Damar Hamlin and ventricular fibrillation

I know this is an AFIB forum but is VFIB off limits?

IMHO - they were fast to do CPR last night but 8+ minutes is a little long to realize "oh shit this isn't working" and go for the AED. IDK and hope it's not the case but there might be some brain damage as a result. Hoping Carey and others can discuss what most of the nation is talking about today.

This is the best explantion I've found, there are some tech issues but still worthwhile.



[www.youtube.com]



Edited 2 time(s). Last edit at 01/03/2023 01:37PM by PavanPharter.

It took 8 minutes to get an AED on the field? WTF?! I thought having an AED available was standard for the NFL these days.

Whatever happened, I understand that they did initiate CPR almost immediately, and they did get a pulse back on the field, so those are positives.

That's my understanding. They were doing CPR for at least 8 minutes before they tried an AED. Would there ever be a need to continue CPR after an AED was used?

Bad stats on this - [www.ncbi.nlm.nih.gov]

Early defibrillation is critical for survival of CC. Unfortunately, resuscitation after CC is often unsuccessful.14,21,22 In a Link et al swine model, animals that were defibrillated in less than 2 minutes generally survived, whereas among those that were defibrillated in more than 4 minutes, fewer than half survived.9 AED use in animals within 1 to 2 minutes resulted in 100% and 92% success, respectively. Only 46% of shocks were successful after 4 minutes; after 6 minutes, success rates dropped to 25% (P < .0001).9 In human cases, resuscitation within 3 minutes resulted in a survival rate of 25% (17 of 68 cases); when resuscitation was prolonged beyond 3 minutes, the survival rate dropped to 3% (1 of 38 cases).7,21 The total survival rate from CC is approximately 15%,7,21 which has improved from 10% in 2001.13



Edited 1 time(s). Last edit at 01/03/2023 12:24PM by PavanPharter.

That's my take on it also Pavan. Although do we know the timeline for sure?



Edited 1 time(s). Last edit at 01/03/2023 04:32PM by The Anti-Fib.

Quote
PavanPharter
Would there ever be a need to continue CPR after an AED was used?

Yes, absolutely. There are several reasons why:

• If a shock doesn't restore a pulse, an AED will prompt you to resume CPR and won't provide another shock for 2 minutes.
• Sometimes a shockable rhythm can degenerate into a non-shockable rhythm. The shockable rhythms are ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT). No other rhythms are shockable, including asystole ("flat line"). Every single medical scene you've ever seen in the movies where they shock asystole is utter nonsense. An AED simply won't let you do that. A manual defibrillator will, but all shocking asystole does is lower the chances of restoring a pulse (and gets you disciplined by your medical director or the state health department).
• It's not uncommon for a patient who's been shocked back into NSR to go into VF again before they can reach a hospital. Not unusual since the most common cause of cardiac arrest is heart attack and heart failure, and being defibrillated doesn't make those things go away. (I've seen a person arrest 3 times on scene and then 4 more times in the ambulance on a 20-minute transport.)
• If there's a delay delivering a shock for any reason, CPR should be in progress. As a general rule, if there's no pulse and the AED isn't actively analyzing or shocking, CPR should be in progress without interruption.

Edited 1 time(s). Last edit at 01/03/2023 04:46PM by Carey.

Has anyone seen a video of the incident that covers the point from his tackle to EMS removing him from the field? All the videos I can find are from various news stations and those are so mamby pamby these days they won't show anything past the tackle. I really want to confirm it's true that it took them 8 minutes to get an AED. If that's true, somebody needs to slap the NFL and the team trainer upside the head. Also interested in how long he was in arrest because that's the main thing that will predict the outcome.

They have Ambulances on standby, so I am thinking that a defibrillator is standard equiptment on an Ambulance?

Maybe they just didn't have the medical personnel on the field to realize quickly, that you need to use an AED to break the Arrythmia.

Also the Bills players intentionally created a human visual shield, to block the view of what was going on. They used to do that sort of thing on the sidelines of football games, when an injured player was undressed and treated, before they had the little tents they use now.



Edited 1 time(s). Last edit at 01/03/2023 05:16PM by The Anti-Fib.

Sure, there's always going to be an EMS crew on duty at big events like this, and every ambulance in the US carries a defibrillator. Anyone certified in CPR knows you need a defibrillator, and I believe trainers are required to be CPR certified. The trouble with the EMS crew is they're most likely positioned to respond to fans, not players, so they could be minutes away. It was my understanding that all pro league trainers have AEDs (hell, most high school gymnasiums do). If they don't that's kind of ridiculous because this isn't the first cardiac arrest among players, and AEDs are inexpensive and trivially simple to use.

With the focus on concussions this year since the Tua/Miami incident my take was it was about at least a minute to 90 seconds before began CPR. I didn't DVR it but wish I did. ESPN covered the game and knowing the NFL they are clawing back any video out there. Yes - Bills did shield the scene but likely out of concern and not to obfuscate.

ESPN kept going to long commercial breaks and studio discussion and briefly showed what was happening on the field. To the best of my memory. I'll look for a video

Injury was at 8:55 PM

Team Drs were on the field in less than a minute

There was one attempt to put him in the ambulance that was aborted.

More CPR and or AED?

Ambulance departed at 9:25 PM

Hamlin might have had the condition called commotio cordis —I heard a doctor describe it and said sports players may have to wear chest protection. A player gets hit in the chest between heart beats and it stops the heart.

Yes CC mentioned above with a link to a paper [www.ncbi.nlm.nih.gov]

Carey - great answers! Thank you.

This article from CNN says that your supposed to give Chest compressions for 2 minutes after using an AED in the circumstance of Cardiac Arrest. [www.cnn.com]

Is this just a general guideline? and in reality a trained person would check the Vitals after the shock, and proceed based on whether a pulse was restored, giving O2 (mouth to mouth), if the person was not breathing on their own?

Yes, it's a general guideline and professionals would do largely the same, but there are distinct differences between professional CPR and community CPR. Pros would continue CPR any time the defibrillator isn't analyzing or shocking, just as laymen would, but they would also be ventilating the patient with a bag valve mask, which is different from community CPR. Community CPR no longer includes mouth-to-mouth at all. Plus pros would be intubating the patient, starting an IV for drugs, administering epinephrine, and so forth. Also, depending on their level of training (paramedic vs EMT), they will likely be using a manual defibrillator rather than an AED. Working a "code" is a team sport for pros, and it's an exhausting one.

The only vitals anyone should be checking during cardiac arrest is the presence of a pulse. There's no point in trying to measure BP, respirations, pulse ox, etc. until a pulse is restored.

I understand that Community CPR no longer includes mouth-to-mouth. But what if your 20-30 min away from help arriving? If you had an air bag mask then you would use it, and if not, then revert to mouth-to--mouth?
This happens all the time in rural areas, where someone goes down, and it's either wait for 20+ minutes, or try to transport the patient towards the Hospital as best you can. Sometimes you have to transport the patient yourself, and then try to meet the Ambulance out on the road halfway there.

There are two reasons why they changed the community CPR protocol to exclude mouth-to-mouth:

1. The ick factor. People are reluctant to do mouth-to-mouth with non-family members, for obvious reasons. And there may be vomit or blood present, which makes it even less likely someone will be willing to do CPR. So the thinking was that removing the mouth-to-mouth part would make people more willing to intervene. In hindsight, that was a timely decision because can you imagine who would have been willing to do mouth-to-mouth during the pandemic?
2. More importantly, researchers found that stopping chest compressions even just for the few seconds it takes to administer three breaths was more harmful than those breaths were helpful. They also discovered that chest compressions alone move enough air in and out of the lungs to suffice, so continuing compressions without interruption is actually more helpful than the old CPR protocols.

So if you're far from help and someone needs CPR, just initiate it and keep it up until help arrives. Chest compressions alone will do more for them than the old CPR protocol of pausing periodically to breath for them.

Oh, and driving them to meet the ambulance? NO! Never do that. You can't do CPR in a vehicle. The patient has to be lying on a flat, hard surface. I suppose you could do it in the back of a pickup, but now everyone in the back of that truck is at risk, you might miss the intercept with the ambulance, and all sorts of crap could go wrong. When CPR is needed, you move the patient out of danger but no farther. You fight the battle where you found them.

I keep a set of CPR masks in my emergency bag -

[www.amazon.com]

Also did Stop the bleed training and have Cat 7 tourniquets and QuickClot gauze


[www.amazon.com]

[www.amazon.com]

Thanks for the links PavanPharter, I ordered the CPR mask.

But there's no reason to use a CPR mask. Really. Not doing the ventilations improves CPR. No matter how counterintuitive that seems, it's true. The only reason professional CPR still includes ventilation is because they're never working alone and they have the proper equipment. They can continue ventilations simultaneously with chest compressions. You can't. I can't either, which is why I have a CPR mask from years ago but I will almost certainly never use it. I'll do community CPR as taught today knowing it's superior to old protocols.

Quote
Carey
But there's no reason to use a CPR mask. Really. Not doing the ventilations improves CPR. ... I'll do community CPR as taught today knowing it's superior to old protocols.

I was in the Canadian Military for 30 years. When we were in garrison, that is, not deployed on operations for short duration, say up to 6 months, we were required to have an annual refresher for 'First Aid'. Prior to an operational deployment, we had all the work-ups, right from a whack of vaccines and CPR, to fieldcraft, survival, gas chamber to verify mask fit and canister effectiveness, etc. Back in the winter of 2001, I prepared to deploy for peacekeeping in Bosnia-Herzegovina. At that time, we were told that mouth-to-mouth was no longer necessary. So, it has been a while.

I can remember quite clearly leaning over a colleague after lunch during the pre-deployment prep and getting a whiff of the roast beef he had ingested. I'm very happy I wasn't going to be obliged to get any closer to his mouth.

Quote
Carey
But there's no reason to use a CPR mask. Really. Not doing the ventilations improves CPR. No matter how counterintuitive that seems, it's true. The only reason professional CPR still includes ventilation is because they're never working alone and they have the proper equipment. They can continue ventilations simultaneously with chest compressions. You can't. I can't either, which is why I have a CPR mask from years ago but I will almost certainly never use it. I'll do community CPR as taught today knowing it's superior to old protocols.

OK, I believe you, but just trying to be prepared, as I was in situations growing up in a rural area where people were all of the sudden dying. What if your not alone? 2 people still just use chest compressions, vs one guy giving compressions, and the other trying to ventilate with CPR mask?

This paper shows a slight benefit to traditional CPR (" Conventional CPR is associated with better outcomes than chest compression only CPR for selected patients with out of hospital cardiopulmonary arrest, such as those with arrests of non-cardiac origin and younger people, and people in whom there was delay in the start of CPR."). However most of the research suggests the big deal is to get people to act and most are more likely to act with hands only CPR (i.e. hands only is much better than not acting). Several reasons: easier to remember so less fear of doing it incorrectly & also less fear of disease transmission.

If you've got two people present trained in 2-person CPR, by all means go for it. But if you're by yourself, the current guidelines of no ventilations are more effective.

One thing everyone needs to keep in mind is that if you're doing CPR for an extended period of time, the odds of the person surviving drop significantly with every passing minute. I've done CPR hundreds of times, and I've never seen a single person survive who went more than about 15 minutes. Actually, I've never personally seen anyone survive who wasn't defibrillated within the first 10 minutes or so. It happens, but we're talking a tiny percentage of cases, like well under 5%. The reason for the cardiac arrest is important too. Blunt or penetrating trauma? Forget it. The survival rate is nearly zero no matter what you do. The best odds are with hypothermia ("they're not dead until they're warm and dead") because hypothermia protects the brain, and electrocution because they started with a healthy heart.