For the up and coming discussion on the 3rd of February about Cardiac Arrest over at The PAD we have prepared some background information for you to peruse at your leisure.
We wouldn’t want you to turn up not knowing what is currently happening in the world of resuscitation!
Cardiac Arrest and Resuscitation
A short history
Bringing people “back from the dead” has been a fascination of generations. Early attempts, for example with tobacco smoke enemas, weren’t exactly evidence based or particularly effective, but a step towards modern resuscitation nonetheless.
Artificial (emergency) ventilation started with similar rudimentary techniques: moving the victims arms, laying them on their side and twisting them, laying them prone and compressing their lower back; all sounding like a good idea at the time, but nothing really standing out as distinctly life-saving. Mouth to mouth resuscitation had been mentioned and tried from ancient times, but only in 1959 did scientists properly acknowledge it as the best way of emergency pulmonary resuscitation, providing good insufflation together with basicc airway patency.
Acceptance of closed chest cardiopulmonary Resuscitation (CPR) followed shortly afterwards in 1960. Peter Safar is widely credited to ‘inventing’ CPR in the 1950′s, although he did not accept this himself, stating he merely brought techniques already known to man together in to what is widely now known as the “ABC’s” – Airway, Breathing, Circulation. That makes him a co-founder of our websites name too!
If you’re interested in the history of resuscitation, Howard P Liss wrote “A history of resuscitation” in 1986. You’ll need access to the Annals of Emergency Medicine, so if you don’t have journal access yourself, ask your employer or find a colleague or student that does.
Current state of cardiac arrest management by paramedics
Since then, CPR has been taught to laypeople and professionals worldwide, in different variations. In 2005 new resuscitation guidelines were revealed – all major councils (American, Australian, European an UK amongst others) recommended a 30:2 compression:ventilation ratio, simplifying and standardising (adult) resuscitative efforts. This has been continued in the 2010 revision.
Have the changes from 15:2 towards 30:2 actually had a positive effect on outcomes? A weak trend can be considered, as these two trials show. Sunday we will discuss implementation and change within your service – maybe you have experienced similar barriers as mentioned in this article?
What has had a demonstrably good effect on outcome is so called “CCR” – Cardiocerebral Resuscitation, a.k.a. compressions only CPR by bystanders. Have you noticed the effects in your community?
We can read and remember the past, we live in the present…but we can’t see in to the future!
But – we can predict, debate, philosophise and dream; nothing wrong with that. On the basis of current trends we can get a feel of where the science of resuscitation may be heading. Above we mentioned the new 2010 guidelines and CCR; have they already been implemented in your service, or is it a thing of the future?
Organisation is the key
A growing trend in medicine, not only for cardiac arrest, is the systematic review and organisation of data and procedures. Dr Richard Lyon (I was lucky to see his presentation last November) helped pick apart every aspect of Edinburgh’s (Scotland) paramedic response to cardiac arrest, and with the implementation of data collection, performance review, and training according to best current knowledge and practices managed to improve survival rates significantly.
Watch the video:
Improving outcome from OHCA: The TOPCAT 2 project from Resuscitation 2012 on Vimeo.
Here is the article in the EMJ about “Establishing a specialist, second-tier response to out-of-hospital cardiac arrest“.
Have you experienced similar ‘makeovers’, does your service have dedicated and trained cardiac arrest paramedics or do you think your service would benefit from something similar?
Mechanical Compression Devices
Another “new big thing” in the last couple of years are mechanical compression devices, e.g. the LUCAS or the Autopulse. Research so far is inconclusive (you will find supportive as well as not so supportive trials). Warwick University (UK) is currently running the PaRAMeDIC trial (Prehospital randomised assessment of a mechanical compression device in cardiac arrest) with the LUCAS-2 Device. The results will be interesting; a well setup trial with a goal sample size of 3650 should hopefully produce some solid results which I’m sure many services around the world will be interested to review.
In my humble opinion, these devices could be the way of the future in cardiopulmonary resuscitation, especially in the environments that paramedics regularly find themselves in. Even if they don’t (yet?) show a direct clinical benefit, they relieve someone on scene from having to do continuous compressions, which in my mind: a) eliminates rescuer fatigue, b) reduces disorganisation from rotating rescuers to counteract rescuer fatigue, c) increases patient ‘mobility’, being able to move the patient with effective compressions being done whilst moving people from incident scene to location of definitive care (ED, cath lab etc), also contributing to paramedic safety.
What can be done in hospital that can’t be done on scene?
An important question to ask! If nothing additional can be done at hospital compared to on scene paramedic efforts, why transport a victim in cardiac arrest? This is obviously dependant on the equipment and training of the staff on scene, but ALS resuscitation according to the ERC guidelines can be performed without having to move the patient from the incident: Hypoxia, Hypovolaemia, Hypothermia, Tension Pneumothorax and even some Toxins and Thrombi can be dealt with on scene.
But what about the other H’s & T’s?
Hypo-/hyperkalaemia/metabolic issues and Toxins are difficult to detect without blood analysis – maybe the future holds the key (or rather: the device)?
Thrombosis: Apart from on scene thrombolysis administration by paramedics in rural and regional areas, mobile cath labs are (if at all) something of the distant future.
And what else?
Still a fairly new ‘weapon’ in the fight against premature death following cardiac arrest, ECMO, or Extra Corporeal Membrane Oxygenation, is quite fascinating. Similar to a heart-lung machine, blood is diverted out of the body, oxygenated by a machine, and then pumped back in to the body. This gives doctors and nurses additional time to try and sort out the cause of the cardiac arrest without having to worry about continuous compressions getting in the way. EMCrit has a very interesting podcast on this topic I can recommend, as well as Resus.Me showing two papers on the topic, one supportive, one more cautiouof it.
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So, that’s it for some information, all this should give us more than enough to discuss on Sunday, 1900hrs GMT.
See you then!