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PubMed2003

Update on cardiac resuscitation for sudden death: International Guidelines 2000 on Resuscitation and Emergency Cardiac Care.

Cardiopulmonary resuscitation developed over the past one half century largely from empiric science and consensus opinions and recommendations. Treatment algorithms and protocols were originally developed to summarize existing recommendations for systematic and regimented use by a heterogenous group of health care providers. Now, resuscitation science and health care teams are focusing on major issues and continuing questions as sudden death rates remain undaunted and the population at risk is rapidly increasing. For the first time, the international resuscitation community has developed an international consensus on Guidelines for Resuscitation and Emergency Cardiac Care. More than 400 basic scientists, clinical trial investigators, and educators defined common priority and scientific areas during the Evidence Evaluation International Meeting in 1999. The science of resuscitation and emergency cardiac care was reviewed for evidence-based support in randomized clinical trials. In 2000, this review was used as a foundation to structure international guidelines. The participants from seven resuscitation councils and foundations realized that regional differences in systems may exist, but the underlying science should be the same. Presented in this article are some of the major issues and controversies discussed in adult advanced cardiac life support, primarily focusing on the major problem of prehospital adult cardiac arrest.

Cardiac Care Facilities↗
PubMed2002

Managing the unique size-related issues of pediatric resuscitation: reducing cognitive load with resuscitation aids.

A resuscitation is a complicated event that requires for its optimal outcome the effective completion of a distinct series of actions, some simple, some complex, most occurring simultaneously or in close proximity. In children, these actions are determined not only by the clinical situation, but also by a series of age and size factors particular to each child. Different tasks require different levels of cognitive load, or mental effort. Cognitive load describes the mental burden experienced by the decision maker and will be higher when the task is less familiar or more demanding. In the setting of resuscitation, it refers to the cumulative demands of patient assessment, the ongoing decisions for each of the various steps, and decisions around procedural intervention (e.g., intubation). In children, the level of task complexity and, hence, cognitive load is increased by the unique component of variability of pediatric age and size, introducing logistical factors, many of which involve computations. The purpose of this paper is to examine the effects of age/size-related variables on the pediatric resuscitative process and to explore how these effects can be mitigated using resuscitation aids. The concept of cognitive load and its relation to performance in resuscitation is introduced and is used to demonstrate the effect of the various aids in the pediatric resuscitative process.

Age Factors↗
PubMed2000

Colloid solutions for fluid resuscitation.

BACKGROUND: Colloids are widely used in the replacement of fluid volume, however doubts remain as to their benefits. Different colloids vary in their molecular weight and therefore in the length of time they remain in the circulatory system. Because of this and their other characteristics, they may differ in their safety and efficacy. OBJECTIVES: To compare the effects of different colloid solutions in patients thought to need volume replacement. SEARCH STRATEGY: The Cochrane Injuries Group specialised register, The Cochrane Controlled trials register (all years), MEDLINE (1994-98), EMBASE (1974-98) were searched. Bibliographies of trials retrieved were searched and drug companies manufacturing colloids were contacted for information. SELECTION CRITERIA: Randomised and quasi randomised trials comparing colloid solutions in critically ill and surgical patients thought to need volume replacement. The main outcomes measured were death, amount of whole blood transfused and incidence of adverse reactions. DATA COLLECTION AND ANALYSIS: Two authors independently extracted the data and assessed the quality of the trials. MAIN RESULTS: 46 trials met the inclusion criteria, with a total of 2884 participants. Many of the trials were small. In the majority of trials quality was poor or uncertain. Deaths were obtained from 27 trials. Twenty three trials recorded the amount of blood transfused, however quantitative analysis was not possible due to skewness and variable reporting. Thirteen trials recorded adverse reactions, but none occurred. For albumin or PPF versus hydroxyethyl starch (HES) 20 trials reported mortality. The pooled relative risk (RR) was 1.17 (95% CI 0.91, 1.50). For albumin or PPF versus gelatin 3 trials reported mortality. The RR was 0.99 (0.69, 1.42). For gelatin vs HES 3 trials reported mortality, RR was 0.97 (0.65, 1.44). RR was not estimable in the albumin vs dextran, gelatin vs dextran, and HES vs dextran groups. REVIEWER'S CONCLUSIONS: From this review, there is no evidence that one colloid solution is more effective or safe than any other, although the confidence intervals are wide and do not exclude clinically significant differences between colloids. Larger trials of fluid therapy are needed if clinically significant differences in mortality are to be detected or excluded.

Blood Proteins↗
PubMed2001

European Resuscitation Council Guidelines 2000 for Basic Paediatric Life Support. A statement from the Paediatric Life Support Working Group and approved by the Executive Committee of the European Resuscitation Council.

The European Resuscitation Council (ERC) last issued guidelines for Paediatric Life Support (PLS) in 1998 [1]. These were based on the "Advisory Statements" of the International Liaison Committee on Resuscitation (ILCOR) published in 1997 [2]. Following this, the American Heart Association, together with representatives from ILCOR, undertook a series of evidence-based evaluations of the science of resuscitation which culminated in the publication of "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" in August 2000 [3,4]. The Paediatric Life Support Working Party of the European Resuscitation Council has considered this document and the supporting scientific literature and has recommended changes to the ERC Basic PLS guidelines. These are presented in this paper. There have been few major changes to the ERC recommended guidelines as some of the changes agreed in "Guidelines 2000" had already been introduced into Europe subsequent to the 1998 ILCOR "Advisory Statements" (Fig. 1).

Adolescent↗
PubMed1993

Prolonged resuscitation efforts for cardiac arrest patients who cannot be resuscitated at the scene: who is likely to benefit?

STUDY OBJECTIVE: To determine who may benefit from prolonged resuscitation efforts after therapy by emergency medical services system (EMS) personnel has failed to restore vital signs. DESIGN: Retrospective chart review. TYPE OF PARTICIPANTS: Two hundred sixteen consecutive adult patients with out-of-hospital cardiac arrest who were admitted to the emergency department without vital signs. METHODS: Identification of prehospital resuscitation data, therapy in the ED, hospital course, and final outcome. RESULTS: Thirty-nine patients (18.1%) were resuscitated successfully. The odds ratio of successful resuscitation in the ED for the patients with ventricular fibrillation at the scene versus those with asystole or electromechanical dissociation was 3.4 (95% confidence interval, 1.5, 7.9). All patients with asystole or electromechanical dissociation, either at the scene or in the ED, died (95% confidence interval, 0, 4.3). CONCLUSION: Prolonged resuscitation efforts in the ED for patients with asystole or electromechanical dissociation usually are futile after previous efforts by the EMS personnel have failed to restore vital signs. Transportation to the hospital may not be indicated. However, for patients with persistent ventricular fibrillation, transport is indicated.

Adolescent↗
PubMed2001

European Resuscitation Council Guidelines 2000 for Advanced Paediatric Life Support. A statement from Paediatric Life Support Working Group and approved by the Executive Committee of the European Resuscitation Council.

The European Resuscitation Council (ERC) last issued guidelines for Paediatric Life Support (PLS) in 1998 [1]. These were based on the "Advisory Statements" of the International Liaison Committee on Resuscitation (ILCOR) published in 1997 [2]. Following this, the American Heart Association, together with representatives from ILCOR, undertook a series of evidence-based evaluations of the science of resuscitation which culminated in the publication of "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" in August 2000 [3,4]. The Paediatric Life Support Working Party of the European Resuscitation Council has considered this document and the supporting scientific literature and has recommended changes to the ERC Advanced PLS guidelines. These are presented in this paper. There have been few major changes to the ERC recommended guidelines as some of the changes agreed in "Guidelines 2000" had already been introduced into Europe subsequent to the 1998 ILCOR "Advisory Statements" (Fig. 1).

Advanced Cardiac Life Support↗
PubMed2002

Common faults in resuscitation equipment--guidelines for checking equipment and drugs used in adult cardiopulmonary resuscitation.

Successful advanced life support relies, in part, upon the availability and correct functioning of resuscitation equipment. However, numerous publications report deficiencies and defects in key items of resuscitation equipment, particularly those relating to airway management and defibrillation. Some of these are generic and relate to basic device failure (e.g. intrinsic design faults, manufacturing errors, random component failure), external factors (e.g. power failure, gas supply failure, electromagnetic interference) and human error (notably, inadequate knowledge, lack of experience and training, inadequate checking, insufficient maintenance). However, others are device specific. This paper identifies the common, generic faults that lead to equipment malfunction and recommends the resuscitation equipment essential for successful cardiopulmonary resuscitation. It also describes examples of specific equipment malfunction and makes suggestions for the nature and frequency of resuscitation equipment and drug checks, using a structured, and easy-to-recall list.

Cardiopulmonary Resuscitation↗
PubMed1995

[Which dosage concept for adrenaline is correct in cardiopulmonary resuscitation? A data analysis of preclinical resuscitations].

AIM: Epinephrine is the drug of choice in cardiopulmonary resuscitation. Its dosage, however, is controversially discussed. The American Heart Association recommends for standard use in adults 1 mg epinephrine every 3-5 minutes, but classifies a medium dose, a high dose and a step-by-step escalating dosage concept as potentially useful alternatives. Aim of this study was to develop a rationale for the escalating dosage concept using an analysis of preclinical resuscitation data. METHODS: Bonn city (141 km2, 310,000 residents, 52% female, 13.9% > 65 years) was served by a double-response system of two ALS-units (staffed by physicians) and four BLS-units (staffed by paramedics). All patients were included in this data analysis, which were cardiopulmonary resuscitated according to the AHA guidelines by the ALS-unit Bonn-North (66% of area and 240,000 residents) from 1989 to 1994. All relevant data were documented by the emergency physicians using preformed treatment sheets. Discharge rates were determined by reviewing the hospital records, and one-year survival data were collected by mail contact with the primary physicians. The correlations between duration of cardiac arrest, dosage of epinephrine and outcome were determined by regression analysis in patients older than 17 years suffering from unwitnessed and bystander-witnessed cardiac arrest. Statistical significance was assumed for p < 0.05. RESULTS: Within 1989 to 1994 the ALS-team of Bonn-North resuscitated 685 cardiac arrest patients with presumed cardiac aetiology in 383 (56%) return of spontaneous circulation (ROSC) could be achieved. The epinephrine dosage required to achieve ROSC increased with prolongation of cardiac arrest interval (1989-1994; patients with ROSC selected, n = 263; r = 0.2276; p = 0.0002). Resuscitation success, however, decreased with increasing, dosage of epinephrine (1989-1992; n = 345; ROSC: r = -0.2643; p < 0.001; survival > 24 h: r = -0.3393; p < 0.001; discharge: r = -0.1677; p = 0.0018; survival > 1 year: r = -0.2685; p < 0.001). CONCLUSION: Based on these data, we recommend an escalating epinephrine dosage concept, which facilitates titration of the drug to an effective level and meets the needs of the individual patient. This concept avoids overdosage in patients who had just collapsed shortly before initiation of CPR, attains higher levels of epinephrine in patients suffering from prolonged cardiac arrest, and takes into consideration that the effective epinephrine dose varies individually and increases with prolongation of the cardiac arrest interval.

Adolescent↗
PubMed2006

Cardiopulmonary resuscitation algorithms, defibrillation and optimized ventilation during resuscitation.

PURPOSE OF REVIEW: In 2005, the American Heart Association released its Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. This article reviews the treatment algorithms for Advanced Cardiac Life Support, citing the evidence on which the Guidelines are based. Additional focus is placed on defibrillation and optimized ventilation. RECENT FINDINGS: Major changes include a reorganization of the algorithms for cardiac arrest. Emphasis on effective cardiopulmonary resuscitation is placed as the key to improved survival. Single defibrillation shocks are recommended (compared with three 'stacked' shocks) with immediate provision of cardiopulmonary resuscitation and minimal interruptions in chest compressions. The recommended chest compression : ventilation rate for single rescuers has been changed to 30:2. SUMMARY: Despite advances in resuscitation science, basic life support remains the key to improving survival outcomes. Ultimately, as new knowledge is gained, we believe resuscitation therapies will be more individualized, on the basis of pathophysiology and etiology of the initial cardiac arrest.

Algorithms↗
PubMed1986

The pharmacology of neonatal resuscitation and cardiopulmonary intensive care. Part I--Immediate resuscitation.

Resuscitation of a neonate requires both immediate cardiopulmonary resuscitation and extended intensive care. Initial resuscitation of the neonate, as for adults, must include support of the airway, breathing and circulation. Because of the unique physiology of a newborn infant, some aspects of drug therapy differ significantly from their counterparts in the resuscitation of adults, and hypoglycemia and hypothermia pose special threats to a distressed neonate. Epinephrine and atropine can be administered via an endotracheal tube, but vascular access, which is most easily obtained by cannulating an umbilical vessel, is required for administering other drugs. Initial drug therapy, including glucose, oxygen and bicarbonate, is intended to restore metabolic homeostasis. Bicarbonate administration must be preceded by adequate alveolar ventilation. Drugs used to increase cardiac output early in resuscitation include those that increase heart rate, increase preload or improve myocardial function. Other drugs used in extended intensive care may also improve cardiac output, alter the distribution of the circulation or alter pulmonary function or gas exchange. These agents will be reviewed in a subsequent article.

Atropine↗
PubMed2000

Suspended animation for delayed resuscitation from prolonged cardiac arrest that is unresuscitable by standard cardiopulmonary-cerebral resuscitation.

Standard cardiopulmonary-cerebral resuscitation fails to achieve restoration of spontaneous circulation in approximately 50% of normovolemic sudden cardiac arrests outside hospitals and in essentially all victims of penetrating truncal trauma who exsanguinate rapidly to cardiac arrest. Among cardiopulmonary-cerebral resuscitation innovations since the 1960s, automatic external defibrillation, mild hypothermia, emergency (portable) cardiopulmonary bypass, and suspended animation have potentials for clinical breakthrough effects. Suspended animation has been suggested for presently unresuscitable conditions and consists of the rapid induction of preservation (using hypothermia with or without drugs) of viability of the brain, heart, and organism (within 5 mins of normothermic cardiac arrest no-flow), which increases the time available for transport and resuscitative surgery, followed by delayed resuscitation. Since 1988, we have developed and used novel dog models of exsanguination cardiac arrest to explore suspended animation potentials with hypothermic and pharmacologic strategies using aortic cold flush and emergency portable cardiopulmonary bypass. Outcome evaluation was at 72 or 96 hrs after cardiac arrest. Cardiopulmonary bypass cannot be initiated rapidly. A single aortic flush of cold saline (4 degrees C) at the start of cardiac arrest rapidly induced (depending on flush volume) mild-to-deep cerebral hypothermia (35 degrees to 10 degrees C), without cardiopulmonary bypass, and preserved viability during a cardiac arrest no-flow period of up to 120 mins. In contrast, except for one antioxidant (Tempol), explorations of 14 different drugs added to the aortic flush at room temperature (24 degrees C) have thus far had disappointing outcome results. Profound hypothermia (10 degrees C) during 60-min cardiac arrest induced and reversed with cardiopulmonary bypass achieved survival without functional or histologic brain damage. Further plans for the systematic development of suspended animation include the following: a) aortic flush, combining hypothermia with mechanism-specific drugs and novel fluids; b) extension of suspended animation by ultraprofound hypothermic preservation (0 degrees to 5 degrees C) with cardiopulmonary bypass; c) development of the most effective suspended animation protocol for clinical trials in trauma patients with cardiac arrest; and d) modification of suspended animation protocols for possible use in normovolemic ventricular fibrillation cardiac arrest, in which attempts to achieve restoration of spontaneous circulation by standard external cardiopulmonary resuscitation-advanced life support have failed.

Advanced Cardiac Life Support↗
PubMed2004

Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary resuscitation?

BACKGROUND: Documented prehospital asystole justifies termination of resuscitation, but recently it has been proposed to extend this policy to patients in the field with pulseless electrical activity. Consequently, we questioned whether resuscitative thoracotomy is warranted in the critically injured patient who fails to respond to prehospital CPR. STUDY DESIGN: A prospective database of all emergency department resuscitative thoracotomies (EDT) performed at our Level I trauma center has been maintained since January 1977. These registry data were augmented by a review of prehospital paramedic records for all survivors of EDT to verify length of CPR. RESULTS: During the 26-year study period, 959 patients underwent EDT. Of the 62 patients who survived to leave the hospital, 26 (42%) required prehospital CPR. The injury mechanism in these 26 patients was stab wounds in 18 (69%), gunshot wounds in 4 (15%), and blunt trauma in 4 (15%). The duration of prehospital CPR ranged from 3 to 15 minutes and in 7 patients CPR exceeded 10 minutes. Five survivors had asystole documented at the time of EDT; four of these patients had good functional outcomes at discharge. Each of these patients had pericardial tamponade from ventricular stab wounds. Patients with blunt trauma had uniformly dismal neurologic outcomes. CONCLUSIONS: EDT after prehospital CPR can be used to salvage select critically injured patients. Based on these data, we propose that resuscitative thoracotomy is futile care in patients with blunt trauma requiring prehospital CPR longer than 5 minutes, and in patients with penetrating trauma with more than 15 minutes of prehospital CPR. EDT is warranted in those patients with penetrating trauma with less than 15 minutes of prehospital CPR, and should be performed despite documented asystole on arrival if pericardial tamponade is the proximate event.

Adolescent↗
PubMed2001

European Resuscitation Council Guidelines 2000 for Adult Basic Life Support. A statement from the Basic Life Support and Automated External Defibrillation Working Group(1) and approved by the Executive Committee of the European Resuscitation Council.

The European Resuscitation Council (ERC) last issued guidelines for Basic Life Support (BLS) in 1998 [1]. These were based on the "Advisory Statements" of the International Liaison Committee on Resuscitation (ILCOR) published in 1997 [2]. Following this, the American Heart Association, together with representatives from ILCOR, undertook a series of evidence-based evaluations of the science of resuscitation [3] which culminated in the publication of "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" in August 2000 [4,5]. The Basic Life Support and Automated External Defibrillation Working Group (BLS&AED Group) has considered this document and has recommended changes in the ERC BLS guidelines. These are presented in this paper.

Adult↗
PubMed2001

European Resuscitation Council Guidelines 2000 for Automated External Defibrillation. A statement from the Basic Life Support and Automated External Defibrillation Working Group(1) and approved by the Executive Committee of the European Resuscitation Council.

The European Resuscitation Council (ERC) last issued guidelines for Automated External Defibrillators (AEDs) in 1998 [1]. The American Heart Association, together with representatives from the International Liaison Committee on Resuscitation (ILCOR), then undertook a series of evidence-based evaluations of the science of resuscitation [2] which culminated in the publication of "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" in August 2000 [3,4]. The Basic Life Support and Automated External Defibrillation Working Group (BLS&AED Working Group of the ERC) has considered this document and has recommended changes in the ERC AED guidelines. These are presented in this paper.

Algorithms↗
PubMed1993

Near drowning: is emergency department cardiopulmonary resuscitation or intensive care unit cerebral resuscitation indicated?

OBJECTIVES: a) To report the neurologic outcome of a series of near-drowning victims treated with supportive management without aggressive cerebral resuscitation; and b) to identify patient characteristics that indicate prognosis and guide therapy at the scene, the Emergency Department, and in the intensive care unit (ICU). DESIGN: Retrospective review of all near-drowning patients requiring admission to the ICU over a 6-yr period (1/1/82 to 12/31/88). Hospital records were examined for the circumstances of submersion and rescue, patient condition on arrival in the Emergency Department and ICU, treatments, hospital course, and ultimate outcome. SETTING: Emergency departments of the referring hospital and ICU of Children's Hospital. PATIENTS: Forty-four pediatric submersion victims were treated with therapy limited to the support of vital functions. Three patients who met cold-water drowning criteria were excluded from the analysis for predictors of neurologic outcome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In our warm-water near-drowning patients, 56% survived neurologically intact, 32% survived in a persistent vegetative state, and the remaining 32% died. Unreactive pupils in the Emergency Department and a Glasgow Coma Score of < or = 5 on arrival to the ICU were the best independent predictors of poor neurologic outcome (odds ratio and 95% confidence intervals 374 [17 to 16,000] and 51 [5 to 2,200], respectively). However, no predictor was absolute and two nonhypothermic patients who arrived to the Emergency Department without vital signs, requiring cardiopulmonary resuscitation and cardiotonic medications, had full neurologic recovery. CONCLUSIONS: Our results cast further doubt on the utility of aggressive forms of cerebral monitoring and resuscitation and emphasize the need for initial full resuscitation in the Emergency Department.

Adolescent↗
PubMed1999

Resuscitation of the newly born infant: an advisory statement from the Pediatric Working Group of the International Liaison Committee on Resuscitation.

The International Liaison Committee on Resuscitation (ILCOR), with representation from North America, Europe, Australia, New Zealand, Africa, and South America, was formed in 1992 to provide a forum for liaison between resuscitation organizations in the developed world. This consensus document on resuscitation extends previously published ILCOR advisory statements on resuscitation to address the unique and changing physiology of the newly born infant within the first few hours following birth and the techniques for providing advanced life support.

Delivery Rooms↗