in patients with advanced heart failure supported by a left ventricular assist device. J Heart Lung Transplant. 2012; 31:1–8.17 17 Califano S, Pagani FD, Malani PN. Left ventricular assist device associated infections. Infect Dis Clin North Am. 2012; 26:77–87.
18 18 Kiernan MS, Pham DC, DeNofrio D, Kapur NK. Management of HeartWare left ventricular assist device thrombosis using intracavitary thrombolytics. J Thorac Cardiovasc Surg. 2011; 142:712–4.
19 19 Felix SE, Martina JR, Kirkels JH, et al. Continuous flow left ventricular assist device support in patients with advanced heart failure: Points of interest for daily management. Eur J Heart Fail. 2012; 14: 351–6.
20 20 Goebel M, Tainter C, Kahn C, et al. An urban 9‐1‐1 system’s experience with left ventricular assist device patients. Prehosp Emerg Care. 2018; 23:560–5.
21 21 Schweiger M, Vierecke J, Stiegler P, Prenner G, Tscheliessnigg KH, Wasler A. Prehospital care of left ventricular assist device patients by emergency medical services. Prehosp Emerg Care. 2012; 16:560–3.
22 22 Boyle A. Arrhythmias in patients with ventricular assist devices. Curr Opin Cardiol. 2012; 27:13–18.
23 23 Maisel WH, Moynahan M, Zuckerman BD, et al. Pacemaker and ICD generator malfunctions analysis of Food and Drug Administration Annual Reports. JAMA. 2006; 295:1901–6.
24 24 Mulpuru SK, Madhavan M, McLeod CJ, Cha YM, Friedman PA. Cardiac pacemakers: function, troubleshooting, and management: part 1 of a 2‐part series. J Am Coll Cardiol. 2017; 69:189–210.
25 25 Kenny T. The Nuts and Bolts of Implantable Device Therapy Pacemakers. Hoboken, NJ: Wiley & Sons, Ltd, 2015. Chapter 13, Pacemaker modes and codes; p. 140–52.
26 26 Jacob S, Panaich SS, Maheshwari R, Haddad JW, Padanilam BZ, John SK. Clinical applications of magnets on cardiac rhythm management devices. Europace.2011; 13(9):1222‐1230.
27 27 Stevenson, WG, Chaitman BR, Ellenbogen KA, et al. Clinical assessment and management of patients with implanted cardioverter‐defibrillators presenting to non‐electrophysiologists. Circulation 2004; 110:3866–69.
28 28 Cmorej P, Smrzova E, Peran D, Bulikova T. CPR Induced inappropriate shocks from a subcutaneous implantable cardioverter defibrillator during out‐of‐hospital cardiac arrest. Prehosp Emerg Care. 2020; 24:85–89.
29 29 Agarwal J, Narcisse D, Khouzam N, Khouzam RN. Wearable cardioverter defibrillator “The Lifevest”: device design, limitations, and areas of improvement. J Am Coll Cardiol 2018; 42:45–55.
30 30 Byhahn C, Bingold TM, Zwissler B, Maier M, Walcher F. Prehospital ultrasound detects pericardial tamponade in a pregnant victim of stabbing assault. Resuscitation. 2008; 76:146–8.
31 31 Kaniecki DM. Pericardiocentesis in an ambulance: a case report and lessons learned. Air Med J. 2019; 38:382–5.
32 32 Thomson D, Cooney D. Procedures. In: Emergency Medical Services: Clinical Practice and Systems Oversight. Cone DC, O'Connor RE, Fowler RL, editors. Volume 1, Clinical Aspects of Prehospital Medicine, Krohmer JR, Sahni R, Schwartz B, Wang HE, editors. Overland Park, KS: National Association of EMS Physicians, 2009.
CHAPTER 12 Cardiac arrest systems of care
Bryan McNally, Paul M. Middleton, Marcus E.H. Ong, and Gayathri Devi Nadarajan
Introduction
The original motivations to develop emergency medical services (EMS) systems were to improve the care of patients suffering from major trauma and out‐of‐hospital cardiac arrest (OHCA). Physicians and resuscitation researchers often focus on patient‐level perspectives of cardiac arrest care (e.g., specific drugs or treatment algorithms). However, the most important factors determining OHCA survival involve the systems of community care.
Recognition that OHCA survival depended on the time intervals from collapse to initiation of CPR and to defibrillation spurred extensive EMS and public safety efforts to achieve faster response and earlier defibrillation. These efforts included the use of firefighters and police officers as first‐responders, training emergency medical technicians (EMTs) to perform defibrillation, and strategic deployment of advanced life support units (systems status management). However, there were, and remain, inherent logistical limits to first‐responder speed.
Development of the automated external defibrillator (AED) led to the concept of public‐access defibrillation (PAD) [1]. The AED emphasized the potential of immediate bystander action in the management of cardiac arrest. Every EMS medical director, manager, and clinician must recognize the importance of this principle. EMS personnel and hospital staff have less influence on OHCA survival than do bystander CPR and AED use (Figure 12.1) [2]. OHCA survival when there is bystander CPR and an AED is used may be as high as 33‐50% [3–5]. State‐level data from the Cardiac Arrest Registry to Enhance Survival (CARES) program (https://mycares.net), including OHCA incidence and survival rates, demonstrate the effect of bystander interventions early in the “chain of survival” (Table 12.1) [6].
Optimal OHCA survival depends on a comprehensive community‐based approach that includes collecting essential OHCA outcome data as part of a continuous quality improvement program to improve care. Programs like CARES and the Pan Asian Resuscitation Outcomes Study (http://www.scri.edu.sg/index.php/networks‐paros) provide communities with the necessary tools to collect OHCA data in an ongoing efficient manner, enabling benchmarking and gauging effectiveness in a real‐world environment [4,7–8]. In King County, Washington, the Resuscitation Academy (http://www.resuscitationacademy.com) was created to help communities develop local quality assurance programs through a 3‐day fellowship program designed specifically for EMS clinicians, administrators, and medical directors.
Implementation of a community systems‐based approach is as important a role for EMS agencies as the direct patient care they deliver. This chapter provides an overview of the system‐level considerations in cardiac arrest resuscitation and care.
Epidemiology of Cardiac Arrest
The annual incidence of OHCA in the United States is estimated between 166,000 and 450,000 cases [59–10]. The reported incidence varies with the source of the data and definitions used. Precise epidemiological information is limited because the Centers for Disease Control and Prevention does not consider OHCA a reportable disease [11]. The rate of OHCA disability adjusted life years is 1347 per 100,000 population, which ranks third in the United States behind ischemic heart disease and low back and neck pain [12].
Many cardiac arrests are due to ventricular fibrillation (VF) or ventricular tachycardia (VT), but the proportion remaining in shockable rhythms on EMS arrival varies with the time from collapse to initial assessment. Studies based on patients who are hospitalized report shockable rhythms in about 75% of cases, whereas EMS studies report figures ranging from 24% to 60% [413–18]. EMS data suggest that the rate of out‐of‐hospital VF/VT may be decreasing, but the overall incidence of OHCA is not [19–22]. However, studies with rhythms recorded by on‐site defibrillators continue to identify VF/VT as the most common initial rhythm. VF/VT was the presenting rhythm in 61% of arrests
