The Survival Rate of Cardiac Arrest Patients in the Pre-Hospital Setting - Research Paper Example

How has EMS [Emergency Medical Services] impacted the survival rate of cardiac arrest patients in the pre-hospital setting Outline I. Introduction a.Brief outline about Emergency Medical Services about its role in pre-hospital care. b. Presentation of cardiac arrest patients and the usual clinical scenarios. c. Pathophysiological implications of the findings and their significance to survival in the cardiac arrest patients d. Implications of emergency pre-hospital interventions in transit e. Modification the prognosis of cardiac arrest. II. Review of Literature a. Relevant literature to demonstrate the roles of Emergency Medical Services in attending to cardiac arrest patients. b. Pathophysiology of cardiac arrest and importance of emergency interventions in the pre-hospital settings. c. Implications of delay in interventions and pathophysiological correlation with survival or mortality. d. Issues and controlled trials demonstrating in the pre-hospital interventions by emergency medical services. e. Critical analysis and Level of evidence to rate the soundness of the conclusion. III. Conclusion a. Presentation of the summary of the findings and exploration of the utility of these findings in practice b. Practice Implications I. Introduction a. Brief outline about Emergency Medical Services: Role in Pre-Hospital Care As far as Emergency Medical Services (EMS) are concerned, an appropriate and timely management of a patient with cardiac arrest is one of the most challenging events since an appropriate and timely intervention in such patients can positively impact the survival rates of these patients, which otherwise is very poor. This very fact demands on the part of EMS professionals thorough theoretical knowledge about the pathophysiological processes involved in the sudden nature of cardiac arrest and skills and dexterity in management. b. Presentation of cardiac arrest patients: Clinical Scenarios The specific feature of cardiac arrest which makes the dramatic presentation of cardiac arrest significant for EMS is sudden and unexpected pre-hospital event. It is necessary to immediately begin appropriate resuscitation and at the same time arranging for possible hospital care. c. Pathophysiological implications: Survival Clinically, the presentation of a patient with cardiac arrest is that of sudden loss of consciousness accompanied by loss of pulsation in any major artery such as femoral or carotid. The speed of pre-hospital care is the key since even very minor delays may adversely affect prognosis (Ewy, 2007). It has been recommended that the time taken to assess the circulation in such patients should not exceed more than 10 seconds, and wasting time for noting other confirmatory clinical features would be waste of time without any contribution to the diagnosis. d. Implications of emergency pre-hospital interventions in transit In fact taking care of the patients with cardiac arrest in the pre-hospital settings is one of the defining characteristic EMS of professionals since they are trained to recognize and manage the undifferentiated patient with cardiac arrest, although this can be most effectively accomplished through an appropriate understanding of the pathophysiology of cardiac arrest and developing ability and skills to correlate the principles behind the resuscitation of these patients to those pathophysiological events. Although a qualified physician is always involved in such resuscitation teams, the care is delivered by the paramedical staff. e. Modification the prognosis of cardiac arrest However, that does not in any way lead to compromise in the quality of such services since modern cardiopulmonary resuscitation techniques such as closed chest cardiac massage, mouth-to-mouth ventilation, advances in external defibrillation techniques, and development of other relevant noninvasive techniques that can be suitably delivered in the pre-hospital settings have improved the skills of the EMS professionals to an astronomical degree in comparison to the earlier times. These have improved the success rates of pre-hospital resuscitation in patients with cardiac arrest and increased the number of professionals who can be trained adequately to deliver these interventions immediately and without delays (Sanders, 2001). II. Review of Literature a. Literature demonstrating role of EMS in Cardiac arrest Cardiac arrest is an unexpected event that most frequently occurs outside the hospital, occurring most commonly in male patients with atherosclerotic cardiovascular disease in the age group range of 50 to 75 years. The basic pathologic event is sudden cessation of blood supply throughout the body due to asystole of any etiology. Apart from the effect of anaerobic metabolism due to acute hypoxic state, the most dramatic effect occurs in brain which is the most susceptible organ to the failure of circulation and is noted to suffer irreversible damage following a 5-minute of arrest. b. Pathophysiology and Importance of intervention in pre-hospital setting Thus time of intervention is the most crucial component of resuscitation since untreated cardiac arrest for more than a duration of 10 minutes lead to irreversible neurologic damage (Rea et al., 2004). The second most vulnerable organ is the heart which may fail to recover if resuscitation in delayed even in patients with cardiac arrest from a noncardiac cause. Literature indicates that of all factors determining survival from cardiac arrest, the single most critical factor is initiation of early cardiopulmonary resuscitation. One study reported that the fastest the initiation of resuscitation, the best is the outcome. While only advanced cardiovascular life support (ACLS) started within 8 minutes of the event leads to recovery in 27% patients, if cardiopulmonary resuscitation (CPR) is begun within 4 minutes and ACLS within 8 minutes, the recovery rate increases to 43% (Wik et al., 2005). c. Implications of Delay These timelines indicate the need for EMS intervention in pre-hospital settings without which most of the patients sustaining cardiac arrest would not survive. While the management of cardiac arrest is more elaborate and would need invariably hospital critical care management, the later can do their part of the patient reaches them alive, which can be only ensured by the informed, rapid, and skillful intervention by the EMS team in the place of occurrence or while in transit. There are some techniques used by the EMS team to accomplish this are known as chain of survival. These include recognition of early warning signs, activation of emergency medical system, rapid initiation of basic CPR, rapid defibrillation, advanced cardiovascular life support, definitive airway management, and intravenous medication. While these maneuvers are known definitively impart the highest potential survival rates if delivered in an organised and structured manner in the pre-hospital settings, it remains to be seen whether in practice these really improve survival in cardiac arrest patients (Ewy, 2007). d. Issues and Controlled Trials Bobrow et al. (2008) indicates that out-of-hospital cardiac arrest remains a leading cause of death, and the outcomes are still poor for these patients. Early defibrillation has been noted to improve survival, but use of early defibrillation is still rare, and in many states the rate of survival now is in the range of 3%. In order to improve this grim outlook, minimally interrupted cardiac resuscitation has been developed in order to maximize both myocardial and cerebral perfusion through a series of coordinated interventions. Other studies (Weisfeldt and Becker, 2002) have supported that these include minimization of interruptions of chest compression, provision of immediate preshock chest compression for patients with prolonged ventricular fibrillation, delaying or minimization of endotracheal intubation, minimization of positive pressure ventilation, and increasing the frequency of intravenous norepinephrine (Bobrow et al. 2008). e. Critical Analysis and Level of Evidence It has been observed that the survival rates of the cardiac patients may substantially improve with these modifications directed toward restoration of the cardiac and cerebral circulations in the pre-hospital settings. The poor outcomes in cardiac patients in pre-hospital EMS care have been a direct correlate of prolonged inadequate myocardial and cerebral perfusions due to interruptions of chest compression leading to interrupted forward flow of blood. Moreover another contributor is provision of defibrillation after 5 or more minutes, and this is a critical factor in determining the response to pre-hospital therapy. It has also been observed that sequential shocks with automated external defibrillator increase hands-off time of the EMS staff, thus leading to inadequate cerebral and myocardial perfusions (Maheshwari et al., 2002). Woodall et al. (2007) contends that early access to EMS who deliver ACLS can strengthen the chain of survival in patients with cardiac arrest in the pre-hospital settings. Out of all skills defibrillation remains the cornerstone of EMS care. This can be supported by the findings from other studies that EMS staff skilled in ACLS protocols, improve the likelihood of these patients arriving at the hospitals with a restored circulation. This study found out that ACLS skilled EMS staff has a positive effect on the survival of cardiac arrest patients. This has been ascribed to the ability to deliver defibrillation within the optimal time frames. These healthcare professionals are extensively trained and educated to deliver the optimal care (Woodall et al. 2007). Other studies in this area have indicated that an EMS intervention with a number of teams also improve the outcome in the cardiac arrest patients in pre-hospital resuscitation. The authors mention the roles of ICP and BLS crews. These enhance the likelihood of a full range of pre-hospital interventions performed to these patients with greater effectiveness and efficiency. This has been correlated to the minimal interference to chest compressions leading to its sustained positive effects on improvement of coronary or cerebral circulation, and the higher number of paramedics may indeed contribute to increased duration of continuous chest compression (Kern et al., 2002). III. Conclusion a. Summary The findings of this study suggest that EMS services and timely interventions may change the chances of survival of the cardiac arrest patients in the pre-hospital situations. There are many variables that determine the survival chances, and continued research leading to evidence which culminate into ongoing innovations in the processes and timelines of resuscitation protocol of these patients with cardiac arrest are necessary to strengthen the chain of survival. In this away awareness of importance of prompt out of hospital EMS resuscitation will have to be important if survival from out-of-hospital cardiac arrest needs to be improved. b. Practice Implications These may involve dissemination of defibrillators, developments in technology of defibrillation apparatus, variation in CPR techniques, treatment with appropriately indicated pharmaceutical agents, or other relevant therapies are important has been indicated in research in this area. However, the public health challenge of improving survival in the cases of cardiac arrest in the pre-hospital setting remains still crucial to effect a successful hospital outcome in these patients, only when the EMS staff can rapidly recognise the cardiac arrest and more promptly initiate the intervention. Further research has been recommended. References Bobrow, BJ., Clark, LL., Ewy, GA., Chikani, V., Sanders, AB., Berg, RA., Richman, PB., and Kern, KB., (2008). Minimally Interrupted Cardiac Resuscitation by Emergency Medical Services for Out-of-Hospital Cardiac Arrest. JAMA; 299: 1158 - 1165. Ewy, GA., (2007). Cardiocerebral resuscitation: the optimal approach to cardiac arrest. Cleve Clin J Med.; 74(suppl 1):S105-S109. Kern, KB., Hilwig, RW., Berg, RA., et al., (2002). Importance of continuous chest compressions during cardiopulmonary resuscitation. Circulation;105:645-9. Maheshwari, A., Mehrotra, A., Gupta, AK., et al. (2002). Prehospital ACLS-Does it work Emerg Med Clin North Am;20:759-70. Rea, TD., Eisenberg, MS., Sinibaldi, G., and White, RD., (2004). Incidence of EMS-treated out-of-hospital cardiac arrest in the United States. Resuscitation;63(1):17-24. Sanders, AB., (2001). Cardiac arrest and resuscitation. In: Harwood-Nuss A(ed.). The Clinical Practice of Emergency Medicine. Philadelphia: Lippincott Williams & Wilkins, 2001. Weisfeldt, ML. and Becker, LB., (2002). Resuscitation after cardiac arrest: a 3-phase time-sensitive model.JAMA; 288(23):3035-3038. Wik, L., Kramer-Johansen, J., Myklebust, H., et al. (2005). Quality of cardiopulmonary resuscitation during out-ofhospital cardiac arrest. JAMA;293(3):299-304. Woodall, J., McCarthy, M., Johnston, T., Tippett, V., and Bonham, R., (2007). Impact of advanced cardiac life support-skilled paramedics on survival from out-of-hospital cardiac arrest in a statewide emergency medical service. Emerg. Med. J.; 24: 134 - 138 Read More