Responding To Cardiac Arrest - Every Minute Counts!

A Singapore medical team is endeavoring on an ambitious target of emergency response time of 2 minutes (see the news from Channel News Asia below)

This would be especially important in setting of responding to a sudden cardiac arrest case where every minute counts! The reasons being:

• Resuscitation is most successful if defibrillation is performed in about 5 minutes after collapse
• Effective bystander CPR, provided immediately after cardiac arrest, can double a victim’s chance of survival (Click here to download the entire AHA Guidelines 2005 in pdf free)
• Even with the latest development of various gadgets and medications, the interventions that unquestionably contribute to improved survival after cardiac arrest are early defibrillation for VF/pulseless VT and prompt effective bystander BLS
  

Unfortunately, one of the shortcomings of responding to cardiac arrest in Malaysia is the ambulance response time which may take between 15 to 20 minutes or longer (click here to read my article on Shortcomings of Cardiopulmonary Resuscitation in Malaysia or download the article in pdf). Furthermore, our public may be reluctant to perform mouth-to-mouth breathing on a total stranger that we do not know, especially when responding to a victim of a different gender. This could probably be due to the socio-cultural barrier in our community (click here to read or here to download in pdf the article on the survey that I have done with my colleague, Dr. Yazid on the attitudes of our own students in responding to cardiac arrest).

Fortunately, in responding to non-traumatic sudden cardiac arrest in an adult (which most commonly due to a coronary event), it has been found that cardiac compression is more important than mouth-to-mouth breathing. In fact, the American Heart Association (AHA) is advocating performing Hands Only CPR or compression-only CPR in cases when the potential rescuer is not familiar with the steps of CPR or unwilling to perform to mouth-to-mouth breathing.

Hands Only CPR is simplified to 2-step only:
1. Call for emergency medical response (in Malaysia, it is 999)
2. Put your hands in the center of the victim's chest and start pushing fast and hard

Click here to read more on Hands Only CPR or download an article in pdf.
(*Of course, in cases where the primary insult is asphyxia or respiratory etiology, for example, drowning in children, respiratory failure in children, toxicology cases, oxygenation is still very important and in such cases, rescue breathing is important).

Watch the video on Hands Only CPR below:

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SINGAPORE: A medical centre and two medical posts have been set up within Suntec Singapore to take care of APEC delegates. And if needed, a team on standby can render help within two minutes.

So far, there have been no emergency cases.

Three doctors and six nurses are on duty everyday.

And since the start of the summit last Saturday, the medical team has been seeing an average of 10 patients daily, mostly for minor illnesses such as flu, headaches and abdominal pains.

The team is also equipped to respond to major cases like heart attacks and any incident which may involve many casualties.

Suresh Pillai, head, APEC Medical Sub-Committee, said: "There will be an extra medical team that will be activated from all the hospitals. All hospitals will have a field medical team on standby to move in the event of a mass casualty incident.

“So they have been prepped to be on standby and move out within five minutes in a mass casualty incident and they will response to whichever site the incident may be in."

On the potential threat of Influenza A H1N1, the team's response will be similar to any flu-like illness, but precautions are in place.

Mr Suresh added: "We have to make sure that we have the anti-viral drugs available and we also needed to ensure that we could do H1N1 testing at the medical centre itself. At this point of time, there is probably no need to do any of these things, since the situation is well controlled and stabilised."

Those who require follow up treatment in hospital, will be sent to the Singapore General Hospital or National University Hospital.

VVIPs who need to be sent to the hospital will be escorted by police.

Media personnel too are well-taken of with a 24-hour medical centre within the media area.

The media centre is also opened round the clock, housing some 30 broadcast booths and 300 work stations. - CNA

Compression Only CPR

I saw the article "CPR Can Help, Even With No Training" from The New York Times (1st April 2008). This is what the article says:

April 1, 2008

CPR Can Help, Even With No Training

By NICHOLAS BAKALAR

Even people without CPR training can save the life of an adult whose heart stops, and the American Heart Association has issued an advisory urging everyone, trained or not, to act immediately in such an emergency.

The procedure is simple: if you see an adult collapse after having a heart attack, immediately call 911 and then push hard and fast in the middle of the chest continuously, until emergency medical personnel arrive or an external defibrillator can be used.

Dr. Michael R. Sayre, the lead author of the recommendations, said in a telephone interview that the ideal would be 100 pushes a minute with enough force to make the chest go down two inches, but, he added, “there is no need to use a metronome and a ruler.” Dr. Sayre is an associate professor of emergency medicine at Ohio State University.

CPR or cardiopulmonary resuscitation, can more than double the survival rate in cardiac arrest, but only about a third of people who collapse get CPR from bystanders.

The advice does not apply to cardiac arrest in children, or that due to drowning or drug overdose, which usually require rescue breathing. Nor does it apply when the bystander does not see the collapse, since it might not have been cardiac arrest.

But the exceptions, Dr. Sayre said, are only about a quarter of all cardiac arrests. “We want people to act no matter what,” he said, “and one of the reasons it’s important to take a CPR class is because of this other 25 percent.

“But doing chest compressions alone in these situations is better than doing nothing,” he said. “Even for children, the procedure would be the same.”

Chest compression keeps blood flowing, but it does not reoxygenate the blood, as mouth-to-mouth resuscitation does.

The recommendations, being published in the April issue of Circulation, are based on new studies of CPR techniques. They update advisories published in 1997 and 2005.

Numerous studies in animals, and five others in humans, have convinced experts that hands-only CPR from an untrained bystander is usually as effective as CPR with mouth-to-mouth resuscitation performed by a person trained in the technique.

There may be several reasons. Rescuers performing traditional CPR take longer to start than those who use hands only, maybe because it takes more time to prepare, intellectually and emotionally, for the more complex and intimate procedure. Studies have also shown that bystanders performing conventional CPR interrupted chest compressions for longer than the recommended 10 seconds while doing mouth-to-mouth resuscitation, resulting in fewer compressions.

Surveys suggest there may be reluctance to perform mouth-to-mouth resuscitation because of fear of infection, but this is probably a minor barrier. More commonly, CPR-trained bystanders cite panic and fear of causing further harm as reasons for inaction. Such fears are unwarranted.

“If you do nothing, the person will die,” Dr. Sayre said. “And you can’t make them worse than dead.”

Few days later, we read this article "CPR Vital To Saving Lives" in THE STAR, our local newspaper:

CPR vital to saving lives

KUALA LUMPUR: More than 93% of cardiac arrest victims die before they receive in-hospital treatment because bystanders do not know how to perform cardiopulmonary resuscitation (CPR).

This prompted the National Heart Association of Malaysia to organise its first free Public CPR Education Programme yesterday

“CPR in the first four minutes of a sudden heart attack gives a person a 40% chance of survival while waiting for proper medical aid and can prevent brain damage due to lack of oxygen. Training more people on CPR can make a significant difference for cardiac arrest victims,” said project leader Dr Chee Kok Han.

Apart from heart attack cases, CPR is also vital for emergencies such as choking, drowning, or a lack of pulse.

The association found that 45% of physicians and 80% of nurses were unwilling to perform CPR for various reasons including fear of performing CPR wrongly, distaste for mouth-to-mouth resuscitation and unfounded fear of contracting disease from the victim.

Health Minister Datuk Liow Tiong Lai said a lack of awareness and access to free courses left millions of Malaysians ignorant about how to perform CPR and urged the public to learn CPR from first aid organisations such as St John Ambulance Malaysia and the Malaysian Red Crescent Society.

“Around 70% to 80% of out-of-hospital cardiac arrests occur at home. This is where you and I, and the public can save a life through simple techniques such as CPR,” he said at the programme launch at KLCC Convention Centre yesterday.

All schoolchildren – not just Red Crescent and St John Ambulance members – must know CPR, he said.

The one-day progrxamme themed “Give the Gift of Life, Today” was organised in conjunction with the association's 12th Annual Scientific Meeting

It involved 400 participants n cardiovascular health and CPR as well as videos of CPR demonstrations.

Health Minister Datuk Liow Tiong Lai said a lack of awareness and access to free courses left millions of Malaysians ignorant about how to perform CPR and urged the public to learn CPR from first aid organisations such as St John Ambulance Malaysia and the Malaysian Red Crescent Society.

“Around 70% to 80% of out-of-hospital cardiac arrests occur at home. This is where you and I, and the public can save a life through simple techniques such as CPR,” he said at the programme launch at KLCC Convention Centre yesterday.

All schoolchildren – not just Red Crescent and St John Ambulance members – must know CPR, he said.

The one-day progrxamme themed “Give the Gift of Life, Today” was organised in conjunction with the association's 12th Annual Scientific Meeting

It involved 400 participants with cardiovascular health and CPR as well as videos of CPR demonstrations.

My Comments:

My personal opinion is that, putting pressure on public members may temporarily encourage them to adopt a willing attitude towards CPR during the immediate period after a CPR training workshop when they are still full of zeal and their memory of the complicated steps of performing both mouth-to-mouth breathing and chest compression is still fresh, but what happens six months to one year down the line, when one really witness a victim collapse right in front of them? They may have well forgotten the complicated steps they learned in the CPR workshop six months ago especially during the spur of the panicked moment.

Coupled with the distasteful sight of seeing the total stranger collapsed with bluish discolored, sweaty face and secretions coming from the mouth, would one still be full of zeal and spring to action to perform full bystander CPR (both mouth-to-mouth breathing and chest compression)?

At the end of the day, our aim is that encourage more public members to do CPR while awaiting the arrival of ambulances that may often take at least 20 minutes to arrive at the scene. So, why should we make CPR so complicated and imposing the “kiss” on an already collapsed stranger, which in our Asian culture is not something we would normally do in public even on a living person?

Firstly, we should not give the impression to our public that only those who are trained in CPR can perform CPR when no one else are willing to do so in a dire moment. The AHA latest advisory this month clearly states that anyone, whether trained previously or not, should start compressing the chest fast and hard after getting someone to call the ambulance. Secondly, we should also never give the impression to our public that any CPR performed must include mouth-to-mouth breathing. Whenever we teach CPR, we should make at least a mention that compression-only CPR is better than no CPR.

Download the AHA Statement on Chest Compression Only CPR (released 1 April 2008) here