Advances in the Acute Management of Cardiac Arrest

September 2008 Advances In The Acute Volume 10, Number 9 Management Of Cardiac Arrest Authors Bakhtiar Ali, MD Atlanta Veterans Affairs Medical Center, Decatur, GA A 47-year-old man presents with nonspecific chest discomfort intermittently over the past 3 days. Episodes are not related to exertion and last 10 to 30 A. Maziar Zafari, MD, PhD, FACC, FAHA minutes. He has a history of hypertension and smokes 1 pack per day. In the Atlanta Veterans Affairs Medical Center, Decatur, Georgia; Emory University School of Medicine, Division of ED, he is pain free and has an ECG with evidence of left ventricular hypertro- Cardiology, Atlanta, GA phy and j-point elevation. You doubt that he has an acute cardiac syndrome but Peer Reviewers decide to err on the conservative side and admit him to your observation unit. The patient looks well, his first troponin is negative, and the monitor continues Bentley J. Bobrow, MD, FACEP Assistant Professor of Emergency Medicine, Department to show a normal sinus rhythm. Two hours later you go to check on the patient of Emergency Medicine, College of Medicine, Mayo and find him disconnected from his monitor, unresponsive, and with no pulse Clinic, Scottsdale, AZ; Medical Director, Bureau of Emergency Medical Services and Trauma System, Arizona (no wonder there was so much beeping coming from the obs unit). The nurse Department of Health Services, Phoenix, AZ has been on break for the past 30 minutes, and due to “sick calls” there was no cross coverage. You call for help which doesn’t immediately come, and you Barbara K. Richardson, MD, FACEP Associate Professor, Emergency Medicine, Mount Sinai must decide what is more important — beginning chest compressions, securing School of Medicine, New York, NY the airway, getting intravenous access, or getting the defibrillator. You decide on chest compressions but are not inclined to begin mouth to mouth — you CME Objectives wonder if that is negligence. When the crash cart finally arrives, you note the Upon completion of this article, you should be able to: 1. Identify the significant changes in the 2005 American new biphasic defibrillator and wonder what voltage to start at and if you should Heart Association guidelines. “stack” shocks the way you used to. The nurse asks if you want to stop CPR 2. Examine the evidence which prompted changes to the American Heart Association guidelines. to establish intravenous access and what drugs you want. You begin to realize 3. Indicate future therapies that may impact outcomes there is more that you’re unsure of than you would like to admit. from sudden cardiac death. Date of original release: September 1, 2008 ardiac arrest is the cessation of effective cardiac output as a result Date of most recent peer review: August 10, 2008 Termination date: September 1, 2011 Cof either ventricular asystole, ventricular tachycardia, or ventricu- Medium: Print and Online lar fibrillation (VT/VF): the end result is sudden cardiac death (SCD).1 Method of participation: Print or online answer form and evaluation Sudden cardiac death describes the unexpected natural death from Prior to beginning this activity, see “Physician CME cardiac cause within 1 hour of onset of symptoms in a person without Information” on the back page. Editor-in-Chief Professor, UT College of Medicine, Charles V. Pollack, Jr., MA, MD, Corey M. Slovis, MD, FACP, FACEP International Editors Andy Jagoda, MD, FACEP Chattanooga, TN FACEP Professor and Chair, Department Valerio Gai, MD Chairman, Department of of Emergency Medicine, Vanderbilt Professor and Vice-Chair of Michael A. Gibbs, MD, FACEP Senior Editor, Professor and Chair, Emergency Medicine, Pennsylvania University Medical Center, Academic Affairs, Department Chief, Department of Emergency Department of Emergency Medicine, Hospital, University of Pennsylvania Nashville, TN of Emergency Medicine, Mount Medicine, Maine Medical Center, University of Turin, Turin, Italy Sinai School of Medicine; Medical Health System, Philadelphia, PA Portland, ME Jenny Walker, MD, MPH, MSW Peter Cameron, MD Director, Mount Sinai Hospital, New Michael S. Radeos, MD, MPH Assistant Professor; Division Chief, Steven A. Godwin, MD, FACEP Chair, Emergency Medicine, York, NY Research Director, Department of Family Medicine, Department Assistant Professor and Emergency Monash University; Alfred Hospital, Emergency Medicine, New York of Community and Preventive Editorial Board Medicine Residency Director, Melbourne, Australia Hospital Queens, Flushing, NY; Medicine, Mount Sinai Medical William J. Brady, MD University of Florida HSC, Assistant Professor of Emergency Center, New York, NY Amin Antoine Kazzi, MD, FAAEM Professor of Emergency Medicine Jacksonville, FL Medicine, Weill Medical College of Associate Professor and Vice and Medicine Vice Chair of Ron M. Walls, MD Gregory L. Henry, MD, FACEP Cornell University, New York, NY. Chair, Department of Emergency Chairman, Department of Emergency Medicine, University CEO, Medical Practice Risk Medicine, University of California, Robert L. Rogers, MD, FAAEM Emergency Medicine, Brigham of Virginia School of Medicine, Assessment, Inc.; Clinical Professor Irvine; American University, Beirut, Assistant Professor and Residency and Women’s Hospital; Charlottesville, VA of Emergency Medicine, University Lebanon Director, Combined EM/IM Associate Professor of Medicine Peter DeBlieux, MD of Michigan, Ann Arbor, MI Program, University of Maryland, (Emergency), Harvard Medical Hugo Peralta, MD Professor of Clinical Medicine, John M. Howell, MD,FACEP Baltimore, MD School, Boston, MA Chair of Emergency Services, LSU Health Science Center; Clinical Professor of Emergency Hospital Italiano, Buenos Aires, Alfred Sacchetti, MD, FACEP Director of Emergency Medicine Medicine, George Washington Research Editors Argentina Assistant Clinical Professor, Services, University Hospital, New University, Washington, DC;Director Nicholas Genes, MD, PhD Department of Emergency Medicine, Maarten Simons, MD, PhD Orleans, LA of Academic Affairs, Best Practices, Chief Resident, Mount Sinai Thomas Jefferson University, Emergency Medicine Residency, Emergency Medicine Residency Wyatt W. Decker, MD Inc, Inova Fairfax Hospital, Falls Director, OLVG Hospital, Philadelphia, PA New York, NY Chair and Associate Professor of Church, VA Amsterdam, The Netherlands Scott Silvers, MD, FACEP Emergency Medicine, Mayo Clinic Keith A. Marill, MD Lisa Jacobson, MD Medical Director, Department of College of Medicine, Rochester, MN Assistant Professor, Department of Mount Sinai School of Medicine, Emergency Medicine, Mayo Clinic, Emergency Medicine, Massachusetts Emergency Medicine Residency, Francis M. Fesmire, MD, FACEP Jacksonville, FL Director, Heart-Stroke Center, General Hospital, Harvard Medical New York, NY Erlanger Medical Center; Assistant School, Boston, MA Accreditation: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the sponsorship of EB Medicine. EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Ali, Dr. Zafari, Dr. Bobrow, and Dr. Richardson report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Commercial Support: Emergency Medicine Practice does not accept any commercial support. any prior condition that appears fatal.2 Even after 48 years, a significant portion of manage- In 2005, the American Heart Association (AHA) ment of SCD is based on animal experiments and released updated guidelines based on the Interna- expert consensus. However, over the past 15 years an tional Consensus Conference on Cardiopulmonary increasing number of evidence-based management Resuscitation and Emergency Cardiovascular Care strategies were put into practice, as reflected by the Science with Treatment recommendations.3 These most updated AHA guidelines. The classification of recommendations are based on both experimental AHA recommendations is presented in Table 2. In data and expert consensus. The new guidelines incor- this review, we use the classification system consistent porated significant changes in the algorithms in the with the AHA and the American College of Cardiology treatment of cardiac arrest (Table 1). The AHA also collaboration on evidence-based guidelines.6 Class I identified future areas of research that may impact recommendations were based on high-level prospec- outcomes in cases of cardiac arrest. These changes tive studies where the benefit substantially outweighs include the manner in which CPR is to be carried out the potential of harm. Class IIa recommendations with increased emphasis on the continuity of chest were based on cumulative weight of evidence, and the compressions with minimal interruptions. This issue therapy is considered acceptable and useful.6 When of Emergency Medicine Practice highlights significant a therapy demonstrates only short-term benefit or changes in the 2005 AHA guidelines, examines the when a positive result was based on lower level of evidence that prompted the changes, and explores evidence, a Class IIb recommendation was used. For future therapies that may impact outcomes from SCD. Class III therapies, there is evidence and/or general agreement that the procedure/treatment is not use- Critical Appraisal Of The Literature ful/effective and in some cases may be harmful. Class Indeterminate

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