[Quality indicators and structural requirements for Cardiac Arrest Centers-Update 2021]

A potentially lifesaving error: unintentional high-dose adrenaline administration in anaphylaxis-induced cardiac arrest; a case report

BACKGROUND

Cardiopulmonary resuscitation is a crucial skill for emergency medical services. As high-risk-low-frequency events pose an immense mental load to providers, concepts of crew resource management, non-technical skills and the science of human errors are intended to prepare healthcare providers for high-pressure situations. However, medical errors occur, and organizations and institutions face the challenge of providing a blame-free error culture to achieve continuous improvement by avoiding similar errors in the future. In this case, we report a critical medical error during an anaphylaxis-associated cardiac arrest, its handling and the unexpected yet favourable outcome for the patient.

CASE PRESENTATION

During an out-of-hospital cardiac arrest due to chemotherapy-induced anaphylaxis, a patient received a 10-fold dose of epinephrine due to shortcomings in communication and standardization via a central venous port catheter. The patient converted from a non-shockable rhythm into a pulseless ventricular tachycardia and subsequently into ventricular fibrillation. The patient was cardioverted and defibrillated and had a return of spontaneous circulation with profound hypotension only 6 min after the administration of 10 mg epinephrine. The patient survived without any residues or neurological impairment.

CONCLUSIONS

This case demonstrates the potential deleterious effects of shortcomings in communication and deviation from standard protocols, especially in emergencies. Here, precise instructions, closed-loop communication and unambiguous labelling of syringes would probably have avoided the epinephrine overdose central to this case. Interestingly, this serious error may have saved the patient's life, as it led to the development of a shockable rhythm. Furthermore, as the patient was still in profound hypotension after administering 10 mg of epinephrine, this high dose might have counteracted the severe vasoplegic state in anaphylaxis-associated cardiac arrest. Lastly, as the patient was receiving care for advanced malignancy, the likelihood of termination of resuscitation in the initial non-shockable cardiac arrest was significant and possibly averted by the medication error.

[Post Resuscitation Care]

After successful resuscitation, further treatment has a decisive influence regarding patient outcome. Not only overall survival, but also the neurological outcome that is crucial for patients' quality of life can be positively influenced by optimized post-cardiac arrest treatment. The management of various consequences of post-cardiac arrest syndrome is discussed in the current version of the ERC-guidelines in the chapter "post resuscitation care". A step-by-step approach based on an algorithm provides the necessary structure. The immediate treatment and stabilization of patients after ROSC is followed by the diagnosis of the triggering pathology in order to initiate adequate therapy. During the subsequent intensive care treatment, the focus is on optimizing neurological recovery.

[Role of German cardiac arrest centers in mediating basic life support]

BACKGROUND AND OBJECTIVE

Despite a measurable increase in recent years, the bystander resuscitation rate in Germany lags behind the European comparison. Special centers for the care of patients after cardiac arrest, so-called cardiac arrest centers (CAC), have been established. The aim of this work is to evaluate the role of CACs, in addition to in-hospital patient care, in improving the bystander resuscitation rate in Germany and what obstacles exist in the implementation of resuscitation training.

MATERIALS AND METHODS

Online survey by the working group cardiopulmonary resuscitation (AG42) of the German Society of Cardiology (DGK) and the German Resuscitation Council (GRC) RESULTS: Of the 74 participating clinics (78.4% certified as CAC), 23 (31.1%) conduct lay resuscitation training. These mainly take place within the framework of action days for resuscitation (82.6%) or in schools (39.1%). Permanent cooperation with at least one school existed in 52.2%. Basic life support (BLS) resuscitation dummies are available in 63.5% of these clinics and an automated external defibrillator (AED) demonstration device in 43.2%. According to the interviewees, the biggest obstacles to the consistent implementation of resuscitation courses in schools include lack of qualified instructors, lack of refinancing and difficulties with regard to coordinating activities between schools and providers.

CONCLUSIONS

Direct training of lay rescuers by hospitals faces several obstacles. To increase the bystander resuscitation rate, focusing on targeted training of teachers as multipliers (train-the-trainer) can be a good approach for cardiac arrest centers.

Improving survival after cardiac arrest in Europe: The synergetic effect of rescue chain strategies

Sudden cardiac arrest is a global problem and is considered the third leading cause of death in industrialized countries. Patient survival rates after out-of-hospital cardiac arrest (OHCA) vary significantly between countries and continents. In particular, the 2021 European Resuscitation Council (ERC) Resuscitation Guidelines place a special focus on the chain of survival of patients after OHCA. As a complex, interconnected approach, the focus is on: Raising awareness for cardiac arrest and lay resuscitation, school children's education in resuscitation "KIDS SAVE LIVES", first responder systems - technologies to engage the community, telephone-assisted resuscitation (telephone-CPR; T-CPR) by dispatchers, and cardiac arrest centers (CAC) for further treatment in specialized hospitals. The Systems Saving Lives approach is a comprehensive strategy that emphasizes the interconnectedness of all links in the chain of survival following an OHCA, with a particular focus on the relationship between the community and emergency medical services (EMS). This system-level approach emphasizes the importance of the connection between all those involved in the chain of survival. It has a high potential to improve overall survival after OHCA. Therefore, it is recommended that these strategies be promoted and expanded in all countries.

Telephone cardiopulmonary resuscitation, first responder systems, cardiac arrest centers, and global campaigns to save lives

PURPOSE OF REVIEW

The latest resuscitation guidelines contain a new chapter, which focuses on systems improving care for patients with out-of-hospital cardiac arrest (OHCA). In this article, we describe recent developments regarding telephone cardiopulmonary resuscitation (CPR), first responder systems, cardiac arrest centers, and global campaigns.

RECENT FINDINGS

Telephone CPR has been implemented in many countries, and recent developments include artificial intelligence and video calls to improve dispatch assisted CPR. However, the degree of implementation is not yet satisfying. Smartphone alerting systems are effective in reducing the resuscitation-free interval, but many regions do not yet use this technology. Further improvements are needed to reduce response times. Cardiac arrest centers increase the survival chance after OHCA. Specific criteria need to be defined and professional societies should establish a certification process. Global campaigns are effective in reaching people around the world. However, we need to evaluate the effects of the campaigns.

SUMMARY

Telephone CPR, first responder systems, cardiac arrest centers, and global campaigns are highlighted in the recent resuscitation guidelines. However, the degree of implementation is not yet sufficient. We do not only need to implement these measures, but we should also aim to monitor the systems regarding their performance and further improve them.

Extracorporeal Cardiopulmonary Resuscitation

BACKGROUND

Around the world, survival rates after cardiac arrest range between <14% for in-hospital (IHCA) and <10% for outof- hospital cardiac arrest (OHCA). This situation could potentially be improved by using extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (CPR), i.e. by extracorporeal cardiopulmonary resuscitation (ECPR).

METHODS

A selective literature search of Pubmed and Embase using the searching string ((ECMO) OR (ECLS)) AND (ECPR)) was carried out in February 2023 to prepare an up-to-date review of published trials comparing the outcomes of ECPR with those of conventional CPR.

RESULTS

Out of 573 initial results, 12 studies were included in this review, among them three randomized controlled trials comparing ECPR with CPR, involving a total of 420 patients. The survival rates for ECPR ranged from 20% to 43% for OHCA and 20% to 30.4% for IHCA. Most of the publications were associated with a high degree of bias and a low level of evidence.

CONCLUSION

ECPR can potentially improve survival rates after cardiac arrest compared to conventional CPR when used in experienced, high-volume centers in highly selected patients (young age, initial shockable rhythm, witnessed cardiac arrest, therapy-refractory high-quality CPR). No general recommendation for the use of ECPR can be issued at present.

[Cardiac arrest centers-certification fosters inflow of patients by emergency medical services]

BACKGROUND

Since 2015, the international resuscitation guidelines recommend the implementation of specialized hospitals (so-called cardiac arrest centers, CAC) for patients with out-of-hospital cardiac arrest (OHCA).

OBJECTIVES

The aim was to investigate the potential influence of hospital certification as a CAC on the decision of emergency medical service staff (EMS, including out-of-hospital emergency physicians and paramedics) when transporting OHCA patients to a hospital.

MATERIALS AND METHODS

A web-based, anonymous questionnaire with 20 items was performed from 15 May 2018 to 15 June 2018 in Germany. Target groups were out-of-hospital emergency physicians and paramedics.

RESULTS

Of 437 respondents, 378 responses (n = 292 emergency physicians, n = 86 paramedics) were included in the statistical analysis. In all, 75.1% (n = 284) indicated that CAC certification of hospitals would matter in their own transportation decisions for OHCA patients in future transportations, 78.3% (n = 296) expected that CAC certification will result in an improvement in patient care, and 78.8% (n = 298) were in favor of implementing the CAC certification. Respondents would accept an additional 16.3 min (95% confidence interval 15.2-17.3) of transportation time to reach a CAC.

CONCLUSIONS

Certification of hospitals as CAC has the potential to influence emergency medical personnel decisions about which hospital to transport OHCA patients to. Due to the limited additional acceptable transport time to reach a CAC, a close network of certified hospitals is needed nationwide.

100. Krankenhaus erfolgreich zum Cardiac Arrest Center zertifiziert

Cardiac Arrest Center (CAC) sind zertifizierte Krankenhäuser, die zur Weiterbehandlung prähospital reanimierter Patientinnen und Patienten spezialisiert sind. In Deutschland finden Audits seit Ende 2018 statt. Unter dem Ziel eines bundesweiten, flächendeckenden Ausbaus konnte nun das 100. Krankenhaus als CAC zertifiziert werden. Auch in den neuen internationalen Reanimationsleitlinien 2021 wird die besondere Bedeutung von CAC im neu entwickelten Kapitel „lebensrettende Systeme“ hervorgehoben.

[The new 2021 resuscitation guidelines and the importance of lay resuscitation]

Lay resuscitation is one of the most important measures to increase the survival rate of patients after out-of-hospital cardiac arrest. While European countries, and especially Scandinavian countries, achieve lay resuscitation rates of over 80%, the rate in Germany is only around 40%. The 2021 Resuscitation Guidelines updated by the European Resuscitation Council give special weight to Systems Saving Lives and focus on resuscitation by laypersons. The Systems Saving Lives emphasize the interplay between all actors involved in the chain of survival and thereby specify the link between the emergency service and the general population.Based on the BIG FIVE survival strategies after cardiac arrest, five key strategies are outlined that can achieve the greatest improvement in survival. These are (1) increasing lay resuscitation rates through campaigns and KIDS SAVE LIVES school-based resuscitation training, (2) implementing telephone resuscitation in dispatch centers, (3) first responder systems, (4) advanced life support, and (5) specialized cardiac arrest centers.

Zertifizierung von Cardiac-Arrest-Zentren

Die Versorgung von Patienten mit bzw. nach einem Kreislaufstillstand ist besonders komplex und sollte in einem Cardiac Arrest Center (CAC) erfolgen. Zur Etablierung der CAC finden Zertifizierungen mit regelmäßigen Reaudits statt. Dieser Artikel beschreibt den Zertifizierungsprozess. Die Zertifizierung zum CAC ist ein mehrstufiger Prozess und nimmt insgesamt etwa ein Jahr Zeit in Anspruch. Ein CAC vereint multidisziplinär alle relevanten prä- und innerklinischen Akteure. Die vorgegebene Infrastruktur, evidenzbasierte Behandlungsalgorithmen und eine systematische Ausbildung sind zu organisieren. Im Rahmen regelmäßiger Konferenzen sind die Abläufe anhand statistischer Auswertungen zu evaluieren und Ansätze zur Prozessoptimierung zu etablieren. Entscheidend ist die fokussierte Organisation dieses Zentrums, sodass Patienten mit ähnlichen Gegebenheiten und Voraussetzungen den annähernd gleichen Behandlungspfad erfahren, ohne dass dies von einzelnen Akteuren abhängig wäre. Multidisziplinäre Zusammenarbeit, präzise Vorgehensweisen unter hoher Patientensicherheit und exakter Dokumentation sichern das Zertifizierungsziel. Das Ergebnis dieser Maßnahmen führt zur Behandlungsoptimierung und Outcomeverbesserung von Patienten mit bzw. nach Kreislaufstillstand. In den aktualisierten internationalen Reanimationsleitlinien von 2020/21 führte dies zu einer stärkeren Empfehlung für die Etablierung von CAC.