What’s new in resuscitation? A global update

You may have seen that updated resuscitation guidelines for 2015 have been released by ILCOR, l'European Resuscitation Council, the British Resuscitation Council and the American Heart Association in the last week. While these are, obviously, for other populations, they may provide an early indication of what is to come in the Australian guidelines, which are due for release sometime in December.

Really, there's not much new or surprising. They recommend the same algorithms, chest compressions (not too fast ; 100-120bpm) with minimal interruption (<5 seconds) and the same drugs (but with "greater equipoise"), and seem largely in line with our current practice.

You can read the guidelines, or summaries of changes (AHA, EU and UK), at the respective sites, or you can have a quick look at this review of the AHA guideline summary from First 10 EM.

ALS algorithm

  • Monitoring is now recommended to include end-tidal capnography; this allows you to assess adequacy of compressions (providing some lung perfusion) as well as an early indication of ROSC
  • This, obviously requires definitive airway management, and a stepwise approach is advocated
  • Mechanical chest compression devices are not recommended for routine use, but can be an alternative for sustained high quality compressions, or where ongoing compressions may be a safety risk for rescuers (such as during transport or under hostile fire)
  • The use of ultrasound to assess for reversible causes during CPR is suggested (see this algorithm as well)
  • Extracorporeal life support is included as an option in select patients
  • The UK guidelines also include a useful Prevention and Decision Making chapter, and the European guidelines discuss Ethics and End-of-Life Decisions

Special populations

  • There is a new algorithm for managing cardiac arrest due to hyperkalaemia
  • There is a new algorithm for management of traumatic cardiac arrest, including resuscitative thoracotomy
  • Suggestions for resuscitation of obese patients include following the standard algorithm, but ensuring more frequent changeover of rescuer doing compressions to ensure adequate compressions
  • Resuscitation in pregnancy should not include a wedge—this detracts from compression quality—but should include manual uterine displacement to the left

Post ROSC care

  • There is an increased emphasis on PCI for patients with out of hospital cardiac arrest
  • Therapeutic temperature management is advocated, including the option of maintaining a temperature of 36°C, with a clear goal of preventing fever
  • There is a new section on post–cardiac arrest rehabilitation

Acute Coronary Syndrome

  • Initial high-sensitivity troponin alone is not sufficient to exclude ACS, and is "strongly discouraged" by the AHA. It is suggested for use in conjunction with very low risk scores to identify those suitable for discharge
  • Routine supplemental oxygen is not recommended, unless there is an indication for it (also see the AVOID trial)

Paediatrics

  • Post-ROSC normothermia with fever prevention is recommended
  • Judicious use of IV fluids in cardiac arrest in sepsis is recommended and may improve outcomes
  • Cardioversion in SVT is simplified to 1 joule/kg for all

The European Guideline also includes a timeline version of this algorithm:

Neonatal

  • A routine delay in clamping the cord of 1 minute is recommended in uncomplicated births
  • ECG can be used to monitor heart rate
  • Temperature at presentation is a strong predictor of morbidity and mortality
  • Resuscitation begins on room air, then titrated to oxygenation (eg oximetry); preterm neonates may be resuscitated with a low FiO2 from birth (21-30%)
  • The presence of meconium no longer dictates a need for intubation
  • Initial ventilatory support can be with CPAP instead of intubation
  • Drugs recommended are adrenaline (1:10,000), sodium bicarbonate (ideally 4.2%) and glucose (10%). All resuscitation drugs are best delivered via an umbilical venous catheter or an intraosseous needle

 

We wait with bated breath for the Australian versions...

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