It can be said that practitioners of emergency medicine have their own unique language. As a member of this subset of healthcare, I can unequivocally agree that we have invented pseudonyms, algorithms, protocols, expressions and even our unique brand of humour to give expression to what we do every day. Codes come in various colours- blue, black, white, yellow, orange… in order to succinctly convey an emergency in a manner that is efficient, and somewhat covert from the unsuspecting public.

(Part I)

In most organizations, a code blue is a cardiac arrest, code orange can mean an external disaster, code grey or white may mean a violent patient, and a code pink is often reserved for paediatric cardiac arrest.

Algorithms and pathways are created to provide a quick reference to a standardized set of protocols used in specific circumstances. We use one to manage a cardiac arrest, another to manage stroke, one for pneumonia admissions, and the list goes on. These algorithms are created to ensure that no matter how stressful the situation, that a certain set of actions is ensured for each patient, and a standard of care can be maintained under any circumstance. The more dire the affliction, the more likely it is that a protocol has been written to manage it.

According to the World Health Organization, in 2013, the leading cause of death in the developed world was ischaemic heart disease. One of the most used axioms we have in the emergency department is “Time Is Muscle”. When a patient arrives with chest pain, the goal is to have them diagnosed promptly and then undergo treatment within 30 minutes of arrival. It is imperative that diagnosis and treatment are done rapidly, as every minute that the patient’s heart is starved for oxygen results in irreversible muscle death.

The reason that I am outlining this is twofold. I want to convey that it is in everyone’s best interest to recognize a potential cardiac event, and I want to discuss what is new in the management of cardiac emergencies. As I discussed in part I of this series, the only way to safely navigate the medical system is to understand, as much as one can, about their unique medical needs, and provide effective, thoughtful advocacy for themselves.

Generally speaking, there are two types of cardiac emergencies: rhythm disturbances and ischaemic cardiac events. Explaining each in detail is beyond the scope of this article. To put it as succinctly as possible, there are at least 10 types of rhythm disturbances. Some, like atrial fibrillation, can be chronically managed, whereas others, such as ventricular fibrillation are devastatingly sudden and lethal. They are not reserved for the elderly, or medically frail, and can be seen across a wide age spectrum. They most often kill patients in their early 50’s. The survival rate of sudden cardiac arrest patients is less than 10%. (1) Many times, arrhythmias are the result of damage to cardiac muscle, caused by ischaemic cardiac events. There are a few things that can be done to improve those odds.

Ischaemic cardiac events are colloquially called “heart attacks”. They usually occur when a clot or plaque from a blood vessel becomes dislodged, enters an artery that supplies the heart with oxygen, and blocks cardiac muscle “downstream” from the clot from receiving nutrients and oxygen. The larger the clot, the more muscle tissue is affected. The single most important thing a patient having a heart attack can do, is recognize symptoms early, and seek immediate medical attention. What are the symptoms?

Chest pain is the most typical presentation. It doesn’t have to be severe. It is often described as crushing, heavy or pressure-like, but not always. I have lost count of the number of patients I have assessed that insist they are experiencing indigestion, when in fact they are having cardiac symptoms. Nausea is common, so is weakness, sweating and shortness of breath. Older women tend to present with atypical symptoms that we would call “sick, tired and weak”. They don’t often experience the classic, crushing chest pain. Diabetics very commonly do not have many, if any symptoms, but may see a sudden, unexplained spike in their blood glucose readings.

This is not an inclusive list (3), so please seek medical advice from your healthcare provider. It is important to understand your risk factors, gather as much data you can- from blood pressure monitors, glucometers, and now, even from home ECG’s. AliveCor has just had a single lead ECG device approved by the FDA, that not only can take a reading of the electrical activity of a heart, but it can be interpreted online by a medical professional with a subscription service. It is an attachment designed to work with your smart-phone device. (2) The lifesaving message for ischaemic cardiac events is early recognition and treatment. Personal telemetry and other measures of medical data are evolving, and are crucial to assisting a person in recognizing what is dangerous from that which is benign. From the moment that cardiac tissue is deprived of circulation, to the onset of tissue injury is about 20 minutes. By 6 hours, death of disrupted tissue is complete and permanent. (4) Move quickly and never be embarrassed to seek immediate medical advice.

Some of the most exciting, recent advances I have seen in cardiac care involve the treatment of sudden cardiac arrest. Now we are speaking of abrupt changes in heart rhythm that cannot support circulation, such as ventricular fibrillation and pulseless ventricular tachycardia, which lead very rapidly to death if left untreated.

These lethal arrhythmias often have little warning, and render the patient unconscious almost instantly. The only hope one has is if those around them have the tools and knowledge to step in and assist. There are things that we can do, to help improve the survival rates of our loved ones in such a crisis.

If you ever have the experience of calling 911, for a home emergency, you will notice that it takes emergency responders at least 10 minutes to arrive and begin patient resuscitation. In my entire career, I have seen less than 10 successful resuscitations of patients, where CPR was initiated by EMS or other emergency responders. It’s too late. Resuscitation efforts should not “wait for the experts”, but instead should be initiated by yourself. If nothing else is done, the patient is dead, and has a very low probability of revival. CPR has been completely rewritten to eliminate the need for rescue breathing, but instead to focus solely on good quality, uninterrupted chest compressions. The two most important things you can do are to learn effective CPR, and to have an AED in your home. An AED is an automatic external defibrillator.

They are becoming commonplace in public areas, but still quite rare in the home. This is easily remedied as an AED can be purchased by anyone, and may be the single, most valuable piece of equipment you will ever own. With prompt defibrillation and effective, immediate CPR (within 10 minutes of arrest), probability of survival can increase from a dismal 5% to 35%. (5) From experience attending countless “code blues” over the years, I can attest that these numbers may not seem like a lot, but they truly are remarkable.

The second exciting development in recent years is the application of post- arrest hypothermia to the management of patients to whom circulation has been restored. Research has demonstrated that reperfusion injury is a very lethal aspect of cardiac arrest. This is the damage done when circulation is restored to tissue. It involves an inflammatory cascade and biochemical changes that are also outside of the scope of this article, but in some studies, has been demonstrated to contribute to at least 50% of cardiac tissue death. Deliberate, therapeutic hypothermia for a 24-48 hour period, post arrest, has been proven to mitigate this effect, and greatly improve the survival and minimize the disability of the patient. (6,7)

Post-arrest hypothermia is quickly becoming the standard of care for all hospitals, and often is utilized in smaller centers, to give the patient time to be transported to a larger healthcare facility with specialized cardio-thoracic intervention resources, once stabilized and cooled. Research is currently underway to see if more profound hypothermia can be used for other types of shock, such as the hypovolemic shock encountered in traumatic and violent injury. (7) The takeaway message here is to go to your local hospital and find out if they are using this technique to manage cardiac arrest, and if not, ask why.

If you would like to learn more about early defibrillation, effective CPR and its relationship to successful patient resuscitation, and more about post arrest hypothermia, I strongly recommend the introduction offered via Coursera, at https://class.coursera.org/rosc-001. I also strongly encourage getting together with your loved ones and taking a CPR class together. http://www.heart.org/HEARTORG/CPRAndECC/CPR_UCM_001118_SubHomePage.jsp

Taking steps to understand more fully your risk factors for cardiac disease, taking an active role during the doctor’s visit by asking questions and taking notes, as well as learning how to save the life of a loved one are real, decisive steps to living a longer, higher quality life.

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