Resuscitation 83 (2012) 925
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Resuscitation
jo u rn al hom epage : www.elsevier.com/locate/resuscitation
Editorial
CPR cardiopulmonary resuscitation or cerebral perfusion restoration
It has long been recognised that following cardiac arrest, cere- Further research into the effects of SADs on carotid blood flow
bral oxygenation falls rapidly. The brain is a metabolically highly
is required. It would be useful to know if devices with no inflat-
active organ and cell death begins after only a few minutes of
able cuffs such as the iGEL (Intersurgical, Wokingham, UK) have the
anoxia.1 The main mode of death following resuscitation from car- same potential to cause alterations in blood flow. It is also important
diac arrest remains neurological death.2
to understand if the reductions in carotid blood flow are associated
Recent guidelines have stressed the importance of continu- with reduced cerebral blood flow or if there is compensation via
ous chest compressions in order to maintain coronary perfusion
the vertebral arteries.
pressure.3 This has led towards a greater emphasis on the use of
One of the most important issues that this paper points to is the
supraglottic airway devices (SADs) to manage the airway in order
ultimate outcomes we are aiming for in the management of cardiac
to minimise interruptions in chest compressions.
arrest. Long term good neurological outcome has to be the ultimate
A paper in this edition of resuscitation shows that in a swine
focus of all clinicians involved in resuscitation, and it is reassuring
model, inflation of a SAD causes impairment in carotid artery blood
that this has been recognised in the recommended outcomes of
flow.4 This has been shown with a number of different devices all of
resuscitation trials.10
which have inflatable cuffs. There are obvious limitations in being
1. Conflict of interest
a swine model, but it is already known that SADs reduce carotid
blood flow in anaesthetised humans so the effects are probably
We report no conflict of interest.
translatable.5 In addition the use of epinephrine during CPR can
further reduce carotid blood flow.6 This leads to the very real con- References
cern that recent changes in the management of cardiac arrest will
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lead to an increased number of survivors but those survivors will
2. Laver S, Farrow C, Turner D, Nolan J. Mode of death after admission to an inten-
be in a poor neurological condition.
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Should the management of cardiac arrest then be aimed pri- 3. Lim SH, Shuster M, Deakin CD, et al. Part 7: CPR techniques and devices: 2010
International Consensus on Cardiopulmonary Resuscitation and Emergency
marily at minimising neurological damage during resuscitation?
Cardiovascular Care Science with Treatment Recommendations. Resuscitation
Advances such as extracorporeal life support and prehospital cool-
2010;81(Suppl. 1), e86 92.
4. Segal N, Yannopoulos D, Mahoney BD, et al. Impairment of carotid artery blood
ing of patients would suggest that this may be the direction to go.
flow by supraglottic airway use in a swine model of cardiac arrest. Resuscitation
The concept of CPR as cerebral perfusion restoration as opposed to
2012;83:1025 30.
trying to maximise coronary perfusion.
5. Colbert SA, O Hanlon DM, Flanagan F, Page R, Moriarty DC. The laryngeal mask
So the pendulum may be swinging again in favour of brain airway reduces blood flow in the common carotid artery bulb. Can J Anaesth
1998;45:23 7.
focussed resuscitation potentially at the expense of coronary perfu-
6. Burnett AM, Segal N, Salzman JG, McKnite MS, Frascone RJ. Potential nega-
sion. The concept of focussing resuscitation on the brain is not new,
tive effects of epinephrine on carotid blood flow and ETCO(2) during active
we have attempted abdominal binding and leg raises to improve compression-decompression CPR utilizing an impedance threshold device.
Resuscitation 2012;83:1021-4.
cerebral blood flow for over twenty years.7 These techniques how-
7. Koehler RC, Chandra N, Guerci AD, et al. Augmentation of cerebral perfusion
ever have never translated into an improved outcome for patients.8
by simultaneous chest compression and lung inflation with abdominal binding
Then if we were to utilise only level one evidence in cardiac arrest
after cardiac arrest in dogs. Circulation 1983;67:266 75.
8. Koster RW, Sayre MR, Botha M, et al. Part 5: Adult basic life support: 2010
management then we would have little in our armoury.
International consensus on cardiopulmonary resuscitation and emergency
What is concerning considering the amount of healthcare
cardiovascular care science with treatment recommendations. Resuscitation
resource that is used in the management of cardiac arrest, is how
2010;81(Suppl. 1), e48 70.
9. Komorovsky R, Desideri A. Carotid ultrasound assessment of patients with coro-
little is known regarding the incidence of carotid disease as either
nary artery disease: a useful index for risk stratification. Vasc Health Risk Manag
a cause or an incidental finding following cardiac arrest. Carotid
2005;1:131 6.
disease has a high incidence in patients with coronary artery dis-
10. Becker LB, Aufderheide TP, Geocadin RG, et al. Primary outcomes for resuscita-
tion science studies. Circulation 2011;124:2158 77.
ease reported as high as 40% and in these patients there is a higher
incidence of myocardial events even following revascularisation.9 "
Matt Thomas
It is highly likely therefore that patients following cardiac arrest
R. Jonathan Hadfield
are at high risk of impaired carotid blood flow even with ade-
Intensive Care Unit, University Hospitals Bristol,UK
quate cardiac output. Further impairing that flow with SADs and
"
Corresponding author.
epinephrine could have serious consequences. The reasons for the
E-mail address:
large variations in neurological outcome following cardiac arrest
[e-mail] (M. Thomas)
remain unclear, and it is entirely plausible that altered cerebral
blood flow is a factor in this.
8 May 2012
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http://dx.doi.org/10.1016/j.resuscitation.2012.05.002