If you’re anything like me, reading new resuscitation guidelines looking for the subtlest of subtle changes does not fill you with excitement. In a way, it’s a good thing that no major changes are being introduced. It means the research is working and we are on the right track to continually improving survival rates.
However, the new guidelines still need to be consumed. Thankfully, there are now various media available to consume such topics and my favourite is the podcast.
Community response is critical! The Chain of Survival remains as vitally important as ever and early intervention, particularly by encouraging bystander CPR, is THE most effective way to achieve a positive outcome from out-of-hospital cardiac arrest.
In hospital, recognising pre-arrest signs and symptoms and preempting cardiac arrest while managing conditions such as Myocardial Infarction (heart attack) and Sepsis is a key focus.
Elsewhere in the guidelines changes are subtle. High-quality chest compressions with minimal interruption are of paramount importance. No intervention should cause an interruption of chest compressions longer than 5 seconds.
The simplest airway intervention is considered the best. Endotracheal intubation should only be performed in systems with high success rates. This is defined as a 95% success rate within 2 attempts.
First-line airway management treatment should be Bag-Valve-Mask and supraglottic airways such as i-gel. If the LMA is working properly there is no need to change it.
Intubation remains a controversial topic, Jasmeet Soar said, “we don't know which airway technique works best but there is a signal of potential harm with failed resus attempts due to delays dealing with advanced airways. Unless you can deliver endotracheal intubation with a high success rate, you shouldn't be using it".
Another controversial topic; Adrenaline has been shown to be highly effective at restarting the heart, although if introduced later in the treatment pathway it has a lower effect. There is no significant evidence to show improvement in long term neurological outcome.
Gavin Perkins said, "over time, the catastrophic brain ischemia outweighs the benefits of restarting the heart with adrenaline".
Soar added, "If we were starting from scratch it would be quite hard to get Adrenaline into the guidelines. We don't know the optimal dose, we don’t know the optimal timing, and we're not sure in which patient groups it works best."
That said, consideration should be given to the benefits of the patient reaching ICU even if survival is unlikely. For example, the patient may be afforded a ‘good death’ with their family by their side and involved in decision making and some will have their wishes of organ donation fulfilled.
The Paramedic 3 study will look at an intraosseous (IO) first approach. The study is due to start in autumn 2021 and will run for 2-3 years. It is anticipated an IO-first protocol will provide patients with a quick and secure route of drug administration so it will be interesting to see the results of the study.
Ultrasound during CPR should only be performed by skilled operators minimising interruption in compressions when acquiring images. Ultrasound can be helpful to rule in conditions such as pneumothorax, tamponade and pericardial infusion.
However, complications such as right ventricular dilatation are common in cardiac arrest and don't necessarily mean pulmonary embolism is present. Another example of where caution must be exercised is when the heart looks still on an ultrasound scan. This shouldn't be used as sole reason for stopping CPR.
As with any intervention, ultrasound can be very helpful but should be used in conjunction with all available methods for diagnosis and treatment.
The UK is lagging behind Europe and other parts of the world when it comes to Extracorporeal membrane oxygenation (ECMO) adoption. Younger, healthier patients suffering from cardiac arrest with a defined, treatable cause such as hypothermia, PE, STEMI etc. ECMO should only be used in settings where the full treatment pathway can be implemented. An elite team is required at every step of the process to ensure safety and success.
Trials are underway in London so we can expect to see ECMO becoming more common in time.
A recent trial in Minneapolis, Minnesota was stopped early because survival rates in cases that used ECMO were 50% vs 0-10% in the standard ALS group. This is exciting news, however, there is a window of opportunity for ECMO which typically needs to be started within 30 minutes. The specialist equipment needed means ECMO may only be available within a small radius of special cardiac arrest treatment centres. This could create health inequalities because the treatment is not available to all, which could be a barrier to adoption.
Soar concluded the interview by saying, "If I was going to invest a lot of money in something, it would be front-end intervention such as teaching people CPR and improving access to early defibrillation."
|Click here to download the Executive summary of the main changes since the 2015 Guidelines from Resuscitation Council UK|