Published in the September 2009 issue of Today’s Hospitalist
While the conventional wisdom holds that the safest place to have a heart attack is the hospital, the medical literature has shown that emergency workers in the field typically do a better job at resuscitation than physicians and nurses in the hospital. That remains true even when the hospital has a rapid response team.
Why? For one, code teams respond too slowly. They don’t start chest compressions early enough, and their compressions are too weak. Doctors waste precious seconds checking pulses and reflexes, and they fixate unnecessarily on ventilation. And most hospitals don’t spend money to train nurses in advanced cardiac life support.
Those are just the top items on the resuscitation “mistake” list, according to hospitalist Jason Persoff, MD, assistant professor of internal medicine with Mayo Clinic in Jacksonville, Fla., and a member of the American Heart Association. To improve that dismal situation, Dr. Persoff shared resuscitation tips and tools at the American College of Physicians’ annual meeting in Philadelphia earlier this year.
The first mistake doctors make when trying to resuscitate a patient is to wait to start compressions until they determine if a person is really having a cardiac arrest. “Start now, and don’t wait,” Dr. Persoff said. “If somebody looks dead, then fundamentally they are dead until proven otherwise.”
Also, don’t waste time trying to set up equipment to perform defibrillation at the expense of immediately starting compressions. An observational study published in the April 7, 1999, Journal of the American Medical Association found that deaths increased after paramedics were allowed to use automated external defibrillators (AEDs) in the field.
When researchers analyzed the data more closely, they realized that paramedics had stopped doing immediate compressions on patients to fumble around with the machines. Once the protocol was changed to require a one-minute minimum of chest compressions before AEDs could be used, “survival went back up again,” Dr. Persoff explained.
“If patients do not get chest compressions immediately, they won’t survive,” he said. “They go from a 34% to a 14% survival rate.” To be most effective, compressions need to start when the person is still in the electrical phase of cardiac arrest (0-4 minutes). Once the patient enters the circulatory phase (4-10 minutes) or the metabolic phase (after 10 minutes), it may be too late.
Because speed is so important, don’t check for a pulse before starting compressions, Dr. Persoff said. Not only does taking a pulse eat up 20 to 30 seconds that could be better spent compressing the chest, but studies have found that physicians are bad at finding a pulse in controlled circumstances, let alone in a crisis.
What about fears that you will hurt patients if you start compressions unnecessarily? “This is not a time for thinking,” Dr. Persoff urged. “If patients scream, then they’re perfusing and that’s a good thing.”
Push hard, pump fast, have good recoil
Another major flaw, Dr. Persoff said, is ineffective compressions. Studies, like one published in the Feb. 1, 2005, issue of Circulation, have found that not only are chest compressions often delivered at rates much lower than recommended, but they are frequently too shallow. Dr. Persoff joked that he recommends approaching resuscitation like a marriage: “Push hard, pump fast and have good recoil.” He also advises rotating rescuers so you can keep up strong compressions.
Then there’s this problem: People stop doing compressions to check for a rhythm. “At the end of the day, rhythm analysis doesn’t matter nearly as much as good chest compressions,” said Dr. Persoff. “Eventually, rhythm analysis is important “after 10 minutes “but for the initial phase, stopping compressions decreases survival.”
Of course, compressions aren’t the whole answer; defibrillation is important too. While you should start with compressions, “the number of minutes that you delay defibrillation results in decreased survival,” Dr. Persoff said. “There is a mixed message here: You need to be doing chest compressions, but you also need to shock the patient” without worrying what rhythm he or she is in.
In addition, he said, research clearly shows that the common practice of a “hands-off interval” for an AED is not only unnecessary but harmful. While everyone fears getting shocked, the risks are negligible to non-existent. “You probably get more current from your iPhone,” he said.
European guidelines already propose shocking a patient while CPR is ongoing. Revised American guidelines due out in 2010, he said, probably will recommend a “zero hands-off interval” as well.
From ABC to CCR
Other practices that Dr. Persoff labeled as “misguided” include worrying about oxygen depletion and hooking people up to ventilators in the early minutes of resuscitation. That practice often leads to iatrogenic hypotension caused by over-zealous use of bag valve masks.
Mouth-to-mouth resuscitation has now been omitted from layperson CPR guidelines, and it should not be in health care-directed resuscitation either. A new paradigm (and acronym) is replacing the ABCs (airway, breathing and circulation) with CCR, or cardiocerebral resuscitation. (One study Dr. Persoff recommended on CCR was published in the Jan. 13, 2009, issue of the Journal of the American College of Cardiology.)
The key to CCR, he explained, is “rapid initiation of continuous chest compressions for any witnessed arrest,” interrupted occasionally to administer a rhythm shock. Only after a number of series of compressions and shocks should you consider intubation.
While a patient who survives a cardiac arrest will eventually need oxygen, he said, people likely have plenty of oxygen reserves initially. That’s partly because patients gasp during cardiac arrest. Gasping, a forceful agonal respiration, is a marker of better prognosis and increases cerebral blood flow, decreases intracranial pressure, improves upper airway patency and generates cardiac output by itself.
“When we bag the patient or try to intubate them, we stop them from gasping,” Dr. Persoff pointed out. In fact, putting a bag valve mask on patients who can’t generate enough negative pressure to open the valves can actually suffocate them.
Evidence also suggests, he added, that ventilating patients is done badly, even by experts and especially during a code.
“I’d rather have somebody placing their hands on the chest rather than on the bag and valve mask,” he said. “The data are fairly convincing that we really do decrease good outcomes by ventilating patients.”
Epinephrine for PEA
If the patient goes into pulseless electrical activity (PEA) after being shocked, it is extremely important to “fill the tank,” he said. That translates into lots of IV fluids.
“People go into circulatory shock when they are in resuscitation,” Dr. Persoff noted. “We say that we don’t want to volume overload patients, but you have plenty of room, and that will only serve them better. Give patients fluid through every port.” If they end up volume overloaded, he said, they can always be dialyzed “but only if their heart is beating.
Patients in PEA will also need oxygen, he said, but not by intubation. Instead, use a non-rebreather mask. “Bagging them is not going to help,” he said. “You just need to get the tongue out of the way by using an oropharyngeal airway.”
In addition to compressions, fluids and oxygen, patients in PEA need epinephrine. In terms of resuscitation medications, epinephrine should be the go-to drug of choice, Dr. Persoff said. Most of the literature has found that epinephrine is either superior to or the same as vasopressin. While there has been interest in combining the two, a recent meta-analysis concluded that a combination worked no better than epi alone, he said. “So don’t be trendy.”
The sooner you can give epinephrine, the better, Dr. Persoff added. He recommends delivering epinephrine “as soon as you have IV access and you are doing chest compressions.” Preferably, the IV should be a central line, not a peripheral IV in the hand, because the goal is to get the drug into the circulation quickly.
If a peripheral IV is all that is available, he said, remember to flush it “at a high, high rate.” If you can put in a central line, the best place on a person needing resuscitation is in the groin. And aim to give the epinephrine before shocking the patient.
Overall, Dr. Persoff said, the timing of the epinephrine is not as important as getting it on board quickly and then repeating it every five minutes.
The newest thinking, he noted, is that adding steroids may help. One single-center study published in the Jan. 12, 2009, issue of Archives of Internal Medicine found that “combined vasopressin-epinephrine and methylprednisolone during resuscitation and stress-dose hydrocortisone in post-resuscitation shock improved survival in refractory in-hospital cardiac arrest.”
“It’s too soon for us to recommend this,” Dr. Persoff said, “but it makes sense to me.”
Cold is cool
Once you initiate compression-only resuscitation, shocking patients without worrying about rhythms and implementing passive oxygen insufflation (using intubation only as a last resort), it’s time to consider another pillar of CCR: rapid hypothermia.
Dr. Persoff acknowledged that outside of academic settings, many facilities have a hard time investing in hypothermia or putting hypothermia protocols into place. But cooling patients after resuscitating them, he explained, is the “only brain-preserving therapy we have.” The downsides of inducing hypothermia include coagulopathy, decreased white blood cell function, potential for sepsis, decreased cardiac index and true hyperglycemia. However, patients are less likely to die if they are cooled, and the newest thinking actually recommends starting cold saline during the code.
The way to induce hypothermia “which should be done rapidly, but often can take up to six hours to achieve a target of 32-34Â°C “is to infuse patients with cold lactated ringers or cold saline and cover them in ice. Continuous bladder thermography is a must because precise core temperatures need to be known.
Paralyzing patients is also recommended; otherwise, they shiver and raise their temperature. And if patients develop an elevated CK, CK-MB, troponin or other indication of acute coronary syndrome, send them immediately for catheterization.
“When we cool patients, it’s because we are hoping they survive,” said Dr. Persoff, “not because we’re getting them ready for the morgue.”
No one knows yet how long a patient should be kept cool. At his institution, Dr. Persoff said, 24 hours is the arbitrarily chosen guideline. “You would probably be safe with 36 hours, but 48 hours is a lot harder to maintain,” he said. “Believe it or not, it’s very hard to keep somebody cold.”
Patients should be allowed to warm up passively, and you should stop paralytics when the patient’s temperature reaches 35Â°C. However, Dr. Persoff said, “you should still keep them sedated.”
Deborah Gesensway is a freelance health care writer who covers U.S. health care from Toronto.
Rapid response teams: waiting too long to call
LOGIC WOULD DICTATE that hospitals with rapid response teams would save more lives than those without. But according to Jason Persoff, MD, assistant professor of internal medicine with Mayo Clinic in Jacksonville, Fla., studies looking at the effectiveness of rapid response teams have so far found “a mixed bag.”
The overarching problem, said Dr. Persoff, appears to be that “people don’t call for help.”
“People, by and large” “including doctors and nurses “are “paralyzed when something goes wrong,” he said during a session on resuscitation at the American College of Physicians’ annual meeting this spring. When someone has a cardiac arrest in a hospital, statistics show that most providers are “not actually doing anything to help the patient survive.”
The exception, he said, is when an arrest happens in the emergency department. “Because the ER staff are trained to respond to emergencies,” Dr. Persoff said, “they jump in and actually begin resuscitation.” But on the floors, he added, “the tendency to hold back is reflected in everything, including rapid response teams.”
Even when hospitals have good guidelines that dictate which abnormal vital signs should trigger a call for a rapid response team, “it turns out that nurses still won’t call,” he said. “They don’t want to bother somebody, and they want to handle it themselves.”
The solution he proposes is an electronic health record that “automatically triggers a rapid response team” when a vital sign abnormality is added to the chart. Until that happens, he added, data “don’t back us necessarily using rapid response teams, though I think they are a good idea.”
What data do show, however, is that everyone needs to practice doing chest compressions. Otherwise, team members won’t be able to do compressions properly during a code.
In addition, Dr. Persoff said, hospitals should invest in training all nurses in advanced cardiac life support (ACLS). Studies clearly show that if nurses aren’t trained, survival rates fall.
One study he cited found that one in five patients who had an ACLS-trained nurse at the time of his or her code survived, while 0% of those with non-ACLS-trained nurses were alive at a year. “Zero percent,” Dr. Persoff said, “is pretty significant to me.”
How well does resuscitation work on the elderly?
A STUDY IN THE JULY 2, 2009, New England Journal of Medicine looked at outcomes from in-hospital resuscitation between 1992 and 2005 for patients 65 and older. Researchers found that survival-to-discharge rates have not improved over that period. Further, they found that fewer minority patients survive resuscitation.
Here’s a look at the results:
- Overall survival-to-discharge rate: 18.3%
- Adjusted survival odds for black patients: 23.6% lower than for whites
- Survival rate for patients diagnosed with MI: 20.4%
- Lower survival rates were noted for men, older patients, those with more coexisting illnesses, lower-income patients and those admitted from a skilled-nursing facility.
Source: New England Journal of Medicine