A church that had been converted to a meeting space seemed a particularly apt setting for a discussion on “reanimation,” or, bringing cardiac arrest victims back to life.
Baltimore’s Westminster Cathedral recently hosted the University of Maryland’s Emergency Cardiology Symposium on Cardiac Arrest. The April 5 conference was directed by Amal Mattu, MD, Professor of Medicine at UM’s School of Medicine and well-known emergency cardiology guru.
Emergency physicians and cardiologists on Mattu’s panel shared their expertise on the management, history and best practices of cardiac arrest with an audience of medical residents and emergency medicine providers. Following is a recap of some of the takeaways and highlights for prehospital and in-hospital providers.
John Field, MD, professor of medicine at Penn State’s Hershey Medical Center, opened the symposium by quoting T.S. Eliot. Eliot’s words describe well the historically cyclical nature of cardiac arrest standards: “Time present and time past/ are both perhaps present in time future/ and time future contained in time past.”
Field traced the history of CPR and modern ACLS innovations, like the AED, that were sometimes seen as potentially dangerous or too difficult to implement for an EMS provider. In 1980, JAMA considered CPR a “complex skill” and advised that a defibrillator should be used only “under physician direction.”
“The first portable defibrillator weighed 72 pounds and was recharged by two car batteries,” Field said. Inventor Frank Pantridge, an Irish cardiologist who also advocated the use of the mobile ICU back in 1967, persisted in making his defibrillator smaller and getting it into the field where it was needed most.
Now, Field pointed out, devices like Amazon’s Alexa give people CPR instructions in their own homes. In fact, wearable devices that track vital signs are broadly used by the public and may soon become a useful reality in the system of resuscitation.
“In the home at 2 a.m., where most arrests occur, a device might awaken your spouse and say, ‘Check your pulse!’ and, if no response, activate 9-1-1,” he said.
Despite the numerous improvements in cardiac arrest treatment, Field emphasized that for the first time in many years, life expectancy for Americans is down. Heart disease, which includes the incidence of sudden cardiac arrest, is a leading cause of death, and only about one quarter of cardiac arrest victims receive CPR. There is still much basic work to be done in education and motivation.
Field, who also was the co-editor of AHA’s 2010 CPR and ECC Guidelines, closed with a call for continued innovation and forward-thinking champions to address this health crisis. When innovators get discouraged, Field said he reminds them how far we’ve come from the first 72-pound defibrillator that most said was useless and would never work.
“We need to go find the Pantridges of our time,” Field said.
How Much Has Changed in 30 Years?
Michael Winters, MD, and associate professor at UMEM, who is also a graduate of the emergency medicine/internal medicine combined residency program, opened with a personal story that highlighted the importance of running a “perfect” code. At the age of 14, Winters watched his grandfather suffer a cardiac arrest in their home. He remembers the chaos of the code from start to finish, from the multiple on-scene failed intubation attempts to the disorganization of the hospital team who treated his grandfather and ultimately pronounced him dead.
Winters, editor-in-chief of ACEP’s textbook Emergency Department Resuscitation of the Critically Ill, continued the motif of Field’s talk, stressing that over 325,000 people die each year from cardiac arrest. There should be more outrage at the abysmal rate of only 15% of victims surviving with meaningful neurological outcomes.
“Deficits in team leadership during resuscitation can cost the lives of patients who may have otherwise survived,” he said. Winters acknowledged, as did the audience, that physicians often walk out of a resuscitation thinking, “We could have done that better.”
They can do it better, with more attention paid to the choreography of resuscitating a patient in cardiac arrest. Winters highlighted the importance of strategic placement of personnel and equipment, the donning of color-coded badges to help identify roles around the bedside, and the use of short utterances, clear commands and a communication feedback loop by the resuscitation crew.
Get the Echo, Have the Answer
Sarah Stahmer, MD, an emergency medicine physician and Associate Professor at University of North Carolina-Chapel Hill, spoke about echocardiographic evaluation in cardiac arrest. Reflecting on the novelty of ultrasound use in cardiac arrest in the 1980s, Stahmer said that when she finished her fellowship, she went to the University of Pennsylvania and surprised her colleagues.
“There was a big Zamboni of an ultrasound machine in the corner,” she said. “I went over and revved it up and started using it in cardiac arrest patients.”
Stahmer detailed a recent case of a 23-year-old woman found unresponsive in her crashed car, who was treated in the emergency department as a trauma code. Finding no visible trauma, Stahmer decided to change the response and treat the patient as a medical code. An echocardiogram revealed that there was cardiac activity, even with a pulseless electrical activity reading on the EKG.
The patient would not have survived, she argued, had ultrasound not been used.
“The change in management [of this patient] all happened because I looked,” Stahmer said.
Citing the FEEL study where 35% of patients in asystole and 58% of patients in PEA were shown to have cardiac motion on echo, Stahmer noted that the presence of cardiac motion not only is associated with increased survival, but also improves the team’s treatment of the patient.
With a lot of cases, ultrasound tells the physician what they may not be able to feel or see without an instrument.
“[Echo] is much faster than, ‘Can you feel a pulse?’” Stahmer said.
Stahmer’s approach is to look for the “4 Fs”: fluid, form, function and filling. Using this approach can diagnose things like pericardial effusions much sooner, leading to a definitive treatment.
“We used to do pericardiocentesis at the very end of the code, as sort of a last-ditch effort. Now you can diagnose right up front, because that’s the time to intervene,” she said.
Just When I Thought I Had to Memorize all the Hs and Ts…
Pulseless electrical activity (PEA) is the rhythm in about 30% of cardiac arrests, and the prognosis for these cases is poor, with no evidence-based therapies available. Laszlo Littmann, MD, cardiologist and professor of medicine at UNC Chapel Hill, argued for a different approach to PEA.
Instead of “throwing the kitchen sink” at PEA with the ACLS “Hs and Ts” approach, Littmann’s approach prompts the provider to consider why the PEA is a narrow or wide complex.
“You can be proud of yourself for [remembering all the ‘Hs and Ts’] of PEA, but then what are you going to do?” Littmann asked. “And, for the ‘Hs and Ts’ to work, you have to die in an English-speaking country.”
Littmann’s explained that most narrow complex PEA has a mechanical cause, like pneumothorax or a pulmonary embolism, and most wide complex PEA has a metabolic cause like sepsis or hyperkalemia. Using these ideas for a differential diagnosis will logically lead to more improved treatment. Littmann’s approach also furthered Stahmer’s claims, strongly encouraging the use of bedside ultrasound in cardiac arrest.
While Littmann doesn’t claim that his algorithm is purely evidence-based or doesn’t have limitations, he believes that it is logical and should help providers make sense of causes while also considering the clinical scenario.
Mattu not only recommended the title of “A Rational Approach to PEA” for Littmann’s talk, but also introduced Littmann by saying, “Just as soon as I had all the ‘Hs and Ts’ memorized, Dr. Littmann’s paper suddenly made it unnecessary.”
Hilary Gates, MEd, NRP, is a paramedic in Alexandria, VA. She is an EMT instructor and teaches in the School of Education at American University. She began her career as a volunteer with the Bethesda-Chevy Chase Rescue Squad. Gates has experience as an EMS educator and symposium presenter and is involved in quality management and training for the fire department.