Discovery

Emergency Medicine Research: Making Every Second Count

By Jaron Terry, APR

In addition to breakthroughs in pharmaceuticals and biomedical technology, some of the greatest health-care advances of the past 50 years have come in emergency response systems and in hospital emergency and trauma care. Researchers in The Ohio State University Department of Emergency Medicine have dramatically improved health and survival in emergency rooms across the country by writing new guidelines for cardiopulmonary resuscitation (CPR), cooling trauma patients and making ultrasound portable.

To be able to provide emergency patients with the most recent, evidence-based care as quickly and safely as possible requires research and the creation of new knowledge and new therapies,” says Douglas Rund, MD, who chairs Ohio State’s Department of Emergency Medicine.

Approximately every 25 seconds, a coronary event occurs in the United States. Given that startling statistic and the American Heart Association’s prediction that in 2010, 785,000 Americans will experience a new coronary event, it’s not surprising that the heart is a major research focus at Ohio State.

“Along with trauma, sudden cardiac arrest (SCA) is still among the more serious problems seen in emergency departments across the nation,” adds Rund. “In fact, when I first joined the Department in 1978, the outlook for patients experiencing SCA was rather grim.” Since then, significant strides have been made – most recently in the introduction of Hands- Only CPR, which Rund notes has brought considerable acclaim to Ohio State.

Cardiac Events Defined
SCA – Sudden cardiac arrest is the immediate cessation of the heart beat, followed by the absence of breathing and blood circulation. Without quick intervention, such as CPR and defibrillation, death is certain. Usually, the patient is immediately unconscious without normal breathing. According to the American Heart Association, 310,000 people in the United States die each year from out-of-hospital SCAs.

MI – Myocardial infarction, also known as “heart attack,” is the destruction of heart tissue caused by an obstruction of blood supply to the heart. Usually, obstruction is caused by a blood clot or by narrowing of the arteries. Although the window for treatment (generally cardiac catheterization) varies depending on the severity and location, onset of symptoms is usually more gradual and the victim remains awake, able to breathe and talk, for some time.

Every Second Matters
“For a variety of reasons, people are reluctant to provide CPR for someone experiencing SCA,” says Michael Sayre, MD, associate professor and leader of the Department of Emergency Medicine’s Resuscitation Research Program. “Either they have not been trained in CPR, are uncertain of their skills or are unwilling to provide the mouth-to-mouth (breath) portion of CPR to a stranger.”

Sayre hopes to increase SCA survival through his work in simplifying CPR. As national chair of the American Heart Association (AHA) Emergency Cardiovascular Committee, he has been instrumental in developing the AHA’s new guidelines using the innovative Hands-Only CPR model.

“Bystanders who witness the sudden collapse of an adult should immediately call 9-1-1 and start Hands-Only CPR, which involves administering high-quality chest compressions by pushing hard and fast in the middle of the victim's chest, without stopping, until emergency medical services (EMS) responders arrive,” explains Sayre, who also co-chairs the Basic Life Support Task Force for the International Liaison Committee on Resuscitation.

Without immediate, effective CPR from a bystander, a person’s chance of surviving SCA decreases 7 to 10 percent per minute. On average, fewer than one-third of out-of-hospital SCA victims receive bystander CPR, which can double or triple a person’s chance of survival.

The new AHA recommendation for Hands-Only CPR for adults who suddenly collapse is an update to the 2005 guidelines, which recommended that lay rescuers use Hands-Only CPR only if they were unable or unwilling to provide breaths. The update puts Hands-Only CPR on par with conventional CPR when used for an adult who has suddenly collapsed. This significant change is supported by evidence published from three separate large studies in 2007, each describing the outcomes of hundreds of instances of bystanders performing CPR to SCA victims. Hands-Only CPR not only is easier to remember, but also results in a greater number of chest compressions, with fewer interruptions, prior to arrival of more advanced care.

Translating Findings
In the mid-1980s, Ohio State investigators began basic research to determine the most effective treatment for SCA. Today, Mark Angelos, MD, extends that work in Ohio State’s Laboratory Research Program, where he and his colleagues are working to understand and identify optimal reperfusion conditions to provide a higher success rate in restarting the heart after SCA.

“With SCA, there are only a few minutes to restart the heart – between four and nine at most – before mild to severe brain damage occurs,” says Angelos. “Our lab is looking at reperfusion – or how blood flow is re-established – in terms of oxygen free radicals that flood into the heart when it is restarted. These can be quite damaging, and our goal is to understand how this process might be controlled.”

Staying Cool
“We’re investigating other ways to facilitate normal recovery following a cardiac event,” says Sayre, who was the Ohio State site investigator in a multicenter clinical trial that tested cooling techniques to minimize damage to the brain after cardiac arrest.

“By cooling the brain, metabolism is slowed, thus slowing down or stopping brain damage commonly seen in these situations,” he explains. In this study, patients whose families agreed to participate were randomly assigned one of two different methods of cooling. One technique used traditional cooling blankets and ice bags, while the other used a special cooling machine. The goal of the study was to determine the optimal way to reduce the body temperature.

“Cooling a patient who remains in a coma after a cardiac arrest increases the chance from 40 to about 60 percent that the patient will have a normal recovery. We hope cooling patients after cardiac arrest will soon become normal practice,” Sayre adds.

Timely Treatment
“Emergency cardiac care has changed a great deal in the last quarter century,” Rund points out. “Before early cardiac catheterization and thrombolysis, we had to take a wait-and-see approach, trying to make patients as comfortable as possible and trying to prevent arrhythmia, heart failure and other complications.”

Ohio State’s departments of Emergency Medicine and Cardiovascular Medicine and the Center for Emergency Medical Services recently launched a new, collaborative initiative to reduce the amount of time it takes for patients experiencing the most serious type of heart attack to receive cardiac catheterization. STEMI, or ST-segment elevation myocardial infarction, occurs when a coronary artery suddenly becomes blocked, causing heart tissue to die.

The new STEMI program provides equipment for EMS technologists to communicate with Emergency Department clinicians to identify this type of heart attack and transport patients directly to Ohio State’s Ross Heart Hospital for treatment.

Taking a Quick Look Inside
Another major step forward in emergency care is being championed by David Bahner, MD, RDMS, who has piloted portable ultrasound devices to obtain faster diagnoses in critical situations.

“Ultrasound is a ‘green’ form of imaging, in that it is less expensive and safer for the patient, because no radiation is involved,” says Bahner, who serves on the Board of Governors for the American Institute of Ultrasound in Medicine. His research, which has been internationally presented, focuses on educating clinicians – including medical students – on how to use the device.

The new screening tool is not intended to replace other imaging modalities, such as MRI, CT or X-ray, but it provides a rapid assessment by allowing physicians to perform diagnostic ultrasound at the bedside rather than sending patients out of a treatment room for imaging. The “Trinity protocol” advocates that, for a critically ill patient, three separate exams are initiated to look inside the body to quickly answer “yes-or-no” questions – such as, “Is there fluid in the abdomen?” – to enable more timely care.

Passing It On
“An important part of our mission is educating emergency physicians of the future, and we pride ourselves on our residency and fellowship programs – the breadth of experience and forward-looking curricula we provide,” says Rund. The program offers five fellowships annually. The three-year residency program accommodates 36 individuals, with 12 in each year. “There is one thing of which we can be certain: thanks to our research efforts and those of others, emergency medicine will continue to evolve, providing improved care and better outcomes,” he adds.

Story Summary
• Ohio State’s Department of Emergency Medicine has been an innovator in improving emergency medical care nationwide for nearly 40 years.
• Ohio State physicians were instrumental in developing the American Heart Association’s new Hands-Only CPR guidelines, which can double or triple a sudden cardiac arrest victim’s chances of survival.
• Ohio State Emergency Medicine physicians and scientists are studying post-trauma cooling techniques, heart perfusion processes and portable imaging devices, among other improvements, to increase survival and speed recovery for emergency and trauma patients.