Anatomy of a Cardiac Arrest
A closer look at Monroe County's first experience with PAD
by Peter Bonadonna, EMT-P
The day was July 2, 1998, it seemed like any other summer day at the Rochester Public Safety Building. Courts were in session, visitors and reporters were finding their way into courtrooms, judges and juries were deciding fates, and Monroe County Sheriff Deputies were busy ensuring the safety of all. But despite the normal beginnings, no one yet realized that this day was going to be a test of the recently deployed Public Access Defibrillation (PAD)1 program. A program that, just recently, prepared the staff and facilities for the most catastrophic medical emergency know to man ......Cardiopulmonary Arrest.
The Thursday started like a normal day for Officer Patrick (Jerry) Fedele. He is a Monroe County Sheriff Court Deputy, an A-EMT-I and a Captain of Webster Fire Department. It was late morning when Officer Fedele heard a transmission on his portable radio. The call indicated that in the next building (the Public Safety Building), there was a possible heart attack2 in the courtroom. At 11:17:00, 911 was called and an ALS unit was dispatched.
Officer Fedele, having many years of EMS experience, had a gut feeling that this was a cardiac arrest. He was in the building were the defibrillator was housed so he ran to get it. The unit is stored in the Hall of Justice were it is constantly being charged.3 As he picked up the unit he heard that CPR was in progress. Realizing that he was in an entirely different building, and that time was crucial,4 Officer Fedele ran as fast a he could with the unit.
He arrived at Judge Geraci's courtroom to find that the judge had stopped the proceedings and asked people to step out of the room. People were still milling out as Officer Fedele entered the room. In the back area were the spectators are seated, he found several people encircling someone in the pew-like seats. He saw the familiar bobbing of CPR and rushed in.
A middle-aged woman was observed stretched out on the seat surface of the pew, unconscious and without a pulse. Although cramped for space, CPR was started early5 thanks to the Sheriffs Deputies who witnessed the collapse. A woman in the courtroom who identified herself as a nurse was performing CPR while Deputies used a pocket facemask and oxygen to provide her with life sustaining respirations.6
CPR was continued, the shirt was quickly cut through, and the Laerdal 9117 defibrillator pads were securely attached to her chest. The CPR was briefly interrupted and the woman's pulse was checked again......nothing. This particular semi-automatic defibrillator unit has no EKG waveform screen but that in no way affected its function. In fact many studies suggest that no screen is better for patient care.8 The Analyze button was pressed and the welcomed rising tone and prompt indicated a shockable rhythm.9 Once charged to 200 ws, the command to "clear" was issued, and the shock button was pressed. Her body lurched characteristically, indicating that a shock had been delivered. Her pulse was checked as the analyze button was pressed for the second time. No pulse........No shock indicated.10 A quick recheck of the pulse and heart sounds indicated no cardiac activity at all. CPR was resumed.
Concerned that the CPR compressions were not as accurate as they needed to be, Officer Fedele relieved the bystander and he continued the chest compressions personally.11
After several minutes of CPR the patient made a guttural noise.12 CPR was interrupted and a check of the pulse revealed a good, strong pulses felt at the carotid and at the radial artery. The patient was making agonal attempts to breathe13 at about 10 per minute. Ventilations were assisted with the pocket mask and oxygen.
Shortly thereafter, the ALS units from Rural Metro called "on location". The time was 11:22:00. Further stabilization techniques were employed by four members of the Rural Metro team such as IVs, medications to prevent return of cardiac arrest,14 and transportation to St. Mary's Hospital Emergency Department.
After several days in the Intensive Care Unit, the patient was discharged to home, neurologically intact.15
1. PAD is very valuable program but not a panacea (only ~18% arrest in PAD
2 In EMS 25-35% of all chest pain calls are AMI. ~30% of all AMIs arrest peri-
infarct. More AMIs occur in the morning hours.
3 Critical for the success of PAD will be rapid deployment, vigilant retraining and
battery replacement. As batteries age they lose capacity whether they are used or
not, care should be taken to assure that in a crisis, the batteries will work. EMS and
PAD providers need to know that the self-test functions of the unit can not fully
indicate battery capacity and therefore a backup battery or defibrillator should be
4 Time from arrest to application of shocks appears to be the most important factor
in surviving cardiac arrest! And to a much lesser degree, whether CPR was applied
or not. (AHA) Advanced age alone does not have a negative effect on outcomes.
Children are much less likely to fibrillate and when they do, it is caused by severe
metabolic or structural damage to the heart. Defibrillation alone is not likely to be
enough in this situation. This makes a good outcome very unlikely.
5 Discuss the role of CPR: Pros-maintains some O2 to brain, removes CO2.
Cons- can distract people from defibrillation, can cause pulmonary aspiration of
GI contents, a life-ending complication if it occurs.
6 Pros and Cons for pocket facemask. Some infection protection, more attractive
option than mouth to mouth, can be supplemented with oxygen. List pros and cons
of ambubags in this environment. Pocket mask is probable the best choice here.
7 Discuss that defibs do not need to have special "bells and whistles". All they really
need to do is deliver a shock! Although sales people say biphasic waveform is
better, at this time, there is not enough evidence to believe this. Biphasic
technology may be as effective, the same, or less effective than standard
monophasic defibrillation. We just don't know yet (studies are ongoing). It is
true, that the biphasic wave is easier to electronically produce. This results in
smaller, cheaper, lighter, more battery efficient units.
8 Some studies suggest that ECG display screens slow down the delivery of
lifesaving shocks. They also cause inappropriate analyzes. Medics with minimal
ECG training become enthralled with rhythm changes rather than pushing buttons
9 Discuss the ODDS that VF will be present and that this is the treatable one!
Asystole/PEA - unlikely to survive, shocks will not help and will only worsen
the prognosis as injury from shocks accumulate to the already very sick
myocardium. Defibrillation of this rhythm also delays the treatment that is needed
such as good CPR, Oxygen, and in the case of ALS, medications/pacing.
10 A patient found in asystole will have a very grave prognosis, On the other hand, when asystole occurs after a defibrillation it is a success! It means that enough current traversed the chest and depolarized enough myocardium to realign muscle fibers back into time. This is also called "successful defibrillation". The natural pacemaker cells like the SA node tend to be stunned more by defibrillation than other myocardial structures and it is not uncommon for 1-2 minutes of asystole to exist after the defibrillation impulse. Good CPR here, can help bridge the gap until a natural pacemaker recovers and takes over.
11 It is OFTEN the case, that CPR provided in the field is less than optimal. The most
common variance is incorrect rate (too slow) by FF/EMS. The lay public has the
addition of placement/technique errors.
12 Non intubated patients can make agonal noises. Describe this and the problems it
sometimes causes first responders and green EMSers.
13 Most agonal respirations are deep and slow, with a snoring quality. Assisting with
an ambu or other device is preferred rather that applying oxygen by non-rebreather
14 Medications and an ALS Unit are needed! Approximately 18% of
defibrillated/non-medicated patients will remain in a perfusing rhythm and will not re-fibrillate. This means that ~82% will re-fibrillate, often in the next 20-30 minutes. Some experts believe that defibrillation itself makes the heart even more irritable. While some may think that you should just defibrillate again, it is better to prevent the reoccurrence so that myocardial damage from defibrillation can be minimized. Today there are highly effective strategies to "chemically" stabilize an irritable myocardium.
15 A true "Save" is one where the patient can walk into your base and
complement or complain about your care! -Peter Bonadonna
Each year 350,000 Americans experience Sudden Cardiac Death (SCD).
It is believed that >60% of these people could be saved by timely care.
Talk about Kodak's experience. 13/14 = 93%
Currently the National average of survival is 5%.
Updated: June 8, 1999