Resuscitation highlights in 2011
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Royal United Hospital, Bath, UK
Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA, USA
Liverpool and Macquarie University Hospitals, University of New South Wales, University of Western Sydney and Macquarie University, Sydney, Australia
University of Warwick, Warwick Medical School, Warwick, CV4 7AL, United Kingdom
Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK
Article Outline
Following the publication in 2010 of the International Liaison Committee on Resuscitation (ILCOR) Consensus on Cardiopulmonary Resuscitation (CPR) Science with Treatment Recommendations (CoSTR)1 and the European Resuscitation Council (ERC) Guidelines,2 the Resuscitation editorial team was expecting a relatively quiet 2011. Instead, we are delighted to report a substantial increase in the number and, more importantly, the quality of submissions to the journal. Here we summarise briefly the key papers published in Resuscitation in 2010.
1. Epidemiology
Several recent publications provide important insights into the present and changing epidemiology of cardiac arrest in the community. Vayrynen et al. reported that the internationally-observed decline in the incidence of out-of-hospital ventricular fibrillation (VF) seems to have ended in Helsinki, Finland, where the annual VF incidence has stabilised at 11.6 (95% CI 9.7-13.5) per 100,000 inhabitants.3 Sasson et al. reported on 1108 out-of-hospital cardiac arrest (OHCA) cases from Fulton County/Atlanta, Georgia, that appeared eligible to receive bystander CPR; only 279 (25%) victims actually received bystander CPR.4 Cardiac arrest patients in highest income areas were much more likely to receive bystander CPR than individuals living in lower income neighbourhoods. Finally, Stromsoe et al. found no significant association between population density and incidence or survival from OHCA in the Swedish Cardiac Arrest Register, although bystander CPR, cardiac aetiology and longer emergency medical services (EMS) response times were more frequent in less populated areas.5
2. Prevention
Prevention of in-hospital cardiac arrest (IHCA) has remained a major topic in this journal ever since readers were alerted to the concept of the medical emergency team (MET) in 2001.6 The 2010 CoSTR and ERC guidelines recommended that hospitals should provide a system of care that includes education, regular vital signs monitoring, clear guidance (via calling criteria) in the early detection of patient deterioration, a system to call for assistance, and timely clinical responses.7, 8
Studying the effects of the MET, rapid response teams (RRT) and critical care outreach services (CCOS) on patient outcomes is difficult but single centre studies continue to report fewer adverse outcomes after implementation of these systems. Moon and colleagues demonstrated significant reductions in the incidence of cardiac arrest calls, patients admitted to the intensive care unit (ICU) after CPR and their in-hospital mortality, in the four years following the introduction of a CCOS and modified early warning scoring (MEWS) charts.9 Implementation of the MET in a regional hospital was also associated with statistically significant reductions in hospital-wide mortality rates, ICU admissions and cardiopulmonary arrests.10
The impact of afferent limb failure - ward staff not calling for assistance when MET criteria are fulfilled - was studied by Trinkle and co-workers and accompanied by an editorial.11, 12 Despite 20 years of implementation, afferent limb failure is still a major issue even in mature systems and results in poor outcomes. Strategies to ensure afferent limb activation are needed and suggested by the authors. With reference to the afferent limb, Tarassenko et al. aimed to develop a centile-based EWS system based on the statistical properties of at-risk patients vital signs.13 They found their system to be comparable to previously published systems but with some differences in scoring of respiratory rate and systolic blood pressure. The system requires validation and in the accompanying editorial, Subbe comments that despite the many reviews of track and trigger criteria, hospitals continue to create their own set of criteria and national and internationally standardization does not exist; this is probably overdue.14
Two studies from Australia looked at the epidemiology of common reasons for activation of MET calls: atrial fibrillation (AF) and the need for non-invasive ventilation (NIV).15, 16 In the first, they found AF triggers 10% of MET activations and associated mortality is high. Admitting these patients to wards with higher-level care reduced mortality, suggesting that some of these deaths are preventable. In the second study, one in ten MET call patients received NIV, two-thirds were transferred to a higher care area, one in four progressed to intubation, and one in four died. They concluded that NIV use during a MET call identified high-risk patients for whom admission to high-level care should be strongly considered.
Micallef et al. showed that a MET system also provides an opportunity to identify patients for whom a do not attempt CPR (DNACPR) order should be considered, thus avoiding unnecessary intervention and costs.17
3. Quality of CPR
The quality of CPR remains an important theme in resuscitation science.18 Previous research highlighted the need to avoid interruptions in chest compressions during ventricular fibrillation/tachycardia.19 Vaillancourt et al. extended these findings by confirming that chest compression fraction was independently associated with a trend toward an increased likelihood of return of spontaneous circulation in patients with non-VF/VT initial rhythm.20
Simulation provides a safe opportunity to examine factors which influence CPR process variables and team performance.21Insights from such an observational study identified un-necessary interruptions in CPR 32% of the time.22 Analysis of activities during interruptions identified secondary medical activities, particularly observing the monitor (47%) and dealing with the defibrillator (47%) as the predominant cause. There was evidence of loss of situational awareness and poor task distribution as all team members frequently focussed their attention on the same secondary activity. Non-technical skills or the way in which team members / team leaders interact and behave in a crisis impacts technical skill performance. Fernandez Castelao et al. elegantly showed how the inclusion of crew resource management training during advanced life support training was able to reduce no flow duration by increasing the number of team leader verbalisations.23
Another recommendation contained in Guidelines 2010 included an increase in chest compression depth to 5-6
cm during adult CPR.18 The rationale was in part motivated by the observation that the majority of chest compressions delivered by people following the previous guidelines were too shallow. Mpotos et al. investigated the impact of this change on CPR skill retention 6 months after initial training.24 Medical student participants (n
=
180) were randomised to training with CPR feedback targeting compressions of 40-50
mm vs. >50
mm. At follow-up assessment the proportion of students achieving a depth <40
mm was 29% in the standard group vs. 14% in the deep compression group (P
=
0.01). Compressions above 50
mm were achieved by 6% in the standard group compared to 49% in the deep group (P
<
0.001). Together these findings support the recommendation to `push hard and fast and please do not stop!'25
Concerns have been expressed about the potential for injuries from deeper chest compressions or hand positioning.26, 27Similar expressions of concern also frequent the literature in relation to mechanical chest compression devices.28, 29Compression injuries in non-survivors are optimally identified by autopsy30 or non-invasively with CT scanning.31 However what remains important is the overall impact on patient outcomes as opposed to injury patterns in non-survivors.29 We encourage the on-going collection and publication of prospective data linking CPR quality to outcome to enable a complete picture to be drawn linking compression quality to outcome.
The now almost universal carriage of mobile phones positions them as a potentially powerful tool to reinforce the chain of survival.32, 33, 34 Specific opportunities include as an adjunct to CPR training,35 dispatcher CPR, activating trained bystanders to the site of an arrest,36 location of automated external defibrillators (AEDs),37 locating the site of an incident/emergency and providing feedback on CPR performance.38
4. Defibrillation
Automated external defibrillators using biphasic waveforms continue to dominate the resuscitation literature. Hess and colleagues found that shock success (termination of VF within 5
s post-shock) did not differ between initial and recurrent episodes of VF using a rectilinear biphasic waveform.39 Several papers explored novel methods to increase early defibrillation in the community by laypeople using AEDs. Scholten et al. sent 3227 SMS-text AED-alerts to 2287 laypersons concerning 52 patients suspected of cardiac arrest.40 Action was taken by only 579 of these laypeople. The principal reasons for non-response were because the laypeople were not in the patient's vicinity (41%) or noticed the alert too late (35%). In 298 alerts, laypeople faced problems with retrieving an AED (51%), finding the victim (29%), or traversing traffic (5%). The SMS-text activated laypeople provided aid to 47 patients, arriving before EMS personnel in 21 patients, starting CPR and defibrillating 18, and assisting EMS personnel in 9 patients. In a similar report, Rea et al. document the value of having an AED registry that can alert emergency dispatchers to the presence of a nearby public access AED that a caller can retrieve and use on a victim while awaiting EMS arrival.41
5. Advanced life support
5.1. Airway
The best airway technique for use during cardiac arrest is unknown and likely to depend on several factors. Wang et al. described tracheal intubation success rate using data from the 2008 National Emergency Medical Services Information System (NEMSIS).42 Among 4,383,768 EMS activations, there were 10,356 tracheal intubations, 2246 alternate airways (Combitube, laryngeal mask airway (LMA), laryngeal tube (LT), Esophageal-Obturator Airway), and 88 cricothyroidotomies. The overall tracheal intubation success rate was 77.0% (95% CI: 76.1-77.9%), and the alternate airway success rate was 87.2%. In a physician-staffed EMS, difficult pre-hospital tracheal intubation occurred in 13% of cases.43 Predisposing factors included lack of space around the victim, or victims with a short neck, obesity, or face and neck injuries.
A tracheal rapid ultrasound exam (TRUE) performed during emergency intubation with the transducer placed over the suprasternal notch enables accurate identification of correct tube placement.44, 45 In 112 patients (17 [15.2%] with oesophageal intubation determined by waveform capnography), the overall accuracy of TRUE was 98.2%, with a median time of 9
s, and no differences were observed between cardiac arrest and non-cardiac arrest patients.
Numerous alternatives to tracheal intubation are available. Frascone et al. observed that placement success (ventilation to chest rise, no gastric sounds, bilateral lung sounds, and when applicable, quantitative end-tidal CO2 readings) by paramedics was similar for the disposable laryngeal tube with suction port (LTS-D) and tracheal intubation (tracheal intubation 80.2% vs. LTS-D 80.5%; P
=
0.97).46 Another study of OHCA patients, observed that first attempt success rates by basic life support (BLS) first responders using the LT-D were higher than tracheal intubation success rates by paramedics (87.8% vs. 57.6%).47
Whether the findings of manikin studies of airway devices can be extrapolated to real patients is controversial. The i-gel and LMA-Supreme had the highest first attempt insertion success in a randomized manikin study of 267 medical students using four different supraglottic airway devices (i-gel, LMA-Supreme, LMA-Unique, LMA-ProSeal) or a bag-mask.48 In another manikin study, 40 EMS technicians with no previous advanced airway management experience, performed airway management, after brief training, with six airway devices (tracheal tube, Combitube, EasyTube, LT, LMA, and i-gel) during on-going chest compressions.49 Interruptions to CPR were significantly longer with tracheal intubation that the other devices. Only a third of technicians were successful with tracheal intubation whereas all successfully inserted the other devices.
A study to assess LMA use in newborn resuscitation showed improved success compared with bag-mask ventilation with a first attempt LMA insertion success rate of 98.5%.50, 51 A study of pre-term (<32 weeks gestation) newborn resuscitations that required tracheal intubation showed that colorimetric CO2 detectors can fail to change colour in spite of correct tube placement in up to one third of the cases.52
5.2. Mechanical devices
Mechanical devices continue to offer theoretical advantages over manual chest compression, but evidence for clinical benefit continues to be elusive. Several studies documented the value of mechanical chest compression devices in minimizing the hands-off time during resuscitation. Fischer and colleagues found that a team of two trained flight attendant rescuers had significantly less `absolute hands-off time' when they performed CPR on a manikin in a simulated aircraft environment using a manually-powered mechanical device compared to performing compressions manually.53
Bonnemeier et al. studied 28 pulseless electrical activity (PEA) patients in a university hospital setting and concluded that continuous chest compression with a Lund University Cardiac Assist System (LUCAS) device proved feasible and safe during transport or diagnostic procedures.54 However, a 149 patient randomised pilot study conducted in two Swedish cities showed no difference in early survival in patients treated with mechanical LUCAS vs. manual chest compressions.28
5.3. Extracorporeal life support
Use of extracorporeal circulation to treat selected patients who do not respond to conventional resuscitation is becoming increasingly popular, particularly in Japan. An increasing number of case reports document the feasibility and benefit of this strategy.55, 56, 57 Morimura et al. reviewed case reports, case series and abstracts of scientific meetings of 1282 OHCA patients who received extracorporeal support between 1983-2008 and concluded that this strategy can provide a high survival rate with excellent neurological outcome.58
5.4. Drugs
Adrenaline (epinephrine) has been a mainstay of cardiac arrest guidelines despite limited evidence for its efficacy. A randomised study comparing adrenaline with placebo is therefore welcome. Jacobs and colleagues studied 534 (262 placebo vs. 272 adrenaline) OHCA patients.59, 60 The study showed improved return of spontaneous circulation (ROSC) with adrenaline (22 [8.4%] placebo vs. 64 [23.5%] adrenaline; OR
=
3.4; 95% CI 2.0-5.6) but no difference in survival to hospital discharge (5 [1.9%] placebo vs. 11 [4.0%] adrenaline; OR
=
2.2; 95% CI 0.7-6.3). All but two patients (both in the adrenaline group) had a cerebral performance category (CPC) score of 1-2. This study was underpowered to provide useful data on longer-term outcomes, but does suggest that adrenaline has an ongoing role in resuscitation.
5.5. Drowning
Drowning is an important cause of morbidity and mortality, particularly in the young. Analysis of the results of long term follow-up children involved in drowning incidents revealed that good health related quality of life will be achieved in the majority of patients. This highlights the importance focusing efforts on early rescue and resuscitation.61 However the evidence for the treatment of drowning is predominantly based on case reports or observational studies. The usefulness of the water temperature and duration of submersion as a guide to rescuers for deciding whether a rescue and resuscitation attempt is worthwhile is hotly debated, especially in terms of how the available data should be interpreted.62, 63 Early oxygen therapy is considered important in drowning victims. Ideally oxygen therapy should be guided by pulse oximetry monitoring. In a small study of healthy volunteers submersed in warm of cold water, pulse oximeters were found to be unreliable.64
5.6. Trauma
Guly et al. assessed the validity the Advanced Trauma Life Support (ATLS) classification of the severity of shock. They found that with increasing estimated blood loss there is a trend to increasing heart rate (HR) and a reduction in systolic blood pressure (SBP) but not to the extent indicated by the ATLS classification of shock.65
Acute traumatic coagulopathy, its management and massive transfusion strategies are hot topics in trauma management. Rainer et al. aimed to risk stratify patients with major trauma to predict need for massive transfusion (MT).66 They found seven variables measured in the emergency department (ED) predicted the need for MT: HR
≥
120
min−1; SBP
≤
90
mmHg; Glasgow Coma Scale
≤
8; displaced pelvic fracture; computerised tomography (CT) scan or focussed assessment with sonography for trauma (FAST) positive for fluid; base deficit >5
mmol
L−1; haemoglobin
≤
7
g
dL−1; and haemoglobin 7.1-10
g
dL−1. The sensitivity was low at 31.5% and specificity of 99.7% and requires validation in an independent data set. On the same theme, Mitra et al. have tried to develop a tool to identify accurately patients with acute traumatic coagulopathy using pre-hospital variables alone.67 The COAST score was developed, scoring points for entrapment, temperature
<
35
°C, SBP
<
100
mmHg, abdominal or pelvic content injury and chest decompression. The score was then validated using 1225 major trauma patients: a COAST score of ≥3 had a specificity of 96.4% with a sensitivity of 60.0%, with an area under the receiver operating characteristic (ROC) curve of 0.83 (0.78-0.88). In his accompanying editorial, Brohi concluded that the score lacked the sensitivity to act as a sole activator of a major haemorrhage protocol and appealed to the trauma community to focus research on new or improved diagnostics that are suitable for the emergency environment, accurately detect acute traumatic coagulopathy and can guide therapeutic interventions.68
6. Post resuscitation care
There is trend toward regionalisation of the treatment of post cardiac arrest patients. This driven partly by the need for 24/7 access to percutaneous coronary intervention (PCI) but there also some limited data suggesting that centres treating more cardiac arrest patients achieve better outcomes than those treating few. In an observational study, which used propensity analysis, Shin co-workers documented that emergency departments in Korea receiving many post arrest patients achieved better outcomes than those receiving few.69
The topic of therapeutic hypothermia after cardiac arrest continues to be the focus for considerable research. A systematic review by Walters and colleagues provides a useful up-to-date overview of most studies on this topic.70 Although there is high-level evidence for benefit of hypothermia after out-of-hospital VF cardiac arrest, evidence for a benefit after non-shockable rhythms is from observational studies only. Testori et al. have added to this evidence: they documented in a retrospective study, improved neurological outcome (odds ratio 1.84; 95% confidence interval 1.08-3.13) among 145 patients treated with hypothermia compared with a control group not treated with hypothermia after OHCA with asystole or PEA.71 In contrast, in another retrospective study, Pfeifer and colleagues failed to show any benefit from hypothermia among 143 patients treated after OHCA from all rhythms compared with a control cohort who were not cooled.72 In an accompanying editorial, Nielsen and Friberg state that there are weaknesses in all the hypothermia studies undertaken to date and emphasise the need for more high-quality studies.73
There is limited evidence that hypothermia may be more effective after cardiac arrest the earlier it is initiated and target temperature achieved. In a retrospective study, Garrett and associates documented improved rates of ROSC, but not survival to discharge, among 208 patients given cold normal saline (IV or IO) during cardiac arrest in comparison with 334 patients who did not receive cold saline.74 The use of the cold saline to induce hypothermia is inexpensive and, in another study, Kory et al. documented rapid, effective cooling and maintenance of target temperature using a combination of cold saline infusion, evaporative surface cooling and ice water gastric lavage.75 Measurement of cardiac output non-invasively during post cardiac arrest therapeutic hypothermia would be useful. Haenggi et al. report that, under these clinical conditions, a non-calibrated pulse-contour analysis system (Vigileo, Edwards Lifesciences, Saint-Prex, Switzerland) is unreliable.76
Impairment of the microcirculation plays a significant role in the development of sepsis-induced organ failure. Donadello et al. have undertaken one of the first clinical studies of the microcirculation after cardiac arrest.77 Using a sidestream dark field device in 10 post cardiac arrest patients, they documented abnormalities in microvascular density and flow in the sublingual microcirculation; these returned to normal by 48
h after cardiac arrest. The extent to which these changes were influenced by hypothermia needs further clarification.78
A group from Oslo, Norway has previously shown that implementation of a standardised post cardiac arrest protocol is associated with improved outcome.79 This group has produced an updated report of their outcomes using this standardised protocol: among 248 patients admitted to ICU after OHCA of cardiac origin, 56% achieved a favourable neurological outcome (hospital discharge).80 A systematic review by Elliott et al. concluded the quality of life among cardiac arrest survivors is generally good.81
7. Prognostication
The prediction of outcome among those who achieve ROSC after cardiac arrest remains challenging. Shinozaki et al. documented an association between blood ammonia and lactate values measured at the time of admission to hospital and outcome among 98 post cardiac arrest patients.82 In other study from Japan, Hayakawa and colleagues report that a model based on four indicators (age, time to ROSC, pre-hospital ROSC and conversion to VF for initial non-shockable rhythms) showed a high predictive value for favourable among OHCA patients with ROSC.83
Magnetic resonance imaging (MRI) has been studied as a potential means for predicting outcome in comatose post cardiac arrest patients. However, Heradstveit et al. have shown that an admission MRI often fails to shown evidence of cerebral ischaemia in post arrest patients who later show ischaemic lesions on repeat MRI.84 Many of the tests used to predict outcome in comatose post-cardiac arrest patients may be modified by the use of therapeutic hypothermia. In a prospective observational study of 31 post cardiac arrest patients treated with mild hypothermia, Mortberg et.al. conclude that blood values of S-100 measured at 24
h after ROSC are predictive of outcome.85 In contrast, Bisschops et al. determined the effect of mild hypothermia on the validity of internationally recognised predictors of outcome in 103 patients.86 They reach the important conclusion that no single clinical or electrophysiological test has sufficient accuracy to determine prognosis in patients treated with hypothermia after cardiac arrest.
Conflicts of interest statement
JPN is Editor-in-Chief of Resuscitation.
GDP, JPO, MJAP and JS are Editors of Resuscitation
JO is on the Science Advisory Board for ZOLL Circulation and serves as Cardiac Co-Chair for the National Institutes of Health-sponsored Resuscitation Outcomes Consortium (ROC). He serves as the Virginia Commonwealth University Principal Investigator for the National Institutes of Health-sponsored Neurological Emergency Treatment Trials Network (NETT).
JS is Chairman of the Resuscitation Council (UK)
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