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
A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association on the management of spontaneous intracerebral haemorrhage has been published in Stroke. The full text is available here.
In summary: Medical Treatment for ICH
Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets, respectively
Patients with ICH whose INR is elevated due to oral anticoagulants (OAC) should have their warfarin withheld, receive therapy to replace vitamin K–dependent factors and correct the INR, and receive intravenous vitamin K. Prothrombin Complex Concentrates have not shown improved outcome compared with FFP but may have fewer complications compared with FFP and are reasonable to consider as an alternative to FFP.
rFVIIa does not replace all clotting factors, and although the INR may be lowered, clotting may not be restored in vivo; therefore, rFVIIa is not routinely recommended as a sole agent for OAC reversal in ICH
Although rFVIIa can limit the extent of hematoma expansion in noncoagulopathic ICH patients, there is an increase in thromboembolic risk with rFVIIa and no clear clinical benefit in unselected patients. Thus rFVIIa is not recommended in unselected patients. Further research to determine whether any selected group of patients may benefit from this therapy is needed before any recommendation for its use can be made.
The usefulness of platelet transfusions in ICH patients with a history of antiplatelet use is unclear and is considered investigational
Patients with ICH should have intermittent pneumatic compression for prevention of venous thromboembolism in addition to elastic stockings
After documentation of cessation of bleeding, low-dose subcutaneous low-molecular-weight heparin or unfractionated heparin may be considered for prevention of venous thromboembolism in patients with lack of mobility after 1 to 4 days from onset
Blood Pressure
Until ongoing clinical trials of BP intervention for ICH are completed, physicians must manage BP on the basis of the present incomplete efficacy evidence. Current suggested recommendations for target BP in various situations are listed in an accompanying table and may be considered
In patients presenting with a systolic BP of 150 to 220 mmHg, acute lowering of systolic BP to 140 mm Hg is probably safe
Inpatient Management and Prevention of Secondary Brain Injury
Initial monitoring and management of ICH patients should take place in an intensive care unit with physician and nursing neuroscience intensive care expertise
Glucose should be monitored and normoglycemia is recommended
Seizures and Antiepileptic Drugs
Clinical seizures should be treated with antiepileptic drugs
Continuous EEG monitoring is probably indicated in ICH patients with depressed mental status out of proportion to the degree of brain injury
Patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with antiepileptic drugs
Prophylactic anticonvulsant medication should not be used
Procedures/Surgery
Patients with a GCS score of ≤8, those with clinical evidence of transtentorial herniation, or those with significant IVH or hydrocephalus might be considered for ICP monitoring and treatment. A cerebral perfusion pressure of 50 to 70 mmHg may be reasonable to maintain depending on the status of cerebral autoregulation
Ventricular drainage as treatment for hydrocephalus is reasonable in patients with decreased level of consciousness
Intraventricular Hemorrhage Recommendation
Although intraventricular administration of recombinant tissue-type plasminogen activator in IVH appears to have a fairly low complication rate, efficacy and safety of this treatment is uncertain and is considered investigational
Clot Removal
For most patients with ICH, the usefulness of surgery is uncertain. Specific exceptions to this recommendation follow
Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible. Initial treatment of these patients with ventricular drainage alone rather than surgical evacuation is not recommended
For patients presenting with lobar clots ≥30 mL and within 1 cm of the surface, evacuation of supratentorial ICH by standard craniotomy might be considered
The effectiveness of minimally invasive clot evacuation utilizing either stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain and is considered investigational
Although theoretically attractive, no clear evidence at present indicates that ultra-early removal of supratentorial ICH improves functional outcome or mortality rate. Very early craniotomy may be harmful due to increased risk of recurrent bleeding
Outcome Prediction and Withdrawal of Technological Support
Aggressive full care early after ICH onset and postponement of new DNR orders until at least the second full day of hospitalization is probably recommended. Patients with preexisting DNR orders are not included in this recommendation. Current methods of prognostication in individual patients early after ICH are likely biased by failure to account for the influence of withdrawal of support and early DNR orders. Patients who are given DNR status at any point should receive all other appropriate medical and surgical interventions unless otherwise explicitly indicated.
Prevention of Recurrent ICH
In situations where stratifying a patient’s risk of recurrent ICH may affect other management decisions, it is reasonable to consider the following risk factors for recurrence: lobar location of the initial ICH, older age, ongoing anticoagulation, presence of the apolipoprotein ε2 or ε4 alleles, and greater number of microbleeds on MRI
After the acute ICH period, absent medical contraindications, BP should be well controlled, particularly for patients with ICH location typical of hypertensive vasculopathy
After the acute ICH period, a goal target of a normal BP of <140/90 (<130/80 if diabetes or chronic kidney disease) is reasonable
Avoidance of long-term anticoagulation as treatment for nonvalvular atrial fibrillation is probably recommended after spontaneous lobar ICH because of the relatively high risk of recurrence. Anticoagulation after nonlobar ICH and antiplatelet therapy after all ICH might be considered, particularly when there are definite indications for these agents. Avoidance of heavy alcohol use can be beneficial. There is insufficient data to recommend restrictions on use of statin agents or physical or sexual activity
Rehabilitation and Recovery
Given the potentially serious nature and complex pattern of evolving disability, it is reasonable that all patients with ICH have access to multidisciplinary rehabilitation. Where possible, rehabilitation can be beneficial when begun as early as possible and continued in the community as part of a well-coordinated (seamless) program of accelerated hospital discharge and home-based resettlement to promote ongoing recovery
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association Stroke published online Jul 22, 2010
The UK’s National Institute for Health and Clinical Excellence (NICE) has produced guidelines on delirium.
Delirium (sometimes called ‘acute confusional state’) is a common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course.
Some snippets from the guideline include:
If indicators of delirium are identified, carry out a clinical assessment based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria or short Confusion Assessment Method (short CAM) to confirm the diagnosis.
In critical care or in the recovery room after surgery, CAM-ICU should be used. A healthcare professional who is trained and competent in the diagnosis of delirium should carry out the assessment.
If there is difficulty distinguishing between the diagnoses of delirium, dementia or delirium superimposed on dementia, treat for delirium first.
If a person with delirium is distressed or considered a risk to themselves or others and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, consider giving short- term (usually for 1 week or less) haloperidol or olanzapine.
The CAM-ICU assessment tool is demonstrated in the video below, which is found along with other helpful delirium resources at http://www.icudelirium.co.uk
The Britsh Thoracic Society has published its 2010 guidelines on the management of spontaneous pneumothorax. These are one of number of guidelines for the management of pleural disease. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010 Thorax 2010;65(Suppl 2):ii18-ii31 All pleural disease guidelines
An algorithm for the management of patients with stab wounds to the neck has been proposed by authors of a review of the topic.
‘Hard’ signs of vascular injury include severe active bleeding, unresponsive shock, evolving stroke, and large/expanding haematoma. ‘Soft’ signs include a non-expanding moderate haematoma, a bruit/thrill, or a radial pulse deficit (although some consider the latter two to be hard signs). Mentioned in the text, but omitted from the algorithm, is the option of placing a Foley catheter into the wound and inflating the balloon to blindly control bleeding in a crashing haemodynamically unstable patient in order to buy time to get to the operating room. Review article: Emergency department assessment and management of stab wounds to the neck. Emerg Med Australas. 2010 Jun;22(3):201-10
A CME article in Critical Care Medicine summarises the literature on ARDS (including its limitations) and provides evidence based recommendations on what to do about severe hypoxaemia. They summarise:
For life-threatening hypoxaemia, initial management with a recruitment manoeuvre and/or high PEEP should be undertaken if plateau airway pressures and lack of barotrauma allow. If not, or if these are not effective, then proceed to the prone position or HFOV. If hypoxemia still persists, then consider the administration of inhaled NO. If NO fails, then glucocorticoids can then be administered. For elevated plateau airway pressures when tidal volumes are 4 mL/kg, consider prone positioning or HFOV. For life- threatening respiratory acidosis, consider the use of a buffer or continuous veno-venous hemofiltration. It is most important to assess for objective physiologic improvement in the appropriate time period for each intervention. If no benefit is evident, then the therapy should be discontinued to minimise harm and delay in the initiation of another therapy. If the patient continues to have life-threatening hypoxemia, acidosis, or elevated plateau airway pressures, then consider ECMO or extracorporeal carbon dioxide removal.
When might you suspect a brain tumour in a child who presents with, say, nausea and vomiting, or behavioural disturbance? A guideline has been produced which might prompt one to think of this important but often delayed diagnosis. The diagnosis of brain tumours in children: a guideline to assist healthcare professionals in the assessment of children who may have a brain tumour Arch Dis Child. 2010 Jul;95(7):534-9
The College of Emergency Medicine (UK) has updated its guideline on ketamine sedation in children.
The summary is copied below Full text is available here Guideline for ketamine sedation of children in Emergency Departments
Before ketamine is used all other options should be fully considered, including analgesia, reassurance, distraction, entonox, intranasal diamorphine, etc.
The doses advised for analgesic sedation are designed to leave the patient capable of protecting their airway. There is a significant risk of a failure of sedation if the procedure is prolonged, and the clinician must recognise that the option of general anaesthesia may be preferred in these circumstances.
There is no evidence that complications are reduced if the child is fasted, however traditional anaesthetic practice favours a period of fasting prior to any sedative procedure. The fasting state of the child should be considered in relation to the urgency of the procedure, but recent food intake should not be considered as an absolute contraindication to ketamine use.
Ketamine should be only used by clinicians experienced in its use and capable of managing any complications, particularly airway obstruction, apnoea and laryngospasm. The doctor managing the ketamine sedation and airway should be suitably trained and experienced in ketamine use, with a full range of advanced airway skills.
At least three staff are required: a doctor to manage the sedation and airway, a clinician to perform the procedure and an experienced nurse to monitor and support the patient, family and clinical staff. Observations should be regularly taken and recorded.
The child should be managed in a high dependency or resuscitation area with immediate access to full resuscitation facilities. Monitoring should include ECG, blood pressure, respiration and pulse oximetry. Supplemental oxygen should be given and suction must be available.
After the procedure the child should recover in a quiet, observed and monitored area under the continuous observation of a trained member of staff. Recovery should be complete between 60 and 120 minutes, depending on the dose and route used.
There should be a documentation and audit system in place within a system of clinical governance.
The brave men and women of the military not only risk their lives for us – they also provide a wealth of trauma experience and publish interesting stuff.
This month’s Journal of Trauma contains a military trauma supplement. One of the articles describes the latest guidelines on Tactical Combat Casualty Care. These include:
tourniquet use
Quikclot Combat Gauze as the haemostatic agent which has replaced Quikclot powder and HemCon. This preference is based on field experience that powder and granular agents do not work well in wounds in which the bleeding vessel is at the bottom of a narrow wound tract or in windy environments. WoundStat was a backup agent but this has been removed because of concerns over possible embolic and thrombotic complications.
longer catheters for decompression of tension pneumothorax (Harcke et al. found a mean chest wall thickness of 5.36 cm in 100 autopsy computed tomography studies of military fatalities. Several of the cases in their autopsy series were noted to have had unsuccessful attempts at needle thoracostomy because the needle/catheter units used for the procedure were too short to reach the pleural space*.)
close open chest wounds immediately with an occlusive material, such as Vaseline gauze, plastic wrap, foil, or defibrillator pads
a rigid eye shield and antibiotics for penetrating eye injury
Tactical Combat Casualty Care: Update 2009
The Journal of TRAUMA 2010;69(1):S10-13 (no abstract available) Full text of guidelines in PDF at itstactical.com
*Harcke HT, Pearse LA, Levy AD, Getz JM, Robinson SR. Chest wall thickness in military personnel: implications for needle thoracentesis in tension pneumothorax. Mil Med. 2007;172:1260 –1263
The UK’s National Institute for Health and Clinical Excellence (NICE) has produced guidelines on alcohol-related physical complications, including alcohol withdrawal syndrome, Wernicke’s encephalopathy, acute and chronic pancreatitis, and acute alcoholic hepatitis.
The acute alcohol withdrawal section includes the following recommendations:
Offer drug treatment for the symptoms of acute alcohol withdrawal, as follows:
Consider offering a benzodiazepine or carbamazepine.
Clomethiazole may be offered as an alternative to a benzodiazepine or carbamazepine. However, it should be used with caution, in inpatient settings only and according to the summary of product characteristics.
Follow a symptom-triggered regimen for the drug treatment of acute alcohol withdrawal in people who are:
in hospital or
in other settings where 24-hour assessment and monitoring are available.
Treatment for delirium tremens or seizures
Offer oral lorazepam as first-line treatment for delirium tremens. If symptoms persist or oral medication is declined, give parenteral lorazepam, haloperidol or olanzapine.
For people with alcohol withdrawal seizures, consider offering a quick-acting benzodiazepine (such as lorazepam) to reduce the likelihood of further seizures.
If delirium tremens or seizures develop in a person during treatment for alcohol withdrawal, review their withdrawal drug treatment.
Do not offer phenytoin to treat alcohol withdrawal seizures.
Alcohol-use disorders: Diagnosis and clinical management of alcohol-related physical complications Quick reference summary
