Walter Kloeck

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 …

Recommended Guidelines for Reviewing, Reporting, and Conducting Research on In-Hospital Resuscitation: The In-Hospital ‘Utstein Style’ A Statement for Healthcare Professionals From the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Australian Resuscitation Council, and the Resuscitation Councils of Southern Africa

This scientific statement is the product of the Utstein ’95 Symposium held June 23-24, 1995, at Utstein Abbey, Island of Mosteroy, Rogaland County, Norway. Draft versions were circulated for comment to participants of the Utstein ’95 Symposium; the European Resuscitation Council Executive Committee; the Emergency Cardiac Care Committee of the American Heart Association; the Executive Committees of the Heart and Stroke Foundation of Canada, the Australian Resuscitation Council, and the Resuscitation Councils of Southern Africa; and several outside reviewers. The development of this statement was authorized by the Science Advisory and Coordinating Committee of the AHA and the Executive Committee of the European Resuscitation Council. We do not know the true effectiveness of in-hospital resuscitation. Observed results of the many published studies vary greatly. Studies originate from different settings and have different patient populations. Reports suffer from nonuniform nomenclature and variable inclusion definitions. Patients differ in the extent of comorbid conditions and interventions in place at the time of cardiac arrest. These differences prevent valid interhospital and intrahospital comparisons and make determining the effectiveness of current resuscitation techniques impossible. To develop these guidelines the task force used a consensus development process that originated with the “Utstein style” for reporting outcome data from out-of-hospital resuscitation events. Task force members performed an integrated review of published studies. An initial draft was prepared, discussed, and revised at a 2-day conference. Further drafts were revised and circulated among task force members and discussed face-to-face at three subsequent meetings. The task force defined a set of data elements that are essential or desirable for documenting in-hospital cardiac arrest. Data categories are hospital variables, patient variables, arrest variables, and outcome variables. The “In-Hospital Utstein-Style Template” was developed to summarize these data and recommendations for reporting a specific set of survival rates and outcomes. The task force …

Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: The in-hospital 'Utstein style'

This scientific statement is the product of the Utstein ’95 Symposium held June 23-24, 1995, at Utstein Abbey, Island of Mosteroy, Rogaland County, Norway. Draft versions were circulated for comment to participants of the Utstein ’95 Symposium; the European Resuscitation Council Executive Committee; the Emergency Cardiac Care Committee of the American Heart Association; the Executive Committees of the Heart and Stroke Foundation of Canada, the Australian Resuscitation Council, and the Resuscitation Councils of Southern Africa; and several outside reviewers. The development of this statement was authorized by the Science Advisory and Coordinating Committee of the AHA and the Executive Committee of the European Resuscitation Council. We do not know the true effectiveness of in-hospital resuscitation. Observed results of the many published studies vary greatly. Studies originate from different settings and have different patient populations. Reports suffer from nonuniform nomenclature and variable inclusion definitions. Patients differ in the extent of comorbid conditions and interventions in place at the time of cardiac arrest. These differences prevent valid interhospital and intrahospital comparisons and make determining the effectiveness of current resuscitation techniques impossible. To develop these guidelines the task force used a consensus development process that originated with the “Utstein style” for reporting outcome data from out-of-hospital resuscitation events. Task force members performed an integrated review of published studies. An initial draft was prepared, discussed, and revised at a 2-day conference. Further drafts were revised and circulated among task force members and discussed face-to-face at three subsequent meetings. The task force defined a set of data elements that are essential or desirable for documenting in-hospital cardiac arrest. Data categories are hospital variables, patient variables, arrest variables, and outcome variables. The “In-Hospital Utstein-Style Template” was developed to summarize these data and recommendations for reporting a specific set of survival rates and outcomes. The task force …

Guidelines for the basic management of the airway and ventilation during resuscitation

Writing Subcommittee: P.J.F. Baskett ** (UK), L. Bossaert (Belgium), P. Carli (France), D. Chamberlain (UK), W. Dick (Germany), J.P. Nolan (UK), M.J.A. Parr (UK), D. Scheidegger (Switzerland), D. Zideman (UK) With contributions from: W. Blancke (Belgium), H. Delooz (Belgium), A. Handley (UK), D. Kettler (Germany), W. Kloeck (South Africa), E. Kramer (South Africa), L. Quan (USA), W. Studer (Switzerland), A. Van Drenth (The Netherlands)

Special Resuscitation Situations An Advisory Statement From the International Liaison Committee on Resuscitation

### Background Children who require basic life support (BLS) and advanced life support (ALS) interventions account for 5% to 10% of all ambulance runs and approximately one quarter of emergency department visits in the United States. The principles, equipment, and drugs used for pediatric BLS and ALS are similar to those used for adults. However, the care of seriously ill or injured children requires specific knowledge of pediatric anatomy, physiology, and psychology plus practical pediatric expertise. ### Key Interventions to Prevent Arrest In infants and children, respiratory distress and failure is a much more common cardiac arrest etiology than sudden dysrhythmia or ventricular fibrillation. As a result, hypoxia, hypercarbia, and global ischemia often precede cardiac arrest. Critical organ perfusion is dependent on more rapid heart and respiratory rates than for adults. Therefore, additional attention is focused on early recognition and intervention for respiratory failure and shock, and less emphasis is placed on rapid early defibrillation than for adult cardiac arrest victims. ### BLS and ALS Interventions During Arrest Commentary on the specific application of BLS and ALS principles to pediatric patients is contained in the accompanying ILCOR pediatric advisory statements. 1. Tsai A, Kallsen G. Epidemiology of pediatric prehospital care. Ann Emerg Med . 1987;16:284-292. 2. Cummins RO, ed. Textbook of Advanced Cardiac Life Support. Dallas, Tex: American Heart Association; 1994:60-68. 3. Zaritsky A, Nadkarni V, Getson P, Kuehl K. CPR in children. Ann Emerg Med . 1987;16:1107-1111. ### Background Cardiac arrest due to electrolyte abnormalities is uncommon except in the case of hyperkalemia. Electrolyte concentrations change during cardiac arrest due to the rapidly changing acid-base status, catecholamine levels, and hypoxia. These changes do not require intervention unless the cardiac arrest is primarily caused by the electrolyte abnormality. ### Key Interventions to Prevent Arrest

Part 4: Advanced life support

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 …

The Universal Advanced Life Support Algorithm An Advisory Statement From the Advanced Life Support Working Group of the International Liaison Committee on Resuscitation

Valid scientific evidence supports only three interventions as unequivocally effective in adult cardiac resuscitation: The universal algorithm presents these interventions simplistically and recommends a specific sequence that rescuers should follow. The sequence of interventions is based, whenever possible, on sound scientific information. But there is a paucity of convincing human data on some aspects of resuscitation. Until such time as new information becomes available, the working group made no changes to well-established procedures but suggested some modifications on educational rather than scientific grounds. Cardiac arrest rhythms can be divided into two subsets: ventricular fibrillation/pulseless ventricular tachycardia (VF/VT) and non-VF/VT. Non-VF/VT incorporates both asystole and pulseless electrical activity (PEA). The only difference in management between the two arrest rhythms is the need for rescuers to perform defibrillation for patients in VF/VT. Otherwise the actions and interventions are essentially the same: basic CPR, tracheal intubation, epinephrine administration, and correction of reversible causes. …

Part 2: International collaboration in resuscitation science: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations.

With the founding of the International Liaison Committee on Resuscitation (ILCOR) in 1992, an international collaboration of clinicians and researchers was convened to identify, evaluate, and interpret the most valid resuscitation science. This supplement to Circulation (simultaneously published in Resuscitation) presents the results of ILCOR’s most recent and extensive efforts to reach consensus on interpretation of resuscitation science and treatment recommendations. ILCOR continues to strive to reach a common goal of universal resuscitation guidelines. Building on the 2005 International Consensus on CPR and ECC Science With Treatment Recommendations,1,2 the 2010 International Consensus Conference held in Dallas, Texas, in February 2010 involved 313 experts from 30 countries. During the 2 years leading up to this conference, over 350 worksheet authors reviewed several thousand relevant, peer-reviewed publications to address more than 400 specific resuscitation questions, each in standard PICO (Population, Intervention, Comparison, Outcome) format. The experts reviewed, summarized, and categorized several thousand relevant, peerreviewed publications into level of evidence grids, proposed consensus on science statements, and where possible, provided evidence-based treatment recommendations.3 Key knowledge gaps were also identified and documented, with the purpose of stimulating further research in those areas. Ultimately scientific consensus was achieved by continuous discussion and debate in multiple face-to-face meetings and webinars, and finally through focused discussions of the evidence evaluation worksheets during the 3 days of the International Consensus Conference. Particular attention was paid to recognizing applicable advances in resuscitation science, while managing potential conflicts of interest among participants and identifying topics that lacked good evidence to support or change current practice. The year 2010 marks the 50th Anniversary of cardiopulmonary resuscitation (CPR). The original reports of rescue breathing,4 closed-chest compressions,5 and the effective combination of the two6 created an immediate demand for CPR training and resuscitation guidelines. In 1966, the Institute of Medicine (in the United States) convened the first conference to specifically review available evidence and to recommend standards for CPR and emergency cardiovascular care (ECC) techniques.7 The American Heart Association (AHA) sponsored subsequent conferences in 1973 and 1979.8,9 Parallel efforts occurred internationally as other resuscitation organizations faced a growing demand for CPR training.10 Inevitably variations in resuscitation techniques and training methods began to emerge from countries and regions of the world. Increasing awareness of these variations in resuscitation practices sparked interest in gathering international experts at a single location with the aim of achieving consensus in resuscitation techniques. The AHA convened such a meeting in 1985, inviting resuscitation leaders from many countries to observe the process by which the AHA reviewed evidence to create guidelines for CPR and ECC.11 Observation by these international guests, many of whom were passionately devoted to improving resuscitation outcomes in their own countries, soon led to the realization that much could be learned from international collaboration. By 1992, when the AHA convened their next Guidelines Conference, more than 40% of the participants were from outside the United States.12 During this 1992 conference, a panel on international cooperation on CPR and ECC endorsed the need to foster a multinational base of evidence for resuscitation practices. What was lacking was a focused and structured mechanism with which to capture and assess this growing body of published evidence. That panel strongly recommended that an expanded group of international experts initiate a systematic review of the world’s resuscitation

Global health and emergency care: a resuscitation research agenda--part 1.

At the 2013 Academic Emergency Medicine global health consensus conference, a breakout session on a resuscitation research agenda was held. Two articles focusing on cardiac arrest and trauma resuscitation are the result of that discussion. This article describes the burden of disease and outcomes, issues in resuscitation research, and global trends in resuscitation research funding priorities. Globally, cardiovascular disease and trauma cause a high burden of disease that receives a disproportionately smaller research investment. International resuscitation research faces unique ethical challenges. It needs reliable baseline statistics regarding quality of care and outcomes; data linkages between providers; reliable and comparable national databases; and an effective, efficient, and sustainable resuscitation research infrastructure to advance the field. Research in resuscitation in low- and middle-income countries is needed to understand the epidemiology, infrastructure and systems context, level of training needed, and potential for cost-effective care to improve outcomes. Research is needed on low-cost models of population-based research, ways to disseminate information to the developing world, and finding the most cost-effective strategies to improve outcomes.

Part 2: International Collaboration in Resuscitation Science

With the founding of the International Liaison Committee on Resuscitation (ILCOR) in 1992, an international collaboration of clinicians and researchers was convened to identify, evaluate, and interpret the most valid resuscitation science. This supplement to Circulation (simultaneously published in Resuscitation ) presents the results of ILCORs most recent and extensive efforts to reach consensus on interpretation of resuscitation science and treatment recommendations. ILCOR continues to strive to reach a common goal of universal resuscitation guidelines. Building on the 2005 International Consensus on CPR and ECC Science With Treatment Recommendations ,1,2 the 2010 International Consensus Conference held in Dallas, Texas, in February 2010 involved 313 experts from 30 countries. During the 2 years leading up to this conference, over 350 worksheet authors reviewed several thousand relevant, peer-reviewed publications to address more than 400 specific resuscitation questions, each in standard PICO (Population, Intervention, Comparison, Outcome) format. The experts reviewed, summarized, and categorized several thousand relevant, peer-reviewed publications into level of evidence grids, proposed consensus on science statements, and where possible, provided evidence-based treatment recommendations.3 Key knowledge gaps were also identified and documented, with the purpose of stimulating further research in those areas. Ultimately scientific consensus was achieved by continuous discussion and debate in multiple face-to-face meetings and webinars, and finally through focused discussions of the evidence evaluation worksheets during the 3 days of the International Consensus Conference. Particular attention was paid to recognizing applicable advances in resuscitation science, while managing potential conflicts of interest among participants and identifying topics that lacked good evidence to support or change current practice. The year 2010 marks the 50th Anniversary of cardiopulmonary resuscitation (CPR). The original reports of rescue breathing,4 closed-chest compressions,5 and the effective combination of the two6 created an immediate demand for CPR training and resuscitation guidelines. In …