Welcome to Talking All Things Cardiopulm. I am your host, Dr. Rachele Burriesci, physical therapist and board-certified Cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions, and patient experiences.
The goal is to learn, inspire, and bring cardiopulm to the forefront of conversation. Thanks for joining me today and let's get after it.
Hello. Hello and welcome to episode six of Talking All Things Cardiopulm. I am your host, Rachele Burriesci. So today we're gonna be talking all about Cardiac arrest and really bringing that to the forefront. One of my missions of starting this podcast was to be able to talk about cardiopulm conditions, pulmonary conditions, and bring it into today and to the forefront of conversation.
And while with this topic, I don't have to do the work, it's been at the forefront of conversation. And so I feel like I need to address it, talk about it, discuss it, and really start to break down some of the words around it. So I'm sure you all know we had an episode on January 2nd, uh, 2023.
Um, Buffalo Bills player, Demar Hamlin collapsed on the field and CPR was started on the field. This podcast won't be specifically about Demar because I can't speculate what happened. there hasn't been a lot of information given after his hospitalization. There are a few things that I'll talk about just to kind of put some words around.
What has been said, but I actually just looked prior to starting this talk and he has just been officially discharged from the hospital in Buffalo, so he's made some pretty significant improvements in a short bit of time. And this is a significant event and I really want to bring that to the forefront.
Cardiac arrest is no joke. The stats for survival are dire, and I really thought that the NFL did a great job of stopping the game and not restarting that day. And I just kind of wanna put words around the fact that it was very emotional. That was hard for a lot of people to see. The commentators were talking about the players crying and you can just see the suspense. Is he okay? I can't imagine his family being in the stands, having to witness and having no control. The point I want to make here is this is something that has never happened at an N F L game, but it is something that happens every single day in somebody's life, somewhere. In the hospital setting you have healthcare providers that deal with this type of trauma on a daily basis.
What happened that day was traumatic for Demar, for his family, for his teammates and for the league. That sort of trauma exists in healthcare on a daily basis. and I'm really glad that they did not push that game to start. I, I honestly didn't know if they were going to, but I was very happy to see that they just called it because you need a minute and sometimes more than a minute to really process what happened.
For those players, that's their teammate, that's their brother. That is someone that they spend more time with likely than their own family. It's scary. From a healthcare perspective, when that happens, if you have someone that has a syncopal episode, if you are involved in a code, if you are literally the person performing CPR, if you witness a code, if a patient collapses on you, you need a minute.
And I don't think that's always given. And this is something I talk to my students about if they're ever in an acute care. if something like that was to happen, even if it's just syncope, and I'm saying just because in the moment, a syncopal episode, even when your patient comes back, even when it's non-traumatic in the sense of it didn't escalate, it is traumatic.
It takes a minute to regroup, and you need that time.
This is something that happens often. I put a not-so-fun fact up on Friday, and that was 350,000 cardiac arrests occur annually and only 10% survive. Those are out of hospital stats. And just to kind of put some numbers around this, out of hospital, have improved, due to more training in the community, access to AEDs, ability for EMS services over the phone to be able to give instruction to the person who finds the person who collapses.
So there has been some improvement, but that's still, that number is still a scary, it's a scary number. Cardiac arrest is scary because the likelihood of being resuscitated and being able to be discharged from the hospital with minimal impact to your neurologic system, to your respiratory system, to your other organs is poor.
In-hospital stats are a bit better and have improved again. So I have two numbers here. In 2010, Sur survival for in-hospital cardiac arrest was about 20%. And then American Heart Association did another, um, there was another article and the Stats for Survival in 2020 were 36%. So that's, that's. . So, um, just understanding cardiac arrest at base is not a heart attack, and so there's a lot of, verbiage kind of around that.
Most people think they're synonymous. They're not, heart attack or myocardial infarction can lead to cardiac arrests, but they are not one and the same. So I'm not going to spend a ton of time on myocardial infarction today, but this is a problem within the vessels of the coronary artery. So the way I like to break it down is it's the.
We have obstruction, clogging of the plumbing. You have an obstruction in the coronary arteries that's decreasing blood flow to the myocardium. So the coronary artery's job is to supply blood to the myocardium, right? The heart's job is to supply blood to the whole body, it has its own system. The coronary arteries supply blood to the myocardium.
Each artery supplies a different aspect of the heart. It's a backup system, right? If one was to be fully occluded, the other parts of the hearts are still a heart is still being, perfused. And typically we have small arteries coming off the large branch that is also giving extra blood, collateral flow essentially is what we call it.
A heart attack or myocardial infarction is when one of those arteries, or more than one of those arteries is fully occluded. So this is something that typically occurs over long periods of time due to atherosclerosis or the buildup of cholesterol in those arteries, which decreases blood flow to the myocardium when you have decreased blood flow anywhere, you have decreased oxygen delivery to the heart tissue or to the muscle that it's supplying. When you have decreased oxygen, that usually produces pain. That pain in the heart is, is what we call angina. So before you're at full occlusion, you might have signs of said occlusion due to onset of angina with activity in a true myocardial infarction where you have a st elevation, you are going to have decreased blood flow to the heart tissue itself, which is gonna cause ischemia and in worst case scenarios, infarction, basically necrosis and death of the myocardial tissue, which is going to be a problem long term, that process can result in cardiac arrest. They're not one and the same.
Cardiac arrest is a problem with the electrical conduction system. Something happens to flip you into a ventricular rhythm, and that's honestly best case scenario because v-tach, vfib are shockable rhythms. Meaning if you collapsed and you are in vtach or V-fib and you put an a, e d on that patient, that machine will read that as a shockable rhythm, meaning that it will deliver a shock and hopefully that will basically retrip the system. Restart in a normal rhythm. Not every cardiac arrest is a Vtach, Vfib problem. It can also be a PEA, which is pulseless electrical activity, or asystole. Now, both of those rhythms are non-shockable, so you again, have better percent of survival if you have a shockable rhythm.
So let's talk a little bit about it. CPR, BLS, the importance of the village, the community. If you have never taken a BLS class, I highly recommend that you do. Honestly, you never know when you're gonna need that skill, and usually it's when you at least expect it. It could be a family member, a friend, someone that you don't know out in the community.
If someone was to collapse and you assess them and they have no pulse, no breath. , you should call 911 star chest compressions and have someone get an AED. That is best chance survival. It. You have a higher chance of survival if the collapse is witnessed. If it's not witnessed, you don't know how much time has passed before the start of, or you dunno how much time has.
Since you got there, right? So the longer the time, the person is unresponsive, no pulse, no breathing, the less likely they are to be able to be resuscitated. So there's some stats behind that. I believe it's uh, 45 minutes. You're going to hear my page turn cause I have some percents and facts here. Somewhere around the 20-minute mark is where the numbers will decrease for survival.
But witnessed being able to basically start the chain of command for emergency service is your best bet. Call 911 star chest compressions. Get an AED. So a question. Oh, sorry. A question a lot of people have is, do I have to do. mouth to mouth, the answer is no. If you're a bystander in the community, you don't have to do, um, breaths and the chest compressions technically hold a lot of weight in the ability to be resuscitated.
So chest compressions sort of outweigh in some shape or form. Obviously both is better, but if you do take a BLS class, you likely will get a pocket device. So a bag valve or. , portable mass sort of deal. Keep that on you. I have one in my car. I usually have one in one of my work bags. You just honestly never know, and you may never have to use it, but when you do, you'll be happy that you have it.
The other thing, the other thing I really recommend is starting to pay attention to AEDs in the community. You walk into a building, you notice an A, e, D, you notice it. Start to notice it, because. The faster an a e D can be brought to your person, the higher likelihood you have of survival. So there's a lot of luck behind cardiac arrest and being able to be resuscitated and live your life after.
Sometimes you are lucky that the right person is right. , right person, right place, right time, knows what to do, is able to start the whole process of emergency assistance. So you have a higher chance of survival. When we can identify the collapse, we call 9 1 1. We start chest compressions. We get an A, e, D, and then medical support helps and gets that person to the hospital.
So the earlier the cardiopulm, resuscitation and defibrillation occurs, the higher likelihood that patient has to survive. So just as a recap for some jogging of the memory, if you haven't had BLS in a while, when you are doing chest compressions, you are not restarting the heart. You are compressing the heart.
So essentially, when the electrical conduction system stops, you don't have electricity going to the ventricles to say, Hey, squeeze the heart. So the contraction of the heart to create or push cardiac output to the rest of the body. seizes. The chest compressions essentially takes the place of that. So when you are compressing the chest, you are basically causing contraction of the ventricle to push blood out to the rest of the body and basically provide some level of cardiac output.
When you are doing chest compressions, two hands over, mid sternum, usually around nipple level, hard and fast, you're gonna compress about five to six centimeters. allow for full recoil the chest at a rate of a hundred to a hundred beats per minute, which many people say is the rhythm of staying alive.
Staying alive. So as you're compressing, sing that song because that is what you are trying to manifest in that moment as well. When we do chest compressions, we do a set of 30 followed by two breaths. So if you're out in the field and you out in the field and you're a bystander 30 chest compress. Two breaths, 30 chest compressions, two breaths.
You should count out loud. If you have a second person there. You should be watching for quality of chest compressions. And this takes a lot of force and energy. And if your person, it looks like they're getting tired, you say We're switching on the next one. There is no, um, what is the word sensitivity in this moment if you are not providing high-quality CPR.
If you have the opportunity to switch, um, if you have a second person, hopefully that second person is able to locate an AED for you. You get that AED on the patient. It is self-explanatory. The machine does all the work. It tells you where to place the pads. It tells you to turn it on. It tells you if the rhythm is shockable, and it will warn you to not touch the patient while a shock is given.
This is super important that you are. When assessing or assisting someone else, because if you get hurt, then no one is gonna be able to get help. So it's super important that you always stay safe. Check the scene, make sure that you're not in water. Make sure that you are not touching the patient in any way, shape, or form when the shock is delivered.
If shock is able to be delivered, if no shock is advised, likely, that means the person's in a non-shockable rhythm, typically PEA or asystole. You continue to do chest compressions and breaths until, EMT arrives. So the chain of survival or chance of survival increases when it is witnessed. There's prompt start of cpr, it's a shockable rhythm, and you can get EMS services there and take them to the hospital.
Oh, there's my stat. 48 minutes at around 48 minutes. You have a 1% chance of survival if you have a shockable rhythm and if it's a non-shockable rhythm, about 15 minutes. So that's, you know, these numbers aren't, um, really in your favor. So super important if you’re not BLS certified. Get that certification.
American Heart Association has them all over the place. It's not expensive. Do your due diligence. You might be someone's luck that day. You might be a family member's luck that day, so key people around you. Safe. The title of this podcast is called Surviving Cardiac. Cardiac Arrest Takes a Village because it's exactly that.
Sometimes you're just in the right place, the right time when the worst thing happens to you. So the more people that can be BLS certified, or at least have some knowledge and what to do the better, the chance or survival. So while I was researching, because these are things that I see in practice I talk about, but I never dive into and technology is awesome.
So I'm always wondering, well, what's new? Um, so some things that are kind of coming up that are in the process. Number one, there's an app for that. So I haven't found the AED locator yet, but there is supposed to be an. That shows you where the nearest AED is, which would be awesome, especially if you're in a city-type area.
There's another app, actually, there's a few of them for people who are a BLS certified in your area, and if a cardiac arrest happened and it was notified that an alert goes out to the app, and if you were close to that location, you might be first person to arrive on the scene. So I thought, Awesome. And then there's a number of apps, basically walking you through how to perform CPR, which is, I think, fantastic.
It takes some of the onus off of you and in the moment, right, the, your adrenaline is going, are you gonna remember to go find the app that tells you how to do it? Maybe that has a metronome going. So there are possibilities, right? So these things exist and. I think it's super important that we all do our due diligence and keep the people around us safe.
So let's talk about a little bit what causes cardiac arrest. So one of the primary causes is myocardial infarction. Second is arrhythmia and heart failure. Heart failure. Our top three is like 50 to 60% of cases. Heart failure is a big one though, because that pulls in. The young athlete that collapses on the field on the court.
Most likely when a cardiac arrest occurs, it might be the first sign that something is wrong with that person's cardiovascular system. In the heart failure world, especially if you don't know and the person is young, there might be a history of congenital heart disease. There might be hypertrophic cardiomyopathy, very high risk, chance of sudden cardiac death with left, left ventricular hypertrophy.
So any of the hypertrophic cardiomyopathies are at high risk for cardiac arrest. So usually if patients or people know that they have. Hypertrophic cardiomyopathy. They tend to have an
ICD, especially in young active people because the purpose of an I C D is to defibrillate. If they were to flip into a rhythm like vtach, V-fib, some other causes.
So when you take a BLS, which is a higher level resuscitation, Uh, you learn about the four H's and T's. So the four H's are hypokalemia, hyperkalemia, hypothermia, hypovolemia, and hypoxia. Those are problems that can lead to cardiac arrest. This is why it's so important if you are a physical therapist or an occupational therapist or whoever else.
Nurses who work in the hospital and you are working with patients with electrolyte imbalance, do not ignore. Hypo and hyperkalemia have high risk chance of arrhythmia, specifically ventricular arrhythmias. So less than three, greater than six. Those are like numbers that you don't like to play with. So if you know your patient is an electrolyte imbalance, speak with your physician, speak with your team, see if there's a plan in place.
Supplement that electrolyte because it puts 'em at high risk for vtach, V-fib, which then will lead to cardiac arrest, hypothermia, hyperemia, very common in the hospital setting, as well as hypoxia. So the best way to prevent death with cardiac arrest is to prevent cardiac. So especially if you're in a hospital setting and things aren't going well and you are aware of these things, the point of that process is to support your patient to provide.
oxygen to supr to provide supplementation of potassium, whatever the issue is that they're there. And it's also the reason why rapid response teams were created. The point of a rapid response team is to basically assess patients that are deteriorating. So if patients are starting to decline and they're not coding in that moment, but they're getting worse, they're hemodynamically unstable, whatever it is that they're showing is worsen.
That team gets brought to that patient to basically stunt the progression of what's happening, and usually that results in transfer to an icu. So lots of different things have been put in place to help prevent cardiac arrest because even in the hospital setting, the percent of survival is not great.
It's actually interesting that they break a percent of survival based on location of patient in the hospital as well. So they'll break it down into like a regular room, a step-down floor, an ICU. And obviously the patients in the ICU have a higher, uh, chance or survival. The four Ts that are usually involved in cardiac arrests are tamponade, so you have inflammation around the.
Tension pneumothorax, thrombosis either in the cardiac or pulmonary system as well as other toxins. So there are a number of things that can basically trigger decline in the patient that can lead to cardiac arrest, some of which from a clinician in the hospital setting you would know is occurring based on a good chart review or assessing your patient.
So my advice is always, do not ignore what you observe because you don't wanna be in a situation where you're pushing a patient who is hypokalemic or hyperkalemic and fill in the blank, and then they start to decline further while you're pushing their exercise capacity or goals for the day. Sepsis is also a really, uh, common reason for cardiac arrest.
So if patients are in the hospital with sepsis, that can lead to organ failure, which can lead to cardiac arrest. Cardiac arrest can lead to organ failure, so dependent on the how much time the patient is down, the patient is not being perfused, oxygenated blood to their brain, to their lungs, to their liver, their kidneys.
Major important organ. Can lead to organ failure and the problems that kind of evolve from that can typically be the cause of mortality as well. So pay attention to your patient. Um, when those signs are there, don't ignore them because the progression is worse, right? If you can stunt something before it happens, you have a better chance of improving that outcome. So your patient has a cardiac arrest, they get to the hospital. There are a couple of things that are typically put in place for post-cardiac arrest care, uh, one of which is targeted temp management. And so this was discussed with Demar Hamlin as well. And essentially they are dropping the temperature of the body for at least 24 hours and for patients or hospitals, physicians may choose to do this longer, but this is primarily used to basically maintain neurologic protective reasons. So very common to use targeted 10th management to help protect the neurologic system, but it also has some benefit for the hemodynamics as well. Patients typically are put on mechanical ventilation, post cardiac, re cardiac arrest.
When you are in a mechanical vent, you are able to control, a lot of different settings. Tidal volume, how much oxygen is being delivered. Respiratory rate, you can control the system a bit more and ensure that you're having good oxygenation. So it's important to maintain oxygenation, especially in an event where your heart just stopped, right?
Because you just stopped pushing oxygenated blood to the rest of the body. So the mechanical. Can help protect the lungs as well. And also ensure oxygenation is occurring properly to support your major organs. Your lungs are the most vulnerable organ postcard arrest. And this is actually something that I learned because I was digging for, for a specific piece of information that I didn't quite find the answer to, but I kind of got there.
Your heart and lungs are like a married couple, your right side of the heart feeds ox, um, deoxygenated blood to the lungs to get oxygenated the lungs, oxygenate the blood, and return them to the left side of the heart. So they're constantly working together. If the heart was to stop, you're not getting blood flow to the lungs.
So there's a process that occurs that, number one, you're not getting, you're not getting oxygenation to the lungs itself. And there's this event that occurs once the heart restarts and it basically triggers an inflammatory response, and the lungs are a little susceptible to that. So typically after cardiac arrest, you're going to have elevated inflammatory markers, including CRP.
So acute respiratory failure is super common post-cardiac arrest, which is also the reason for mechanical ventilation, to basically create protective settings to protect the lungs, oxygenate the body, and hopefully give the best.
Okay. The last piece I wanted to talk about was also in relation to some of the speculation as. , why this occurred in DeMar Hamlin, and I don't have the answer, but I I did wanna at least talk about it. So Commotio Cordes was one of the first things that popped up when you Googled DeMar Hamlin collapsed on field.
Commotio cordis is a very specific cardiac event that typically occurs due to blunt trauma force to the chest. So this is most commonly seen in. and it's actually more commonly seen in young athletes. So 15 years of age is the most common age and younger. And the reason is, is when their blunt trauma force hits a patient, uh, or person who is 15 years of age, their chest wall is thinner, less stiff, has less protection than someone who is in their twenties, thirties, forties.
So age is actually a really important piece of it. Um, there's also a lot of talk about the specific type of hit, the force of the hit, the location of the hit, and what is hitting the chest. So the size of whatever is hitting the chest is important. The baseball is like the quintessential size, The size, the hardness of material that's hitting the chest wall at a specific speed.
So usually around 30 miles per hour and above 30 to 40 miles per hour is the two numbers that they kept, um, talking about in the article I was reading because at that speed you're going to basically trip the wiring but not cause contusion because contusion is a different issue. So, 30% of, um, and in this case, this, this research article was related to animal testing at 30 miles per hour of a, with, with a baseball.
30% of those. S it was swine, um, went into vfib and then 50% at 40 miles per hour, I believe it was 60 miles an hour and above started contusion, which creates a different issue. So what's happening in Commotio cordis is that the baseball basically hits the anterior wall of your left vent. and it's like perfect timing.
So in your electrical conduction system, you have a P wave, then an isoelectric line, which allows for time to fill a QRS complex, which is your ventricular depolarization when the ventricles are contracting and then you have. A T-wave and right before that T wave, you have another basically tiny isoelectric line before it kind of hits the T-wave.
And the T-wave indicates repolarization or relaxation of the ventricle. So during repolarization we have an efflux of potassium, and this is considered the most vulnerable part of the electrical conduction system. If you were to have a PVC fall on the up slope of the T-wave, that creates a phenomenon that basically throws that person into a ventricular rhythm.
So that T-wave or in introduction into the T-wave is a very vulnerable point in your ECG. Okay, so it's like perfect storm. , the hardness of the ball, the speed of the ball, the location of the hit hits the anterior left ventricle right on the up slope of the T-wave, and bam throws you into V-fib. So it's straight to V-fib versus Vtach to Vfib two, Asystole.
Vfib is a little bit more severe than vtach because it's less. and it has a smaller amount of amplitude with contraction. So basically you start to get a squiggly line, which gets smaller and smaller and smaller. So fibrillation means that it's just quivering. So it's a, it's not a full contraction.
And so it begins to become more unstable the longer the time goes. So Commotio cordis is a cardiac event that occurs due to blood trauma. To the chess wall, typically in young males in the sport of baseball, because the hardness of the baseball, the speed of the baseball and the size of the baseball hits at a perfect location at a perfect time in the ECG rhythm.
Um, 35% of people with commotio cordis are able to be resuscitated. So the last question is, is can commotio cordis occur in other. The answer is yes, but it happens less frequently. So the other two sports that you typically see it, or three now, is hockey, softball, and lacrosse. Sorry, that took me a second.
Um, but it doesn't always occur because of the ball. So lacrosse ball actually makes sense. But, uh, players with lacrosse wear chess protectors. Hockey also has some sort of, uh, protection. So a lot of the time it's that. actual chess protector moves out of the way when that hit occurs. But as I said that another piece, uh, or another article, article I was reading about, commotio Cordis talked about that the most likely people to be affected by Commotio Cordis in a baseball game is the catcher, the batter, or the pitcher.
So now the catcher has chest protection and one of the articles basically says that the chest protector is not enough to. Commotio Cordes, and I was actually very surprised by this, but that was, um, one of the pieces of information that that article gave. So it could just be that the protection isn't enough, that the forest, the size of the ball is significant enough and hits at the right time at the right point.
The other piece was that, especially in Little league and the, the younger ages, that they're trying to change the hardness of the ball. So they have safe, they call them safety balls, so they're basically softer than an average or a typical baseball. And so that has helped decrease, decrease incidents of commotio.
So I wanted to put those terms out there because we're hearing in them in the news, we're very involved in wanting to know if DeMar Hamlin is doing well, what are gonna be the next steps for him. All the questions I still have, and like I said, I don't have the answers, but I will be curious if they do announce cause of collapse.
Um, commotio Cordis has been thrown around. I'd be curious if we're talking hypertrophic cardiomyopathy. That was just never. Addressed or known. Um, I'd be curious if there's talk of i c d placement post, however, um, is he wearing a life vest or anything like that? From my understanding, I think the answer is no.
He's not wearing a life vest, but I also don't know. But these are the questions that I have. And I really thought it was important to bring this to the forefront because this is literally in the news on the daily. We're all invested, we're all looking out, lots of prayers for Demar Hamlin and also the process and, and prayers for the teammates, right?
The processing of such a traumatic event. The other thing I wanted to bring to the forefront, which I already mentioned, is that this happens in the community. 350,000 cardiac arrests per. We as community members, as people who are involved with other people, can do our due diligence and BLS certified know what to do when this happens because.
Even if you don't know exactly what to do, doing something is better than nothing and likely increases the chance or survival for someone, whoever that is, even if you don't know the person, you literally might be someone's lucky day. So with that, do your due diligence. Get BLS certified, learn CPR, look up an app for that, because they exist, and when I find the ones I like, I will post them.
But yeah, I want to put some words around that. Wanted to discuss it a little bit and basically just give some rationale as to why this happens and what it means. So hopefully this was helpful for you. I'll be on the lookout to see if there's any changes or updates on Demar Hamlin. I think they did a really great job of protecting his confidentiality.
At the end of the day, he is still a patient and being a health healthcare professional, HIPAA is always at the forefront, right? So I didn't expect to have all of the information put out there, and I, I really. Um, I'm proud of the team that has been taking care of him to, to, to hold to that because that's super important.
So hopefully this was helpful for you. Um, if you have any questions, if you have any concerns, if anything else comes up that you are interested about, shoot me a DM, write me an email. I am always excited to hear from you, and that's all I have. So have a wonderful day and whatever you have to do, get after it.