Anaesthesia. 2006; 61:873–7.117 117 Merchant RM, Soar J, Skrifvars MB, et al. Therapeutic hypothermia utilization among physicians after resuscitation from cardiac arrest. Crit Care Med. 2006; 34:1935–40.
118 118 Oksanen T, Pettila V, Hynynen M, Varpula T. Therapeutic hypothermia after cardiac arrest: implementation and outcome in Finnish intensive care units. Acta Anaesthesiol Scand. 2007; 51:866–71.
119 119 Wolfrum S, Radke PW, Pischon T, Willich SN, Schunkert H, Kurowski V. Mild therapeutic hypothermia after cardiac arrest—a nationwide survey on the implementation of the ILCOR guidelines in German intensive care units. Resuscitation. 2007; 72:207–13.
120 120 Stub D, Bernard S, Pelligrino V, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO, and early reperfusion. Resuscitation. 2015; 86:88–94.
121 121 Davis DP, Fisher R, Aguilar S, et al. The feasibility of a regional cardiac arrest receiving system. Resuscitation. 2007; 74:44–51.
122 122 Mann NC, Mullins RJ, Hedges JR, Rowland D, Arthur M, Zechnich AD. Mortality among seriously injured patients treated in remote rural trauma centers before and after implementation of a statewide trauma system. Med Care. 2001; 39:643–53.
123 123 Newgard CD, McConnell KJ, Hedges JR, Mullins RJ. The benefit of higher level of care transfer of injured patients from nontertiary hospital emergency departments. J Trauma. 2007; 63:965–71.
124 124 Sampalis JS, Denis R, Frechette P, Brown R, Fleiszer D, Mulder D. Direct transport to tertiary trauma centers versus transfer from lower level facilities: impact on mortality and morbidity among patients with major trauma. J Trauma. 1997; 43:288–95.
125 125 Sampalis JS, Denis R, Lavoie A, et al. Trauma care regionalization: a process‐outcome evaluation. J Trauma. 1999; 46:565–79.
126 126 Kajino K, Iwami T, Daya M, et al. Impact of transport to critical care medical centers on outcomes after out‐of‐hospital cardiac arrest. Resuscitation. 2010; 81:549–54.
127 127 Lick CJ, Aufderheide TP, Niskanen RA, et al. Take heart America: a comprehensive, community‐wide, systems‐based approach to the treatment of cardiac arrest. Crit Care Med. 2011; 39:26–33.
128 128 Cudnik MT, Sasson C, Rea TD, et al. Increasing hospital volume is not associated with improved survival in out of hospital cardiac arrest of cardiac etiology. Resuscitation. 2012; 83:862–8.
129 129 Wik L, Kramer‐Johansen J, Myklebust H, et al. Quality of cardiopulmonary resuscitation during out‐of‐hospital cardiac arrest. JAMA. 2005; 293:299–304.
130 130 Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resuscitation during in‐hospital cardiac arrest. JAMA. 2005; 293:305–10.
131 131 Recommended guidelines for uniform reporting of data from out‐of‐hospital cardiac arrest: the ‘Utstein style’. Prepared by a Task Force of Representatives from the European Resuscitation Council, American Heart Association, Heart and Stroke Foundation of Canada, Australian Resuscitation Council. Resuscitation. 1991; 22:1–26.
CHAPTER 13 Cardiac arrest: clinical management
Jon C. Rittenberger and Vincent N. Mosesso, Jr.
Introduction
Detailed algorithms and consensus guidelines, often referred to as basic life support (BLS) and advanced cardiac life support (ACLS), exist for cardiac arrest management. However, there are unique practical and scientific considerations that may affect the execution of resuscitation efforts in the out‐of‐hospital setting. EMS medical directors and field personnel including EMS physicians must be aware of these factors when developing protocols for prehospital resuscitation. They must also understand the scientific basis for, and the controversies surrounding, recommended resuscitation actions.
This chapter reviews scientific and practical considerations for carrying out BLS and ACLS in the prehospital setting. For specific treatment algorithms, the reader is referred to the American Heart Association (AHA) Emergency Cardiac Care (ECC) Guidelines [1].
Specific interventions
Chest compressions
Chest compressions are essential in cardiac arrest resuscitation. In consideration of ECMO, chest compressions generate coronary perfusion pressure (CPP), and a CPP of at least 20 mmHg is important for achieving return of spontaneous circulation (ROSC) [2]. Multiple studies highlight the role of early chest compressions in survival from cardiac arrest [3–6].
The most recent BLS and ACLS guidelines emphasize the delivery of continuous chest compressions with as few interruptions as possible [1]. Several consecutive chest compressions are necessary to generate adequate CPP [7]. CPP drops off immediately when chest compressions are discontinued [8]. The proportion of resuscitation time without chest compressions, termed hands‐off time or no‐flow fraction, is inversely associated with cardiac arrest survival [9]. Compression depth, rate, and full recoil are also critical characteristics for effectiveness.
Prior work has highlighted the often‐substandard CPR performed by prehospital and in‐hospital clinicians. In a series of prehospital cardiac arrests in Europe, chest compressions were delivered on average only half of the time while the patient was in arrest, and most compressions were too shallow [10]. There have been similar observations made in analyses of in‐hospital resuscitations [11].
Delivering chest compressions during cardiac arrest resuscitation poses practical challenges. The treating EMS team must provide continuous chest compressions with as few interruptions as possible and must ensure high‐quality chest compressions with adequate depth, rate, and recoil. To achieve these chest compression goals, additional rescuers should be dispatched to provide assistance at cardiac arrests. Team members providing chest compressions should rotate frequently, ideally every 1‐2 minutes [1].
Several cardiac monitors use a compression paddle or other technology to measure the depth and rate of chest compressions [10, 11]. These monitors are able to provide real‐time audio or visual feedback, indicating to the rescuer whether or not to increase the depth or rate. Audiovisual feedback improves chest compression performance [12].
Various mechanical devices for automating chest compressions are now available. The Thumper (Michigan Instruments, Grand Rapids, MI) has been used for approximately 40 years and provides chest compressions using a pneumatic piston [13]. The Autopulse Resuscitation System (Zoll Corporation, Chelmsford, MA) facilitates chest compressions using a circumferential load‐distributing band [14, 15]. The Lund University Cardiopulmonary Assist Device (LUCAS) (Lund, Sweden) provides active compression and decompression through a pneumatic piston attached to a suction cup on the chest [16].
The scientific data evaluating the effectiveness of these devices remain inconclusive. One urban EMS agency evaluated the Autopulse in a before‐after fashion and found increases in both ROSC and survival [14]. However, a larger, multicenter, randomized controlled trial demonstrated worsened outcomes with the intervention [15]. The authors attributed this observation to potential delays in CPR required to place and activate the device. The LUCAS device was effective in a small study of 100 patients, but its benefit was noted only in those who received it within 15 minutes from the ambulance call [16].
Data suggest there is no difference in survival, but these devices may be useful in settings where high‐quality
