Sudden Cardiac Arrest Part III: First Aid
This is the third installment in a series on the science of heart disease set against the backdrop of my father’s experience of having and surviving a sudden cardiac arrest (SCA). If you’d like to start at the beginning, here are the links for Parts I and II. Also, please note that the first aid advice below is culled from the American Heart Association and the Sudden Cardiac Arrest Association.
At the end of Part II, I promised that this week I’d teach you how to save a life. So let’s get started. When you come upon someone having cardiac distress the first order of business is to determine if they are having a heart attack or a cardiac arrest. A heart attack victim will exhibit some combination of the following symptoms: pain, shortness of breath, nausea or vomiting, sweating and weakness. Since the person’s heart is still partially functioning, he or she is likely to be conscious. In this situation you need to keep the person as calm and comfortable as possible and call 911. You should only consider transporting the person to the hospital yourself if contacting emergency personnel is impossible.
In a sudden cardiac arrest the victim’s blood stops flowing. He/she will lose consciousness, stop breathing and will not have a discernible pulse. This is an extremely serious situation which impacts approximately 800 Americans a day. When your blood stops flowing, your cells no longer receive oxygen and quickly begin to die. If this situation is allowed to persist, damage quickly accumulates, resulting in death. Successful resuscitations after 10 minutes of cardiac arrest are rare. The current survival rate in the United State for sudden cardiac arrest is a dismal 7%.
If you survive a cardiac arrest, the next concern is brain injury. Most of the cells in your body can be repaired or replaced rather easily, a process which occurs millions of times a day. Unfortunately, in what would appear to be a bit of an evolutionary error, you have only a very limited capacity to repair or replace the nerve cells in your brain. Therefore, to the extent that nerve cell death occurs during the cardiac arrest, reduced brain function becomes more likely.
The primary reason that so few people survive a SCA is that 68% percent of victims receive no first aid at all. Many of these people receive no first aid because they are alone. Sadly, other victims have potential saviors nearby who either don’t know what to do or are afraid to intervene. So let me emphasize the single most important point about SCA first aid. Intervene! If someone is lying unconscious on the ground and is not breathing and you do nothing he/she will die. You actions cannot make matters worse.
Given the prevalence of SCA, it is reasonably likely that you will encounter a victim at some point in your lifetime. That victim may well be a loved one, so you want to be prepared to respond. The goal of first aid for SCA is to reestablish blood flow, which can be accomplished either by performing cardio-pulmonary resuscitation (CPR) or by using an Automated External Defibrillator (AED). In order to be prepared, I strongly recommend that you become trained and certified in CPR and AED use. A single training session from you local fire department, YMCA, Red Cross or other such organization will cover both topics in just a couple of hours. My family and I received our free training form the South Orange Rescue Squad in Carrboro.
CPR involves giving chest compressions at a rate of about 100 per minute. To teach us how to achieve a 100 compression per minute pace, our CPR instructor told us to push along with the beat to Stayin’ Alive. (If your Bee Gees knowledge is lacking, “Another One Bites the Dust” by Queen is also a 100 beats per minute rhythm song.) For an adult, you need to compress the chest at least two inches to circulate their blood. You will need to use your body weight in order to press hard enough. Since 2008, the American Heart Association has been recommending compression-only CPR versus the traditional technique which also included mouth-to-mouth resuscitation. At first this change was recommended because many potential rescuers did not attempt CPR due to a reluctance to make mouth-to-mouth contact. As time passed, it has been determined that compression-only CPR is just as effective in saving lives as the traditional approach. Furthermore, it is being attempted at higher rates, a clear win-win.
The other way to reestablish blood flood is by restarting the heart with an AED. (See the picture above.) An AED has two conductive pads which are placed on the bare chest. The inside of the case will have simple instructions with pictures, and the device will have an electronic voice to talk you through the necessary steps to use it. One of the persons who came to my dad’s rescue said, “Even a monkey could follow the oral instructions.” Another study showed that untrained sixth graders successfully used the device in an average of 90 seconds. The AED pads have sensors which first detect if the heart is contracting at all and if so, whether the rhythm is “shockable” or not. The explanation of which rhythms are shockable and which are not is too long to include here. If the heart has a shockable rhythm, which is the case for the majority of SCAs, the AED will deliver a shock to the chest, either automatically or by telling you to hit the shock button, and then check for a normal heart beat. If the device senses a normal heart beat, it will inform you to stop giving CPR. If instead the AED senses a non-shockable rhythm, or if the shock was not effective, it will advise you to continue with CPR. Often the first shock is not sufficient. Just listen to the the machine and continue CPR and deliver additional shocks as instructed.
An SCA victim’s chance of survival when both CPR and an AED are used increases dramatically. According the Sudden Cardiac Arrest Association, victims who have their hearts restarted within five minutes have a survival rate of 90 percent! Units cost approximately $1,500-2,000 (my sense is that this data is already out of date, as I was able to find units for sale at $800). This is a very small price to pay to save a life. The Sudden Cardiac Arrest Association and other organizations are working hard to support efforts to ensure that AEDs are available in shopping malls, churches, stadiums, airports and anywhere else where people congregate.
Before reviewing what happened with Dad’s first aid, let me summarize how you should respond if you encounter someone unconscious and not breathing:
1. Do not attempt to check for a pulse. Untrained personnel are often not effective at this, and it wastes time. Furthermore, you will not harm the person by performing CPR even if their heart is still beating.
2. If you have at least one person to assist you, use the first 10 seconds to determine if anyone has CPR training, then assign someone to seek an AED and someone else to call 911. Assign these tasks clearly to specific people. Begin CPR.
3. If you are alone, unless you are certain that you can summon help or retrieve an AED in under a minute, begin CPR and call loudly for help.
4. Utilize the AED as soon as it arrives.
I’ll close out this week’s column with the story of the first aid that my father received. Dad was playing squash with his friend Joe at Recreation Hall on the campus of Penn State University. Dad collapsed with no prior warning: no pain, no feeling of light-headedness, nothing. Joe shouted for help and Alison and Daria, who work in the athletic department, responded. A call to 911 was immediately placed. Daria reported that “We did not expect a good outcome. He was completely unresponsive. We thought that, at best, he might survive, but with severe neurological deficit.” Fortunately, they were trained in CPR and began chest compressions immediately. Daria later said that “It really helped to have been trained on manikins that light up when you push down hard enough.” Based on their training, the compressions were hard enough to keep Dad’s blood flowing, and also cracked several ribs. As Dad said, “A small sacrifice in exchange for continuing to live!”
Within minutes, an AED (a number of which are situated in the building) was ready to be used. (We don’t know who retrieved the AED. Our heartfelt thanks to whoever did.) The next response came from officers Mike Baker and Randy Hoffman of the Campus Police. They took over the compressions and helped with the use of the AED. The AED sensed a shockable rhythm and after four shocks restarted Dad’s heart. In the end, it took more than 25 minutes for Dad’s heart to resume beating on its own. This timeline illustrates that CPR can be effective for extended periods of time. Next on the scene were the EMTs, who transported Dad via ambulance to the State College Area Hospital.
The first aid response to Dad’s SCA was nearly perfect, putting him on the best possible path to survival and recovery. Next in Part IV, I’ll tell you about the absurdly simple but amazingly effective medical procedure that was used on Dad next. Don’t miss it.
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