I-20 Circulation December 13. 2005 Public access defibrillation and first-responder AED pro- Acute Coronary Syndromes grams may increase the number of SCA victims who receive Coronary heart disease continues to be the nation bystander CPR and early defibrillation, improving survival leading cause of death, with >500 000 deaths and 1.2 from out-of-hospital SCA. 4 These programs require an patients with an acute myocardial infarction(AMD) organized and practiced response with rescuers trained and ly. 6l Approximately 52% of deaths from AMI occur out of the provide CPR, and use the AED. 43 Lay rescuer AED programs symptoms. 6263 thin the first 4 hours after onset of in airports, 9 on airplanes, 0.2I in casinos, 2 and in first- Early recognition, diagnosis, and treatment of AMI can responder programs with police officers23,44-46 have achieved improve outcome by limiting damage to the heart, 64. 65 but survival rates as high as 49% to 75%019-23 from out-of- treatment is most effective if provided within a few hours of hospital witnessed VF SCA with provision of immediate the onset of symptoms. 6.67 Patients at risk for acute coronary bystander CPR and defibrillation within 3 to 5 minutes of syndromes(ACS)and their families should be taught to collapse. These high survival rates, however, may not be recognize the signs of Acs and immediately activate the attained in programs that fail to reduce time to EMS system rather than contact the family physician or drive defibrillation. 47-49 to the hospital. The classic symptom associated with ACs is chest discomfort, but symptoms may also include discomfort Cardiopulmonary Emergencies in other areas of the upper body, shortness of breath, Emergency Medical Dispatch sweating, nausea, and lightheadedness. The symptoms of Emergency medical dispatch is an integral component of the AMI characteristically last more than 15 minutes. Atypical EMS response. 50-63 Dispatchers should receive appropriate symptoms of ACS are more common in the elderly, women, training in providing prearrival telephone CPR instructions to and diabetic patients. 68-71 callers(Class Ila).0,54-67 Observational studies (LOE 4)5 aprove ACs outcome, all dispatchers and EMS and a randomized trial (Loe 2)57 documented that dispatcher providers must be trained to recognize ACS symptoms. EMS CPR instructions increased the likelihood of bystander CPR providers should be trained to determine onset of ACS symptoms, stabilize the patient, and provide prearrival noti being performed. It is not clear if prearrival instructions fication and transport to an appropriate medical care facility increase the rate of survival from sca spatchers who provide telephone CPR instructions to EMS providers can support the airway, administer oxygen bystanders treating children and adult victims with a high (Class IIb), and administer aspirin and nitroglycerin. If the likelihood of an asphyxial cause of arrest(eg, drowning) patient has not taken aspirin and has no history of should give directions for rescue breathing followed by chest allergy, EMS providers should give the patient 160 to 325 mg compressions. In other cases(eg, likely SCA) telephone before arrival. 72-75 Paramedics should be trained and instruction in chest compressions alone may be preferable equipped to obtain a 12-lead electrocardiogram (ECG)and ( Class IIb). The EMS systems quality improvement program transmit the ECG or their interpretation of it to the receiving should include periodic review of the dispatcher CPR instruc- hospital( Class Ila). More specifics on these topics are tions provided to specific callers( Class Ila). covered in Part 8: * Stabilization of the patient with Acute When dispatchers ask bystanders to determine if breathing Coronary Syndromes is present, bystanders often misinterpret occasional gasps as indicating that the victim is breathing. This erroneous infor- Stroke mation can result in failure to initiate CPR for a victim of Stroke is the nations No. 3 killer and a leading cause of cardiac arrest (LOE 5). 0 Dispatcher CPR instruction pro- severe, long-term disability. 6l Fibrinolytic therapy adminis- grams should develop strategies to help bystanders identify tered within the first hours of the onset of symptoms limits patients with occasional gasps as likely victims of cardiac neurologic injury and improves outcome in selected patients arrest and thus increase the likelihood of provision of by- with acute ischemic stroke. 76-78 The window of opportunity is stander CPR for such victims(Class Ilb) extremely limited, however. Effective therapy requires early Figure 1. Adult Chain of Survival.Public access defibrillation and first-responder AED pro￾grams may increase the number of SCA victims who receive bystander CPR and early defibrillation, improving survival from out-of-hospital SCA.43 These programs require an organized and practiced response with rescuers trained and equipped to recognize emergencies, activate the EMS system, provide CPR, and use the AED.43 Lay rescuer AED programs in airports,19 on airplanes,20,21 in casinos,22 and in first￾responder programs with police officers23,44–46 have achieved survival rates as high as 49% to 75%19–23 from out-of￾hospital witnessed VF SCA with provision of immediate bystander CPR and defibrillation within 3 to 5 minutes of collapse. These high survival rates, however, may not be attained in programs that fail to reduce time to defibrillation.47–49 Cardiopulmonary Emergencies Emergency Medical Dispatch Emergency medical dispatch is an integral component of the EMS response.50–53 Dispatchers should receive appropriate training in providing prearrival telephone CPR instructions to callers (Class IIa).10,54–57 Observational studies (LOE 4)51,58 and a randomized trial (LOE 2)57 documented that dispatcher CPR instructions increased the likelihood of bystander CPR being performed. It is not clear if prearrival instructions increase the rate of survival from SCA.58,59 Dispatchers who provide telephone CPR instructions to bystanders treating children and adult victims with a high likelihood of an asphyxial cause of arrest (eg, drowning) should give directions for rescue breathing followed by chest compressions. In other cases (eg, likely SCA) telephone instruction in chest compressions alone may be preferable (Class IIb). The EMS system’s quality improvement program should include periodic review of the dispatcher CPR instruc￾tions provided to specific callers (Class IIa). When dispatchers ask bystanders to determine if breathing is present, bystanders often misinterpret occasional gasps as indicating that the victim is breathing. This erroneous infor￾mation can result in failure to initiate CPR for a victim of cardiac arrest (LOE 5).60 Dispatcher CPR instruction pro￾grams should develop strategies to help bystanders identify patients with occasional gasps as likely victims of cardiac arrest and thus increase the likelihood of provision of by￾stander CPR for such victims (Class IIb). Acute Coronary Syndromes Coronary heart disease continues to be the nation’s single leading cause of death, with
500 000 deaths and 1.2 million patients with an acute myocardial infarction (AMI) annual￾ly.61 Approximately 52% of deaths from AMI occur out of the hospital, most within the first 4 hours after onset of symptoms.62,63 Early recognition, diagnosis, and treatment of AMI can improve outcome by limiting damage to the heart,64,65 but treatment is most effective if provided within a few hours of the onset of symptoms.66,67 Patients at risk for acute coronary syndromes (ACS) and their families should be taught to recognize the signs of ACS and immediately activate the EMS system rather than contact the family physician or drive to the hospital. The classic symptom associated with ACS is chest discomfort, but symptoms may also include discomfort in other areas of the upper body, shortness of breath, sweating, nausea, and lightheadedness. The symptoms of AMI characteristically last more than 15 minutes. Atypical symptoms of ACS are more common in the elderly, women, and diabetic patients.68–71 To improve ACS outcome, all dispatchers and EMS providers must be trained to recognize ACS symptoms. EMS providers should be trained to determine onset of ACS symptoms, stabilize the patient, and provide prearrival noti￾fication and transport to an appropriate medical care facility. EMS providers can support the airway, administer oxygen (Class IIb), and administer aspirin and nitroglycerin. If the patient has not taken aspirin and has no history of aspirin allergy, EMS providers should give the patient 160 to 325 mg of aspirin to chew (Class I) and notify the receiving hospital before arrival.72–75 Paramedics should be trained and equipped to obtain a 12-lead electrocardiogram (ECG) and transmit the ECG or their interpretation of it to the receiving hospital (Class IIa). More specifics on these topics are covered in Part 8: “Stabilization of the Patient With Acute Coronary Syndromes.” Stroke Stroke is the nation’s No. 3 killer and a leading cause of severe, long-term disability.61 Fibrinolytic therapy adminis￾tered within the first hours of the onset of symptoms limits neurologic injury and improves outcome in selected patients with acute ischemic stroke.76–78 The window of opportunity is extremely limited, however. Effective therapy requires early Figure 1. Adult Chain of Survival. IV-20 Circulation December 13, 2005