Hi Everyone
11 years back a professional footballer collapsed on field in UK. He was in cardiac arrest and successfully resuscitated, diagnosed with a dysrhythmia and treated definitively with an implantable cardiac defibrillator. He could no longer continue as a professional footballer but carried on living a near normal life being a son, brother, husband and father. It could easily have been a tragic end, but a lot of things happened on that day which helped him return back to his near normal life after this life changing event. A year back Karnataka and India were shocked to hear the news of the collapse and death of a film and public superstar. He was only in his forties and was known to be super fit. In recent times most of you might have come across the news of a young person (possibly in 30s/40s/50s) having a tragic early end of his life after suddenly collapsing. In this little reflective writing, I wanted to give junior doctors and allied health professionals some basics about common causes, initial approach and international standards in management of these patients. Please feel free to add comments and forward this to others who might benefit from this article.
A sudden collapse of an adult from standing or sitting position is a rapid event with very little forewarning in most cases. There are only two body organs which can do this to a human being- the brain and the heart. If the primary problem is the brain, they could have a preceding sudden onset of a headache, but this is not always the case. It is the more or less the same for pathologies of the heart. The commonest underlying pathology in both organs is related to the vascular supply. In the case of the heart, it could be due to the electrical wiring of the heart (a dysrhythmia). The most important link in the survival chain of such patients is the provision of appropriate immediate care immediately after a collapse. In the vast majority of situations such care needs to be provided by somebody who is not a health professional. The footballer in the previous paragraph was fortunate to collapse on a football field during a professional match where well-trained paramedics, doctors and nurses are available right next to the playing field. It is mandated by the English football association to have such a support facility at all such matches. There are other health and safety measures mandated in various public places in UK and other well-developed nations the chief among this being training of employees in BASIC LIFE SUPPORT and provision of AUTOMATIC EXTERNAL DEFIBRILLATORS(AED) in key public places like shopping malls and sports facilities like gyms and sports fields. Personally, I felt ecstatic when the UP Chief Minister made arrangements for all governmental offices to be provided with AED. Something which could be emulated by other chief ministers in India.
The person who collapses from a brain pathology is commonly suffering from either a sudden bleeding in the brain (subarachnoid or intraparenchymal) or a large blood clot (cerebrovascular event/Stroke). Other common cause is epilepsy, but this is usually characterized by typical involuntary jerky movements and in the vast majority of cases does not lead to a fatal outcome. Therefore, the key focus for healthcare professionals is to correctly identify the underlying pathology of either a large bleeding or a large clot. The gold standard investigation for this is a CT scan. However, the priority even before the CT scan is to ensure appropriate immediate care in the form of BLS and safe transportation to an appropriate healthcare facility (somewhere were a good quality CT scanner and radiologist is available immediately). Even better would be a place with a good quality emergency physician, anesthesiologist, intensive care specialist, neurologist, neurosurgeon and interventional radiologist. A lot of lives in India are lost because this chain of survival gets broken in multiple places. Only a small proportion of members of public are trained in provision of first aid/BLS, very few cities have access to good quality prehospital team(paramedics/doctors), many times they are taken to a healthcare facility which does not even have the basic facilities needed for immediate care of these patients etc.
The person who collapses from a heart pathology commonly is either having a heart attack (blood clot in the arteries which supply blood to the heart) or is having a fatal cardiac dysrhythmia. In these patients once again the key to survival is good quality immediate care in the form of BLS, however the one single factor which can significantly increase survival percentages is early access and use of a defibrillator. A heart which stops beating suddenly commonly is in ventricular fibrillation (VF). This is a potentially reversible rhythm if there is immediate provision of BLS and use of defibrillation(shock). The easiest and most effective way to achieve this would be train as many members of the public as possible on BLS and ensure that AED is available at strategic places in key crowd gathering venues around a city and in all emergency response vehicles(ambulances). This needs an impetus from a governmental level and will only happen if the regional health minister and chief minister takes an initiative. Doctors in general but emergency physicians and cardiologists in particular need to lobby these decision makers for such a move in every single state in India.
Basic life support used to be complicated many years back. Maybe the thought of giving mouth to mouth breathing to a random stranger puts off most people. The good news is that this is no longer part of basic life support teaching and training. research over the years has shown that simply providing good quality chest compressions alone at the right rate and depth will save lives without the need for breathing support (mouth to mouth breathing). These days well qualified paramedics and doctors have other easier ways to deliver breathing support during advanced life support (ALS). Small pocket masks with a one-way valve, bag and mask ventilation and supraglottic airway devices(I-gel) have revolutionized ALS and emergency care. I am hoping for a day when India and other similar low/medium income countries make training in BLS mandatory for all school children, employees and citizens. I think it is as important as learning ABDEFGH...Z. In BLS you can stop with just ABCDE! And someday even a common man could get a chance to save somebody's life. As an emergency physician I can guarantee you there is no better feeling you can ever get compared to the ecstasy you feel when you have successfully resuscitated a collapsed person.
Automatic external defibrillators are nifty little gadgets no bigger than a small suitcase and can be securely mounted in strategic public places and be easily carried by emergency responders(paramedics/doctors) in the back of an ambulance or the boot of a car. The additional advantage is that you need no medical knowledge to use these gadgets. They are so beautifully designed that the machine talks you through the steps needed and in most developed countries there is a helpline number which is manned 24/7/365 by trained health care professionals who can talk you through this at the end of phone. My aim in the next few months is to have at least five of these installed in strategic places in my hometown in northwestern Tamil Nadu. If this is successful, I am hoping to lobby the government with the help of other like-minded doctors from IMA, SEMI and Cardiology societies to implement this plan across all towns and cities in Tamil Nadu and beyond.
If anybody reading this is enthused about providing BLS training or be involved in the project to place AED in public places, please email me on drgarun@gmail.com. Every little help will be useful. I have provided a link for some useful websites for further reading. Please have a look at them.
Thank you for your patience in reading this article. Please feel free to add comments/feedback. Please forward it to others who will benefit from reading this.
Sudden Cardiac Arrest: Causes & Symptoms (clevelandclinic.org)
Sudden cardiac arrest - Symptoms and causes - Mayo Clinic
Sudden Cardiac Death - StatPearls - NCBI Bookshelf (nih.gov)
Learn CPR in 15 minutes | RevivR | BHF - BHF
Basic Life Support BLS Training | American Heart Association CPR & First Aid
3.BLS-Algorithms-STEP-BY-STEP.pdf (cprguidelines.eu)
Provider Course Manual for Paramedics.pdf (mohfw.gov.in)
Basic Life Support (BLS) Course in Delhi, Mohali, Mumbai & Pune (smart-academy.in)
Automated external defibrillators: Do you need an AED? - Mayo Clinic
What Is an Automated External Defibrillator? (heart.org)
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