Maaret Castrén

European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators.

Basic life support (BLS) refers to maintaining airway patency and supporting breathing and the circulation, without the use of equipment other than a protective device.(1) This section contains the guidelines for adult BLS by lay rescuers and for the use of an automated external defibrillator (AED). It also includes recognition of sudden cardiac arrest, the recovery position and management of choking (foreign-body airway obstruction). Guidelines for in-hospital BLS and the use of manual defibrillators may be found in Sections 3 and 4b.

Intra-Arrest Transnasal Evaporative Cooling A Randomized, Prehospital, Multicenter Study (PRINCE: Pre-ROSC IntraNasal Cooling Effectiveness)

Background— Transnasal evaporative cooling has sufficient heat transfer capacity for effective intra-arrest cooling and improves survival in swine. The aim of this study was to determine the safety, feasibility, and cooling efficacy of prehospital transnasal cooling in humans and to explore its effects on neurologically intact survival to hospital discharge. Methods and Results— Witnessed cardiac arrest patients with a treatment interval ≤20 minutes were randomized to intra-arrest cooling with a RhinoChill device (treatment group, n=96) versus standard care (control group, n=104). The final analysis included 93 versus 101 patients, respectively. Both groups were cooled after hospital arrival. The patients had similar demographics, initial rhythms, rates of bystander cardiopulmonary resuscitation, and intervals to cardiopulmonary resuscitation and arrival of advanced life support personnel. Eighteen device-related adverse events (1 periorbital emphysema, 3 epistaxis, 1 perioral bleed, and 13 nasal discolorations) were reported. Time to target temperature of 34°C was shorter in the treatment group for both tympanic (102 versus 282 minutes, P=0.03) and core (155 versus 284 minutes, P=0.13) temperature. There were no significant differences in rates of return of spontaneous circulation between the groups (38% in treated subjects versus 43% in control subjects, P=0.48), in overall survival of those admitted alive (44% versus 31%, respectively, P=0.26), or in neurologically intact survival to discharge (Pittsburgh cerebral performance category scale 1 to 2, 34% versus 21%, P=0.21), although the study was not adequately powered to detect changes in these outcomes. Conclusions— Prehospital intra-arrest transnasal cooling is safe and feasible and is associated with a significant improvement in the time intervals required to cool patients. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00808236.

Part 4: Advanced life support: 2015 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations

The International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support (ALS) Task Force performed detailed systematic reviews based on the recommendations of the Institute of Medicine of the National Academies1 and using the methodological approach proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group.2 Questions to be addressed (using the PICO [population, intervention, comparator, outcome] format)3 were prioritized by ALS Task Force members (by voting). Prioritization criteria included awareness of significant new data and new controversies or questions about practice. Questions about topics no longer relevant to contemporary practice or where little new research has occurred were given lower priority. The ALS Task Force prioritized 42 PICO questions for review. With the assistance of information specialists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library). By using detailed inclusion and exclusion criteria, articles were screened for further evaluation. The reviewers for each question created a reconciled risk of bias assessment for each of the included studies, using state-of-the-art tools: Cochrane for randomized controlled trials (RCTs),4 Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 for studies of diagnostic accuracy,5 and GRADE for observational studies that inform both therapy and prognosis questions.6 GRADE evidence profile tables7 were then created to facilitate an evaluation of the evidence in support of each of the critical and important outcomes. The quality of the evidence (or confidence in the estimate of the effect) was categorized as high, moderate, low, or very low,8 based on the study methodologies and the 5 core GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and other considerations (including publication bias).9 These evidence profile tables were then used to create a …

Compression-Only CPR or Standard CPR in Out-of-Hospital Cardiac Arrest

BACKGROUND Emergency medical dispatchers give instructions on how to perform cardiopulmonary resuscitation (CPR) over the telephone to callers requesting help for a patient with suspected cardiac arrest, before the arrival of emergency medical services (EMS) personnel. A previous study indicated that instructions to perform CPR consisting of only chest compression result in a treatment efficacy that is similar or even superior to that associated with instructions given to perform standard CPR, which consists of both compression and ventilation. That study, however, was not powered to assess a possible difference in survival. The aim of this prospective, randomized study was to evaluate the possible superiority of compression-only CPR over standard CPR with respect to survival. METHODS Patients with suspected, witnessed, out-of-hospital cardiac arrest were randomly assigned to undergo either compression-only CPR or standard CPR. The primary end point was 30-day survival. RESULTS Data for the primary analysis were collected from February 2005 through January 2009 for a total of 1276 patients. Of these, 620 patients had been assigned to receive compression-only CPR and 656 patients had been assigned to receive standard CPR. The rate of 30-day survival was similar in the two groups: 8.7% (54 of 620 patients) in the group receiving compression-only CPR and 7.0% (46 of 656 patients) in the group receiving standard CPR (absolute difference for compression-only vs. standard CPR, 1.7 percentage points; 95% confidence interval, -1.2 to 4.6; P=0.29). CONCLUSIONS This prospective, randomized study showed no significant difference with respect to survival at 30 days between instructions given by an emergency medical dispatcher, before the arrival of EMS personnel, for compression-only CPR and instructions for standard CPR in patients with suspected, witnessed, out-of-hospital cardiac arrest. (Funded by the Swedish Heart–Lung Foundation and others; Karolinska Clinical Trial Registration number, CT20080012.)

A systematic review of triage-related interventions to improve patient flow in emergency departments

BackgroundOvercrowding in emergency departments is a worldwide problem. A systematic literature review was undertaken to scientifically explore which interventions improve patient flow in emergency departments.MethodsA systematic literature search for flow processes in emergency departments was followed by assessment of relevance and methodological quality of each individual study fulfilling the inclusion criteria. Studies were excluded if they did not present data on waiting time, length of stay, patients leaving the emergency department without being seen or other flow parameters based on a nonselected material of patients. Only studies with a control group, either in a randomized controlled trial or in an observational study with historical controls, were included. For each intervention, the level of scientific evidence was rated according to the GRADE system, launched by a WHO-supported working group.ResultsThe interventions were grouped into streaming, fast track, team triage, point-of-care testing (performing laboratory analysis in the emergency department), and nurse-requested x-ray. Thirty-three studies, including over 800,000 patients in total, were included. Scientific evidence on the effect of fast track on waiting time, length of stay, and left without being seen was moderately strong. The effect of team triage on left without being seen was relatively strong, but the evidence for all other interventions was limited or insufficient.ConclusionsIntroducing fast track for patients with less severe symptoms results in shorter waiting time, shorter length of stay, and fewer patients leaving without being seen. Team triage, with a physician in the team, will probably result in shorter waiting time and shorter length of stay and most likely in fewer patients leaving without being seen. There is only limited scientific evidence that streaming of patients into different tracks, performing laboratory analysis in the emergency department or having nurses to request certain x-rays results in shorter waiting time and length of stay.

Predictive power of serum NSE and OHCA score regarding 6-month neurologic outcome after out-of-hospital ventricular fibrillation and therapeutic hypothermia

AIM OF THE STUDY To determine the predictive power of the out-of-hospital cardiac arrest (OHCA) score and serum neuron-specific enolase (NSE) in patients resuscitated from ventricular fibrillation treated with therapeutic hypothermia (TH) and glucose control. METHODS An analysis of prospectively collected data of 90 TH patients. Serum NSE was measured at 24 and 48 h. Outcome was measured by neurologic exam 6 months after cardiac arrest with good outcome defined as a Cerebral Performance Category (CPC) of 1 or 2. RESULTS In multiple logistic regression analysis, age (odds ratio [OR], 95% confidence interval 1.1 [1.03-1.18]/year), NSE at 48 h (OR 1.1 [1.02-1.26]/microg/l), and increase in NSE levels (OR 7.2 [1.7-31.3]) were predictors of poor outcome, but the OHCA score was not. Cut-off points with 100% specificity in predicting poor outcome were 33microg/l for NSE at 48h (sensitivity 43% [28-60%]) and 6.4microg/l for delta NSE 24-48 h (sensitivity 44% [28-60%]). CONCLUSION Increase in NSE between 24 and 48h and NSE at 48h is specific but only moderately sensitive markers of 6-month outcome. Outcome prediction at ICU admission using the OHCA score was not possible in this selected patient population.

Part 3: Adult Basic Life Support and Automated External Defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This review comprises the most extensive literature search and evidence evaluation to date on the most important international BLS interventions, diagnostics, and prognostic factors for cardiac arrest victims. It reemphasizes that the critical lifesaving steps of BLS are (1) prevention, (2) immediate recognition and activation of the emergency response system, (3) early high-quality CPR, and (4) rapid defibrillation for shockable rhythms. Highlights in prevention indicate the rational and judicious deployment of search-and-rescue operations in drowning victims and the importance of education on opioid-associated emergencies. Other 2015 highlights in recognition and activation include the critical role of dispatcher recognition and dispatch-assisted chest compressions, which has been demonstrated in multiple international jurisdictions with consistent improvements in cardiac arrest survival. Similar to the 2010 ILCOR BLS treatment recommendations, the importance of high quality was reemphasized across all measures of CPR quality: rate, depth, recoil, and minimal chest compression pauses, with a universal understanding that we all should be providing chest compressions to all victims of cardiac arrest. This review continued to focus on the interface of BLS sequencing and ensuring high-quality CPR with other important BLS interventions, such as ventilation and defibrillation. In addition, this consensus statement highlights the importance of EMS systems, which employ bundles of care focusing on providing high-quality chest compressions while extricating the patient from the scene to the next level of care. Highlights in defibrillation indicate the global importance of increasing the number of sites with public-access defibrillation programs. Whereas the 2010 ILCOR Consensus on Science provided important direction for the “what” in resuscitation (ie, what to do), the 2015 consensus has begun with the GRADE methodology to provide direction for the quality of resuscitation. We hope that resuscitation councils and other stakeholders will be able to translate this body of knowledge of international consensus statements to build their own effective resuscitation guidelines.

Observations and warning signs prior to cardiac arrest. Should a medical emergency team intervene earlier

Background:  The Medical Emergency Team (MET) has evolved in some hospitals as a means of delivering effective treatment early enough to prevent cardiac arrests. Our aim was to analyze the effectiveness of observation practice to detect abnormalities in vital signs prior to cardiac arrest and to determine the need for a MET system in Finnish hospitals.

Scandinavian Clinical practice guidelines for therapeutic hypothermia and post‐resuscitation care after cardiac arrest

Background and aim: Sudden cardiac arrest survivors suffer from ischaemic brain injury that may lead to poor neurological outcome and death. The reperfusion injury that occurs is associated with damaging biochemical reactions, which are suppressed by mild therapeutic hypothermia (MTH). In several studies MTH has been proven to be safe, with few complications and improved survival, and is recommended by the International Liaison of Committee on Resuscitation. The aim of this paper is to recommend clinical practice guidelines for MTH treatment after cardiac arrest from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI).

Evaluation of the in-hospital Utstein template in cardiopulmonary resuscitation in secondary hospitals.

INTRODUCTION The in-hospital Utstein template for cardiopulmonary resuscitation (CPR) was assessed in four secondary hospitals (334-441 beds) which did not have systematic data collection. MATERIALS AND METHODS The reports and outcome over a period of 12 months during the years 2000-2001 were evaluated. RESULTS Of a total of 1690 patients that had a cardiac arrest (CA), 204 (12%) were resuscitated. Information on the collected Utstein parameters were available as follows: initial rhythm in 91%, time interval from collapse to defibrillation (in case of ventricular fibrillation or ventricular tachycardia as initial rhythm) in 90%, time interval to return of spontaneous circulation (ROSC) in 83% and duration of resuscitation in 83%. ROSC was achieved in 69 patients (34%, CI 27-41%) and 34 (17%, CI 11-23%) survived to hospital discharge. Twenty patients showed satisfactory neurological recovery (10%, CI 6-14%). Eighteen (9%, CI 5-13%) patients were alive at 12 months from the event. Factors associated with survival to hospital discharge were VF/VT (P=0.007) as the initial rhythm and shorter interval to defibrillation (P=0.046). CONCLUSION The in-hospital Utstein template was logical but laborious and it provided tools for resuscitation management evaluation in the study hospitals. For continuous use, a slightly compressed model may be warranted. In the present material, the overall survival rate to hospital discharge was in line with previous reports but there were somewhat less neurologically satisfactory survivors. There is an evident need to improve the outcome of patients suffering CA on the wards. An important step is to reduce the time interval to defibrillation.