I got the opportunity to interview Dr. Monica Kleinman, incoming Chair of the Emergency Cardiovascular Care committee at the American Heart Association (Heart.org/cpr) and Tom Bouthillet, author of the Prehospital 12 Lead blog and a Lieutenant/Paramedic with Hilton Head, SC Fire and Rescue.
Don’t miss the follow-up conversation between Tom and I just after the interview with Dr. Kleinman. We talk about the ECC update and tracking sudden cardiac arrest in your community.
Tom and I asked Dr. Kleinman several questions including about the 2010 Guidelines and how they reinforce the direction of the 2005 guidelines. In 2000, it was the year of defibrillation and in 2005 the ECC updates were about the basics. In 2010 the ECC guidelines change the basic ABC’s of before change to CAB sequence of steps.
In EMS there is a necessity to continue to push for focus on high quality CPR compressions and basic life support. Better outcomes have happened as EMS systems have implemented changes from the 2005 guidelines and as we move forward there is an expectation to contintue to see improvements in patient survival of sudden cardiac arrest.
It’s important to know how prepared our community is to provide care for what Dr. Kleinman calls this “rather large public health problem.” What we do to prepare and educate our public and responders is important and then tracking our response and success for improvement and quality.
Tom Bouthillet asks about how important is it to know the specific rates in your EMS system for each part of the chain of survival?
Dr. Kleinman says, “You have to be able to be measure what you’re doing.” She points out that it is odd that it’s not something we do for emergency cardiac care, even though we track water quality, police response, and other aspects of public services in our communities.
The NEW 5th Chain of Survival Link
The change to adopt a new link in the chain of survival was a topic of great discussion among the committee. The new link that stresses post resuscitation care as vital to recovery of our cardiac arrest patients shows the importance on system wide improvements. We need not only to bring that patient to the point of return of spontaneous circulation (ROSC) or readiness for ROSC, we also need to focus on what is done to provide an organized care system for the patients after ROSC is just as important.
When asked about how solid is the evidence that post cardiac arrest patients should be cooled, Dr. Kleinman responded, “I think it’s very solid.” The data continues to accumulate that with patients with ROSC, our previous assumptions about survivability are being challenged by the application of therapeutic hypothermia.
Tom responds with “Does that mean the previous dogma about downtimes greater than 10 minutes leading to irreversible brain deaths may not be true in the era of hypothermia?”
To which Dr. Kleinman responds “I think that’s the one area where we can’t be certain we are going to make a difference. . . . We have to challenge all of our assumptions, including that one. But there probably will, at some point, be a ‘point of no return’ I just don’t know where that will be.”
Ratio of Compression to Ventilations in ECC Unchanged
The ratio of 30:2 for compressions to ventilation ratio did not change. What was the discussion like about not changing those numbers?
“There certainly is a camp that would like to eliminate ventilations or perhaps look at a modified way of doing ventilations” said Dr. Kleinman, “Meaning providing some sort of passive oxygenation by oxygen delivery or airway pressure devices that don’t require interruption of chest compressions in order to administer ventilations.”
“It is hard to make a major change like (eliminating ventilations) without having solid enough evidence that it is superior to what we are doing now. In other words, the fact that there may be a technique that’s just as good is encouraging and is something that we need to consider but the changes to the guidelines need to be made on evidence that shows ‘here’s a better way to do things.'”
The new guidelines also mention a choreographed model as opposed to a sequence model for conducting a code. Tom Bouthillet asks if this suggests that it is a “false dilema that we need to choose between ventilating a patient and doing chest compressions.”
Dr. Kleinman answers that the concept that things must happen in order instead of simultaneously is not what the ECC wants providers to take away from the algorithm. The interventions don’t have to happen across a fixed timeline. This may apply more readily to the team approach seen in the in-hospital setting where they typically have more resources than those seen in the prehospital setting.
The 2010 guidelines recommending assynchronous ventilations every 6-8 seconds once the airway is secured and many providers who sit and time it with a stopwatch might be surprised how slow that is. Tom asks, “Dr. Kleinman, are we hyperventilating our cardiac arrest patients?”
“We have been.” Dr. Kleinman responds. “I think that’s a fact we can’t ignore.”
She points out that it’s not surprising in a cardiac arrest that people who are responding to an emergency with their own adreniline pumping and are likely to do things in a more exagerated or vigorous way. This is fine with compressions but when we hyperventilate our patients, we interfere with the effectiveness of the cardiac compressions. This has been observed not only in the prehospital setting but also in the hospital setting as well. “We need to consistently reinforce (slowing down ventilations) with our teams.”
Minimizing Interruptions in CPR Chest Compressions
The 2010 guidelines talk about minimizing the interval between the last compression and providing the shock. Tom wonders how important that is, and, can rescuers or first responders perform chest compressions while the AED is charging without confounding the diagnostics built in to their AED?
Dr. Kleinman points out,
“The difference in your ability to resuscitate someone from cardiac arrest is remarkable when you’ve got interruptions in compressions compared to those who have much briefer interruptions.”
These interruptions are inevitable but by focusing on shortening the interval between last compression and shock and shock and next compression, you can improve the outcome for the cardiac arrest patient. We will have to work with industry to solve the problems that might be associated with shortening the time needed to stop compressions for analysis, charging cycle, defibrillation.
The ACLS Algorithm & Capnography
Let’s make sure that we focus on the things that really make a difference on the outcome rather than try to create an algorithm that’s so inclusive that you miss the key points to successful resuscitation.
The authors of the guidelines felt very strongly that quantitative waveform capnography is important for confirmation of ET tube placement and also for confirmation of quality of compressions and cardiac output during resuscitation.
Tom asks about how Atropine has been removed from the algorithm for PEA and Assystole and does this mean there is a renewed emphasis on the “H’s and T’s or rather than a renewed focus on H’s and T’s, or that the guidelines will focus on the importance of good BLS skills, high quality compressions with minimal interruptions.
The addition of the use of Adenosine for undifferentiated wide complex tachycardias as a treatment option in place of other anti-arrhythmics is also discussed. A certain proportion of patients with a wide complex tachycardia will have a supraventricular origin to the tachcardia. Adenosine may provide conversion for these patients. This does not mean that Adenosine should be considered prior to other treatments but that it should be considered alongside or after other treatments were ineffective.
Does this mean that if a wide complex tachycardia responds to treatment with adenosine that it is diagnostic of an SVT with aberrancy or are some types of ventricular tachycardia amenable to treatment with adenosine?
Dr. Kleinman says that a truly ventricular tachycardia will not be responsive to adenosine to Dr. Kleinman’s knowledge. It does meant that if a wide complex tachycardia responds to treatment with Adenosine, it would be strongly indicative that the rhythm was supraventricular in origin.
More ACLS ECC Updates
Tom Bouthillet asks why the role of transcutaneous pacing is no longer recommended above other interventions like chronotropic agents.
Dr. Kleinman points out that the application of transcutaneous pacing and the use of chronotropics have been equalized because the strength of evidence is not supportive of a hierarchical ranking as it might have seemed in the past. She points out as well that the use of Amiodarone continues to be recommended along with other treatments that have been recommended in the past.
The use of adenosine in cases of wide complex tachycardia should be limited to cases of regular tachycardia without aberrancy. Irregular or polymorphic wide complex tachycardias should be treated with other medications named in the algorithm.
Oxygen and Resuscitation in Cardiac Arrest
There has been a growing concern about overuse of oxygen in patient treatment in the field of EMS. Dr. Kleinman addresses how this applies to the new guidelines and their recommendations.
“For a patient who has NOT experienced a cardiac arrest, our belief is that oxygen is still appropriate and beneficial. There’s no suggestion that one should withhold oxygen from a patient who’s having an acute coronary syndrome or some other type of medical emergency that is not cardiac arrest.”
“There is certainly debate, and this started with the neonatal population and is spilling over into the older folks about what’s the ideal concentration of oxygen to use during resuscitation from cardiac arrest. But, at this point, we don’t have any evidence to suggest that you should use anything other than while you’re in the process of performing CPR and attempting return of circulation.”
“In the post-resuscitation phase, that’s where hyperoxia in the setting of reperfusion has the most potential harm and so that’s where we’re really concentrating our message of avoiding excessive oxygen exposure in that population. It is not intended for the people in a pre-arrest state.”
Final Thoughts for EMTs and Paramedics
As we wrapped up the interview, I asked Dr. Kleinman to share her thoughts about what is the most important thing that she’d like the prehospital professional to keep in mind when they care for their cardiac arrest patients?
“It’s important to know that what they’re doing makes a difference. We are seeing the impact of high quality prehospital care every day on the lives of children and adults. Certainly all of us in our professions see the routine nature of a lot of what we do. But the fact that these professionals continuously try to improve, are dedicated to their continuing education and, to the patients that they serve, it’s making a difference. Outcomes are improving. It may appeart to be happening at an infintessinally slow pace to some people but all of these things, cummulatively, are making a difference and everyone in the system are tremendously important to the ultimate survival of a patient with an acute cardiac problem.”