Tag Archives: ACLS

Is defibrillation an electric threat for bystanders?

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

10 ml syringe for Valsalva manoeuvre

Previous studies have suggested the following are necessary for a successful Valsalva manoeuvre with maximum vagal effect:

  • Supine posturing
  • Duration of 15 seconds
  • Pressure of 40 mmHg (with an open glottis)

One popular method of generating a Valsalva Manoeuvre is to get the patient to blow into a syringe in an attempt to move the plunger. Different syringe sizes were tested. A 10ml (Terumo) syringe was best
The 10 mL syringe is useful in generating the recommended standard of 40 mmHg intrathoracic pressure for the Valsalva manoeuvre
Emerg Med Australas. 2009 Dec;21(6):449-54

Biphasic shocks for AF and Atrial flutter

Based on a study of 453 consecutive patients undergoing their first transthoracic electrical cardioversion for atrial tachyarrhythmias, recommendations were developed to aim at delivering the lowest possible total cumulative energy with ≤2 consecutive shocks using the specific truncated exponential biphasic waveform incorporated in Medtronic Physio-Control devices: they recommend an initial energy setting of 50 J in patients with atrial flutter or atrial tachycardia, of 100 J in patients with atrial fibrillation (AF) of 2 or less days in duration, and of 150 J with AF of more than 2 days in duration. If the initial shock fails to restore sinus rhythm, a rescue shock of 250 J for AFL/AT or of 360 J for AF should be applied to secure the highest possible probability of successful cardioversion for each patient.
Optimization of initial energy for cardioversion of atrial tachyarrhythmias with biphasic shocks
Am J Emerg Med. 2010 Feb;28(2):159-65

Cardiocerebral resuscitation

An emergency medical service introduced a cardiocerebral resuscitation protocol and compared outcomes with a standard ACLS protocol.
Cardiocerebral resuscitation (CCR) was defined as:

  1. initiation of 200 immediate, uninterrupted chest compressions at a rate of 100 compressions ⁄ min
  2. analyzing the rhythm and delivering a single defibrillator shock, if indicated
  3. 200 more chest compressions before the first pulse check or rhythm reanalysis
  4. epinephrine (1 mg intravenous or intraosseous) as soon as possible or with each 200 compression cycle
  5. endotracheal intubation delayed until after three cycles of chest compressions

Data was analysed from a registry including data on 3515 patients from 62 EMS agencies, some of which instituted CCR (in a total of 1024 patients). Outcome predictors were identified using logistic regression analysis and
Individuals who received CCR had better outcomes across age groups. The increase in survival for the subgroup with a witnessed Vfib was most prominent on those <40 years of age (3.7% for standard ALS patients vs. 19% for CCR patients, odds ratio [OR] = 5.94, 95% confidence interval [CI] = 1.82 to 19.26). Neurologic outcomes were also better in the patients who received CCR (OR = 6.64, 95% CI = 1.31 to 32.8). Within the subgroup that received CCR, the factors most predictive of improved survival included witnessed arrest, initial rhythm of Vfib⁄Vtach, agonal respirations upon arrival, EMS response time, and age. Neurologic outcome was not adversely affected by age.
Cardiocerebral Resuscitation Is Associated With Improved Survival and Neurologic Outcome from Out-of-hospital Cardiac Arrest in Elders
Academic Emergency Medicine 2010;17(3):269 – 275

Pre-hospital thoracotomy and aortic clamping in blunt trauma

This is one of those ‘wow they really do that!?‘ papers…Patients undergoing thoracotomy and aortic clamping for pre-hospital blunt traumatic arrest either in the field or in the ED were evaluated for the outcome of survival to ICU admission. None of the 81 patients who underwent this intervention survived to discharge.
Field thoracotomy resulted in shorter times from arrival of the emergency medical team to performance of the thoracotomy (19.2 vs 30.7 mins). Patients who arrested in front of the team had a greater ICU admission rate than those who were already in cardiac arrest when the team arrived (70% vs 8%).
One may argue against an intervention that seems to have resulted in no benefit to the patient. However a counterargument might be that an ICU admission allows for better end-of-life management for grieving families, and for the possibility of organ donation.
Interestingly, there were some neurologically intact survivors of emergency thoracotomy for blunt trauma by this service, although they were excluded from the study for either (i) receiving the field thoracotomy before full arrest or (ii) arresting after arrival in the ED.
Role of resuscitative emergency field thoracotomy in the Japanese helicopter emergency medical service system
Resuscitation. 2009 Nov;80(11):1270-4

External jugular vein a tricky one

Emergency medicine residents and paramedics cannulated patients who were anaesthetised. The external jugular vein (EJV) took longer to cannulate and had a higher failure rate than an antecubital vein. More than a quarter of the paramedics and a third of the doctors failed to cannulate the EJV.
Is external jugular vein cannulation feasible in emergency care? A randomised study in open heart surgery patients
Resuscitation. 2009 Dec;80(12):1361-4

HEMS paramedic intubation success

All medical out of hospital cardiac arrests attended by the Warwickshire and Northamptonshire Air Ambulance (WNAA) over a 64-month period were reviewed. There were no significant differences in self-reported intubation failure rate, morbidity or clinical outcome between doctor-led and paramedic-led cases. The authors conclude that experienced paramedics regularly operating with physicians have a low tracheal intubation failure rate at out of hospital cardiac arrests, whether practicing independently or as part of a doctor-led team, and that this is likely due to increased and regular clinical exposure.
Can experienced paramedics perform tracheal intubation at cardiac arrests? Five years experience of a regional air ambulance service in the UK
Resuscitation. 2009 Dec;80(12):1342-5

DC shock? I want my blankie!

A blanket made of nonconducting material was used to allow CPR to continue during defibrillation of arrested swine. Coronary perfusion pressure was maintained when the blanket was used

but fell when there was a hands-off interruption for defibrillation. Also, the defibrillation threshold was significantly lower when the blanket was used. A good idea, although even the authors point out that “Thus far, medical literature has not reported any rescuer or bystander serious injury from receiving an inadvertent shock while in direct or indirect contact with a patient while performing CPR
The resuscitation blanket: A useful tool for “hands-on” defibrillation
Resuscitation. 2010 Feb;81(2):230-23

Precordial thump

The precordial thump is recommended for witnessed and monitored ventricular fibrillation/ventricular tachycardia (VF/VT) cardiac arrest when a defibrillator is not immediately available.
Haman et al investigated the precordial thump in patients in whom VT or VF was initiated during an electrophysiological study, applying a single thump after initiation of ventricular arrhythmia in 155 patients. This terminated the tachycardia in two (1.3%) patients.
Pellis et al investigated the precordial thump as an initial measure by paramedics in 144 patients in out-of-hospital cardiac arrest, irrespective of the initial rhythm. Three patients had return of spontaneous circulation and two were discharged alive.
Precordial thump efficacy in termination of induced ventricular arrhythmias
Resuscitation 2009;80:14–6
Utility of pre-cordial thump for treatment of out of hospital cardiac arrest: a prospective study
Resuscitation 2009;80:17–23