International Liaison Committee On Resuscitation Guidelines Research Articles

GRACE-recurrent low-risk chest pain: A user's guide.

GRACE-recurrent low-risk chest pain: A user's guide.

Hands-On Times, Adherence to Recommendations and Variance in Execution among Three Different CPR Algorithms: A Prospective Randomized Single-Blind Simulator-Based Trial.

Background: Alternative cardiopulmonary resuscitation (CPR) algorithms, introduced to improve outcomes after cardiac arrest, have so far not been compared in randomized trials with established CPR guidelines. Methods: 286 physician teams were confronted with simulated cardiac arrests and randomly allocated to one of three versions of a CPR algorithm: (1) current International Liaison Committee on Resuscitation (ILCOR) guidelines (“ILCOR”), (2) the cardiocerebral resuscitation (“CCR”) protocol (3 cycles of 200 uninterrupted chest compressions with no ventilation), or (3) a local interpretation of the current guidelines (“Arnsberg“, immediate insertion of a supraglottic airway and cycles of 200 uninterrupted chest compressions). The primary endpoint was percentage of hands-on time. Results: Median percentage of hands-on time was 88 (interquartile range (IQR) 6) in “ILCOR” teams, 90 (IQR 5) in “CCR” teams (p = 0.001 vs. “ILCOR”), and 89 (IQR 4) in “Arnsberg” teams (p = 0.032 vs. “ILCOR”; p = 0.10 vs. “CCR”). “ILCOR” teams delivered fewer chest compressions and deviated more from allocated targets than “CCR” and “Arnsberg” teams. “CCR” teams demonstrated the least within-team and between-team variance. Conclusions: Compared to current ILCOR guidelines, two alternative CPR algorithms advocating cycles of uninterrupted chest compressions resulted in very similar hands-on times, fewer deviations from targets, and less within-team and between-team variance in execution.

Evaluation of the Quality of Manual, Compression-Only Cardiopulmonary Resuscitation in a Moving Ski Patrol Toboggan.

Introduction: Cardiopulmonary resuscitation (CPR) quality may be impacted by location and setting of an out of hospital cardiac arrest. This study compared the quality of CPR performed on a moving ski patrol toboggan versus stationary CPR, both performed outdoors in winter. Materials and Methods: Compression-only CPR was performed on a manikin attached to a backboard secured into a toboggan. A CPR device was used to measure compression rate, depth and recoil, and elapsed time. A convenience sample of 30 patrollers, in weather-appropriate clothing, participated in this nonrandomized, crossover study. Each first performed 5 continuous sets of 30 compressions of stationary CPR straddling the manikin while kneeling. After 15 minutes rest, participants performed CPR while moving down the designated ski run (fixed length, vertical drop, and slope angles). Each ski run was video captured with a GoPro camera. Quality was defined as compliance with 2015 International Liaison Committee on Resuscitation (ILCOR) guidelines for CPR. Results: Overall, stationary and moving chest compressions complied with ILCOR guidelines, but there was a statistically significant degradation of CPR quality while moving and over time. Fewer compressions met ILCOR guidelines in comparison to stationary CPR compressions: (1) stationary mean depth 87% compliant, moving mean depth 35% compliant, 95% confidence interval: 39-65 (p < 0.001); (2) stationary mean rate 90% while moving mean rate 64% compliant; and (3) stationary recoil 74%, while moving recoil 77% compliant. Noncompliant compressions were typically too shallow, and noncompliance for rate was typically too fast. There were no pauses over 10 seconds once compressions were started. Conclusions: Despite CPR quality being reduced while moving, there were sufficient compliant compressions to support the use of CPR in this setting. Maintaining regular CPR training in a working environment and optimal body position in relation to the patient may be keys to performing high quality CPR on a moving toboggan.

Update for Canadian NRP providers: A case-based review.

The International Liaison Committee on Resuscitation (ILCOR) Neonatal Task Force reviews available resuscitation science every 5 years and develops guidelines which are integrated into educational programs such as the Neonatal Resuscitation Program (NRP). The most recent ILCOR Neonatal Task Force consensus guidelines were published in October 2015. The Canadian Paediatric Society's NRP Steering Committee has reviewed ILCOR guidelines alongside the 7th edition (2016) NRP materials. Using a case-based approach, this practice point highlights the main changes relating to the delivery of NRP, within the Canadian context.

The transition to extra‐uterine life by extremely preterm infants – handle with care

The transition to extra‐uterine life by extremely preterm infants – handle with care

Future cardiopulmonary resuscitation: should we adopt dedicated systems of care?

Cardiac arrest is one of the important major health issues [5]. In Europe, more than 300,000 patients have a cardiac arrest during a single year. During the last 30 years, treatment recommendations have been devised to deliver the best way of emergency care. New scientific understanding is continually reflected in updated treatment recommendations from the International Liaison Committee on Resuscitation (ILCOR). Nevertheless, only a small group of victims survived the event and are still alive more than 1 year after the arrest. To improve long-term survival, every link of the chain of survival must be analyzed and – if necessary – optimized [14]. Starting with bystander cardiopulmonary resuscitation (CPR), we found a huge variety in the incidence of resuscitation efforts before professional Emergency Medical Services (EMS) arrived on scene [8]. All over Europe this figure differs between 10 and 70%, and has a different impact on the first step of success, called ‘return of spontaneous circulation’ (ROSC). Following the BLS sequence, EMS advanced life support started with chest compression, airway management, drug administration, treatment of reversible causes for the arrest and – if necessary – defibrillation. Success of BLS and EMS treatment, also measured in ROSC or admission to hospital, can be achieved in more than 40% all over Europe. But ROSC is only the first step of survival. Different studies during the last years evaluated the role of postROSC treatment. A post-resuscitation care bundle was defined. A recommendation for temperature management, coronary angiography and optimized intensive care treatment was devised in the 2005 and 2010 ILCOR guidelines [6]. Several studies and register analyses demonstrated the impact of good post-resuscitation care [7]. Several studies have demonstrated that outcome after OHCA can be improved with the implementation of mild therapeutic hypothermia (MTH) and target temperature management (TTM) [1,3,15,20], as well as percutaneous coronary intervention (PCI) [2,17,18] and the combination of both [9,11,18]. Nevertheless, single treatment or combinations of treatments are only one part of successful post-resuscitation care.

Mask leak increases and minute ventilation decreases when chest compressions are added to bag ventilation in a neonatal manikin model

To determine changes in respiratory mechanics when chest compressions are added to mask ventilation, as recommended by the International Liaison Committee on Resuscitation (ILCOR) guidelines for newborn infants. Using a Laerdal Advanced Life Support leak-free baby manikin and a 240-mL self-inflating bag, 58 neonatal staff members were randomly paired to provide mask ventilation, followed by mask ventilation with chest compressions with a 1:3 ratio, for two minutes each. A Florian respiratory function monitor was used to measure respiratory mechanics, including mask leak. The addition of chest compressions to mask ventilation led to a significant reduction in inflation rate, from 63.9 to 32.9 breaths per minute (p < 0.0001), mean airway pressure reduced from 7.6 to 4.9 cm H2 O (p < 0.001), minute ventilation reduced from 770 to 451 mL/kg/min (p < 0.0001), and there was a significant increase in paired mask leak of 6.8% (p < 0.0001). Adding chest compressions to mask ventilation, in accordance with the ILCOR guidelines, in a manikin model is associated with a significant reduction in delivered ventilation and increase in mask leak. If similar findings occur in human infants needing an escalation in resuscitation, there is a potential risk of either delay in recovery or inadequate response to resuscitation.

The 2010 Guidelines on Neonatal Resuscitation (AHA, ERC, ILCOR): Similarities and Differences – What Progress Has Been Made since 2005?

In 2010, the American Heart Association (AHA), the European Resuscitation Council (ERC) and the International Liaison Committee on Resuscitation (ILCOR) issued new guidelines on newborn resuscitation. The new recommendations include: (1) pulse-oximetry for patient assessment during newborn resuscitation; (2) to start resuscitation of term infants with an FiO (2) of 0.21; (3) cardio-respiratory resuscitation with a 3:1 chest compression/inflation ratio for a heart rate <60 beats/min; (4) regarding infants born from meconium stained amniotic fluid: no recommendation is given to suction the upper airways at the perineum (when the head is born), but it is recommended to inspect the oropharynx and trachea for obstruction and suction the lower airway before inflations are given when the infant is depressed; (5) for birth asphyxia in term or near term infants, to induce hypothermia (33.5-34.5°C) within 6 h after birth. AHA, ERC and ILCOR used nearly identical literature for their evidence evaluation process. While the AHA and ILCOR guidelines are almost identical, the ERC guidelines differ slightly from the latter with regards to (i) promoting sustained inflations at birth, (ii) promoting a wider range in applied inflations during resuscitation, and (iii) to suction the airways in infants born from meconium stained amniotic fluid, before inflations are given.

Resuscitation Guidelines 2005: does experienced nursing staff need training and how effective is it?

Introduction Even among health care professionals, resuscitation performance has been shown to be poor. So far, it remains unclear whether cardiac arrest staff with frequent practice in resuscitation requires training to adapt to the new International Liaison Committee on Resuscitation (ILCOR) guidelines of 2005. This study evaluated the need for basic life support training in nurses with emergency experience. Methods and Results Nurses (N = 24) recruited from an intensive care unit self-assessed their resuscitation skills and performed a cardiac arrest scenario using a manikin. After a theoretical instruction and hands-on training followed by feedback, participants once again performed a resuscitation scenario in addition to completing posttraining self-assessments. Participating nurses considered resuscitation skills training—in particular in adapting to the new ILCOR guidelines of 2005—to be important. Pretraining data revealed performance deficits even in this sample of emergency-experienced nursing staff. Training resulted in significant improvement in ventilation volume ( P < .001), rate of compressions with correct depth ( P < .031) and full release ( P < .001), and a reduction in total hands-off time ( P < .050). Objective data were mirrored in participants' self-assessed competencies. Conclusion Results suggest that basic life support training based on the ILCOR guidelines of 2005 is necessary even in nurses with emergency experience. Training followed by the application of a feedback algorithm seems to improve short-term resuscitation performance and is well accepted by experienced nurses who work on an intensive care unit and who also comprise the inner-hospital cardiac arrest team.

Sometimes, all I need is the air that I breathe (and a blender)

Sometimes, all I need is the air that I breathe (and a blender)

Our experiences with therapeutic hypothermia

The single most important clinically relevant cause of global cerebral ischemia is cardiac arrest. The estimated rate of sudden cardiac arrest is between 40 and 130 cases per 100.000 people per year. Almost 80% of patients initially resuscitated from cardiac arrest remain comatose for more than one hour. One year after cardiac arrest only 10-30% of these patients survive with good neurological outcome. The ability to survive anoxic no-flow states is dramatically increased with protective and preservative hypothermia. The results of clinical studies show a marked neuroprotective effect of mild hypothermia in resuscitation. In our clinic, 12 patients were treated with therapeutic hypothermia. A combination of intravascular and external method of cooling was used according to the ILCOR (International Liaison Committee on Resuscitation) guidelines. The target temperature was 33 degrees C, while the duration of cooling was 24 hours. After that, passive rewarming was allowed. All patients also received other necessary therapy. Six patients (50%) had a complete neurological recovery. Two patients (16.6%) had partial neurological recovery. Four patients (33.3%) remained comatose. Five patients (41.66%) survived, while 7 (58.33%) patients died. The main cause of cardiac arrest was acute myocardial infarction (91.6%). One patient had acute myocarditis. Mild resuscitative hypothermia after cardiac arrest improves neurological outcome and reduces mortality in comatose survivors.

GREAT simulation debriefing

Context and setting Debriefing is an essential part of simulation used for education and training. We developed a simple checklist to assist debriefing after simulations of medical emergencies and to ensure that best practice is being applied. The debriefing checklist is based on the mnemonic GREAT: G = Guidelines: the facilitator must have the most recent best-evidence guidelines and local policy guidelines for managing the situation being simulated. R = Recommendations: if comprehensive guidelines are not available then recommendations such as those contained in published reviews should be used. E = Events: participants are given time to reflect on the simulation and identify what were the important events (e.g. the patient began fitting). A = Analysis: were signs identified promptly, how did treatments given compare with guidelines and recommendations, were resources used effectively, etc.? T = Transfer of knowledge to clinical practice: what has been learned to improve patient care? Are there any key ‘take-home messages’? Why the idea was necessary Debriefing has not been used widely in medicine and is rarely conducted in a way designed to improve future performance. The use of simulation in medical education is growing rapidly, so a simple guide to focus students on the educational goals of the simulation would be useful to help facilitators new to debriefing a simulation. What was done Aviation debriefing literature was used to identify the generic features of responding to an emergency or crisis. Several debriefing aids were tested in the simulation unit before we adopted GREAT. Evaluation of the results and impact A simulation course for post-anaesthesia care nurses included a scenario that resulted generally in a cardiac arrest. When the video of their performance was viewed during the debriefing, participants were very surprised that treatment deviated from the International Liaison Committee on Resuscitation (ILCOR) guidelines as much as it did. All had current resuscitation certification and realised that during a stressful event it can be difficult to recall important information accurately. Items identified for ‘transfer’ to the workplace included having a copy of the ILCOR algorithm attached to every cardiac arrest cart and for the team leader to use it. In another example, rural general practitioners needed to perform emergency endotracheal intubation. This was accomplished with difficulty by participants, but was not identified as an issue during debriefing. However, when the ILCOR guidelines were presented it became apparent that the manner in which intubation was achieved was outside accepted limits. Participants then discussed what other guidelines they might not be following and resolved to review other emergency care guidelines related to their practice. Use of standard operating procedures is important in crisis management. We have identified that individual and local procedures may be at variance with current guidelines, so that debriefing relying only on the memory of them is unhelpful or even dangerous. The GREAT checklist encourages participants to use guidelines published and validated by peak organisations to benchmark their practice and improve patient care. Recent feedback from users indicates that GREAT can also be used to facilitate debriefing after real clinical events.

Therapeutic hypothermia after cardiac arrest - the implementation of the ILCOR guidelines in clinical routine is possible!

Therapeutic hypothermia after cardiac arrest is a treatment with a high level of evidence. In 2003 the International Liaison Committee on Resuscitation (ILCOR) recommended such treatment for all comatose survivors of out-of-hospital cardiac arrest when the initial rhythm was ventricular fibrillation [1]. However, recent studies have shown that only a minority of resuscitated patients are treated with therapeutic hypothermia in both American and European intensive care units [2-4]. A letter recently published in Critical Care reported the use of therapeutic hypothermia in Germany in only 38% of departments treating patients after cardiac arrest [5]. To improve adherence to the ILCOR guidelines we developed a written standard operating procedure (SOP) for patients after cardiac arrest admitted to our 38-bed medical intensive care unit. Starting in December 2005 the SOP was to be applied to all comatose patients after cardiac arrest, irrespective of the initial rhythm. Since then the SOP has been applied in 28 out of 34 eligible patients. For four patients the physician in charge did not consider therapeutic hypothermia despite clear indication. In two other patients hypothermia was considered to be contraindicated because of extensive coronary vasospasm or massive pulmonary bleeding of a bronchial carcinoma, respectively. In all the remaining 28 patients surface cooling with technical devices (CritiCool from MTRE, Yavne Israel, and ArcticSun from Medivance, Louisville, KY, USA) was used to induce and maintain hypothermia for 24 hours. The target temperature of 33°C was reached in 6.0 ± 3.2 hours (mean ± SD). In none of the patients were serious adverse events potentially related to therapeutic hypothermia, such as clinically relevant bleeding episodes or arrhythmias, observed. In 12 out of 28 patients (42.9%) treated with therapeutic hypothermia a favourable neurologic outcome was reached (Cerebral Performance Category 1 or 2). Although our limited experience does not yet permit a valid statistical evaluation of the impact of therapeutic hypothermia on the neurological outcome of the patients, initial results are encouraging. We are currently trying to shorten the time to target temperature, which we feel was still too long in some patients. However, the simple availability of a written SOP has already led to the application of therapeutic hypothermia in the vast majority of our patients after cardiac arrest. All physicians caring for such patients should be encouraged to establish their own protocol for therapeutic hypothermia at their institutions, to facilitate the widespread application of this evidence-based treatment.

How good is your defibrillation technique?

In 1956, a patient in ventricular fibrillation (VF) was successfully treated via externally applied electricity.1 The history of human defibrillation, which is still the only effective means of cardioverting VF back into sinus rhythm, began here. By 1962, electric shock had also been found effective in atrial fibrillation and atrial flutter.2 In August 2000 the International Liaison Committee on Resuscitation (ILCOR) published evidence-based guidelines for adult and paediatric life support.3 All the UK training courses on advanced life support are now based on the ILCOR guidelines; yet, in this document of over 400 pages, the defibrillation section is only 4 pages long. This is partly because the topic had been under-researched. New information has emerged since 2000. Our own group has taken a special interest in the defibrillation technique used by hospital practitioners and how it could be improved. Survival to discharge from in-hospital cardiac arrest in the UK is still, at best, only 17% in a monitored area of the hospital such as a coronary care unit.4 It is considerably worse on general hospital wards. The most important factor in determining whether defibrillation will be successful is the time that elapses before delivery of the first shock.5 For every minute post-arrest, the chances of cardioversion decrease by as much as 10%.3 Many defibrillators in hospitals now have an automated facility, so that a nurse suspecting a cardiac arrest can connect the patient to the machine via two pads;6 the device analyses the cardiac rhythm and delivers a shock if appropriate. A study in hospital inpatients has shown that use of the automated facility on new biphasic defibrillators can yield a 2.6-fold increase in survival post-arrest.7 All nurses should therefore be trained to use an automated defibrillator if one is available on their ward.8 Recently, there have been two major developments in defibrillator technology. One is the emergence of pads made of flexible conductive material.9 Our group found that the transthoracic impedance (TTI) to current flow created by use of these pads is the same as that with paddles.10 At present there is uncertainty as to which method is preferable. The second advance concerns the waveform used for defibrillation. Originally, the waveform created by defibrillators was monophasic but over the last ten years the biphasic waveform has taken over and nearly all new models use this technology11 (Figure 1). The relative merits of these two waveforms are beyond the scope of this article. In summary, a biphasic shock of 150 joules is far more likely than a monophasic shock of either 200 or 360 joules to convert VF; yet, so far, no study has shown a survival advantage for the biphasic method.12 Figure 1 Monophasic and biphasic waveforms used by defibrillators Successful defibrillation depends on delivery of the shock to a critical mass of myocardium13 and this in turn depends on the transthoracic current flow (TCF) achieved. If the TCF is too low, defibrillation will fail; if it is too high the result may be myocardial cell damage and even necrosis. On the evidence of post-mortem studies and troponin measurement after defibrillation, necrosis is not a common result of multiple shock delivery.14,15 The most likely reason for failure is a TCF that is too low. TCF is determined by the energy selected and the TTI:16 Clearly a low TTI will result in a high TCF. Numerous studies have shown that a high TTI will decrease the chances of delivering a successful shock to the patient;17-19 therefore, during defibrillation, TTI has to be reduced as far as possible. Some contributory factors, such as thoracic size, are intrinsic and cannot be altered; but extrinsic factors include paddle force, presence of chest hair, use of an electrical coupling agent, 20 the size of the paddles (larger electrodes have a lower impedance but when excessively large can result in less TCF18), the number of shocks delivered21 and paddle position. This article focuses on techniques for minimizing TTI.

What is the optimal paddle force for defibrillation?

Introduction - Firm paddle pressure during defibrillation is important to minimize transthoracic impedance (TTI) and optimize trans-myocardial current. Previous European Resuscitation Council (ERC) guidelines recommended that 12 kg force should be used [1] and the more recent International Liaison Committee on Resuscitation (ILCOR) guidelines recommend 'firm' pressure [2]. The actual relationship between force and transthoracic impedance has not been established. Methods - 55 patients (36 male, 19 female) undergoing general anaesthesia for cardiac surgery were investigated. Male chests were shaved. A pair of gel pads and paddles were placed in the anterior-apical position according to the ILCOR guidelines. The endotracheal tube was opened to air and paddles instrumented with force sensors were applied to the chest wall with progressive force to a maximum of 12 kgf. The resultant TTI was recorded at 10 measurements per second to a hard drive. Results - Light pressure results in a high TTI that rapidly decreases as paddle force increases (Fig. 1). An 18.7% fall in overall TTI occurs when applying force from 0.5 to 6.0 kg. Increasing paddle force from 6 to 12 kg results in a further decrease in TTI of 3.2%. Conclusion - A minimum of 6 kg force applied to each paddle is necessary to achieve 83% of the overall decrease in TTI seen at 12 kgf. Further decrease in TTI as force is applied in excess of 6 kgf is small and a force of 12 kgf only reduces TTI by a further 3.2% compared with TTI at 6 kgf. The additional clinical benefit of applying 12 kgf as opposed to 6 kgf is questionable.

The new German resuscitation guidelines in the context of international recommendations

The German Guidelines for Cardiopulmonary Resuscitation were adapted to match the revised International Guidelines. The revised German edition was based both on the guidelines issued by the American Heart Association (AHA) in 1992 and on those of the European Resuscitation Council (ERC) of 1998, as well as on those released by the International Liaison Committee on Resuscitation (ILCOR) in 1997. Due to the diverging instructions for action the emergency physicians felt considerably unsafe as to what they should really do to achieve maximum results. Only 10.3 per cent of the german emergency physicians followed the recommendations given by the German Federal Chamber of Physicians. Innovations in respect of the basic checkup concern the time for controlling the respiration and circulation (ten seconds). Contrary to the international recommendations the "diagnostic block" is performed in Germany without interspersing basic reanimation. In artificial respiration the tidal volume has been reduced to 600 ml in accordance to the ERC and ILCOR guidelines. The search for the pressure point for cardiac pressure massage has also been adapted to the international recommendations. Also in accordance with the international recommendations defibrillation in case of ventricular fibrillation is now being performed only thrice in series without interspersed basic reanimation. There is some uncertainty with regard to choosing the requisite energy: 16.6% of the emergency physicians opt for less than 200 joule in primary defibrillation whereas 13% are in favour of more than 200 joule. Contrary to the international recommendations which prescribe peripheral venous access as application site for reanimation by drugs, the german guidelines favour the endobronchial path, which is already being practised by 57.4% of the emergency physicians. Hence, emergency medication can be effected in Germany 4 minutes earlier than in other countries. After three unsuccessful applications of 1 mg each of adrenalin the dosage is increased to 5 mg, and in agreement with the AHA guidelines escalating doses are also possible. Sodium bicarbonate is recommended only after more than 20 minutes of reanimation and if so, only in a reduced dose of 0.5 mval/kg body weight. In accordance with the international recommendations there is now a universal algorithm that decides on application only between ventricular fibrillation and nonfibrillation. The new german recommendations have adapted the reanimation procedure in agreement with ERC to national usage without abandoning any principles of the international guidelines.

A comparison of manikin CPR performance by lay persons trained in three variations of basic life support guidelines

This paper reports on a randomised controlled trial comparing the acquisition and retention of cardiopulmonary resuscitation (CPR) skills by lay persons trained in three variations of basic life support. Training was provided either in 1992 European Resuscitation Council (ERC) guidelines, or in the 1997 International Liaison Committee on Resuscitation (ILCOR) Advisory Statement (adopted with minor revisions as 1998 ERC guidelines), and an American Heart Association ‘call first’ version of the 1997 ILCOR statement. Evaluation of manikin CPR using the established Cardiff tests (CARE and VIDRAP) showed that 51% of those trained in the current ILCOR guidelines performed effectively compared with 38% trained in the ERC 1992 guidelines and 25% trained in the ‘call first’ variation ( P<0.01). Whilst the current ERC and ILCOR guidelines appeared easiest to learn, retention at 6 months was poor (14% effective) irrespective of method.