The relationship between shocks and survival in out-of-hospital cardiac arrest patients initially found in PEA or asystole
Al HallstromThomas D. ReaVince MosessoLeonard A. CobbAndy R. AntonLois Van OttinghamMichael R. SayreJames Christenson
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Asystole
Pulseless electrical activity
Fibrillation
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Indexes such as amplitude spectrum area (AMSA) and power spectrum area (PSA) obtained from electrocardiogram waveform analysis are possible predictors of outcome after electrical defibrillation for ventricular fibrillation (VF). In this study, we examined AMSA and PSA to determine whether these parameters can predict defibrillation outcome.A total of 83 out-of-hospital VF victims were classified into four groups according to type of cardiac rhythm after shock: return of spontaneous circulation (ROSC), VF, pulseless electrical activity (PEA), and asystole. AMSA and PSA were calculated from electrocardiograms prior to shock and compared between groups.The mean AMSA (4.0-48 Hz) in the ROSC group was 24.2 ± 8.5 mV-Hz, which was significantly higher than that in the VF and asystole groups.It is possible by analyzing the AMSA of VF to predict cases where electrical defibrillation is more likely to return cardiac rhythm. Furthermore, unnecessary electrical shocks with a low possibility of ROSC can be avoided, and chest compression should be continued to prevent myocardial damage and consequently improve prognosis.
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Guidelines in cardiopulmonary resuscitation [CPR] improve survival of patients in cardiac arrest. Programs with both Basic Life Support [BLS], promptly initiated, and early defibrillation must be designed to motivate persons trained in prehospital CPR. The most frequent lethal rhythm in cardiac arrest is ventricular fibrillation [VF], affecting over 75% of patients. Early defibrillation must have the highest priority as the only method for termination of VF and being the major determinant for survival. Administration of 1.0 mg epinephrine iv as the drug of choice, followed by defibrillation [360 J] in patients with recurrent/persistent VF remains gold standard in Advanced Cardiac Life Support [ACLS]; epinephrine administered in the same, or higher, dosage can be repeated every 3-5 minutes followed by defibrillation within 30-60 seconds. Management of asystole and pulseless electrical activity is discussed, including the necessity to search for treatable causes as one major action, in addition to performing ACLS and administering epinephrine.
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Advanced Life Support
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Asystole
Pulseless electrical activity
Fibrillation
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The first recorded heart rhythm for cardiac arrest patients can either be ventricular fibrillation (VF) which is treatable with a defibrillator, or asystole or pulseless electrical activity (PEA) which are not. The time course for the deterioration of VF to either asystole or PEA is not well understood. Knowing the time course of this deterioration may allow for improvements in emergency service delivery. In addition, this may improve the diagnosis of possible electrocutions from various electrical sources including utility power, electric fences, or electronic control devices (ECDs) such as a TASER ® ECD. We induced VF in 6 ventilated swine by electrically maintaining rapid cardiac capture, with resulting hypotension, for 90 seconds. No circulatory assistance was provided. They were then monitored for 40 minutes via an electrode in the right ventricle. Only 2 swine remained in VF; 3 progressed to asystole; 1 progressed to PEA. These results were used in a logistic regression model. The results are then compared to published animal and human data. The median time for the deterioration of electrically induced VF in the swine was 35 minutes. At 24 minutes VF was still maintained in all of the animals. We conclude that electrically induced VF is long-lived - even in the absence of chest compressions.
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In briefChanges in the advanced car-brief diac life support guidelines in-elude a new classification system for interventions, training in the use of automated defibrillators, and required early defibrillation for ventricular fibrillation. The algorithms for treating ventricular fibrillation and pulseless ventricular tachycardia, pulseless electrical activity, and asystole are reviewed. Cardiac arrest caused by special circumstances—hypothermia, near drowning, trauma, and electrical injuries—presents additional treatment considerations.
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Defibrillation threshold
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To compare immediate countershocks (defibrillation 1st) with precountershock cardiopulmonary resuscitation (CPR 1st) for prolonged ventricular fibrillation (VF).Randomized, controlled trial.University animal laboratory.Thirty swine (27 +/- 1 kg).After 8 mins of untreated ventricular fibrillation, swine were randomly assigned to receive either immediate countershocks or CPR for 90 secs followed by countershocks.After the first set of shocks, nine of 15 CPR 1st animals attained return of spontaneous circulation vs. 0 of 15 defibrillation 1st animals (p <.001), and pulseless electrical activity occurred in only one of 15 CPR 1st animals vs. ten of 15 defibrillation 1st animals (p <.01). The ultimate outcomes in the two groups were not different: Return of spontaneous circulation and 24-hr survival occurred in 15 of 15 CPR 1st and 13 of 15 defibrillation 1st animals. Good neurologic outcome at 24 hrs occurred in 12 of 15 CPR 1st and nine of 15 defibrillation 1st animals. None of the animals was successfully resuscitated with defibrillation alone; all successfully resuscitated animals were provided with chest compressions during the resuscitation. The ventricular fibrillation median frequency by fast Fourier transformation decreased during the untreated ventricular fibrillation interval in both groups (9.7 +/- 0.3 Hz and 10.1 +/- 0.2 Hz after 1 min vs. 8.8 +/- 0.3 Hz and 8.9 +/- 0.5 Hz at 8 mins, respectively). Because the ventricular fibrillation median frequency substantially increased after CPR 1st, it was much higher in the CPR 1st group before the first shock (15.1 +/- 0.9 Hz vs. 8.9 +/- 0.5 Hz, p <.001). The ventricular fibrillation median frequency before the first countershock was much higher in the animals that attained return of spontaneous circulation after the first set of shocks vs. those that did not (16.1 +/- 1.3 Hz vs. 10.0 +/- 0.6 Hz, p <.0001)Precountershock CPR can result in substantial physiologic benefits and superior response to initial defibrillation attempts compared with immediate defibrillation in the setting of prolonged ventricular fibrillation.
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There is increasing evidence that defibrillation from prolonged ventricular fibrillation (VF) before CPR decreases survival. It remains unclear, however, whether harmful effects are due primarily to initial countershock of ischemic myocardium or to resultant postdefibrillation rhythms (ie, pulseless electrical activity [PEA] or asystole).We induced 15 dogs into 12 minutes of VF and randomized them to 3 groups. Group 1 was defibrillated at 12 minutes and then administered advanced cardiac life support (ACLS); group 2 was allowed to remain in VF and was subsequently defibrillated after 4 minutes of ACLS; group 3 was defibrillated at 12 minutes, electrically refibrillated, and then defibrillated after 4 minutes of ACLS. All group 1 and 3 animals were defibrillated into PEA/asystole at 12 minutes. After 4 minutes of ACLS, group 2 and 3 animals were effectively defibrillated into sinus rhythm. The extension of VF in group 2 and 3 subjects paradoxically resulted in shorter mean resuscitation times (251+/-15 and 245+/-7 seconds, respectively, versus 459+/-66 seconds for group 1; P<0.05) and improved 1-hour survival (10 of 10 group 2 and 3 dogs versus 1 of 5 group 1 dogs; Fisher's exact, P<0.005) compared with more conservatively managed group 1 subjects.Precountershock CPR during VF appears more conducive to resuscitation than CPR during postcountershock PEA or asystole. The intentional induction of VF may prove useful in the management of PEA and asystolic arrests.
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