Chain of survival

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The chain of survival refers to a series of actions that, properly executed, reduce the mortality associated with sudden cardiac arrest. Like any chain, the chain of survival is only as strong as its weakest link. [1] [2] The six interdependent links in the chain of survival are early recognition of sudden cardiac arrest and access to emergency medical care, [3] early CPR, early defibrillation, early advanced cardiac life support, and physical and emotional recovery. The first three links in the chain can be performed by lay bystanders, while the second three links are designated to medical professionals. [4] Currently, between 70 and 90% of cardiac arrest patients die before they reach the hospital. [4] However, a cardiac arrest does not have to be lethal if bystanders can take the right steps immediately. [4]

Contents

Background

According to the American Heart Association, out-of-hospital cardiac arrest can affect more than 300,000 people in the United States each year. [5] Three minutes after the onset of cardiac arrest, a lack of blood flow starts to damage the brain, and 10 minutes after, the chances of survival are low. [6] Therefore, bystanders have only a few minutes to act to optimize a person's chances of survival and recovery.[ citation needed ]

To improve survival outcomes for people who have experienced out-of-hospital cardiac arrest, the American Heart Association–International Liaison Committee on Resuscitation recommended the chain of survival concept in the early 2000s. [3] Originally, the chain consisted of four steps: early access to emergency medical care was the first link, the second link was early CPR, early defibrillation was the third link, and the final link was early advanced cardiac life support. [3] Over the years, the American Heart Association has added two new links to the chain: post-resuscitation care in 2010, [7] [3] and physical and emotional recovery in 2020. [4] Also in 2020, the American Heart Association issued a new pediatric chain of survival for infants, children, and adolescents. [8]  

Mary M. Newman, co-founder and president/CEO of the Sudden Cardiac Arrest (SCA) Foundation and previous executive director of the National Center for Early Defibrillation at the University of Pittsburgh, [9] developed the chain of survival metaphor and first described it [6] in an article she wrote for the Journal of Emergency Medical Services in 1989, [10] and further promoted in an editorial she wrote for the first issue of Currents in Emergency Cardiac Care in 1990. [11] The American Heart Association later adopted the concept and elaborated on it in its 1992 guidelines for cardiopulmonary resuscitation and emergency cardiac care, [12] [13] The International Liaison Committee on Resuscitation (ILCOR) echoed the concept in 1997. [1] The links of the Chain of survival are described below.

Early access to emergency medical care

Ideally, someone must recognize an impending cardiac arrest or otherwise witness the cardiac arrest and activate the EMS system as early as possible with an immediate call to the emergency services. Unfortunately, many persons experiencing symptoms (for example, angina) that may lead to a cardiac arrest ignore these warning symptoms or, recognizing these warning symptoms correctly, fail to activate the EMS system, preferring to contact relatives instead (e.g., the elderly often contact their adult offspring rather than contact emergency services).[ citation needed ]

Early CPR

To be most effective, bystanders should provide CPR immediately after a patient collapses. In their 2015 guidelines, the American Heart Association re-emphasized the importance of more bystanders performing hands-only CPR until EMS personnel arrive because, at present, fewer than 40% of people who have an out-of-hospital cardiac arrest receive CPR from a bystander. [4] The guidelines recommend lay rescuers start CPR on a person with presumed cardiac arrest because the overall risk of harm to patients from CPR is low, even if their heart hasn't stopped beating. [4] Properly performed CPR can keep the heart in a shockable rhythm for 10–12 minutes longer.[ citation needed ]

Early defibrillation

Most adults who can be saved from cardiac arrest are in ventricular fibrillation or pulseless ventricular tachycardia, which means their heart has fallen out of rhythm. [14] Early defibrillation is the link in the chain most likely to improve survival since defibrillation can help shock the heart back into a regular beat. [15] Early, rapid defibrillation is considered the most important link in the chain of survival. [15] Rapid defibrillation outside of the hospital improves the chances of survival by as much as 30%, and involves using an automated external defibrillator (AED) to shock the patient's heart. [16]

While CPR keeps blood flowing artificially, [17] rapid defibrillation is the only way to restart the heart and reset it to a healthy rhythm. [18] And while only 40% of adults experiencing cardiac arrest receive CPR, fewer than 12% receive shocks from an AED before EMS arrival. [8] What is more, the chances of the patient's survival decrease by as much as 10% with every minute that they do not receive rapid defibrillation. [19]

AEDs are becoming more common in businesses, schools, and even the home as the public becomes more aware of the importance of rapid defibrillation. [20] [6] AEDs come with pre-recorded instructions and are easy to use. [18] If an AED is not available, bystanders will need to continue CPR until emergency responders arrive with a defibrillator, which is why it is important to recognize cardiac arrest and call for help quickly. [21] [6]

Public access defibrillation may be the key to improving survival rates in out-of-hospital cardiac arrest, [1] but is of the greatest value when the other links in the chain do not fail.

Early advanced care

Early advanced cardiac life support by paramedics is another critical link in the chain of survival. In communities with survival rates > 20%, a minimum of two of the rescuers are trained to the advanced level.[ citation needed ]

Some ACLS ambulance providers will administer medications to manage pain, arrhythmias, shock, and pulmonary congestion; monitor the heart rhythm to identify any potentially lethal cardiac arrhythmias; or initiate transcutaneous pacing. [15] ACLS ambulance providers use the mnemonic "MONA" (morphine, oxygen, nitroglycerin, and aspirin) to reflect the out-of-hospital therapies they will use for cardiac arrest. [15]

Often, ACLS ambulance providers will attach an electrocardiogram to the patient and transmit its findings to the receiving hospital or care facility, which leads to earlier diagnosis of a heart attack, and significantly reduces time to treatment at the hospital. [15] This prearrival ECG and notification has been shown to improve patient outcomes. [15] In the event of a complication at the scene of the event or on the way to the hospital, ACLS ambulance providers can administer life saving therapies, including CPR, rapid defibrillation, airway management, and intravenous medications. [15]

Recovery

In October 2020, the American Heart Association added the recovery phase as the sixth link in the chain of survival. [4] Recovery consists of cardiac arrest survivors receiving treatment, surveillance, and rehabilitation at a hospital. [4] It also includes an assessment for anxiety, depression, and post-traumatic stress, which can all lead to future repeated events. Before being discharged from the hospital, the American Heart Association recommends that cardiac arrest survivors receive rehabilitation assessment and treatment for physical, neurologic, cardiopulmonary, and cognitive impairments. [4] [8] They also recommend that cardiac arrest survivors and their caregivers receive comprehensive, multidisciplinary discharge planning to include medical and rehabilitative treatment recommendations and return to activity and work expectations. [4] [8]

A patient's recovery from cardiac arrest continues long after their initial hospitalization following the event, so the American Heart Association recommended in their 2020 guidelines that patients have formal assessment and support for their physical, cognitive, and psychosocial needs. [8]

See also

Related Research Articles

<span class="mw-page-title-main">Cardiac arrest</span> Sudden stop in effective blood flow due to the failure of the heart to beat

Cardiac arrest, also known as sudden cardiac arrest, is when the heart suddenly and unexpectedly stops beating. As a result blood will not be pumped around the body in normal circulation, consciousness will be rapidly lost, and breathing will be abnormal or absent. Without immediate intervention such as cardiopulmonary resuscitation (CPR), and possibly defibrillation, death will occur within minutes.

<span class="mw-page-title-main">Cardiopulmonary resuscitation</span> Emergency procedure for cardiac arrest

Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation, or mouth to mouth in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest. It is recommended for those who are unresponsive with no breathing or abnormal breathing, for example, agonal respirations.

<span class="mw-page-title-main">Advanced cardiac life support</span> Emergency medical care

Advanced cardiac life support, advanced cardiovascular life support (ACLS) refers to a set of clinical guidelines for the urgent and emergent treatment of life-threatening cardiovascular conditions that will cause or have caused cardiac arrest, using advanced medical procedures, medications, and techniques. ACLS expands on Basic Life Support (BLS) by adding recommendations on additional medication and advanced procedure use to the CPR guidelines that are fundamental and efficacious in BLS. ACLS is practiced by advanced medical providers including physicians, some nurses and paramedics; these providers are usually required to hold certifications in ACLS care.

<span class="mw-page-title-main">Defibrillation</span> Treatment for life-threatening cardiac arrhythmias

Defibrillation is a treatment for life-threatening cardiac arrhythmias, specifically ventricular fibrillation (V-Fib) and non-perfusing ventricular tachycardia (V-Tach). A defibrillator delivers a dose of electric current to the heart. Although not fully understood, this process depolarizes a large amount of the heart muscle, ending the arrhythmia. Subsequently, the body's natural pacemaker in the sinoatrial node of the heart is able to re-establish normal sinus rhythm. A heart which is in asystole (flatline) cannot be restarted by a defibrillator; it would be treated only by cardiopulmonary resuscitation (CPR) and medication, and then by cardioversion or defibrillation if it converts into a shockable rhythm.

<span class="mw-page-title-main">Do not resuscitate</span> Legal order saying not to perform CPR if heart stops

A do-not-resuscitate order (DNR), also known as Do Not Attempt Resuscitation (DNAR), Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), no code or allow natural death, is a medical order, written or oral depending on the jurisdiction, indicating that a person should not receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating. Sometimes these decisions and the relevant documents also encompass decisions around other critical or life-prolonging medical interventions. The legal status and processes surrounding DNR orders vary in different polities. Most commonly, the order is placed by a physician based on a combination of medical judgement and patient involvement.

<span class="mw-page-title-main">Ventricular fibrillation</span> Rapid quivering of the ventricles of the heart

Ventricular fibrillation is an abnormal heart rhythm in which the ventricles of the heart quiver. It is due to disorganized electrical activity. Ventricular fibrillation results in cardiac arrest with loss of consciousness and no pulse. This is followed by sudden cardiac death in the absence of treatment. Ventricular fibrillation is initially found in about 10% of people with cardiac arrest.

<span class="mw-page-title-main">Asystole</span> Medical condition of the heart

Asystole is the absence of ventricular contractions in the context of a lethal heart arrhythmia. Asystole is the most serious form of cardiac arrest and is usually irreversible. Also referred to as cardiac flatline, asystole is the state of total cessation of electrical activity from the heart, which means no tissue contraction from the heart muscle and therefore no blood flow to the rest of the body.

<span class="mw-page-title-main">Automated external defibrillator</span> Portable electronic medical device

An automated external defibrillator or automatic electronic defibrillator (AED) is a portable electronic device that automatically diagnoses the life-threatening cardiac arrhythmias of ventricular fibrillation (VF) and pulseless ventricular tachycardia, and is able to treat them through defibrillation, the application of electricity which stops the arrhythmia, allowing the heart to re-establish an effective rhythm.

Basic life support (BLS) is a level of medical care which is used for patients with life-threatening illnesses or injuries until they can be given full medical care by advanced life support providers. It can be provided by trained medical personnel, such as emergency medical technicians, and by qualified bystanders.

The Seattle & King County Emergency Medical Services System is a fire-based two-tier response system providing prehospital basic and advanced life support services.

Precordial thump is a medical procedure used in the treatment of ventricular fibrillation or pulseless ventricular tachycardia under certain conditions. The procedure has a very low success rate, but may be used in those with witnessed, monitored onset of one of the "shockable" cardiac rhythms if a defibrillator is not immediately available. It should not delay cardiopulmonary resuscitation (CPR) and defibrillation, nor should it be used in those with unwitnessed out-of-hospital cardiac arrest.

Pulseless electrical activity (PEA) is a form of cardiac arrest in which the electrocardiogram shows a heart rhythm that should produce a pulse, but does not. Pulseless electrical activity is found initially in about 20% of out-of-hospital cardiac arrests and about 50% of in-hospital cardiac arrests.

<span class="mw-page-title-main">Advanced life support</span> Life-saving protocols

Advanced Life Support (ALS) is a set of life saving protocols and skills that extend basic life support to further support the circulation and provide an open airway and adequate ventilation (breathing).

<span class="mw-page-title-main">ABC (medicine)</span> Initialism mnemonics

ABC and its variations are initialism mnemonics for essential steps used by both medical professionals and lay persons when dealing with a patient. In its original form it stands for Airway, Breathing, and Circulation. The protocol was originally developed as a memory aid for rescuers performing cardiopulmonary resuscitation, and the most widely known use of the initialism is in the care of the unconscious or unresponsive patient, although it is also used as a reminder of the priorities for assessment and treatment of patients in many acute medical and trauma situations, from first-aid to hospital medical treatment. Airway, breathing, and circulation are all vital for life, and each is required, in that order, for the next to be effective. Since its development, the mnemonic has been extended and modified to fit the different areas in which it is used, with different versions changing the meaning of letters or adding other letters.

<span class="mw-page-title-main">AutoPulse</span> Cardiopulmonary resuscitation device

The AutoPulse is an automated, portable, battery-powered cardiopulmonary resuscitation device created by Revivant and subsequently purchased and currently manufactured by ZOLL Medical Corporation. It is a chest compression device composed of a constricting band and half backboard that is intended to be used as an adjunct to CPR during advanced cardiac life support by professional health care providers. The AutoPulse uses a distributing band to deliver the chest compressions. In literature it is also known as LDB-CPR.

The history of cardiopulmonary resuscitation (CPR) can be traced as far back as the literary works of ancient Egypt. However, it was not until the 18th century that credible reports of cardiopulmonary resuscitation began to appear in the medical literature.

Return of spontaneous circulation (ROSC) is the resumption of a sustained heart rhythm that perfuses the body after cardiac arrest. It is commonly associated with significant respiratory effort. Signs of return of spontaneous circulation include breathing, coughing, or movement and a palpable pulse or a measurable blood pressure. Someone is considered to have sustained return of spontaneous circulation when circulation persists and cardiopulmonary resuscitation has ceased for at least 20 consecutive minutes.

<span class="mw-page-title-main">Rearrest</span>

Rearrest is a phenomenon that involves the resumption of a lethal cardiac dysrhythmia after successful return of spontaneous circulation (ROSC) has been achieved during the course of resuscitation. Survival to hospital discharge rates are as low as 7% for cardiac arrest in general and although treatable, rearrest may worsen these survival chances. Rearrest commonly occurs in the out-of-hospital setting under the treatment of health care providers.

Extracorporeal cardiopulmonary resuscitation is a method of cardiopulmonary resuscitation (CPR) that passes the patient's blood through a machine in a process to oxygenate the blood supply. A portable extracorporeal membrane oxygenation (ECMO) device is used as an adjunct to standard CPR. A patient who is deemed to be in cardiac arrest refractory to CPR has percutaneous catheters inserted into the femoral vein and artery. Theoretically, the application of ECPR allows for the return of cerebral perfusion in a more sustainable manner than with external compressions alone. By attaching an ECMO device to a person who has acutely undergone cardiovascular collapse, practitioners can maintain end-organ perfusion whilst assessing the potential reversal of causal pathology, with the goal of improving long-term survival and neurological outcomes.

Every year sudden cardiac arrest (SCA) kills between 35,000 and 45,000 people in Canada and approximately 350,000 people in the United States; 85% of SCAs are caused by ventricular fibrillation (VF). Receiving defibrillation from an automated external defibrillator (AED) is a key component of the 'chain of survival' for victims of SCA. Chances of survival from a SCA decrease by 7–10% every minute that a victim does not receive defibrillation. Attempts at reducing time until defibrillation have largely focused on improving traditional emergency medical service (EMS) responders and implementing publicly available defibrillator (PAD) programs. In the United States approximately 60% of SCAs are treated by EMS. Equipping police vehicles with AEDs and incorporating them in the emergency dispatching process when a SCA is suspected, can reduce the time until defibrillation for a victim suffering an out-of-hospital sudden cardiac arrest. There are numerous studies which confirm a strong coloration between equipping police vehicles with AEDs and reduced time until defibrillation which ultimately translates into improved survival rates from SCA. As a result of these demonstrable statistics, police departments across North America have begun equipping some or all of their police vehicles with AEDs.

References

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  2. ↑ Bossaert LL (1997). "Fibrillation and defibrillation of the heart". British Journal of Anaesthesia. 79 (2): 203–13. doi: 10.1093/bja/79.2.203 . PMID   9349131.
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  4. 1 2 3 4 5 6 7 8 9 10 "Updated CPR guidelines address physical and emotional recovery". www.heart.org. Retrieved 2021-05-19.
  5. ↑ "CPR Facts and Stats". cpr.heart.org. Retrieved 2021-05-19.
  6. 1 2 3 4 "Chain of Survival - What is it? Cardiac, Stroke & Pediatric". avive.life. 2021-04-27. Retrieved 2021-05-19.
  7. ↑ Peberdy, Mary Ann; Callaway, Clifton W.; Neumar, Robert W.; Geocadin, Romergryko G.; Zimmerman, Janice L.; Donnino, Michael; Gabrielli, Andrea; Silvers, Scott M.; Zaritsky, Arno L.; Merchant, Raina; Vanden Hoek, Terry L. (2010-11-02). "Part 9: Post–Cardiac Arrest Care". Circulation. 122 (18_suppl_3): S768–S786. doi: 10.1161/CIRCULATIONAHA.110.971002 . PMID   20956225. S2CID   573398.
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  9. ↑ "Mary M. Newman, MS". Sudden Cardiac Arrest Foundation. Retrieved 2021-05-19.
  10. ↑ Newman M (1989). "The chain of survival concept takes hold". JEMS. 14: 11–13.
  11. ↑ Newman MM (1990). "The Chain of Survival: Converting a Nation". Currents in Emergency Cardiac Care. 1 (1): 3.
  12. ↑ Cummins RO, Ornato JP, Thies WH, Pepe PE (1991). "Improving survival from sudden cardiac arrest: the "chain of survival" concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association". Circulation. 83 (5): 1832–47. doi: 10.1161/01.cir.83.5.1832 . PMID   2022039.
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  20. ↑ "Public access to AEDs is growing, so why aren't they being used?". www.cardiovascularbusiness.com. Retrieved 2021-05-19.
  21. ↑ "Automated external defibrillators: Do you need an AED?". Mayo Clinic. Retrieved 2021-05-19.
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