Mechanical CPR Helps Save the Day—and the Patient

 

 
 
 

A.J. Heightman, MPA, EMT-P | Christopher Greb, NREMT-P | From the February 2014 Issue | Wednesday, January 29, 2014


On a later summer night, Phillip Solomon, a healthy 61-year-old male with no known medical history, is walking out of Macungie (Pa.) Memorial Park after attending a car show. Suddenly, he falls to the ground, striking the back of his head.

Solomon’s wife thinks he’s simply fallen, but realizes something is terribly wrong when he doesn’t respond to her.

Prehospital Care
A bystander summons nearby Macungie Police Department (MPD) officer Todd Bernhard, who’s in his vehicle 50 yards away, as the wife calls 9-1-1. Officer Bernhard arrives on scene within seconds, determines Soloman is in cardiac arrest, begins CPR, attaches the AED from his vehicle to Solomon and requests additional help.

MPD Corporal Mike Mullen arrives a few moments later and assists Bernhard with CPR. An ATV ambulance crew from inside the park and another ambulance crew member from the event’s first-aid stand arrive moments later finding high-quality CPR in progress by the police officers. They learn the patient has already received one shock and begin ALS care as the officers continue CPR.

During this time period Soloman exhibits agonal respirations and even some movement of his arms; however, he remains in v fib with no pulse. The excellent CPR is keeping his brain perfused with blood and oxygen—buying him precious minutes until his heart might restart. (See Figure 1.)

Within four minutes of the arrest, another ambulance arrives with three additional crew members, followed by yet another ambulance crew a few minutes later. In total, two police officers, three paramedics and five EMTs are on scene within eight minutes.

The EMS crew attaches a Physio-Control LUCAS automated chest compression device onto the patient. This mechanical CPR device performs compressions at the proper rate and depth in a fully controlled, uninterrupted manner while allowing the EMS providers to secure the airway, attach the cardiac monitor, start an IV and administer resuscitative medications.

During this early care, Solomon still exhibits agonal respirations with some movement of his arms, but he doesn’t have a pulse. ACLS protocols are followed and IV epinephrine, amiodarone and magnesium sulfate are administered.

Amazingly, after the LUCAS device is attached, Solomon becomes so alert that he’s able to respond to the rescuers and even answers some of their questions. However, when the device is stopped to reassess Solomon’s status without CPR, he loses consciousness and remains in v fib.

During approximately 10 minutes of manual CPR and 10 minutes of mechanical CPR, Solomon receives a total of nine shocks and multiple medications in an effort to restart his heart. (See Figures 2–3 and Table 1.) He’s also treated for a possible head or neck injury because of his fall, fully immobilized and moved into the ambulance.

While en route to Lehigh Valley Hospital Center, approximately 20 minutes after suffering cardiac arrest, the patient regains a pulse, begins responding to the EMS team and is awake and alert upon arrival at the ED. (See Figure 4.)

Statistics
Each year, 359,400 people in the U.S. (about 1,000 per day) experience EMS-assessed out-of-hospital non-traumatic sudden cardiac arrest, and nine out of 10 victims die. This is roughly equivalent to the number of people who die from Alzheimer’s disease, assault with firearms, breast cancer, cervical cancer, colorectal cancer, diabetes, HIV, house fires, motor vehicle accidents, prostate cancer and suicides combined. 1

Heart disease is the leading cause of death for both men and women—more than half of deaths due to heart disease in 2009 were in men. Every year, about 715,000 Americans have a heart attack. Of these, 525,000 are a first heart attack and 190,000 happen in people who have already had a heart attack.2 Coronary heart disease alone costs the U.S. $108.9 billion each year. This total includes the cost of health care services, medications and lost productivity.3

The chances of surviving an out-of-hospital cardiac arrest are generally considered to be less than 10% in the U.S. Research has shown quality CPR, coupled with early ALS, can result in increased cardiac arrest survival. Continuous CPR delivery has also been shown to be a key component to cardiac arrest resuscitation.2

Patient Outcome
At the hospital, the patient is quickly taken for X-rays, a CT scan, numerous blood tests and an emergency cardiac catheterization. These tests and catheterization all come back negative, and it’s determined the patient suffered cardiac arrest as a result of a previously undiagnosed medical condition that made him susceptible to arrhythmias and v fib. The patient has a cardiac stent placed and an implantable cardiovertor defibrillator implanted, and he’s discharged after three days with few side effects.

Conclusion
The integrated training between EMS responders and the CPR/AED-equipped police officers; the multilayered, coordinated response and resuscitation effort by police and EMS familiar with the pit-crew approach to resuscitation and use of a mechanical CPR device; and the rapid response and time-to-care by the rescuers—particularly at such a large gathering—were all key factors in this successful resuscitation.

References

1. Kochanek KD, Xu JQ, Murphy SL, et al. Deaths: Final data for 2009. Natl. Vital Stat Rep. 2011;60(3): 1–116.

2. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2013 update: A report from the American Heart Association. Circulation. 2013;127(1):e6–e245.

3. Heidenreich PA, Trogdon JG, Khavjou OA, et al. Forecasting the future of cardiovascular disease in the United States: A policy statement from the American Heart Association. Circulation. 2011;123(8):933–944.

Table 1: ROSC time sequence

8:59 p.m.

Cardiac arrest occurs

9:00 p.m.

Police officer at patient’s side and first AED defib.

9:01 p.m.

First EMS crew at patient’s side. Second AED defib.

9:03 p.m.

First ALS ambulance arrives.

9:03 p.m.

Cardiac monitor applied. First manual defib.

9:04 p.m.

IV initiated.

9:05 p.m.

First epinephrine administered.

9:06 p.m.

Second manual defib. Oral airway inserted.

9:07 p.m.

Amiodarone administered. Third manual defib.

9:08 p.m.

Second ALS ambulance arrives.

9:09 p.m.

LUCAS device applied (10 minutes after arrest).

9:09 p.m.

Magnesium sulfate administered.

9:10 p.m.

Fourth manual defib.

9:12 p.m.

Patient immobilized and moved to ambulance.

9:12 p.m.

Fifth manual defib (in ambulance).

9:13 p.m.

Medical command contacted.

9:15 p.m.

Sixth manual defib (in ambulance).

9:17 p.m.

Second epinepherine administered (in ambulance).

9:18 p.m.

Seventh manual defib (in ambulance).

9:19 p.m.

ROSC (LUCAS compression device turned off).

9:21 p.m.

P=100; BP=120/80; R=16; Patient CAOx1.

9:21 p.m.

First 12-lead (22 minutes after arrest).

9:22 p.m.

Re-contact with medical command.

9:25 p.m.

Second IV started (in ambulance).

9:29 p.m.

Arrival at hospital.

 

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Related Topics: Case of the Month, Patient Management, Jems Case of the Month

 
Author Thumb

A.J. Heightman, MPA, EMT-P

JEMS Editor-in-Chief A.J. Heightman, MPA, EMT-P, has a background as an EMS director and EMS operations director. He specializes in MCI management.

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Christopher Greb, NREMT-P

Christopher Greb, NREMT-P, is operations director for Macungie (Pa.) Ambulance Service. He’s also a supervisor at the Lehigh County 9-1-1 communications center and an adjunct instructor for both the Lehigh Carbon Community College and the Pennsylvania State Fire Academy.

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