How Has EMS Impacted the Survival Rate of Cardiac Arrest Patients in the Pre-Hospital Setting - Research Paper Example

I - Introduction II - Study conducted at Casino Windsor Ontario Canada III -The importance of understanding the role of Basic Life Support in cardiac arrest management IV - The Three Phase of Cardiac Arrest V - Understanding CPR VI - Understanding Defibrillation VII - CPR alternative VIII - Quality CPR VIX - Conclusion Introduction: Time plays an important factor in the survival of a cardiac arrest patient in a pre-hospital setting. This study will particularly deal with the impact the Emergency Medical Services (EMS) has in relation to the survival rate of cardiac arrest victims from the time of the collapse to initial defibrillation to hospital discharge. It has long been held by medical practitioners that the survival rate of cardiac arrest victim is higher if defibrillation is done on time (Feroduk et al 2001). As time is a big issue on the survival rate of a cardiac arrest victim, it is also important to look at the role of the Emergency Medical Services team on the matter. Thus, it is of great value on this study to establish the issue of time, well trained and well equipped EMS teams. Study conducted at Casino Windsor Ontario Canada: Base on the study made by the group of Feroduk in 2001 the Casino Windsor Ontario Canada in summer of 1994 has opened its door to the public employing onsite paramedics who were capable of immediately accessing and defibrillate cardiac arrest victims. Soon after then the Casino Windsor transferred emergencies responsibility from the onsite paramedics to the onsite nurse who can also function an occupational and safety nurse. On the other hand, during the same time the City of Windsor was also involved in the study Ontario Pre-hospital Advance Life Support which was coordinated together with the Clinical Epidemiology Unit of the Ottawa Hospital, University of Ottawa. At this time the response system of the City of Windsor consisted of firefighters First Responders and BLS Paramedics. The EMS functioned as BLS and ALS Paramedics. The OPALS study system was meant to look at the survival rate of the cardiac arrest victims in a pre-hospital setting using the Utstein Criteria (Feroduk et al 2001). Furthermore there is legislation by Essex-Kent Base Hospital Program that medical oversight, direction and quality assurance and continuing medical care education to pre-hospital care providers. It has established a set of protocol on defibrillation in the pre-hospital setting. The Casino Windsor became an active participant in this pre-hospital care. The Casino Windsor used the same defibrillation protocols used by the pre-hospital care providers in the community (Feroduk et al 2001). Feroduk et al 2001 – Essex-Kent Base Program, the Casino Windsor and the University of Windsor Worked together to gather in a period of five years from 1991 to 1999 of all cardiac arrests in Casino. All the records were collected and obtained from Ambulance Call Reports (ACRs), fire services Medical Assist Reports (MARs), the medical records of Casino and security cameras. The accuracy of the records was made sure through the time stamped video-tape of every cardiac arrest victim within the Casino vicinity. The collected data were afterwards compared to the Greater City of Windsor OPALS statistics that were obtained from LOEB Institute in Ottawa. The records consisted of all the Patients in Casino that required defibrillation from 1994 to 1999. The patients’ information records included all important details like: Age Gender survival/death presenting rhythm including ventricular fibrillation (VF) ventricular tachycardia (VT) CPR (Yes/No) down time time of the arrival of the security personnel time of the arrival of nurse time of the CPR before defibrillation (if applicable) time of defibrillation time of CPR after defibrillation time of the return of the pulse (if any) EMS arrival time at the Casino time of the EMS at the patient’s side time the EMS left the Casino with the patient time of the EMS arrival at the hospital On the other hand the Greater City of Windsor obtained data from the OPALS Study database from 1994 t0 1999. The study data compared included the following information: age gender survival presenting rhythms VF, VT, other CPR yes/no by citizen (Feroduk et al 2001) The conclusion of the research conducted by the group of Fedoruk in Casino Windsor says that rapid defibrillation may enhance the success of the recovery of the cardiac arrest victim, therefore suggesting the importance of an on-site defibrillator. It has been further asserted as the result of the study that Public Access Defibrillator Program could possibly impact of the successful survival of cardiac arrest patients (Fedoruk et al 2001). The importance of understanding the role of Basic Life Support in cardiac arrest management: The success rate of the survival of a cardiac arrest patient in an out of hospital setting depend on the understanding of the EMS responders about the nature and pathophysiology behind cardiac arrests. An international committee of experts closely examined studies of cardiac arrests to find out what truly works, what does not work and what might work during cardiac arrests (American heart Association 2005). A new insight on what takes place during heart attack will help the EMS responders to decide what the best treatment option to a particular case is. The Three Phase of Cardiac Arrest: Sulivan 2008 – According to the study made by AHA, the large majority of sudden cardiac arrests start with VF, where electrical impulses abnormally shoot from all parts of the heart instead of coming from normal pathways. It makes the heart vibrate tremulously and no blood can be pumped from it. The second case is the heart may have electrical activity and it appears normal on a monitor but the truth is it is not pumping in response to electrical activity; it is known as pulse less electrical activity. The last is the phase of no electrical activity at all and no pumping. It is known as asystole and it appears flat line on a monitor. Previously cardiac arrest focused only on rhythm presented. On the detection of v-fib shocks were given. On the contrary based on the latest study defibrillating anytime is seen as not beneficial in all cases. Thus a three phase model has been proposed corresponding to the body changes during cardiac arrests. The appropriate treatment now depends on the time of the collapse of the patient and depending on which phase the patient is in (Weisfeldt 2002). 1. Electrical phase (05 minutes) –the best treatment is rapid defibrillation. Due to the fact that the collapse time of the patient is usually not known, defibrillation should only be done when the arrest is witnessed by the EMS (Weisfeldt 2002 & Ewy 2005). 2. Circulatory phase (5 to10 minutes) – when the victim has been in arrest longer than five minutes, the best thing that can be done is CPR before defibrillation. Because most patients are in arrest before the arrival of EMS it is safe to assume that five minutes have passed the down time (2&3). 3. Metabolic phase (after 10 minutes) – toxins at this point in time have already circulated in the entire body and systematic cell death has already occurred. The best intervention here is hypothermia which is at the moment being tested in EMS system (2&3). Understanding CPR: According to the AHA guidelines there is now a better understanding on how CPR works. If applied perfectly small amount of oxygenated blood will flow to the chambers of the heart because of the pressure created during chest compressions. The CPP increases upon every compression and it is good to get the CPP as high as possible. Because of this fact there is a renewed emphasis on continuous CPR. Also contrary to the common belief that breathing is as important as heartbeat it appears that many cardiac arrest victims are too ventilated too strongly during CPR. This is not good. The recommended compression by AHA, increasing compression-to-ventilation ratio is 30:2. It also recommends ventilating for only one second so as to limit chest pressures (AHA 2005). Understanding Defibrillation: It has long been accepted that the best way to deal with electrical chaos in the heart during cardiac arrest is defibrillation. What it does is to depolarize all myocardial cells which end the electrical activity in the heart. However new studies have shown the importance of the time plays in defibrillation. It is best to assume if the arrest is not witnessed by EMS that five minutes have passed already, and therefore what is best to do is two minutes to five 30:2 cycles of CPR, then defibrillation. Two minutes of CPR is now recommended by AHA right after defibrillation. It is likely that the patient is already hypotensive and can be assisted after two or more minutes of CPR (Sulivan 2005). Alternative to CPR: A different form of CPR known as cardio-cerebral resuscitation is being promoted by Dr. G. Ewy of the CPR Research group at the University of Arizona’s Sarver Heart Center. The breathing portion of CPR is eliminated instead chest compression alone is advocated at 100 per minute rate. It has displayed good result in many EMS study (Kellum & Ewy 2006). High Quality CPR: Base on many studies, the seemingly very easy task of pumping and blowing on CPR is being performed poorly in and out of the hospital setting. 40% of compression are not deep enough and there are long pauses and patients are hyper ventilated. Therefore new emphasis on high quality CPR is being reiterated by AHA (AHA 2005). The conclusion of the study given in the new guidelines of American Heart Association emphasizes the important role of the EMS responders to the survival rate of the cardiac arrest patients in the in and out of the hospital setting. The role of the BLS in cardiac arrest cannot be over emphasized. The many procedures in EMS require high quality services, and therefore requiring team work, paying attention to details and a lot of practice (Sulivan 2005). Conclusion: Given the studies conducted by the group of Fedoruk at Casino Windsor in Ontario Canada and all the observations and all the statistics and data that has been obtained, it was evident through their study that rapid defibrillation is a major factor in the positive survival rate of the out of the hospital setting cardiac arrests. Furthermore they are advocating that Public Access to Defibrillation may significantly improve the outcome of the out of hospital cardiac arrest cases. On the other hand the American Heart Association is putting the emphasis on the quality EMS services and at the same time putting the emphasis on truly understanding the nature of cardiac arrest so that EMS responders can appropriately respond to the specific need of the patient. Both recommendations are apparently have solid points and if heeded would be beneficial to the outcome of the out of the hospital cardiac cases. The studies are both pointing to the impact of EMS to the issue. The recommendation now by this study is the proper funding of the EMS by both government and NGOs in order to educate further the EMS responders and also to furnish EMS with the right equipments needed. Works Cited: American Heart Association; American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care (2005) Circ 112 (suppl): IV1–IV211,. Ewy G. Cardiocerebral resuscitation: The new cardiopulmonary resuscitation. Circ 111: 2,134–42, 2005 Fedoruk, BA, LlB,MD, CCFP (EM), FACEP, FCLM1;D. Paterson, BSc, MSc,MD1; M. Hlynka2, PhD;K.Y. Fung2, PhD; Michael Gobet1, EMCA, RN, EMAIII; Wayne Currie1, PAD Coordinator 2001 “Rapid Defibrillation: A Comparison Study of Pre-hospital Cardiac Arrest Victim Survival Rates from the Windsor Casino Ltd Rapid On-site Defibrillation Program versus the Greater Windsor Community, p 131 Fedoruk, BA, LlB,MD, CCFP (EM), FACEP, FCLM1;D. Paterson, BSc, MSc,MD1; M. Hlynka2, PhD;K.Y. Fung2, PhD; Michael Gobet1, EMCA, RN, EMAIII; Wayne Currie1, PAD Coordinator 2001 “Rapid Defibrillation: A Comparison Study of Pre-hospital Cardiac Arrest Victim Survival Rates from the Windsor Casino Ltd Rapid On-site Defibrillation Program versus the Greater Windsor Community, p 134 Kellum W, Dennedy K, Ewy G. “Cardio-cerebral resuscitation improves survival of patient with out-of-hospital cardiac arrest (2006) Am J Med 119: 335–40 Sullivan,Robert NREMT-P, is a paramedic with New Castle County (DE) EMS and is a CPR and ACLS instructor (2008)“Cardiac Arrest Management: Part 1 at EMSResponder.com Weisfeldt M, Becker L. (2002) (Resuscitation after cardiac arrest: A 3-phase time-sensitive model. JAMA 288: 3,035–38 Read More