Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.

Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial

BACKGROUND

Among patients with out-of-hospital cardiac arrest (OHCA) and ventricular fibrillation, more than half present with refractory ventricular fibrillation unresponsive to initial standard advanced cardiac life support (ACLS) treatment. We did the first randomised clinical trial in the USA of extracorporeal membrane oxygenation (ECMO)-facilitated resuscitation versus standard ACLS treatment in patients with OHCA and refractory ventricular fibrillation.

METHODS

For this phase 2, single centre, open-label, adaptive, safety and efficacy randomised clinical trial, we included adults aged 18-75 years presenting to the University of Minnesota Medical Center (MN, USA) with OHCA and refractory ventricular fibrillation, no return of spontaneous circulation after three shocks, automated cardiopulmonary resuscitation with a Lund University Cardiac Arrest System, and estimated transfer time shorter than 30 min. Patients were randomly assigned to early ECMO-facilitated resuscitation or standard ACLS treatment on hospital arrival by use of a secure schedule generated with permuted blocks of randomly varying block sizes. Allocation concealment was achieved by use of a randomisation schedule that required scratching off an opaque layer to reveal assignment. The primary outcome was survival to hospital discharge. Secondary outcomes were safety, survival, and functional assessment at hospital discharge and at 3 months and 6 months after discharge. All analyses were done on an intention-to-treat basis. The study qualified for exception from informed consent (21 Code of Federal Regulations 50.24). The ARREST trial is registered with ClinicalTrials.gov, NCT03880565.

FINDINGS

Between Aug 8, 2019, and June 14, 2020, 36 patients were assessed for inclusion. After exclusion of six patients, 30 were randomly assigned to standard ACLS treatment (n=15) or to early ECMO-facilitated resuscitation (n=15). One patient in the ECMO-facilitated resuscitation group withdrew from the study before discharge. The mean age was 59 years (range 36-73), and 25 (83%) of 30 patients were men. Survival to hospital discharge was observed in one (7%) of 15 patients (95% credible interval 1·6-30·2) in the standard ACLS treatment group versus six (43%) of 14 patients (21·3-67·7) in the early ECMO-facilitated resuscitation group (risk difference 36·2%, 3·7-59·2; posterior probability of ECMO superiority 0·9861). The study was terminated at the first preplanned interim analysis by the National Heart, Lung, and Blood Institute after unanimous recommendation from the Data Safety Monitoring Board after enrolling 30 patients because the posterior probability of ECMO superiority exceeded the prespecified monitoring boundary. Cumulative 6-month survival was significantly better in the early ECMO group than in the standard ACLS group. No unanticipated serious adverse events were observed.

INTERPRETATION

Early ECMO-facilitated resuscitation for patients with OHCA and refractory ventricular fibrillation significantly improved survival to hospital discharge compared with standard ACLS treatment.

FUNDING

National Heart, Lung, and Blood Institute.

Prehospital termination of resuscitation in cases of refractory out-of-hospital cardiac arrest

CONTEXT

Identifying patients in the out-of-hospital setting who have no realistic hope of surviving an out-of-hospital cardiac arrest could enhance utilization of scarce health care resources.

OBJECTIVE

To validate 2 out-of-hospital termination-of-resuscitation rules developed by the Ontario Prehospital Life Support (OPALS) study group, one for use by responders providing basic life support (BLS) and the other for those providing advanced life support (ALS).

DESIGN, SETTING, AND PATIENTS

Retrospective cohort study using surveillance data prospectively submitted by emergency medical systems and hospitals in 8 US cities to the Cardiac Arrest Registry to Enhance Survival (CARES) between October 1, 2005, and April 30, 2008. Case patients were 7235 adults with out-of-hospital cardiac arrest; of these, 5505 met inclusion criteria.

MAIN OUTCOME MEASURES

Specificity and positive predictive value of each termination-of-resuscitation rule for identifying patients who likely will not survive to hospital discharge.

RESULTS

The overall rate of survival to hospital discharge was 7.1% (n = 392). Of 2592 patients (47.1%) who met BLS criteria for termination of resuscitation efforts, only 5 (0.2%) patients survived to hospital discharge. Of 1192 patients (21.7%) who met ALS criteria, none survived to hospital discharge. The BLS rule had a specificity of 0.987 (95% confidence interval [CI], 0.970-0.996) and a positive predictive value of 0.998 (95% CI, 0.996-0.999) for predicting lack of survival. The ALS rule had a specificity of 1.000 (95% CI, 0.991-1.000) and positive predictive value of 1.000 (95% CI, 0.997-1.000) for predicting lack of survival.

CONCLUSION

In this validation study, the BLS and ALS termination-of-resuscitation rules performed well in identifying patients with out-of-hospital cardiac arrest who have little or no chance of survival.

Part 10: Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Note From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, “Family Presence During ResuscitationPeds-003”). These callouts are hyperlinked to evidence-based worksheets, which were used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets are available in PDF format and are open access.

Part 7: Systems of Care: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post-cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.

Derivation of a termination-of-resuscitation guideline for emergency medical technicians using automated external defibrillators

OBJECTIVES

To determine the association between characteristics of cardiac arrest and survival to hospital discharge following failed resuscitation by defibrillation-trained emergency medical technicians (EMT-Ds), and to propose an out-of-hospital termination-of-resuscitation (TOR) guideline for EMT-Ds.

METHODS

A 22-month retrospective review of 700 out-of-hospital primary cardiac arrest patients in a large emergency medical services (EMS) system who received exclusively EMT-D care.

RESULTS

Seven hundred primary cardiac arrest patients were identified. Follow-up was obtained in 662 cases (94.6%). Of these, 36 (5.4%) achieved a return of spontaneous circulation (ROSC) prior to transport. Among the 626 patients who failed to achieve ROSC at any time, two (0.3%) survived to discharge. Multivariate analysis showed that ROSC at any time had the strongest association with survival [odds ratio (OR) 45.5; 95% confidence interval (95% CI) = 8.5 to 243.7]. A shock prior to transport (OR 6.9; 95% CI = 1.2 to 40.3) and cardiac arrest witnessed by EMS personnel (OR 4.4; 95% CI = 1.0 to 18.5) were also independently associated with survival. These variables were incorporated into a TOR guideline. The guideline was 100% sensitive (95% CI = 99.1 to 100) in identifying survivors and had 100% negative predictive value (95% CI = 75.3 to 100) for identifying nonsurvivors of out-of-hospital cardiac arrest in the study population.

CONCLUSIONS

In this EMS system, cardiac arrest patients may be considered for out-of-hospital TOR following EMT-D resuscitation attempts when there has been no ROSC, no shock has been given, and the arrest was not witnessed by EMS personnel. These guidelines require prospective validation.

Comparison of Termination-of-Resuscitation Guidelines for Basic Life Support: Defibrillator Providers in Out-of-Hospital Cardiac Arrest

STUDY OBJECTIVE

Termination of resuscitation in the field for out-of-hospital cardiac arrest can reduce unnecessary transport to hospital and associated road hazards and increase availability of emergency medical services (EMS) and emergency department resources for other patients. We compare the performance of 3 termination-of-resuscitation guidelines for basic life support-defibrillator (BLS) providers when applied to cardiac arrest patients in the Ontario Prehospital Advanced Life Support study.

METHODS

This prospective cohort study involved all out-of-hospital cardiac arrest patients attended by BLS defibrillator providers in 21 Ontario urban or suburban communities. The data analyses were conducted secondarily on these prospectively collected data. Three termination-of-resuscitation guidelines (referred to as Marsden, Petrie, and Verbeek rules) were applied and contingency tables calculated to show the relationship between the rule and actual survival.

RESULTS

From 1988 to 2003, 13,684 cardiac arrest patients were attended by BLS defibrillator providers. Six hundred thirty-six (4.7%) patients survived to hospital discharge. For the 3 termination-of-resuscitation rules, sensitivity was 99.8% (95% confidence interval [CI] 99.5% to 100.0%) (Petrie rules), 99.5% (95% CI 99.0% to 100.0%) (Verbeek rules), and 99.8% (95% CI 99.5% to 100.0%) (Marsden rules). Specificity was 9.9% (95% CI 9.4% to 10.4%) (Petrie rules), 52.9% (95% CI 52.1% to 53.8%) (Verbeek rules), and 19.4 % (95% CI 18.8% to 20.1%) (Marsden rules). Negative predictive value was 99.9% (95% CI 99.8% to 100.0%) (Petrie rules), 100.0% (95% CI 99.9% to 100.0%) (Verbeek rules), and 100.0% (95% CI 99.9% to 100.0%) (Marsden rules). These rules would have resulted in field termination of resuscitation in 9.4% (Petrie rules), 50.5% (Verbeek rules), and 18.5 % (Marsden rules) of cases. Termination of resuscitation was recommended for 1 patient (Petrie rules), 3 patients (Verbeek rules), and 1 patient (Marsden rules), who survived.

CONCLUSION

We found all 3 termination-of-resuscitation rules to have high sensitivity and negative predictive value. However, the specificity and transport rates varied greatly. The results of this study will be useful for EMS providers considering adoption of termination of resuscitation in BLS defibrillator systems for out-of-hospital cardiac arrest.

Effects of bystander first aid, defibrillation and advanced life support on neurologic outcome and hospital costs in patients after ventricular fibrillation cardiac arrest

OBJECTIVE

To evaluate the effects of basic life support, time to first defibrillation and emergency medical service arrival time on neurologic outcome and expenses for hospital care in patients after cardiac arrest.

SETTING

Large urban emergency medical services system and emergency department in a 2000-bed university hospital.

DESIGN

Outcome and cost benefit analysis of patients admitted to the hospital after witnessed, out-of-hospital, ventricular fibrillation cardiac arrest from October 1, 1991, until December 31, 1997.

PATIENTS

Out of 1054 patients with out-of-hospital cardiac arrest, 276 were eligible.

MEASUREMENTS AND RESULTS

The effects of basic and advanced life support measures on neurologic outcome and hospital expenses were evaluated. In contrast to intubation (odds ratio 1.08; 95% CI: 0.51-2.31; p=0.84), basic life support (odds ratio 0.44; 95% CI: 0.24-0.77; p=0.004) and time to first defibrillation (odds ratio 1.08; 95% CI: 1.03-1.13; p=0.001) were significantly correlated with good neurologic outcome. Among the patients who did not receive basic life support, the average cost per patient with good neurologic outcome significantly increased with the delay of the first defibrillation (p<0.001).

CONCLUSIONS

In contrast to intubation, bystander basic life support and time to first defibrillation were significantly associated with good neurologic outcome and resulted in fewer expenses spent on in-hospital efforts.

Advanced Trauma Life Support Study: Quality of diagnostic and therapeutic procedures

BACKGROUND

The introduction of the ATLS course in The Netherlands in 1995 provided for an opportunity to compare data of trauma patients between a pre-ATLS and a post-ATLS period.

MATERIALS AND METHODS

Over a 3-year period (May 1996 - September 1997 pre ATLS; December 1997-April 1999 post ATLS) 63 trauma patients with an AIS-ISS > or = 16 (n = 31, pre-ATLS and n = 32, post-ATLS) were prospectively studied in two community residency training (ACS Level III) hospitals. All diagnostic and therapeutic procedures were recorded by a video-camera and evaluated by a neutral faculty of six experienced ATLS trained specialists.

RESULTS

Ten out of 14 interventions were performed qualitatively better in the post-ATLS group, while also the overall score was highly significantly better (4.2 pre-ATLS and 5.8 post-ATLS, p < 0.0001).

CONCLUSION

Using the opinion of an expert team, this study identified a significantly lower number of patients with inadequate management.

Validation of a detailed scoring checklist for use during advanced cardiac life support certification

INTRODUCTION

Defining valid, reliable, defensible, and generalizable standards for the evaluation of learner performance is a key issue in assessing both baseline competence and mastery in medical education. However, before setting these standards of performance, the reliability of the scores yielding from a grading tool must be assessed. Accordingly, the purpose of this study was to assess the reliability of scores generated from a set of grading checklists used by nonexpert raters during simulations of American Heart Association (AHA) Megacodes.

METHODS

The reliability of scores generated from a detailed set of checklists, when used by 4 nonexpert raters, was tested by grading team leader performance in 8 Megacode scenarios. Videos of the scenarios were reviewed and rated by trained faculty facilitators and a group of nonexpert raters. The videos were reviewed "continuously" and "with pauses." The grading made by 2 content experts served as the reference standard, and 4 nonexpert raters were used to test the reliability of the checklists.

RESULTS

Our results demonstrate that nonexpert raters are able to produce reliable grades when using the checklists under consideration, demonstrating excellent intrarater reliability and agreement with a reference standard. The results also demonstrate that nonexpert raters can be trained in the proper use of the checklist in a short amount of time, with no discernible learning curve thereafter. Finally, our results show that a single trained rater can achieve reliable scores of team leader performance during AHA Megacodes when using our checklist in a continuous mode because measures of agreement in total scoring were very strong [Lin's (Biometrics 1989;45:255-268) concordance correlation coefficient, 0.96; intraclass correlation coefficient, 0.97].

CONCLUSIONS

We have shown that our checklists can yield reliable scores, are appropriate for use by nonexpert raters, and are able to be used during continuous assessment of team leader performance during the review of a simulated Megacode. This checklist may be more appropriate for use by advanced cardiac life support instructors during Megacode assessments than the current tools provided by the AHA.

Retention of Pediatric Advanced Life Support (PALS) course concepts

The purpose of this study was to measure, in a population of experienced state-certified paramedics, the decline of Pediatric Advanced Life Support (PALS) course concepts during the 2-year recertification cycle recommended by the American Heart Association. The PALS course contains a written examination designed to measure understanding of course concepts. To successfully complete the course, a PALS course participant must achieve a minimum grade of 84% on this test. In our study, 99 experienced PALS-certified Advanced Life Support (ALS) providers completed a 70-question written test. Nested within this test were all of the PALS examination questions that the participants had previously passed to complete the PALS course. Each participant's PALS test questions were extracted and scored to obtain a "retest score" that measured retention of PALS course principles. These 99 dual-trained paramedic/firefighters comprised more than 90% of the staff of a countywide EMS system averaging 60,000 calls per year. Study participants averaged 10 years of ALS experience, and 3-4 pediatric patient calls per month. In this study, "pediatric patient" was defined as an individual 18 years of age or less. Results revealed that 25 (25%) of the 99 providers achieved a minimum passing score of 84% or greater on the PALS retest. Another 40 (40%) scored within one standard deviation below the minimum passing score. Retest score was unaffected by years of ALS experience, number of pediatric patients seen per month, or by PALS Instructor status. The average retest score was 16 points lower than the original test score. The original test score did not reliably predict a passing grade on the retest. We conclude that the average decline of PALS course principles is such that a 2-year retraining schedule is appropriate for prehospital personnel caring for an average of three to four pediatric patients per month.

High-fidelity simulation for advanced cardiac life support training

OBJECTIVE. To determine whether a high-fidelity simulation technique compared with lecture would produce greater improvement in advanced cardiac life support (ACLS) knowledge, confidence, and overall satisfaction with the training method. DESIGN. This sequential, parallel-group, crossover trial randomized students into 2 groups distinguished by the sequence of teaching technique delivered for ACLS instruction (ie, classroom lecture vs high-fidelity simulation exercise). ASSESSMENT. Test scores on a written examination administered at baseline and after each teaching technique improved significantly from baseline in all groups but were highest when lecture was followed by simulation. Simulation was associated with a greater degree of overall student satisfaction compared with lecture. Participation in a simulation exercise did not improve pharmacy students' knowledge of ACLS more than attending a lecture, but it was associated with improved student confidence in skills and satisfaction with learning and application. CONCLUSIONS. College curricula should incorporate simulation to complement but not replace lecture for ACLS education.

The European Resuscitation Council's paediatric life support course 'Advanced Paediatric Life Support'

The poor outcome for resuscitation from cardiopulmonary arrest in childhood is widely recognised. The European Resuscitation Council has adopted the Advanced Paediatric Life Support course (originating in the UK and now available in a number of countries) as its course for providers caring for children. This paper outlines the course content and explains its remit, which is to reduce avoidable deaths in childhood by not only resuscitation from cardiac arrest but, more effectively, by recognising and treating in a timely and effective fashion life-threatening illness and injury in infants and children. Two related courses Paediatric Life Support, a less intense course for less advanced providers, and Pre-Hospital Paediatric Life Support for immediate care providers are also described.

To lead or not to lead? Prospective controlled study of emergency nurses' provision of advanced life support team leadership

BACKGROUND AND OBJECTIVES

In many emergency departments advanced life support (ALS) trained nurses do not assume a lead role in advanced resuscitation. This study investigated whether emergency nurses with previous ALS training provided good team leadership in a simulated cardiac arrest situation.

METHODS

A prospective study was conducted at five emergency departments and one nurses' association meeting. All participants went through the same scenario. Details recorded included baseline blood pressure and pulse rate, time in post, time of ALS training, and subjective stress score (1 = hardly stressed; 10 = extremely stressed). Scoring took into account scenario understanding, rhythm recognition, time to defibrillation, appropriateness of interventions, and theoretical knowledge.

RESULTS

Of 57 participants, 20 were ALS trained nurses, 19 were ALS trained emergency senior house officers (SHOs), and 18 were emergency SHOs without formal ALS training. The overall mean score for doctors without ALS training was 69.5%, compared with 72.3% for ALS trained doctors and 73.7% for ALS trained nurses. Nurses found the experience less stressful (subjective stress score 5.78/10) compared with doctors without ALS training (6.5/10). The mean time taken to defibrillate from the appearance of a shockable rhythm on the monitor by the nurses and those SHOs without ALS training was 42 and 40.8 seconds, respectively.

CONCLUSION

ALS trained nurses performed as well as ALS trained and non ALS trained emergency SHOs in a simulated cardiac arrest situation and had greater awareness of the potentially reversible causes of cardiac arrest. Thus if a senior or middle grade doctor is not available to lead the resuscitation team, it may be appropriate for experienced nursing staff with ALS training to act as ALS team leaders rather than SHOs.

ATLS practices and survival at rural level III trauma hospitals, 1995-1999

OBJECTIVE

To determine whether Advanced Trauma Life Support (ATLS) practices characterizing initial resuscitation and interfacility transfer at rural trauma hospitals are associated with risk-adjusted survival.

METHODS

Retrospective, observational analysis of rural injured patient survival. Process-of-care variables were associated with TRISS (trauma and injury severity score)-derived Z-statistics (95% confidence intervals) for high-risk population subsets (defined below).

INCLUSION CRITERIA

all patients > or = 12 years of age entered into a statewide trauma system, January 1, 1995, to December 31, 1999, and initially presenting to Level III trauma centers (N = 4,961).

EXCLUSION CRITERIA

pronounced dead on arrival (n = 26), directly admitted to hospital (n = 3), and unknown disposition at first hospital (n = 2). Process variables include: intubation in emergency department (ED) given Glasgow Coma Scale (GCS) score < 9 [INTUB], administration of blood products in ED given systolic blood pressure (SBP) < 90 mm Hg [BLOOD], trauma surgeon presence within 5 minutes of patient arrival given GCS < 9 mm Hg or SBP < 90 mm Hg [UNSTABLE-TS], trauma surgeon presence within 5 minutes of patient arrival given injury severity score (ISS) > 15 [ISS-TS], transfer to higher level of care given ISS > 20 and no hypotension [TRAN], transfer to higher level of care given GCS < 9 [TRAN-GCS].

RESULTS

For the high-risk subpopulations, the following Z-scores (with and without an intervention) were found:

CONCLUSIONS

Some ATLS interventions (BLOOD, TRAN, and TRAN-GCS) are associated with improved survival for selected high-risk subgroups in these 21 rural Level III trauma hospitals.

Variability in the assessment of advanced life support skills

The number of short 'life support' and emergency care courses available are increasing. Variability in examiner assessments has been reported previously in more traditional types of examinations but there is little data on the reliability of the assessments used on these newer courses. This study evaluated the reliability and consistency of instructor marking for the Resuscitation Council UK Advanced Life Support Course. Twenty five instructors from 15 centres throughout the UK were shown four staged video recorded defibrillation tests (one repeated) and three cardiac arrest simulation tests in order to assess inter-observer and intra-observer variability. These tests form part of the final assessment of competence on an Advanced Life Support course. Significant levels of variability were demonstrated between instructors with poor levels of agreement of 52-80% for defibrillation tests and 52-100% for cardiac arrest simulation tests. There was evidence of differences in the observation/recognition of errors and rating tendencies of instructors. Four instructors made a different pass/fail decision when shown defibrillation test 2 for a second time leading to only moderate levels of intra-observer agreement (kappa=0.43). In conclusion there is significant variability between instructors in the assessment of advanced life support skills, which may undermine the present assessment mechanisms for the advanced life support course. Validation of the assessment tools for the rapidly growing number of life support courses is required with urgent steps to improve reliability where required.

Systematic review of the effectiveness of prehospital critical care following out-of-hospital cardiac arrest

BACKGROUND

Improving survival after out-of-hospital cardiac arrest (OHCA) is a priority for modern emergency medical services (EMS) and prehospital research. Advanced life support (ALS) is now the standard of care in most EMS. In some EMS, prehospital critical care providers are also dispatched to attend OHCA. This systematic review presents the evidence for prehospital critical care for OHCA, when compared to standard ALS care.

METHODS

We searched the following electronic databases: PubMed, EmBASE, CINAHL Plus and AMED (via EBSCO), Cochrane Database of Systematic Reviews, DARE, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, NIHR Health Technology Assessment Database, Google Scholar and ClinicalTrials.gov. Search terms related to cardiac arrest and prehospital critical care. All studies that compared patient-centred outcomes between prehospital critical care and ALS for OHCA were included.

RESULTS

The review identified six full text publications that matched the inclusion criteria, all of which are observational studies. Three studies showed no benefit from prehospital critical care but were underpowered with sample sizes of 1028-1851. The other three publications showed benefit from prehospital critical care delivered by physicians. However, an imbalance of prognostic factors and hospital treatment in these studies systematically favoured the prehospital critical care group.

CONCLUSION

Current evidence to support prehospital critical care for OHCA is limited by the logistic difficulties of undertaking high quality research in this area. Further research needs an appropriate sample size with adjustments for confounding factors in observational research design.