Pre Hospital Cardiac Arrest Management

Introduction

Over the previous decades, remarkable advancements have been made in resuscitation science. However, the outcome of survival of patients with cardiac arrests in the pre-hospital context has been fairly improving. The need to increase the survival rate of such patients brings about the essence of cardiopulmonary resuscitation in pre-hospital practice. Cardiopulmonary resuscitation (CPR) is the application of extracorporeal compressions on a patient’s chest as well as artificial ventilation as a way of maintaining oxygenation and the circulatory flow at the moment of cardiac arrest (Bon, 2018). Conventional CPR generates both cardiac output and coronary perfusion pressure. Cardiac output sustains cerebral and organ perfusion which is crucial in the prevention of irreversible ischemic injuries. Coronary perfusion pressure sustains the myocardial perfusion which is crucial in achievement of the return of spontaneous circulation (ROSC) (Singer, et al., 2018).

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Singer et al. (2018) explain that the survival rate for patients having cardiac arrests out of hospital is 9% and even after attempts for resuscitation, 31.5% of the patients will survive. In addition, Noureddine et al. (2016) also posit that pre-hospital cardiac arrest management is a major challenge in a significant number of nations and the average global rate of survival of out-of-hospital cardiac arrests (OHCA) ranges between 0% and 35%. Comparably, the survival rate of in-hospital patients with cardiac arrests is higher than the OHCA (Noureddine, et al., 2016). Whereas the survival rate for in-hospital cardiac arrest (IHCA) in the UK after CPR discharge from hospitals is at 20-35%, the survival rate for OHCA in the same circumstance is roughly 15% (Singer, et al., 2018, p. 2).

Due to the low survival rate concerns, this paper aims at critically evaluating the quality of clinical practice of cardiopulmonary resuscitation in the delivery of responsive, flexible and relevant care within the pre-hospital context. This shall be done by evaluating the evidence-based strategies in the management and application of the paramedic clinical intervention to a diverse range of patients.

Establishment

During the 1960s, cardiopulmonary resuscitation was established as a treatment method for cardiac arrest (British Medical Association, 2016, p. 2). This followed the publishing William Kouwenhoven’s landmark paper concerning CPR where he suggested that two hands were sufficient to initiate a cardiac resuscitation procedure. This technique was already familiar in medical practice throughout the 18th and 19th centuries although it was deemed unsatisfactory, thus it was ignored (Hurt, 2005, p. 327). However, it was revived in the mid-20th century to replace techniques initially thought initially to be satisfactory. In 1868, John Hill who was affiliated with the Royal Free Hospital described sternal compression as a method of restoring heartbeat.

Sternal compression, which is likened with cardiac massage in the present day, would restore the pulse of patients who were ‘apparently dead’ by applying pressure on their chest twelve times. Hill concluded the article by elaborating that the process is extremely simple and little or no assistance is required, not even the patient’s movement from their position (Hurt, 2005, p. 327). William Kouwenhoven and John Hill among other key contributors to the contemporary methods of artificial ventilation inspired today’s adoption of CPR techniques in different clinical contexts. This was through contributions like the distinction between absolute and apparent death, discovery of cardiac compression and defibrillation of the heart (Hurt, 2005).

Delivery of Care

The delivery of primary care in the UK has undergone changes since the publishing of the 2001 “Cardiopulmonary Resuscitation: Guidance for Clinical Practice and Training in Primary Care.” Today, patients with different health and environmental backgrounds have been put into consideration by having medical practitioners with different sets of skills to attend to them. Pre-hospital resuscitation follows the Resuscitation Council (UK) Guidelines 2015 which are deemed reliable by receiving approval from the National Institute for Health and Care Excellence and having factored in stakeholders from different parts of the world, such as cardiac arrests survivors and members of the public (Resuscitation Council (UK), 2018).

Quality of Pre-Hospital CPR

As aforementioned, it is recognized in the medical profession that the survival rate of CPR for OHCA is significantly low. The primary determinant for the responsiveness, flexibility, and relevance of CPR is the quality of the clinical intervention. Some of the factors related to the quality of CPR include chest compressions, early defibrillation, early bystander CPR, the differences in emergency services and the existence of comorbidities like obstructive pulmonary diseases (Noureddine, et al., 2016). To add, factors pertaining the quality of CPR are the absence of standardized and the existence of sub-optimal training procedures for pre-hospital CPR providers, delayed response from emergency medical services (EMS), and delays in reaching a hospital. The quality of pre-hospital CPR is critical to the acquisition of favorable outcome among OHCA.

Chest compressions, also known as cardiac compression, has the potential to resuscitate an arrested heart. Proof that chest compressions are ideal for CPR was illustrated in 1878 by Boehm in Durpat Germany. Boehm explained that after compression, blood from the main veins refills the heart and this causes it to pump out fresh blood (Hurt, 2005, p. 330). To supplement the effectiveness of chest compressions, Kouwenhoven’s chance discovery in 1960 illustrated that rhythmic pressure made by applying weight on the sternum facilitated the adequate circulation of blood to the brain (Hurt, 2005, p. 330). Advanced clinical practice recommends that in order to acquire a well-done CPR, high-quality chest compressions need to be made while paying close attention to depth, rate, hand placement, fraction and full recoil (Abelsson & Lundberg, 2018, p. 652).

Generally, a chest compression ought to be done at a rate of 100 to 120 compressions per minute and at a depth between 5cm and 6 cm. For children, chest compression rates are highly sensitive. For instance, newly born babies require at least 120 compressions per minute; neonates and infants, children from 1-8 years and above 8 years require 100 compressions per minute (Anon., 2017, p. 352). The ventilation that accompanies compression needs to last 1 second to inflate a patient’s chest with enough volume of air. Basic skills are required to perform ventilation using either a bag-mask or a pocket mask, and for every 30 chest compressions, 2 acts of ventilation should be performed (Abelsson & Lundberg, 2018, p. 652).

Alternatively, the Resuscitation Council (UK) recommends the use of mechanical devices for chest compression to substitute top quality manual chest compressions in circumstances where manual compressions can compromise the provider’s safety or may be impractical (Resuscitation Council (UK), 2018). In order to minimize the ‘no-flow time’ (the period between the patient’s collapse due to cardiac arrest and the onset of cardiac compression) dispatcher-assisted compression-only CPR can be done during emergency calls (Singer, et al., 2018, p. 1). The dispatcher uses a metronome to direct the untrained bystander to perform chest compressions correctly at the required rates. This is useful as the emergency caller awaits trained help to arrive (Resuscitation Council (UK), 2018). Despite effectiveness of chest compression devices in ending tidal CO2 and there remains a risk of making assumptions of the measures for compression depths using metronome due to the stiffness of support surfaces (such as the floor or mattress) where CPR is being performed (Yeung, et al., 2009).

Defibrillation was first discovered by James Curry who was a Royal Human Society advisor. A friction kind of electrostatic machine would provide electric shocks which would be transmitted through one’s thorax to successfully restore one’s circulation (Hurt, 2005, p. 331). Poker (2017) opines that while chest compressions restores blood circulation, defibrillation, through regulated electric shocks, restarts the heartbeat (Poker, 2017). In fact, defibrillation is regarded as a quicker and more effective means of terminating the ventricular defibrillation when adhesive pads are used. According to Cage (2016) to successfully terminate ventricular flow using transthoracic defibrillation, sufficient current needs to be delivered. Either a manual defibrillator or an automated external defibrillator (AED) can be used to perform defibrillation. A paramedic ought to apply firm pressure to both paddles to ensure maximum contact with a patient’s chest.

Of great concern during defibrillation is the peri-shock pause which is the time period between stopping of CPR for rhythm analysis before the next shock phase. Regarded as an independent variable in various studies, the peri-shock pause needs not to be longer than 40 seconds. This is because a patient’s chance of survival decreases with every five-second collapse in peri-shock pause by 18% (Cage, 2016). Perkins et al. (2015) state that the chances of survival for a patient decreases by 10% with every one-minute delay in defibrillation. Furthermore, a multi-center trial illustrated that the likelihood of defibrillation to be successful increased with the decrease in peri-shock pause by five minutes.

To ease the public access to defibrillators, the Department of Health in England positioned 681 AEDs at 110 public locations. The positioning of these AEDs does not only increase public access but also reduce the time between the collapse of a patient and the first shock. A trial by the Public Access Defibrillation (PAD) confirmed that implementing PAD programs will lead to a two-fold increase in a patient’s chance of survival (Perkins, et al., 2015, p. 449).

In the case of children whose hearts deteriorate into fibrillation, severe systemic insults are usually brought about, such as ischemia, myocarditis, and electrocution. A child who is pulseless and has ventricular fibrillation needs immediate defibrillation to be performed on them using appropriate techniques. Where a child has shock or ventricular tachycardia, synchronized cardioversion is recommended. However, it is inadvisable to use synchronized cardioversion on a child with supraventricular tachycardia with normal perfusion (Anon., 2017, p. 354).

The quality of CPR also increases with the increase in bystander CPR. According to the Cardiac Arrest Registry to Enhance Survival data, patients who failed to acquire bystander CPR had a 7% rate of survival while those who acquired bystander CPR were 11.2% most likely to survive (Cage, 2016). Cage (2016) argues that the low quality of CPR in several locales is tied with the low rates of survival. Despite the efforts made to increase public education, most bystanders exhibit the fear of transmitting infectious diseases and this breeds reluctance to performing CPR.

Bystander CPR is critical because it minimized the ‘no-flow time’ of a patient. Paramedic ambulance systems cannot get to a scene with a cardiac arrest patient as fast as a bystander can. Therefore, Perkins et al. (2015) implore that any strategies employed to enhance the quality and outcome of CPR bystander response. In England, bystander CPR is projected to be undertaken in 40% to 50% of incidences of cardiac arrest. Comparable to other countries, England’s rate is low. The rate of bystander CPR in Seattle is at 66%; Norway at 73%; and North Holland at 60%. Therefore, Perkins et al. (2015) suggest that CPR ought to be mandatory in the acquiring of a driving license, and family members of patients who are at risk. Furthermore, other modalities like the use of DVD/video training and mobile phone applications can effectively enhance bystander training and eventually increase quality of CPR (Perkins, et al., 2015, p. 449).

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Conclusion

To conclude, cardiopulmonary resuscitation is critical in the reduction of deaths caused by cardiac arrest. There is need to improve the quality of CPR in the pre-hospital context in order to increase the survival rates of such incidences as soon as they occur. To increase quality, focus needs to be laid on the nature of chest compressions, early defibrillation, and bystander CPR. It is important to consider patients of different personal characteristics, such as age and previous health record. High-quality chest compressions, easing public access to defibrillators, and enhancing bystander CPR training are some of the practical efforts that will ensure many lives get saved during emergency situations. As a recommendation, to further improve the quality of CPR so as to increase the survival rates in the community, training should be done to a group consisting a mix of members of the public and professional paramedic officers so that there is a consistent flow and exchange of knowledge about how to perform CPR.

Bibliography

  • Abelsson, A. & Lundberg, L., 2018. Cardiopulmonary resuscitation quality during CPR practice versus during a simulated life-saving event. International Journal of Occupational Safety and Ergonomics, 24(4), pp. 652-655.
  • Anon., 2017. Procedure 17: Cardiopulmonary Resuscitation. [Online] Available at: [Accessed 18 December 2018].
  • Bon, C., 2018. Cardiopulmonary Resuscitation (CPR). [Online] Available at: [Accessed 18 December 2018].
  • British Medical Association, 2016. Decisions relating to cardiopulmonary resuscitation: Guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing, London
  • Cage, T. M., 2016. CPR for Prehospital Providers. [Online] Available at: [Accessed 18 December 2018].
  • Hurt, R., 2005. Modern cardiopulmonary resuscitation—not so new after all. Journal of the Royal Society of Medicine, Volume 98, pp. 327-331.
  • Noureddine, S., Avedissian, T., Hussain, I. & El Sayed, M. J., 2016. Assessment of cardiopulmonary resuscitation practices in emergency departments for out-of-hospital cardiac arrest victims in Lebanon. Journal of Emergencies Trauma and Shock, pp. 115-121.
  • Perkins, G. et al., 2015. National initiatives to improve outcomes from out-of-hospital cardiac arrest in England. Emergency Medicine Journal, 33(7).
  • Poker, R., 2017. 150 years of resuscitation. [Online] Available at: [Accessed 19 December 2018].
  • Resuscitation Council (UK), 2018. Prehospital resuscitation. [Online] Available at: [Accessed 18 December 2018].
  • Singer, B., Reynolds, J., Lockey, D. & O'Brien, B., 2018. Pre-hospital extra-corporeal cardiopulmonary resuscitation. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 26(21).
  • Yeung, J. et al., 2009. The use of CPR feedback/prompt devices during training and CPR performance: A systematic review. Resuscitation, Volume 80, pp. 743-751.

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