Dean Edmondson, head brewer and owner of Dead Hippie Brewing Company.
A huge thanks to Dead Hipping Brewing Co. for hosting our event on March 1st, 2017!
Christy, RN and David hugging after giving a moving presentation on David’s story of cardiac arrest.
Saving a Life/A Survivor’s Story
As ER providers, we often don’t see the results of our care. Finding out what happened to our patients is a rarity. Christy, an ER nurse at Swedish, shared a story with us of when she had that chance.
It was the day after Christmas in 2015. David figured he should go to the gym after partaking in Christmas festivities. David was very healthy and fit, and usually went to the gym 6 times a week to run several miles. This day however, he began to feel unwell around 4 miles. He didn’t remember mile 5.
Christy at this point had only worked in the ED for 3 months and had been involved in 2 codes. She went to the gym the day after Christmas before her shift started. As she was walking towards the water fountain, she saw David fall to his knees, then to his belly. He slid off the treadmill. She ran to him, not knowing exactly what she was doing, but knowing what she had to do and shutting out everything else around her. She yelled “who are you where are you are you ok!?” David woke and began talking to her. About 1.5 minutes into their conversation, David’s eyes rolled to the back of his head and he began seizing. She rolled him onto his side to protect his airway until he stopped seizing. She checked for pulses and did not find any, so she began compressions. Someone brought over an AED, and pads were placed. He had a shockable rhythm. Christy shocked him and resumed compressions. She looked at David and saw that he had woken up. EMS arrived, and she transferred his care.
Christy got home, slightly in shock as to what had just happened. Her husband asked how her workout was and she replied, “oh, you know, resuscitated someone.” She started to get ready for the day, and the charge nurse called her into work early. When she got to work in the ED, she saw David. He had coded twice more en route.
David went up to the cath lab. One hour in, the doctor came out to tell his family it wasn’t going well. One hour later, the chaplain told the family to gather anyone who needed to be there. David says, “I had the easiest part in all of this. I fell down and I don’t remember anything for two and a half days.”
Two days later, David’s EKG returned to normal. Christy came to visit him several times during his hospitalization. Five days later, he was discharged from the hospital. Since that time, David has travelled the world and climbed 14ers. In his words, “life has been wonderful since then.” He attributes all of this to Christy and all the providers who gave him such excellent care.
Christy replied, “It’s moments like these that are so special. People ask why I do this and I struggle with that because I feel that it’s my job. I believe we all have gifts and knowledge and we are called to share in whatever capacity we can. We have the privilege to be emergency providers.”
-Christy Garbus, Rn and David
Jordan Ourada demonstrating the correct way to compress the chest and save a life.
Push Hard, Push Fast, and don’t stop: you are their heart
The most valuable things we do as emergency providers either in the field or in the hospital are compressions. Compressions are the cornerstone of resuscitation for cardiac arrest. Since they are so important, it is vital that they be performed correctly. To do this, there are 5 key aspects to remember.
- Minimize interruptions
The new standard is to keep chest compressions above 80%. Since raising the standard form 60-80%, survivability has drastically increased.
It is also imperative to switch out after 2 minutes to keep compressions effective. Bystanders are not always keen to help, so make sure there are the right number of people and the right frequency of switch outs to get the job done well.
- Keep compression rate at 100-120 compressions per minute
Studies show that when the compression rate is outside of 100-120 compressions/minute, survivability decreases substantially. At this rate, blood gets pumped to the brain semi-effectively. However, even when CPR is perfect, the brain is only receiving 30-40% of its normal blood flow.
- Reach minimum depth for compressions
The goal for compressions should be approximately 5 cm. At 4 cm, survivability decreases. Above 5 cm, there is greater risk of breaking the patient’s ribs and/or sternum.
- Allow full chest recoil
It is important to completely let pressure off the chest between each compression.
Since CPR is only about 30-40% efficient so it is absolutely necessary to do everything possible to not let the efficiency fall. Another important aspect of recoil is coaching people to do it.
- Excessive ventilation
When a patient is intubated it is very easy to move too much air too fast. This increases the intrathoracic pressure and inhibits the effect of compressions. Again, it is very important to coach people through ventilation to prevent hyperventilating.
There are new devices out there that provide automatic compressions. These devices are much better at keeping a controlled rate, depth, and recoil. Additionally, there are devices that give real time feedback during compressions. These devices tell if a person is delivering adequate CPR via recoil, rate, and depth feedback.
-Jordan Ourada, paramedic
Dylan Luyten M.D. enjoying the show after teaching us all about airway management.
Airway Management: Are we doing more harm than good?
Medicine has made many leaps and bounds since the inception of helping our fellow man. Some of the medical practices from the past are painfully erroneous. However, while we aim to do the best we can with what we have, we do not always do the best. One of these practices seems to be intubation during witnessed cardiac arrests. If an arrest is witnessed and compressions are started immediately, there is enough circulating oxygen that compressions alone are all that is needed for a patient to have a good outcome. The time it takes to intubate with a traditional ET tube reduces the quality of CPR being delivered. Additionally, humans are negative pressure breathers and with intubation or any other adjunct airway we increase the pressure in the thoracic cavity via the BVM. This increase in pressure is deleterious to what compressions are actually trying to achieve. As mentioned in a previous section, CPR is not efficient compared to the heart and decreasing time on the chest any further hinders performance substantially.
Physiological pressures in the chest aside, ET tubes allow for hyperventilation of a patient. While oxygen is advantageous for the patient, too much ventilation is a bad thing. Hyperventilation constricts the vasculature that helps perfuse the brain limiting the effectiveness of CPR. The evidence behind this comes from a study done in Japan with over 650,000 patients. In a witnessed arrest, all you need is passive oxygenation via a nonrebreather mask in the immediate stages of a cardiac arrest. While ACLS and PALS are important guidelines, they are designed for reproducibility more so than efficacy in taking care of a patient. Now with all of this being said, intubation itself is not a bad thing. After return of spontaneous circulation intubation can be a valuable method to ensure that a patient is receiving enough oxygen during the recovery phase.
In summary, when Bob goes down in cardiac arrest and CPR is initiated immediately, stay on the chest and don’t think about intubating him until you get a pulse. However, say the third round of CPR comes around and you still do not have a pulse. Then it might be time to think about intubating him.
-Dylan Luyten M.D.
Erik Verzemnieks M.D. demonstrates how to defibrillate a patient – don’t worry he didn’t shock himself!
Defibrillation: How to shock & shock well
There are two quick and easy tips to help reduce the time off the chest and provide maximum effort in minimum time in resuscitation attempts. The first tip seems really intuitive: when delivering a shock, pre-charge the device. This simple thought can save valuable seconds of being on the chest, and in a cardiac arrest we can all agree that even 5 seconds can make a huge difference.
The second tip is getting two machines and using them to shock at the same time. When you use two devices to shock concurrently, you get a summation of current through the chest. “The double shock requires a little bit more coordination but why not? If 200J is good shouldn’t more be better? It’s a little tool to keep in your back pocket and use it when nothing else is working.” Implementing the double shock is easy. Place one set of pads in the AP position and the other set in the anterior and lateral positions. Then charge both devices while providing quality CPR and administer the shock together. Just like that you have 400J to the heart. This is an idea to keep in your back pocket for when 200 J isn’t having the effect you want
-Erik verzemnieks M.d.
Donald Stader M.D. hands over a large check for $4,000 to Lisa Raville – the Executive Director of the Harm Reduction Action Center.
The Harm Reduction Action Center was awarded a check for $4,000 through Emergency Medical Minute. The Emergency Medical Minute donates all of the earnings from the Opioid Symposium, held in September of 2016, to the Harm Reduction Action Center in Denver. Emergency Departments play a key role in the continuing spread of the opioid epidemic and we are proud to be able to help change the way people think about opiates.
“If stigma, shame, and incarceration worked for drug addiction, it would no longer be a problem.” – Lisa Raville, Executive Director of the Harm Reduction Action Center
Rachael Duncan, PharmD BCPS swallows a tough pill letting everyone know drugs don’t do a lot of good in cardiac arrest.
The Drugs Don’t Work
In the setting of cardiac arrest, a drug that commonly comes to mind is epinephrine. In the last 5 years, several studies have critically evaluated whether or not drugs are actually helpful in cardiac arrest. In 2011, a randomized control trial looked at out-of-hospital cardiac arrest and compared epinephrine versus placebo. Patients who received epinephrine were more likely to survive to admission, but there was minimal difference between the two groups in regards to survival to hospital discharge. In 2014, a large retrospective study studied patients diagnosed with cardiac arrest and looked to see if they received epinephrine in the field. Interestingly, patients who did not receive epinephrine were more likely to survive to discharge. All other variables in pre-hospital care were the same. Another paper looked at the timing of epinephrine administration. The earlier epinephrine was given, the less likely the patient was to survive to discharge. All these studies point to the fact that although it is incredibly easy to grab drugs from the crash cart, it is important to wait until they are appropriate to administer. Keep the algorithm in mind, and don’t jump to drugs.
People frequently ask if vasopressin even has a role in cardiac arrest since it doesn’t work on the heart. In situations where vasoconstriction is warranted (trauma, hemorrhage, decreased circulation, etc.) vasopressin is a great drug choice. For everything else, it might not play a big enough role.
Once pulses are back, providers often turn to anti-arrhythmics such as amiodarone or lidocaine. Anti-arrhythmics should only be used for refractory cardiac arrest. In a study published in the NEJM, patients were randomized to receive amiodarone or control. Patients who received amiodarone were more likely to survive to hospital admission than control. A second trial a few years later looked at amiodarone vs lidocaine. Patients who received amiodarone were more likely to survive to hospital admission than those who received lidocaine. Last year, a randomized control trial was published that looked at 3000 patients in refractory cardiac arrest. They were randomized to receive lidocaine, amiodarone, or placebo groups. The groups showed no difference in survival to hospital discharge.
In 15 years of studies on cardiac arrest, we have come so far. We started measuring survival to hospital admission, and are now measuring survival to hospital discharge. The uniting feature of all of these studies is that drugs are not the most important factor in cardiac arrest. EMS and compressions are still what save the most lives.
-Rachael duncan, pharmd bcps
Matt, an MS2 at CU’s medical school, learning to improve his future practice.
Ultrasound in cardiac arrest
Ultrasound can be incredibly useful in cardiac arrest. When you use ultrasound to see the heart, you can start to answer questions and narrow the differential. Bedside echocardiogram can be used to see ejection fraction, effusion, etc. In resuscitation, the AHA states cardiac ultrasound can be performed without interfering with resuscitative efforts. One study used ultrasound on patients with PEA or asystole. A large percentage of PEA patients cardiac activity on ultrasound, and some asystole patients had squeeze on ultrasound. If cardiac activity was seen on ultrasound, 30% survived to admission. If you can find the cause of cardiac arrest from the ultrasound, you improve the outcome for the patient.
– Brian morgan m.d.
Andi and Baby Josi enjoying all of the super amazing new research on temperature control with cardiac arrest.
Cooling and the cath lab
The most important thing to do in a cardiac arrest is to get the pulse back. Without the pulse back, it is impossible to do anything else. As we have already covered the best ways to get back the pulse, now it is time to talk about what happens after you get the pulse back or before you lose the pulse.
When there is ST elevation on an EKG, the patient generally goes to the cath lab to get a vessel opened up. The tissue reperfuses and most of the problems resolve. However, there are problems in the algorithm when there are people having non-STEMIs. How do we manage those patients?
Until recently there has not been a good study to show how people without ST elevation do with percutaneous coronary intervention protocols. Generally, cardiology gets involved and and provides a best estimate on treatment. However, there are some interesting trials that are coming to a close, two of which are the TOMAHAWK trial and the DISCO trial. These trials are aimed at obtaining data on cardiac catheterizations protocols, and so far, are pretty promising in showing improvement in non-STEMI outcomes.
For example, the studies are finding that there are patients with ventricular fibrillation who have obstruction lesions that could benefit from catheterization. The studies teach us two things: one is that cardiology researchers have too much fun contorting study names into fun acronyms like TOMAHAWK and DISCO, and the other is that there are better ways to manage our cardiac patients in the acute setting.
Another topic that is in debate is hypothermic protocols for patients in cardiac arrest and other anoxic insults to delicate tissues. While the thought behind cooling tissue to preserve function in a low oxygen environment is logical, the data behind it just is not strong enough. In 2013 a study showed a lack of promising data for hypothermic protocols, so we might not be doing as much good as we initially thought.
-Erik verzemnieks m.d.
Andy Ziller M.D. speaking to the audience about his cardiac arrest experience.
From Saving to Being Saved
Dr. Ziller’s point of view:
The day started out like any other with some Stairmaster time and a little mundane chit chat about salt and pepper shakers. A tinge of pain that felt like nothing I have ever experienced began in my chest. Naturally as a physician, the pain was immediately brushed off as something unimportant. Well, the pain became more significant and my wife noticed my discomfort. There was no room for protest, not even for the brief lunch we were planning on having. On the way to the emergency room, the pain became worse. A quick phone call to Dr. Lefkowits in the ED and a room was waiting for me with a nervous team on arrival. Once in the room a routine EKG showed signs of a STEMI. Dr. Lefkowits debated on how to phrase it to me not thinking that I had already read it off as it was coming off of the machine. A few moments later and all I remembers is a tech saying “sorry Dr. Ziller I have to perform CPR on you now.” And then I don’t remember anything for 36 hours
Andy Ziller M.D. (right) and Donald Lefkowits M.D. (left).
Dr. Lefkowits’ point of view:
It was a slow day in the ED when I get a call from Andy [Dr. Ziller], who is one of my really good friends, on my cell phone. I thought it was unusual that he called my cell phone so I answered it to see what he was calling about. Hearing the anxiety in his voice I knew something was wrong. I got a room ready and started telling the team that Dr. Ziller was coming in and we needed a room. Everyone was nervous in anticipation about their next patient coming through the door. I went outside at the same time that Andy’s wife pulled in and noticed that Andy did not look good. We got him back to a room and performed an EKG on him. When the EKG was done I was looking at it trying to figure out what to say to him. I finally mustered up the words, “Andy, we have to get you to the cath lab.” I didn’t think about the fact that Andy could read the EKG and he responded with a nervous chuckle and a “yeah, I can see that. Let’s get a move on.”
I called the cardiologist down to the ED and let him know about Dr. Ziller. The confused cardiologist responded with “what about Dr. Ziller’s patient?” I had to quickly correct that, “no, Dr. Ziller was the patient.” With that the cardiologist made haste down to the ED and made his way to the room. In natural fashion, as soon as the cardiologist entered the room Andy started crashing. Of course Andy was fine until the cardiologist walked in, it seems that things always go wrong right as the cardiologist comes in. The ED team buzzed to life and began doing what they were trained to do. Everyone was scared, but they did their jobs just like they were trained. Before Andy completely went out he managed to get out a faint, “don’t intubate me.” I reassured him that we would not, and then turned to my team and asked for succinylcholine. Now how did he know there would be a study later on about not intubating people? After we worked him and got a pulse back he had a quick trip up to the cath lab. I went up there with him after calling another doctor in the area to cover my shift. The minute they cleared Andy’s vessel the ST segments immediately went down.
We knew everything was okay with his heart, but we didn’t know if everything was okay with his cognitive function. After he woke up, Andy asked for a pen and paper since he was still intubated. He scribbled on the pad three things one at a time and looked at us for answers.
“Stents?” I answered yes. “EF?” I told him his EF. After these two questions were asked I knew that he had maintained a good portion if not all of his cognitive abilities. Then Andy thought for a minute and scribbled another statement. “Tell my wife I love her.”
Donald Lefkowits M.D.
Dr. Ziller’s point of view:
I knew that I either had a CABG or stents placed and recalled a study that showed that better EFs after an MI leads to better outcomes. After I had that knowledge I thought to myself, I better let my wife know that I am okay.
A lot of people ask me about being intubated and I tell them that “It’s not that bad.” Then again, I had some pain meds on board and was not really able to judge it. Everything else was pretty normal. The hear cath was definitely something that saved my life but who knows if intubating me immediately was bad or if cooling me made a difference. The whole process was pretty easy on me. It was much harder on my family who had to worry about me, and the skilled teams that took care of me from start to finish. One thing that meant a lot to me was that the ED went on divert after they took me up to the cath lab. I still get a little choked up that they thought that the ED couldn’t take care of patients because they were thinking about me, that was really touching.
A couple of things that I want to leave you with after experience something really close to death. Relationships are really important. Make sure to tell the people you love that you love them and say sorry to the people you hurt.
Dr. Lefkowits’ point of view:
There was 7 and a half minutes from the time he walked through the door until we got him to the cath lab. So to all the EMS people out there, if there is a real suspicion about cardiac events get them to the ED. As for the ED team, I did not really do much. Other than giving him a firm chest thump I did not have much of a roll in his actual care. These people were never people that I thought would take care of someone that I cared about so deeply, but they did all of the hands-on work and we see him here sitting with us now thanks to them.
Donald Lefkowits M.D. (left) and Andy Ziller M.D. (right) hugging after a tear-jerking presentation.
The Emergency Medical Minute would like to give a huge thanks to Travellin’ Adam, who performed during the event.