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
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
I have always had a problem with the ATLS classification of hypovolaemic shock, and omit it from teaching as any clinical applicability and reproducibility seem to be entirely lost on me. I was therefore reassured to read that real physiological data from the extensive national trauma registry in the UK (TARN) of 107,649 adult blunt trauma patients do not strongly support this classification. A key observation we regularly make in trauma patients is the frequent presence of normo- or bradycardia in hypovolaemic patients, which is well documented in the literature. Unreferenced dogma that became viral
An excellent discussion section in this paper states: ‘it is clear that the ATLS classification of shock that associates increasing blood loss with an increasing heart rate, is too simplistic. In addition, blunt injury, which forms the majority of trauma in the UK, is usually a combination of haemorrhage and tissue injury and the classification fails to consider the effect of tissue injury‘ Testing the validity of the ATLS classification of hypovolaemic shock Resuscitation. 2010 Sep;81(9):1142-7
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
Emergency physicians at Hennepin County Medical Centre (HCMC) are trained in skull trephination (drilling a burr hole) for patients with coma, anisocoria and epidural (extradural) haematoma (EDH) who have not responded to osmotic agents and hyperventilation. This may be particularly applicable in centres remote from neurosurgical centres where delays caused by interfacility transfer are associated with increased morbidity and mortality.
Dr Smith and colleagues from HCMC describe a series of five talk-and-deteriorate patients with EDH who underwent skull trephination. 3 had complete recovery without disability, and 2 others had mild to moderate disability but with good to excellent cognitive function. None had complications from the procedure other than external bleeding from the already lacerated middle meningeal artery. In 4 of 5 cases, the times were recorded. Mean time from ED presentation to trephination was 55 min, and mean time from ED to craniotomy was 173 min. The mean time saved was 118 min, or approximately 2 h.
All trephinations were done by emergency physicians, who had received training in skull trephination as part of the HCMC Emergency Medicine Residency or as part of the Comprehensive Advanced Life Support (CALS) course. Training was very brief and involved discussion of the treatment of EDH, review of a CT scan of EDH, and hands-on practice on the skull of a dead sheep, using the Galt trephinator.
An excellent point made by the authors reminds us that patients with EDH who talk-and-deteriorate (those with the traditionally described “lucid interval”) have minimal primary brain injury and frequently have no brain parenchymal injury. Thus, if the EDH is rapidly decompressed, the outcome is significantly better than for deterioration due to other aetiologies. The authors recommend in EDH that the procedure should be done within 60–90 min of onset of anisocoria. A review of other studies on the procedure would suggest that case selection is critical in defining the appropriateness of the procedure: talk-and-deteriorate, coma, anisocoria, and a delay to neurosurgical decompression. Emergency Department Skull Trephination for Epidural Hematoma in Patients Who Are Awake But Deteriorate Rapidly J Emerg Med. 2010 Sep;39(3):377-83
Got an interesting ultrasound case to share? You can upload it to the Asian Emergency Ultrasound Network. A great growing site run by Dr Mok Ka Leung in Hong Kong – a leading light in emergency medicine ultrasound in Asia. http://www.aeun.org
During emergency department procedural sedation, some clinicians (myself included) advocate non-invasive capnography for the early detection of apnoea. Others argue against routine administration of oxygen so that if desaturation occurs it provides an earlier more correctable warning of respiratory depression than if it occurs on supplemental oxygen. A Canadian study using prospective data from research on propofol with either ketamine or fentanyl compared changes in capnography with desaturation in sedated patients breathing only room air. Desaturation detectable by pulse oximeter occurred before overt changes in capnometry were identified.
It’s hard to ascertain the relevance of this finding. The authors wisely state ‘these findings should not be extrapolated to patients administered supplemental oxygen where it is possible capnometry may be helpful’. Since I use capnography in the hope that it will assist in the earlier detection of ketamine-associated laryngospasm in children, I’m not going to discard it in favour of waiting for the saturation to fall. Perhaps we just need to be clear that capnography may be more useful at detecting apnoea than hypoventilation. A comparative evaluation of capnometry versus pulse oximetry during procedural sedation and analgesia on room air CJEM. 2010 Sep;12(5):397-404
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]
Over a thousand patients in North America with blunt traumatic head injury and coma who did not have hypovolaemic shock were randomised to different fluids pre-hospital. 250 ml Hypertonic (7.5%) saline was compared with normal (0.9%) saline and hypertonic saline dextran (7.5% saline/6% dextran 70). There was no difference in 6-month neurologic outcome or survival. Out-of-Hospital Hypertonic Resuscitation Following Severe Traumatic Brain Injury JAMA. 2010;304(13):1455-1464.
In acute pulmonary embolism, a well-recognised pattern of right ventricular wall motion reported by McConnell is characterised by normal RV apex (RVa) contractility with akinesia of the RV free wall. A study using an echo techique called longitudinal velocity vector imaging (VVI) was conducted to describe RVa mechanics in relation to the rest of the RV in patients with a proven acute PE (aPE) and to compare these results to healthy volunteers and to patients with known chronic pulmonary hypertension (cPH). There were no significant differences in segmental strain patterns between the aPE and cPH groups. The authors suggest that McConnell’s sign is probably a visual illusion; preserved RVa contractility might be due to tethering of the RVa to a hyperdynamic left ventricle in the presence of an acutely dilated RV and this is the most likely explanation of the regional pattern of RV dysfunction seen in aPE patients.
Video describing McConnell’s sign from YouTube:
