1998 European guidelines on resuscitation. Simplifications should make them easier to teach and implement

Diaphragmatic Rupture and Hernia after Cardiopulmonary Resuscitation

A 55-year-old man underwent surgical replacement of a mitral valve 10 years earlier. In a retrospective evaluation of a chest radiograph, the diaphragm was intact at the time of initial surgery. He was then admitted to our emergency room with a complaint of vertigo. During evaluation, he developed decreased consciousness. Ventricular fibrillation was diagnosed, and external massage and full cardiopulmonary resuscitation were performed. After 20 minutes, his sinus rhythm returned and hemodynamic status stabilized with inotropic drugs. Transthoracic echocardiography showed normal valvular function and no evidence of left cardiac malfunction or clot. Electrocardiography showed ST elevation in inferior leads, and levels of cardiac enzymes were elevated. Angiography showed an embolic lesion in the mid right coronary artery that was treated with percutaneous coronary intervention (PCI) and insertion of a stent. After 24 hours, the patient was extubated in good condition, but had mild dyspnea that progressed to CO₂ narcosis and subsequent reintubation. Post-extubation chest radiography showed herniation of abdominal organs into the right hemithorax. The diaphragmatic defect was closed with a polytetrafluoroethylene patch by a thoracic surgeon, and the postoperative course was uncomplicated.

A rare case of occult splenic rupture after left pneumonectomy

Cardiopulmonary resuscitation (CPR) techniques are now well-established and play a crucial role in improving survival in cardiac arrest. Recognized complications associated with CPR include injury to the upper abdominal viscera, including the liver, stomach and spleen. We present a rare case of occult splenic rupture following cardiac arrest in a 63-year-old male immediately after left pneumonectomy. We discuss potential mechanisms predisposing the spleen to injury in this case, and highlight the difficulty of promptly identifying such a traumatic injury within the confines of a cardiac arrest scenario. Clinicians should be aware that anatomical changes following thoracic surgery may render the intra-abdominal viscera at increased risk of injury following CPR.

Pneumothorax During CPR Training: Case Report and Review of the CPR Literature

Cardiopulmonary resuscitation is taught widely to both lay persons and health care oworkers. It is a challenging psychomotor skill. Concerns about its safety to the rescuer have centered around the risk of infectious disease exposure. A young nursing assistant developed a minimally symptomatic pneumothorax during CPR training. This case is the first reported example of this complication for a CPR trainee or provider. The literature is reviewed for complications for CPR provider and recipient and the relevant issues regarding the current status and future direction of this intervention.

Strategies and algorithms for management of the difficult airway

Management of the difficult airway is the most important patient safety issue in the practice of anaesthesia. Many national societies have developed algorithms and guidelines for management of the difficult airway. The key issues of this chapter are definition of terms, the advantages and disadvantages of the use of guidelines, and a comparison of different algorithms and guidelines for management of the most important clinical airway scenarios. Although there is no strong evidence of benefit for any specific strategy or algorithm for management of the difficult airway, there is strong agreement that a pre-planned strategy may lead to improved outcome.

Nurses' knowledge and skill retention following cardiopulmonary resuscitation training: a review of the literature

AIM

This paper reports a literature review examining factors that enhance retention of knowledge and skills during and after resuscitation training, in order to identify educational strategies that will optimize survival for victims of cardiopulmonary arrest.

BACKGROUND

Poor knowledge and skill retention following cardiopulmonary resuscitation training for nursing and medical staff has been documented over the past 20 years. Cardiopulmonary resuscitation training is mandatory for nursing staff and is important as nurses often discover the victims of in-hospital cardiac arrest. Many different methods of improving this retention have been devised and evaluated. However, the content and style of this training lack standardization.

METHOD

A literature review was undertaken using the Cumulative Index to Nursing and Allied Health Literature, MEDLINE and British Nursing Index databases and the keywords 'cardiopulmonary resuscitation', 'basic life support', 'advanced life support' and 'training'. Papers published between 1992 and 2002 were obtained and their reference lists scrutinized to identify secondary references, of these the ones published within the same 10-year period were also included. Those published in the English language that identified strategies to enhance the acquisition or retention of Cardiopulmonary resuscitation skills and knowledge were included in the review.

RESULTS

One hundred and five primary and 157 secondary references were identified. Of these, 24 met the criteria and were included in the final literature sample. Four studies were found pertaining to cardiac arrest simulation, three to peer tuition, four to video self-instruction, three to the use of different resuscitation guidelines, three to computer-based learning programmes, two to voice-activated manikins, two to automated external defibrillators, one to self-instruction, one to gaming and the one to the use of action cards.

CONCLUSIONS

Resuscitation training should be based on in-hospital scenarios and current evidence-based guidelines, including recognition of sick patients, and should be taught using simulations of a variety of cardiac arrest scenarios. This will ensure that the training reflects the potential situations that nurses may face in practice. Nurses in clinical areas, who rarely see cardiac arrests, should receive automated external defibrillation training and have access to defibrillators to prevent delays in resuscitation. Staff should be formally assessed using a manikin with a feedback mechanism or an expert instructor to ensure that chest compressions and ventilations are adequate at the time of training. Remedial training must be provided as often as required. Resuscitation training equipment should be made available at ward/unit level to allow self-study and practice to prevent deterioration between updates. Video self-instruction has been shown to improve competence in resuscitation. An in-hospital scenario-based video should be devised and tested to assess the efficacy of this medium in resuscitation training for nurses.

Update on Pediatric Advanced Life Support Guidelines

Accidents are a leading cause of death for children in several nations. Motor vehicle accidents are among the most common causes of cardiac arrest. Other causes include drowning, burns, gunshot wounds, poisoning, smoke inhalation, and airway obstruction caused by asphyxiation from foreign bodies. Approximately 50% to 65% of children who require cardiopulmonary resuscitation are younger than 1 year of age, with most being younger than 6 months of age. To prevent loss and improve quality of life, it is imperative to initiate measures to improve oxygenation and treat cardiac dysfunction. Guidelines for the management of life-threatening emergencies in infants and children are internationally similar but not identical. The Australian Resuscitation Council, the American Heart Association, and the European Resuscitation Council current guidelines all have some basic essential techniques for management of pediatric emergencies.

Difficult Airway Society guidelines for management of the unanticipated difficult intubation

Problems with tracheal intubation are infrequent but are the most common cause of anaesthetic death or brain damage. The clinical situation is not always managed well. The Difficult Airway Society (DAS) has developed guidelines for management of the unanticipated difficult tracheal intubation in the non-obstetric adult patient without upper airway obstruction. These guidelines have been developed by consensus and are based on evidence and experience. We have produced flow-charts for three scenarios: routine induction; rapid sequence induction; and failed intubation, increasing hypoxaemia and difficult ventilation in the paralysed, anaesthetised patient. The flow-charts are simple, clear and definitive. They can be fully implemented only when the necessary equipment and training are available. The guidelines received overwhelming support from the membership of the DAS.

DISCLAIMER

It is not intended that these guidelines should constitute a minimum standard of practice, nor are they to be regarded as a substitute for good clinical judgement.

In-hospital resuscitation--what should we be teaching?

This paper examines the initial actions that should take place following the sudden collapse of a patient in a hospital. The current Basic Life Support guidelines are not designed for this situation, yet are commonly taught to hospital staff. An alternative algorithm for Hospital Resuscitation has been developed. Additional factors, such as the recognition of the sick patient and the importance of audit should be included in hospital resuscitation training. A tiered approach to resuscitation training within a hospital should be adopted and national standards developed.

Cardiopulmonary resuscitation: new European guidelines

Cardiac arrest is the ultimate medical emergency. Without rapid action by witnesses and responding health professionals, chances of survival are remote. In this article the key evidence-based aspects of resuscitation, basic life support and early defibrillation are discussed in light of the recent publication of revised guidelines from the European Resuscitation Council. The importance of calling for skilled help at the earliest opportunity is emphasized, facilitating rapid access to emergency services (in the community) and the cardiac arrest team (in hospital). The advent of the automated external defibrillator (AED) presents additional opportunities to save lives and it is recommended that registered nurses are trained in, and authorized to use, AEDs in their professional practice.