac arrests occur outside of the hospital, with estimated 475,000 Americans dying from cardiac arrests every year [1]
Bystander CPR is a key component in the out-of-hospital “chain of survival” [Figure 1] and studies have shown it improves survival in cardiac arrest [1-3].

Figure 1: The adult out-of-hospital “chain of survival”. Each link of the chain from left to right is numbered 1 through 5: 1- Recognize cardiac arrest and activate the emergency response system, 2- early CPR with high-quality chest compressions, 3- Use AED for rapid defibrillation, 4- basic and advanced emergency services and 5- post-cardiac arrest care and advanced life support [2].

Bystander CPR has been increasing over the recent years in both men and women. Despite that, survival improved in men only, but not women [2]. This is important as it highlights that more work is needed to identify additional predictors of survival in women with cardiac arrest.
Efforts mandating CPR training in high schools in multiple states [5] and availability of AED in public places, including airports [Figure 2], have helped in increasing the awareness and familiarity of bystander CPR in cardiac arrest [4].

Figure 2: A photo of Automated External Defibrillator (AED) in one of the airports.

Personal Experience

From a personal experience, I have visited multiple high schools in my home country as well as in the United States, and have participated as an organizer in the sessions teaching high school students how to perform effective CPR. It is inspiring to see junior students interested in learning and saving lives. The takeaway from my experience is that engagement plays a major role in spreading the word and encouraging the general public to take the extra step and learn how to perform basic and advanced life support techniques.

In conclusion, it is important to remember that the general public are oftentimes our first “link” in the chain of survival; making them an important part of our efforts to improve survival and cardiovascular care in patients with cardiac arrest. A strong chain of survival improves survival and recovery after cardiac arrest. Although there have been improvements in CPR and advanced life support, there remains room for further improvement, and perhaps we can do our part by encouraging our patients, friends and relatives to take the first step and learn how to perform effective CPR and possibly how to use AEDs!!

I have added a few online references for those interested in sharing this with their patients and encouraging them to sign up for both the online and class programs [3,6]!!

References:

Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association [published correction appears in Circulation. 2013 Aug 20;128(8):e120] [published correction appears in Circulation. 2013 Nov 12;128(20):e408]. Circulation. 2013;128(4):417-435. doi:10.1161/CIR.0b013e31829d8654
Malta Hansen C, Kragholm K, Dupre ME, et al. Association of Bystander and First-Responder Efforts and Outcomes According to Sex: Results From the North Carolina HeartRescue Statewide Quality Improvement Initiative. J Am Heart Assoc. 2018;7(18):e009873. doi:10.1161/JAHA.118.009873
CPR facts and stats:

https://cpr.heart.org/en/resources/cpr-facts-and-stats

Chain of Survival:

https://cpr.heart.org/en/resources/cpr-facts-and-stats/out-of-hospital-chain-of-survival

Mandatory CPR training in high school:

https://www.sca-aware.org/schools/school-news/mandatory-cpr-training-in-us-high-schools

CPR AED and first aid classes:

https://cpr.heart.org/en/course-catalog-search

CardioPulmonary Resuscitation (CPR) in the Time of COVID-19

July 17, 2020July 17, 2020 Lina Ya'qoub, MD

As we continue to see the increasing number of coronavirus disease 2019 (COVID-19) cases and amid the second peak of this pandemic in the United States (US), everyone from physicians to the general public should know how to approach and perform basic life support (BLS) with certain precautions and modifications of routine BLS protocols for patients with suspected or confirmed COVID-19 status. Importantly, rescuers should always balance the immediate needs of patients with their own safety. Several recently published articles have demonstrated that many patients with COVID-19 can present with cardiac arrest or experience cardiac arrest while hospitalized. In this post, I am going to share a few points on recommended modifications in order to ensure a safe yet effective CPR protocol for our patients.

Reduce Provider Exposure to COVID-19

Resuscitations carry added risks to rescuers and healthcare workers for many reasons. CPR involves performing numerous aerosol-generating procedures, including chest compressions, positive-pressure ventilation, and establishment of an advanced airway [1]. It is important to keep in mind that these viral particles can remain suspended in the air with a half-life of around 1 hour per some reports and can be inhaled by those nearby [1]. In addition, resuscitation efforts require numerous providers to work in close proximity to each other and to the patient; thus, the advised social distancing protocols may not be applicable.

Strategies

Before entering the scene, all rescuers should don personal protective equipment (PPE) to guard against both airborne and droplet particles.
Limit personnel on the scene to only those essential for patient care.
In settings with protocols in place and expertise in their use, consider replacing manual chest compressions with mechanical CPR devices to reduce the number of rescuers whenever it is available and in patients who meet the manufacturer’s height and weight criteria.
It is important to clearly communicate the COVID-19 status to anyone arriving to the scene and when transferring patients to another setting.

Prioritize Oxygenation and Ventilation Strategies with Lower Aerosolization Risk

Strategies

Attach a high-efficiency particulate air (HEPA) filter securely [Figure 1], if available, to any manual or mechanical ventilation device to lower the risk of aerosolization before giving breaths.
After healthcare providers assess the rhythm and defibrillate any ventricular arrhythmias, patients in cardiac arrest should be intubated with a cuffed tube at the earliest feasible opportunity. Connect the endotracheal tube to a ventilator with a HEPA filter when available.
Minimize the likelihood of failed intubation attempts by doing the following:
- Assign the provider/approach with the best chance of first-pass success, and
- Pause chest compressions while intubating with minimal disruption.
Video laryngoscopy may reduce exposure to aerosolized particles and should be considered.
Once on a closed circuit, minimize disconnections in order to reduce aerosolization.
Barriers can be used to minimize spread of the particles during aerosol-generating procedures (Figure 2).

Figure 1: A high-efficiency particulate air (HEPA) filter (arrow) is securely attached to any manual or mechanical ventilation device to lower the risk of aerosolization before giving breaths [2].

Figure 2: Example of barriers potentially used to minimize the spread of the particles during aerosol-generating procedures [2].

Consider the Appropriateness of Starting and Continuing Resuscitation

Like any cardiac arrest, it is important to know when resuscitation efforts are likely to be futile. Although the outcomes for cardiac arrest in COVID-19 are still unknown, the mortality for critically ill patients with COVID-19 is high, especially with increasing age and comorbidities, particularly cardiovascular disease. As such, it is critical to consider all these factors in determining the appropriateness of initial and continued resuscitation efforts, to weigh the likelihood of success against the risk to rescuers.

Strategies

Address goals of care with patients, or their proxies, in anticipation of the potential need for increased levels of care.
Healthcare systems and Emergency Medical Services (EMS) agencies should institute policies to guide frontline providers in determining the appropriateness of starting and terminating CPR for patients with COVID-19 on the scene, early in the process. The risk stratification and potential policies should be communicated to patients (or proxy) during discussions of goals of care.

In conclusion, there have been modifications to the routine CPR protocols in patients with suspected or confirmed COVID-19. With the increasing number of COVID-19 cases, it is very important, for us as physicians and for the general public as well, to review recommended modifications to BLS protocols and apply them where possible, in a step to win the battle against this virus during these unprecedented times!!

References

Edelson DP, Sasson C, Chan PS, et al. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association. Circulation. 2020;141(25):e933-e943. doi:10.1161/CIRCULATIONAHA.120.047463 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7302067/
Medical Direction and Practice Board White Paper Approach to Out-of-Hospital Cardiac Arrest During the COVID-19 Pandemic: https://www.maine.gov/ems/sites/maine.gov.ems/files/inline-files/2020-04-30%20OHCA%20COVID-19%20White%20Paper%20Final.pdf

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

April 20, 2020April 15, 2023 Alyssa Vermeulen, DO, FAAP

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.

Edelson, Dana P, et al. “Interim Guidance for Life Support for COVID-19.” Circulation, ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.047463.
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.
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.

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

January 16, 2020January 16, 2020 Lina Ya'qoub, MD

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.

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.

It’s Finally Here: New AHA Statement On Resuscitation In Pediatric Patients With Heart Disease And Comments From The Author

May 2, 2018 David Werho, MD

Do you want to read something amazing, awesome, and interesting? The AHA recently published its latest Scientific Statement: Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease.

Cardiac arrest in the hospital is 10 times more common among children with congenital heart defects or other acquired heart conditions compared to children with healthy hearts, according to the statement published Monday in the journal Circulation. As a pediatric cardiac intensivist, I often find myself overthinking things when I go for my PALS or ACLS recertification. “Well, if the patient is having a pulmonary hypertensive crisis, then I’d actually do this also…” or “At this point, I would have already activated ECMO.” In all honesty, I don’t reach for my PALS card during a real-life resuscitation in the pediatric cardiac ICU anymore. Not because I don’t follow the guidelines – I am the first to admit that high-quality CPR is the cornerstone of resuscitation and my team has these algorithms streamlined and burned into the backs of our minds – but because I have so many other things going through my head for this patient population. (Does this baby have pacing wires? What vessels are patent? Is the shunt occluded? How will vasopressin affect this kid’s physiology? Has this chest tube been draining appropriately leading up to the arrest?) None of these things are specifically addressed in the AHA resuscitation guidelines, until now.

Bradley S. Marino, MD, MPP, MSCE, Professor of Pediatrics and Medical Social Sciences at the Northwestern University Feinberg School of Medicine and a Pediatric Cardiac Intensivist at Ann & Robert H. Lurie Children’s Hospital and Chair of the AHA Council on Cardiovascular Disease in the Young along with his expert colleagues on the AHA Congenital Cardiac Defects Committee have painstakingly taken the time to address the unique issues surrounding peri-resuscitation care and considerations for the high-risk pediatric cardiac population. “The new statement is meant to be a powerful tool for health care professionals to both improve survival in children with heart disease who have a cardiac arrest and prevent cardiac arrests from ever happening in these high-risk children,” said Dr. Marino. “This scientific statement is a critical supplement to the American Heart Association’s Pediatric Advanced Life Support Guidelines that has been long overdue,” Marino said.

I asked Dr. Marino what the most important thing was that the authors learned while putting together the statement. “Given the incidence of cardiac arrest in the pediatric cardiac population, activities to prevent cardiac arrest are very important. We need to do more to modify our present clinical care systems to minimize the incidence of cardiac arrest. In addition, we need to tailor our resuscitation strategies for children with cardiac disease. While the PALS recommendations are very helpful to resuscitate all children with cardiac arrest, more information was needed to address the special needs of the pediatric cardiac population.”

The statement reviews all of the stages of cardiopulmonary resuscitation (pre-arrest, during CPR, and post-resuscitation care) and the considerations for each stage of single-ventricle palliation, right- and left-sided heart disease, pulmonary hypertension, cardiomyopathies and myocarditis, and arrhythmias. They also speak to considerations related to patient age, patient location, ECPR, and all of the various pharmacologic agents that we use frequently in these patients.

As for Dr. Marino’s hopes for providers to take away after reading the statement, he says “Tailoring resuscitation is possible once providers understand the specific anatomy, physiology, and cardiopulmonary interaction that is present at each patient’s bedside.”

It’s definitely a long document to read through, but is a critical review for all providers who care for pediatric patients with heart disease, especially those of us in the ICU setting. Click here to read it.

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.

Paradigm Shifts In Resuscitation

March 2, 2018 David Werho, MD

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.