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

Emergency Medicine Digest

1. Prolonged QTc in diabetic ketoacidosis in children

QTc was shown to be prolonged in up to 47% of diabetic ketoacidosis in children and tend to resolves when the ketosis clears (only 13% still with prolonged QTc after recovery).

Implication: Probably monitoring of QT interval in diabetic ketoacidosis in children can be used as a measure of the disease progression?

Reference:
Kuppermann N et al. Prolonged QT interval corrected for heart rate during diabetic ketoacidosis in children. Arch Pediatr Adolesc Med 2008 Jun; 162:544.

2. Nesiritide – Another Disappointing Trial

Nesiritide, a recombinant B-type natriuretic peptide, is approved for as an adjunct for management of acute decompensated heart failure because of its vasodilatory and natriuretic effects.

Previously Follow-Up Serial Infusions Of Nesiritide FUSION I study – shows no benefit from intermittent nesiritide infusions in outpatients with heart failure.

Now, FUSION II study – again shows no benefit of intermittent outpatient nesiritide infusions in high-risk advanced heart failure patients (those in NYHA Class IV, EF 25%). In fact, those with nesiritide has more side effects of hypotension.

Implication:
Initially, when nesiritide was approved for acute heart failure use, I thought that in the future, nesiritide will become a standard drug in all major government (KKM) hospitals and university hospitals. But, well, now that there are more and more disappointing trials, probably this may not become a reality.

Reference:
Yancy CW et al. for the FUSION II Investigators. Safety and efficacy of outpatient nesiritide in patients with advanced heart failure: Results of the Second Follow-Up Serial Infusions of Nesiritide (FUSION II) trial. Circ Heart Fail 2008 May; 1:9.

3. Noninvasive Ventilation (NIV) was shown to be safe and effective as an alternative to immediate endotracheal intubation in acute decompensated heart failure in a retrospective trial.

In fact, the likelihood of in-hospital death was significantly less in the successful-NIV group than in the intubation group. But once the NIV failed (and ultimately required intubation), there is no significant difference in the in-hospital death as compared with those who were intubated earlier.

Implication:
Probably we should put more patients on NIV early (especially those that we anticipate might require respiratory support) but we must be committed to vigilantly and closely observe the patients.

Reference:
Tallman TA et al. Noninvasive ventilation outcomes in 2,430 acute decompensated heart failure patients: An ADHERE registry analysis. Acad Emerg Med 2008 Apr; 15:355.

4. Uninterrupted Manual Chest Compressions During Biphasic Defibrillation?

In this trial, a group of researchers found that that pausing CPR for delivery of shocks might not be necessary because the risk to the rescuer is minimal.

What they did was they measured the leakage voltage and current through mock rescuers while they were still compressing the chests of 43 patients who were receiving external biphasic shocks.

No shocks were perceptible to rescuers (even during delivery of 360 J) and the leakage current measured was found to be below the recommended safety standards.

Implication:
Even though this small trial shows the risk if minimal, I am not sure if anyone of us would be ready to ignore the “one I’m clear, two you’re clear, three everybody clear!” command. One should also remember that the pads used were the pre-gelled electrodes while we were still using the manually applied gel on the electrode pads – when the gel get smeared here and there, I don’t think it is that safe to continue CPR while shock is being delivered.

Reference:
Lloyd MS et al. Hands-on defibrillation: An analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation 2008 May 13; 117:2510.