Cardiopulmonary Resuscitation and Acute Cardiovascular Life Support—A Protocol Review of the Updated Guidelines

Evaluation of the incidence, risk factors, and impact on patient outcomes of postintubation hemodynamic instability

OBJECTIVES

Postintubation hemodynamic instability (PIHI) is a potentially life-threatening adverse event of emergent endotracheal intubation. The objectives of this study were to determine the incidence, risk factors, and impact on patient outcomes associated with PIHI in intubations performed in emergency medicine.

METHODS

A structured chart audit was performed of all consecutive adult patients requiring emergent endotracheal intubations over a 16-month period at a tertiary care emergency department (ED). Data collection included medications, comorbidities, vital signs in the 30 minutes before and after intubation, hospital length of stay, and in-hospital mortality. PIHI was defined as a decrease in systolic blood pressure (SBP) to ≤ 90 mm Hg, a decrease in SBP of ≥ 20% from baseline, a decrease in mean arterial pressure to ≤ 65 mm Hg, or the initiation of any vasopressor medication at any time in the 30 minutes following intubation.

RESULTS

Overall, 218 patients intubated in the ED were identified, and 44% (96 of 218) developed PIHI. On multivariate analysis, increasing age (OR 1.03, 95% CI 1.01-1.05), chronic obstructive pulmonary disease (OR 3.00, CI 1.19-7.57), and pre-emergent endotracheal intubation hemodynamic instability (OR 2.52, 95% CI 1.27-4.99) were associated with the development of PIHI. The use of a neuromuscular blocking medication was associated with a decreased incidence of PIHI (OR 0.34, 95% CI 0.16-0.75).

CONCLUSIONS

Based on our data, postintubation hypotension occurs in a significant proportion of ED patients requiring emergent airway control. Further investigation is needed to confirm the factors we found to be associated with PIHI and to determine if PIHI is associated with increased morbidity and mortality.

Are New Resuscitation Guidelines Better? Experience of an Asian Metropolitan Hospital

Introduction: Cardiopulmonary resuscitation (CPR) guidelines were revised in 2005 based on new evidence and expert consensus. However, the benefits of the new guidelines remain undetermined and their influence has not been published in Asia. This study aimed to evaluate the impact of implementing the new resuscitation guidelines and identify factors that influence the discharge survival of out-of-hospital cardiac arrest (OHCA) patients in an Asian metropolitan city. Materials and Methods: This was an observational cohort study of all OHCA patients seen by the emergency medical service during the period before (Nov 2003 to Oct 2005) and after (May 2006 to Oct 2008) implementing the new resuscitation guidelines. Detailed clinical information was recorded using the Ustein style template. Statistical analysis was done using X2 test or t-test for univariate analysis and the logistic regression model for multivariate analysis. Results: There were 463 patients before and 430 patients after the new guidelines who received resuscitation. The rate of recovery of spontaneous circulation (ROSC), survival-to-intensive care unit (ICU) admission, and survival-to-hospital discharge all showed no benefits regarding the new resuscitation guidelines (ROSC: 42% vs 39%, P = 0.32; Survival-to-ICU admission: 33% vs 30%, P = 0.27; survival-to-hospital discharge: 10% vs 7%, P = 0.09). The rate of ventricular fibrillation/pulseless ventricular tachycardia (VF/pulseless VT), rate of witnessed arrest, and rate of bystander CPR were much lower than in Western studies. After multivariate logistic regression, factors related to discharge survival were witnessed arrest and initial rhythm with VF/pulseless VT. The new resuscitation guidelines did not significantly influence the discharge survival. Conclusions: We did not observe any improvement in survival after implementing the new guidelines. Independent factors of survival-to-hospital discharge are witnessed arrest and initial rhythm with VF/pulseless VT. Because the rates of VF/pulseless VT and bystander CPR in Asia are low, popularising CPR training programmes and increasing the rate of bystander CPR may be more important for improving OHCA survival rates than frequent guideline changes. Key words: Asia, Outcome, Out-of-hospital cardiac arrest, Survival

Successful resuscitation of a patient in asystole after a TASER injury using a hypothermia protocol

New studies have shown the benefit of initiating a hypothermia protocol in the survivors of cardiac arrest. Although the data have shown an improved neurologic end point in patients initially in ventricular fibrillation or pulseless ventricular tachycardia, there is still debate about whether patients initially in other rhythms would benefit from hypothermia after return of spontaneous circulation. This is a report of a 17-year-old male found to be in asystole after sustaining a TASER injury, who was treated with a hypothermia protocol after return of spontaneous circulation and left the hospital with intact neurologic function.