Regional Approach to Cardiovascular Emergencies Cardiac Arrest Resuscitation System

Efforts to increase overall sudden cardiac arrest (SCA) survival rates in the United States have been gaining momentum in the last decade, as the knowledge that improvements in survival are both necessary and attainable. Building on the RACE project, North Carolina is applying its expertise in developing and supporting community to statewide initiatives that focus on a “systems-based” approach to the improvement of SCA survival. The North Carolina HeartRescue partners will look to its statewide colleagues to coordinate training, community and system-wide response, and the application of “best practice” treatments among the general public, first responders (police/fire), emergency medical services (EMS) and hospitals.

Therapeutic Hypothermia

EMS can facilitate initiation of therapeutic hypothermia for eligible post-cardiac arrest patients. Studies have shown that brain injury due to cardiac arrest can be mitigated with therapeutic hypothermia.^1,2,9While this is a relatively simple and inexpensive therapy to implement in the hospital setting, there is no scientific evidence that prehospital initiation of therapeutic hypothermia changes outcome. However, much like delivery of aspirin to patients with chest pain, prehospital initiation of therapeutic hypothermia offers a redundant system to help ensure that appropriate patients are treated.

Examples of hospital therapeutic hypothermia protocols are available from the University of Pennsylvania’s Center for Resuscitation Science at www.med.upenn.edu/resuscitaton/hypothermia

If your system does provide therapeutic hypothermia therapy in the prehospital setting there are a few things to take into consideration.

1. Effective hypothermia (that which decreases metabolic rate) will result in lower end tidal CO₂ levels on capnography readings.
2. Providing prehospital hypothermia must not interfere with excellent quality basic resuscitation skills.
3. Ensure a good continuity of cooling during handoff of the patient from EMS to the Emergency Department (ED), and from the ED to either the Catheterization Laboratory (Cath Lab) or Critical Care (CCU) unit. If body temperature is allowed to fluctuate during therapy, particularly if there are delays before cooling can be initiated/continued in the hospital, this may be detrimental to the patient’s outcome.

Emergent Cardiac Catheterization

EMS must also learn if the institution to which they transport post-cardiac arrest patients will take those who have STEMI or a high suspicion of acute MI expediently to the cardiac catheterization lab.¹⁶Waiting for the patient to “wake up” before treating STEMI will increase loss of heart muscle.^5,17 Patients can be cooled while on the way to and during heart catheterization.¹⁸ Additionally, appropriate survivors should be evaluated for ICD placement prior to hospital discharge.¹⁹

Multidisciplinary Team Care

The comprehensive care required to manage the constellation of problems possible in the post-arrest period requires that the patient be cared for by a multidisciplinary team of critical care as well as cardiology and neurology specialists who have a plan of care available which will allow them to anticipate and treat problems as they arise.

Avoidance of Early Termination

The goal of management is to return patients to their pre-arrest level of functioning. Currently there is no way to predict an individual patient’s outcome based on pre-arrest or intra-arrest parameters. In the hospital setting, it is not possible to predict poor outcome during the first 24 hours, and possibly not until 72 hours after ROSC. It is recommended that patients who have received therapeutic hypothermia be observed for more than 72 hours after ROSC before predicting poor outcome.^12,20

Organ Donation

Victims of sudden cardiac arrest who progress to brain death from cardiac arrest should be considered for organ donation. These patients are an under-recognized source of organ donors whose cause of death does not prohibit them from consideration as a donor.²¹