Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations

Réanimation cardiopulmonaire : nouvelles recommandations

Manual chest compressions for cardiac arrest – With or without mechanical CPR?

Thank you for the opportunity to respond to the letter by Dr Hogan concerning resuscitation for cardiac arrest caused by anaphylaxis during anaesthesia. First, Dr Hogan questions the use of a pulse check to diagnose cardiac arrest with pulseless electrical activity (PEA). Second, Dr Hogan suggests that external chest compressions are potentially harmful in PEA caused by anaphylaxis and other states where there is a profound decrease in systemic vascular resistance because loss of a palpable pulse can occur in the presence of a cardiac output and low systemic vascular resistance. Cardiac arrest secondary to anaphylaxis can occur rapidly following a rapid decrease in the patient’s blood pressure [1]. The precise moment when PEA cardiac arrest occurs is difficult to diagnose clinically. Palpation of the pulse as the sole indicator of the presence or absence of cardiac arrest is unreliable [2]. A pulse check alone to diagnose cardiac arrest has not been part of advanced life support guidelines for many years [3]. Dr Hogan is therefore correct that the absence of a palpable pulse alone should not indicate the need for chest compressions if there are other reliable indicators of the presence of an adequate cardiac output. During anaesthesia, continuous monitoring of vital signs in addition to clinical signs will help make the diagnosis. The most recent guidelines for advanced life support reinforce the important diagnostic role of waveform capnography to indicate the return of a spontaneous circulation [4]. Current guidance for the treatment of anaphylaxis from both the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the Resuscitation Council UK suggests using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach with adrenaline and intravenous fluids as key treatments [5, 6]. Adrenaline should be given in small intravenous increments (e.g. 50 μg in adults) or an infusion, if necessary, to treat anaphylaxis during anaesthesia. These treatments may have already started before cardiac arrest occurs and may be useful in the scenario Dr Hogan describes. If cardiac arrest does occur, standard advanced life support guidelines should be followed [7]. These include high quality chest compressions combined with adrenaline and fluid resuscitation. The recommended doses of adrenaline used during cardiac arrest are much higher (1 mg intravenously in adults). Care therefore needs to be taken to confirm cardiac arrest before giving this significantly higher dose of adrenaline. Although chest compressions are undoubtedly less effective in the presence of hypovolaemia, we are not aware of any evidence that chest compressions reduce cardiac output in the presence of a low blood pressure, regardless of whether this has been caused by a low cardiac output or a vasodilatory state. There are few data to provide a basis for specific guidance on the treatment of cardiac arrest from anaphylaxis during anaesthesia. The current guidance may prevent cardiac arrest in many circumstances, and ensures that cardiopulmonary resuscitation with advanced life support measures is started early if cardiac arrest occurs. Following standard guidelines for advanced life support importantly acknowledges the fact that there may be clinical uncertainty about the cause of cardiac arrest during anaesthesia. If the anaesthetist is unable to feel a pulse, chest compressions should be started unless there are other convincing and reliable indicators of the presence of an adequate cardiac output. JS chairs the anaphylaxis working group of the Resuscitation Council UK and contributed to the AAGBI anaphylaxis guidance. He is an editor of Resuscitation. JPN is a member of the anaphylaxis working group of the Resuscitation Council UK and is Editor-in-Chief of Resuscitation. No external funding declared. Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com.

Effectiveness of different supralottic airways during resuscitation manoeuvres. A systematic review

Animations for teaching the recognition of cardiac arrest

Lateral versus anterior thoracic thrusts in the generation of airway pressure in anaesthetised pigs

It is estimated that approximately 60 000 out-of-hospital cardiac arrests (OHCA) occur in the UK each year.1 2 Resuscitation is attempted by emergency medical services (EMS) in <50% of cases, with non-resuscitation decisions being undertaken according to national guidance.3 The Ambulance Service Association first noted variability in outcomes from cardiac arrest between 2004 and 2006 with return of spontaneous circulation rates ranging from 10% to 25%.1 Recent data from the Scottish and London Ambulance Service confirm similar variability in survival to discharge rates of 1%4 and 8% respectively.5 As part of the focus on improving quality of care, the Department of Health for England introduced survival from cardiac arrest as part of the Ambulance Service National Quality Indicator set in April 2011. Return of spontaneous circulation and survival to hospital discharge rates are reported for all patients who have resuscitation (advanced or basic life support) started/continued by an NHS ambulance service after an out-of-hospital cardiac arrest.6 The first results were published in September 2011 and are summarised in figure 1. Incidence data are not reported, however, as a surrogate measure comparing the number of cardiac arrests with total number of category A 999 calls shows more than threefold differences between services (range 5.2–17.6 per 1000 category A 999 calls). Survival rates similarly show 3–5 fold variability (13.3–26.7% for return of spontaneous circulation upon arrival at the emergency department and 2.2–12% for survival to discharge). This variability …

Despite the overall improvement in cardiovascular disease outcomes in the past decade, the survival of people following an Out of Hospital Cardiac Arrest (OHCA) has remained relatively low, at about 5 to 10% (Sasson et al, 2010). This lack of improvement in OHCA survival is disappointing, however, there are currently several promising interventions emerging that demonstrate the potential to improve these outcomes in the future. The well-established methodological chain of survival that follows as rapidly as possible after an OHCA event, and the two procedures involved therein, can only be said to be as strong or reliable as the weakest link, with the central links depicting the integration of cardiopulmonary resuscitation (CPR) and defibrillation as the fundamental components of early resuscitation in an attempt to restore life (Nolan et al 2006).

IntroductionTherapeutic hypothermia (TH) after out-of-hospital cardiac arrest (OHCA) was adopted early in Norway. Since 2004 the general recommendation has been to cool all unconscious OHCA patients treated in the intensive care unit (ICU), but the decision to cool individual patients was left to the responsible physician. We assessed factors that were associated with use of TH and predicted survival.MethodWe conducted a retrospective observational study of prospectively collected cardiac arrest and ICU registry data from 2004 to 2008 at three university hospitals.ResultsA total of 715 unconscious patients older than 18 years of age, who suffered OHCA of both cardiac and non-cardiac causes, were included. With an overall TH use of 70%, the survival to discharge was 42%, with 90% of the survivors having a favourable cerebral outcome. Known positive prognostic factors such as witnessed arrest, bystander cardio pulmonary resuscitation (CPR), shockable rhythm and cardiac origin were all positive predictors of TH use and survival. On the other side, increasing age predicted a lower utilisation of TH: Odds Ratio (OR), 0.96 (95% CI, 0.94 to 0.97); as well as a lower survival: OR 0.96 (95% CI, 0.94 to 0.97). Female gender was also associated with a lower use of TH: OR 0.65 (95% CI, 0.43 to 0.97); and a poorer survival: OR 0.57 (95% CI, 0.36 to 0.92). After correcting for other prognostic factors, use of TH remained an independent predictor of improved survival with OR 1.91 (95% CI 1.18-3.06; P <0.001). Analysing subgroups divided after initial rhythm, these effects remained unchanged for patients with shockable rhythm, but not for patients with non-shockable rhythm where use of TH and female gender lost their predictive value.ConclusionsAlthough TH was used in the majority of unconscious OHCA patients admitted to the ICU, actual use varied significantly between subgroups. Increasing age predicted both a decreased utilisation of TH as well as lower survival. Further, in patients with a shockable rhythm female gender predicted both a lower use of TH and poorer survival. Our results indicate an underutilisation of TH in some subgroups. Hence, more research on factors affecting TH use and the associated outcomes in subgroups of post-resuscitation patients is needed.

目的：探讨早气管插管对提高急诊窒息病人心肺复苏(CPR)成功率的影响。方法：回顾性分析2008年2月到2015年2月两所医院急诊救治的86例因窒息导致心脏骤停患者。其中心脏骤停后胸外按压5分钟内给予气管插管术48例，超过5分钟以上时间给予气管插管术38例。所有病例均施与人工胸外心脏按压，肾上腺素静注，以及在适应症范围内电击复律等抢救措施。结果：因窒息导致的心脏骤停5分钟内给予气管插管术的48例中，32例复苏成功，成功率67%，有效43例(90%)；超过5分钟以上时间给予气管插管术的38例中,抢救成功3例(8%)，有效20例(53%)。结论：因窒息导致心脏骤停的病人早期进行气管插管术配合常规心肺复苏处理提高了心肺复苏的成功率。 Objective: To investigate the success rate of cardiopulmonary resuscitation by early endotracheal intubation for patients with asphyxia in emergency treatment. Methods: Retrospective analysis of clinical data from 86 cardiac arrest patients caused by asphyxia rescued in emergency room in two hospitals during the course from February 2008 to February 2015. Among these patients, 48 patients were treated with endotracheal intubation within 5 minutes of chest compression after heart arrest and 38 patients were given the same treatment after 5 minutes of chest compression. All patients were offered chest compressions, intravenous epinephrine, cardioversion and other life support treatments within indications. Results: 32 of 48 patients were successfully rescued with endotracheal intubation within 5 minutes (67% of successful rate) and 43 of 48 patients were responded by the same treatment (90% of response rate). In contrast, 3 of 38 patients were suc-cessfully rescued with endotracheal intubation after 5 minutes (8% of successful rate) and 20 of 38 patients were responded by the same treatment (53% of response rate). Conclusion: Early phase endotracheal intubation combined with regular cardiopulmonary resuscitation increased the success rate of cardiopulmonary resuscitation for cardiac arrest patients caused by asphyxia.