Tag Archives: ALS


CAB rather than ABC

The 2010 ILCOR resuscitation guidelines were published today. Key changes and continued points of emphasis from the 2005 BLS Guidelines include the following:

  • Sequence change to chest compressions before rescue breaths (CAB rather than ABC)
  • Immediate recognition of sudden cardiac arrest based on assessing unresponsiveness and absence of normal breathing (ie, the victim is not breathing or only gasping)
  • “Look, Listen, and Feel” removed from the BLS algorithm
  • Encouraging Hands-Only (chest compression only) CPR (ie, continuous chest compression over the middle of the chest) for the untrained lay-rescuer
  • Health care providers continue effective chest compressions/CPR until return of spontaneous circulation (ROSC) or termination of resuscitative efforts
  • Increased focus on methods to ensure that high-quality CPR (compressions of adequate rate and depth, allowing full chest recoil between compressions, minimizing interruptions in chest compressions and avoiding excessive ventilation) is performed
  • Continued de-emphasis on pulse check for health care providers
  • A simplified adult BLS algorithm is introduced with the revised traditional algorithm
  • Recommendation of a simultaneous, choreographed approach for chest compressions, airway management, rescue breathing, rhythm detection, and shocks (if appropriate) by an integrated team of highly-trained rescuers in appropriate settings

2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 5: Adult Basic Life Support
Circulation. 2010;122:S685-S705
http://circ.ahajournals.org/cgi/content/full/122/18_suppl_3/S685

New CPR Guidelines

The International Liaison Committee on Resuscitation has published its five-yearly update of resuscitation guidelines.

The American Heart Association Guidelines can be accessed here

The European Resuscitation Guidelines can be accessed here

2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Circulation. 2010;122:S639

In-flight cooling after out-of-hospital cardiac arrest

Aeromedical retrieval specialists in Scotland developed a simple, cheap, effective in-flight cooling protocol using intravenous (IV) cold Hartmann’s solution and chemical cooling packs. Fluids cooled in a fridge (4°C) were transported in an insulated cool box; the patient was sedated, paralysed and intubated, and controlled ventilation started. The patient was then cooled by IV infusion of 30 ml/kg of cold Hartmann’s. Chemical ice packs were activated and placed in the axillae and groin. The time interval between successful resuscitation and the patient being retrieved and flown to an Intensive Care Unit (ICU) was at least 3.5 h. Cooled patients had a mean decrease in body temperature during retrieval compared to patients not cooled (−1.6 °C vs. +0.9 °C, p = 0.005) and a lower body temperature on ICU arrival (34.1 °C vs. 36.4 °C, p = 0.05). Two of the 5 cooled patients achieved target temperature (<34 °C) before ICU arrival. No complications of in-flight cooling were reported.

Not the only way to cool down in Scotland

In-flight cooling after out-of-hospital cardiac arrest
Resuscitation. 2010 Aug;81(8):1041-2

Echo in life support feasible

Emergency physicians in Cambridge and Ipswich in the UK prospectively documented their echo use in cardiac arrest. Images were easily acquired, were quickly obtained, and influenced management. In keeping with previous studies, absence of ventricular wall motion predicted lack of return of spontaneous circulation, with a negative predictive value of 97%.

An evaluation of echo in life support (ELS): is it feasible? What does it add?
Emerg Med J. 2010 Oct 4. [Epub ahead of print]

ETCO2 and ROSC

One for the ‘hardly surprising’ category….

A study of end-tidal CO2 during out-of-hospital adult and child cardiac arrest resuscitation showed a sudden rise in CO2 was associated with return of spontaneous circulation (ROSC), suggesting that witnessing this would be a good time for a pulse check. Data from the 59 patients who achieved ROSC are shown below, time zero being time of ROSC. There was no such observed rise in the 49 patients who did not achieve ROSC.

A Sudden Increase in Partial Pressure End-Tidal Carbon Dioxide (PETCO2) at the Moment of Return of Spontaneous Circulation
The Journal of Emergency Medicine, Vol. 38, No. 5, pp. 614–621, 2010

Military pre-hospital thoracotomy

Military doctors in Afghanistan reviewed their experience of thoracotomy done within 24 hours of admission to their hospital. The ballistic nature of thoracic penetrating trauma (mainly Afghan civilians without body armour) differs from the typical knife-wound related injury seen in survivors of thoracotomy reported in the pre-hospital literature.

Six of the patients presented in cardiac arrest – four PEA and two asystole. One of the PEA patients survived; this patient had sustained a thoracoabdominal GSW and had arrested 8 minutes from hospital. Following emergency thoracotomy, aortic control, and concomitant massive transfusion, return of spontaneous circulation (ROSC) was achieved and damage control surgery undertaken in both chest and abdomen.

The two patients in asystole had sustained substantial pulmonary and hilar injuries, and ROSC was never achieved. The patients in PEA all had arrested as a consequence of hypovolaemia from solid intra-abdominal visceral haemorrhage. All patients in PEA had ROSC achieved, albeit temporarily.

Following thoracotomy, patients required surgical manoeuvres such as pulmonary hilar clamping, packing and temporary aortic occlusion; hypovolaemia was the leading underlying cause of the cardiac arrest. These factors lead the authors to conclude that although isolated cardiac wounds do feature in war, they are unusual and the injury pattern of casualties in conflict zones are often complex and multifactorial.

Is pre-hospital thoracotomy necessary in the military environment?
Injury. 2010 Jul;41(7):1008-12

Paeds BVM for adult resus

Smaller self-inflating bags produce greater guideline consistent ventilation in simulated cardiopulmonary resuscitation

A comparison between two sizes of self-inflating resuscitation bags revealed improved adherence to resuscitation guidelines with the smaller bag. Student paramedics were more likely to produce suboptimal tidal volumes and ventilation rates with a 1500ml bag than a 1000ml bag during simulated ventilation of an artificial lung model.

BMC Emerg Med. 2009 Feb 20;9:4

http://www.ncbi.nlm.nih.gov/pubmed/19228432

Full text at http://www.biomedcentral.com/1471-227X/9/4

Is defib danger overstated

No rescuer or bystander has ever been seriously harmed by receiving an inadvertent shock while in direct or indirect contact with a patient during defibrillation. New evidence suggests that it might even be electrically safe for the rescuer to continue chest compressions during defibrillation if self-adhesive defibrillation electrodes are used and examination gloves are worn. This paper reviews the existing evidence, but warns more definite data are needed to make absolutely sure that there is no risk before defibrillation safety recommendations are changed.

Is external defibrillation an electric threat for bystanders?
Resuscitation. 2009 Apr;80(4):395-401