Swee Han Lim

Part 8: Advanced Life Support 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Part 8 : Advanced life support : 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Part 1: Executive Summary 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

The International Liaison Committee on Resuscitation (ILCOR) was founded on November 22, 1992, and currently includes representatives from the American Heart Association (AHA), the European Resuscitation Council (ERC), the Heart and Stroke Foundation of Canada (HSFC), the Australian and New Zealand Committee on Resuscitation (ANZCOR), Resuscitation Council of Southern Africa (RCSA), the InterAmerican Heart Foundation (IAHF), and the Resuscitation Council of Asia (RCA). Its mission is to identify and review international science and knowledge relevant to cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) and when there is consensus to offer treatment recommendations. Emergency cardiovascular care includes all responses necessary to treat sudden life-threatening events affecting the cardiovascular and respiratory systems, with a particular focus on sudden cardiac arrest. In 1999, the AHA hosted the first ILCOR conference to evaluate resuscitation science and develop common resuscitation guidelines. The conference recommendations were published in the International Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care .1 Since 2000, researchers from the ILCOR member councils have evaluated resuscitation science in 5-year cycles. The conclusions and recommendations of the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations were published at the end of 2005.2,3 The most recent International Consensus Conference was held in Dallas in February 2010, and this publication contains the consensus science statements and treatment recommendations developed with input from the invited participants. The goal of every resuscitation organization and resuscitation expert is to prevent premature cardiovascular death. When cardiac arrest or life-threatening emergencies occur, prompt and skillful response can make the difference between life and death and between intact survival and debilitation. This document summarizes the 2010 evidence evaluation of published science about the recognition and response to sudden life-threatening events, particularly sudden cardiac arrest and periarrest events in …

2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial.

OBJECTIVES The purpose of this study was to determine whether a new accelerated diagnostic protocol (ADP) for possible cardiac chest pain could identify low-risk patients suitable for early discharge (with follow-up shortly after discharge). BACKGROUND Patients presenting with possible acute coronary syndrome (ACS), who have a low short-term risk of adverse cardiac events may be suitable for early discharge and shorter hospital stays. METHODS This prospective observational study tested an ADP that included pre-test probability scoring by the Thrombolysis In Myocardial Infarction (TIMI) score, electrocardiography, and 0 + 2 h values of laboratory troponin I as the sole biomarker. Patients presenting with chest pain due to suspected ACS were included. The primary endpoint was major adverse cardiac event (MACE) within 30 days. RESULTS Of 1,975 patients, 302 (15.3%) had a MACE. The ADP classified 392 patients (20%) as low risk. One (0.25%) of these patients had a MACE, giving the ADP a sensitivity of 99.7% (95% confidence interval [CI]: 98.1% to 99.9%), negative predictive value of 99.7% (95% CI: 98.6% to 100.0%), specificity of 23.4% (95% CI: 21.4% to 25.4%), and positive predictive value of 19.0% (95% CI: 17.2% to 21.0%). Many ADP negative patients had further investigations (74.1%), and therapeutic (18.3%) or procedural (2.0%) interventions during the initial hospital attendance and/or 30-day follow-up. CONCLUSIONS Using the ADP, a large group of patients was successfully identified as at low short-term risk of a MACE and therefore suitable for rapid discharge from the emergency department with early follow-up. This approach could decrease the observation period required for some patients with chest pain. (An observational study of the diagnostic utility of an accelerated diagnostic protocol using contemporary central laboratory cardiac troponin in the assessment of patients presenting to two Australasian hospitals with chest pain of possible cardiac origin; ACTRN12611001069943).

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 …

Part 8: Advanced Life Support

art 8: Advanced life support 010 International Consensus on Cardiopulmonary Resuscitation and Emergency ardiovascular Care Science with Treatment Recommendations , harles D. Deakin (Co-chair) ∗,1 , Laurie J. Morrison (Co-chair)1 , Peter T. Morley , Clifton W. Callaway , ichard E. Kerber, Steven L. Kronick, Eric J. Lavonas, Mark S. Link, Robert W. Neumar, Charles W. Otto, ichael Parr, Michael Shuster, Kjetil Sunde, Mary Ann Peberdy, Wanchun Tang, aje erry L. Vanden Hoek, Bernd W. Böttiger, Saul Dr dvanced Life Support Chapter Collaborators

Comparison of chest compression only and standard cardiopulmonary resuscitation for out-of-hospital cardiac arrest in Singapore

OBJECTIVE Chest compression only cardiopulmonary resuscitation (CC-CPR) without ventilation has been proposed as an alternative to standard cardiopulmonary resuscitation (CPR) for bystanders. However, there has been controversy regarding the relative effectiveness of both of these techniques. We aim to compare the outcomes of cardiac arrest patients in the cardiac arrest and resuscitation epidemiology study who either received CC-CPR, standard CPR or no bystander CPR. METHODS This prospective cohort study involved all out-of-hospital cardiac arrest (OHCA) patients attended to by emergency medical service (EMS) providers in a large urban centre. The data analyses were conducted secondarily on these collected data. The technique of bystander CPR was reported by paramedics who arrived at the scene. RESULTS From 1 October 2001 to 14 October 2004, 2428 patients were enrolled into the study. Of these, 255 were EMS-witnessed arrests and were excluded. 1695 cases did not receive any bystander CPR, 287 had standard CPR and 154 CC-CPR. Patient characteristics were similar in both the standard and CC-CPR groups except for a higher incidence of residential arrests and previous heart disease sufferers in the CC-CPR group. Patients who received standard CPR (odds ratio (OR) 5.4, 95% confidence interval (CI) 2.1-14.0) or CC-CPR (OR 5.0, 95% CI 1.5-16.4) were more likely to survive to discharge than those who had no bystander CPR. There was no significant difference in survival to discharge between those who received CC-CPR and standard CPR (OR 0.9, 95% CI 0.3-3.1). CONCLUSION We found that patients were more likely to survive with any form of bystander CPR than without. This emphasises the importance of chest compressions for OHCA patients, whether with or without ventilation.

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.

Comparison of Treatment of Supraventricular Tachycardia by Valsalva Maneuver and Carotid Sinus Massage

STUDY OBJECTIVE To compare the efficacy of the Valsalva maneuver with that of carotid sinus massage (CSM) in terminating paroxysmal supraventricular tachycardia (SVT) in the ED. METHODS This prospective, randomized case study was performed in the ED of a tertiary care institution. Patients were at least 10 years of age with regular narrow complex tachycardia and had an ECG diagnosis of SVT. Patients with regular narrow complex tachycardia were randomly assigned to undergo either the Valsalva maneuver or CSM. If the tachycardia was not terminated by the method chosen by randomization, then the alternative method of vagal maneuver was used. If the tachycardia was not converted by both methods of vagal stimulation, patients would undergo either synchronized electrical cardioversion or a pharmacologic method of conversion at the discretion of the treating physician, depending on the patients hemodynamic status. RESULTS One hundred forty-eight instances of SVT were studied. Sixty-two patients underwent Valsalva maneuver first with conversion in 12 (success rate of 19.4%). Eighty-six underwent CSM first with conversion in 9 (success rate 10.5%). Carotid sinus massage was used in the 50 cases of SVT in which conversion was not achieved with the Valsalva maneuver. Conversion occurred in 7 cases (success rate 14.0%). For the 77 cases of SVT in which initial CSM did not achieve conversion, conversion occurred in 13 with the Valsalva maneuver (success rate 16.9%). The Valsalva maneuver and CSM achieved conversion in a total of 41 instances of SVT (success rate 27.7%). CONCLUSION Vagal maneuvers are efficacious in terminating about one quarter of spontaneous SVT cases. There is no detectable difference in efficacy between the Valsalva maneuver and CSM. [Lim SH, Anantharaman V, Teo WS, Goh PP, Tan ATH: Comparison of treatment of supraventricular tachycardia by Valsalva maneuver and carotid sinus massage. Ann Emerg Med January 1998;31:30-35.].

Part 3: Adult Basic Life Support and Automated External Defibrillation

This Part of the 2015 International Consensus on Cardiopul monary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science With Treatment Recommendations (CoSTR) presents the consensus on science and treatment recommendations for adult basic life support (BLS) and automated external defibrillation (AED). After the publication of the 2010 CoSTR, the Adult BLS Task Force developed review questions in PICO (population, intervention, comparator, outcome) format.1 This resulted in the generation of 36 PICO questions for systematic reviews. The task force discussed the topics and then voted to prioritize the most important questions to be tackled in 2015. From the pool of 36 questions, 14 were rated low priority and were deferred from this round of evidence evaluation. Two new questions were submitted by task force members, and 1 was submitted via the public portal. Two of these (BLS 856 and BLS 891) were taken forward for evidence review. The third question (368: Foreign-Body Airway Obstruction) was deferred after a preliminary review of the evidence failed to identify compelling evidence that would alter the treatment recommendations made when the topic was last reviewed in 2005.2 Each task force performed a systematic review using detailed inclusion and exclusion criteria, based on the recommendations of the Institute of Medicine of the National Academies.3 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). Reviewers were unable to identify any relevant evidence for 3 questions (BLS 811, BLS 373, and BLS 348), and the evidence review was not completed in time for a further question (BLS 370). A revised PICO question was developed for the opioid question (BLS 891). The task force reviewed 23 PICO questions for the …

C ARDIAC A RREST AND R ESUSCITATION E PIDEMIOLOGY IN S INGAPORE (CARE I S TUDY )

Objectives. To describe the epidemiology of out-of-hospital cardiac arrest (OHCA) in Singapore, the emergency medical services (EMS) response, and to identify possible areas for improvement. Methods. This prospective observational study constitutes phase I of the Cardiac Arrest and Resuscitation Epidemiology (CARE) project. Included were all patients with nontraumatic OHCA conveyed by the national emergency ambulance service. Patient characteristics, cardiac arrest circumstances, EMS response, and outcomes were recorded according to the Utstein style. Results. From October 1, 2001, to April 30, 2002, 548 patients were enrolled into the study. Mean (standard deviation [SD]) age was 62.2 (17.9) years, with a male predominance (65.6%). A total of 59.8% of collapses occurred at home, 35.3% of arrests were not witnessed, and bystander cardiopulmonary resuscitation was present for 20.6%. Mean (SD) time from collapse to call received by EMS was 10.6 (13.1) minutes. Mean (SD) EMS response time was 10.2 (4.3) minutes. Mean (SD) time from call to defibrillation was 16.7 (7.2) minutes. Mean (SD) on-scene time was 9.9 (4.5) minutes. First presenting rhythm at the scene was asystole in 54.5%, pulseless electrical activity 22.9%, ventricular fibrillation 19.6%, and ventricular tachycardia 0.4%. Of all cardiac arrests, 351 had resuscitation attempted and were of cardiac origin. Among these patients, 17.9% had return of spontaneous circulation, 8.5% survived to hospital admission, and 2.0% survived to discharge. Conclusion. CARE I establishes the baseline for the evaluation of incremental introduction of prehospital Advanced Cardiac Life Support interventions planned for future phases. Continuing efforts should be made to strengthen all chains of survival. This represents the most comprehensive OHCA study yet conducted in Singapore.