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Tuesday, May 7, 2013

The Chain of Survival - done right!

The American Heart Association has been using the phrase "chain of survival for years now. This imagery is used to emphasize the importance of an integrated response to a cardiac arrest. This is common sense - you and your gold patch aren't worth much if no one does CPR before you arrive. Or if no one even calls in the first place!

"He'll be okay!" - Source
We recently had a patient brought into the ED which beautifully illustrated this "chain" concept. And while this case did not get onto channel 12, it's a great example of what can be done when all the pieces work they way they should. I'll quote the AHA concept behind each link, and describe how it worked in that case.

1. Immediate recognition of cardiac arrest and activation of the emergency response system 
 Our patient, a 50-ish female, collapsed while at work. This was witnessed by her coworkers, fortunately, and 911 was immediately called.

2. Early CPR with an emphasis on chest compressions
Rather than waiting for EMS to arrive, or even having to be coached by 911 dispatchers, coworkers started CPR.

"They were doing quality CPR when we got there," recalled Christopher Lovell, the AMR paramedic who responded. "They knew what they were doing - probably had a medical response team at the company, from the way they were acting."

3. Rapid defibrillation
Even while the AMR unit was still enroute, the patient's coworkers were giving her every chance. They grabbed the AED available onsite, and they applied the pads, analyzed, and gave shock #1.

4. Effective advanced life support 
When the ALS unit arrived, they found the patient to be in VF, and gave shock #2. The VF continued, and they gave two more defibrillations before converting her into a sinus rhythm. Her blood pressure and oxygen saturation bounced back almost immediately, and they held off on intubating. A bolus of amiodarone was given to prevent VF recurrence, and they grabbed a 12-lead during transport:


5. Integrated post–cardiac arrest care
EMS arrived in the ED with a patient who had great vitals (indeed, she has hypertensive), but who continued to have a poor mental status. She required RSI for intubation, while therapeutic hypothermia was started with ice bags. Her second ECG looked a lot like the first one:

After a detour for a head CT (She was oddly hypertensive for a post-cardiac arrest patient, raising suspicion that a subarachnoid or intercerebral hemorrhage had triggered the arrest. It happens.), cardiology swooped in to take her to the cath lab.

When I later got a chance to talk with the cardiologist who cathed the patient, he was thrilled to talk about the case. First of all, the infarct-related artery was not a surprise - a 100% occluded RCA.

But more importantly, the therapeutic hypothermia that we had started in the ED wasn't continued, but for all the right reasons. "By the time I had finished deploying the stent, she was moving around. We extubated her in the ICU, and she was talking to us an hour later!"

That's a good reason, we can all agree.

The Bottom Line
It's not just a catchy phrase or a silly graphic. The "chain of survival" works, and it depends on a robust, effective response from each link. 

'Cause even this guy needs the 4 other links!

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