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doi: 10.1093/bjaed/mkw051
Matrix reference
1B04, 1I02, 2CO4
The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
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Current recommendations on adult resuscitation
Fig 1 The chain of survival. Reproduced with the kind permission of Laerdal Medical.
Fig 2 ALS algorithm. Reproduced with the kind permission of the Resuscitation Council (UK).
continues as long as a shockable rhythm persists with epineph- If during the rhythm check there is electrical activity compat-
rine given after alternative shocks, every 35 min. A further dose ible with a cardiac output then signs of return of spontaneous
of amiodarone 150 mg i.v. may be given after ve debrillation circulation (ROSC) should be sought. These include a central
attempts. pulse check, observing end-tidal CO2, and signs of life. If present,
post-resuscitation care should be started. If not the patient is in a Central venous blood analysis which may provide better ana-
non-shockable rhythm and treatment moves to the alternative lysis of tissue pH than blood gas values.
limb of the algorithm. Invasive cardiovascular monitoring in a critical care setting.
Compressions must never be stopped during a cycle of CPR Ultrasound to identify and treat reversible causes.
unless there are obvious signs of life.
Reversible causes
Debrillation During CPR, reversible causes for which there is specic treat-
Debrillation aims to restore a rhythm compatible with cardiac ment should be identied and treated. They are divided into
output and tissue perfusion with minimal insult to the myocar- two groups of four and are included in the ALS algorithm repre-
dium while ensuring the safety of patient and staff. Most debril- sented by the four Hs and four Ts:
lators are equipped with adhesive pads rather than paddles
Hypoxia is minimized by adequate ventilation using maximal
as they are effective, safer, and facilitate a more rapid shock deliv-
inspired oxygen.
ery. The pads are positioned below the right clavicle (sternal) and
Hypovolaemia is usually due to severe haemorrhage.
in the V6 ECG position in the mid-axillary line. Implantable med-
Hyperkalemia and metabolic disturbances which may be
ical devices must be avoided. Oxygen should be delivered via a
suspected from the history or diagnosed by electrolyte or
closed circuit or the device removed at least 1 m away due to
ECG abnormalities should be aggressively treated.
the risk of sparks causing ignition.
Hypothermia may be suggested by the history, for example,
A single-shock strategy and charging the debrillator while
drowning.
Ventilation with a laryngeal mask airway is easier than with a should be the aim as both hypocarbia and hypercarbia have dele-
bag-valve mask and does provide a degree of protection against terious effects.
aspiration. A randomized controlled trial is underway comparing ACS is a major cause of OHCA. More than 80% of patients with
the use of i-gel with tracheal intubation for initial airway man- ROSC and ST segment elevation (STE) or left bundle branch block
agement in OHCA. Currently, a stepwise approach to airway will have an acute coronary lesion and it has been shown that
management is proposed based on patient factors and compe- early percutaneous coronary intervention is benecial.12 In
tencies of the rescuer. those patients without STE but potential ACS, there are conict-
The guidelines emphasize the importance of waveform cap- ing data and treatment should be individualized in consultation
nography in resuscitation. Clinical signs alone are a notoriously with cardiology.
unreliable way to conrm tracheal placement. Waveform capno- Myocardial function may require optimization guided by
graphy allows conformation of correct ETT placement (although basic monitoring, echocardiography, and plasma lactate clear-
it will not distinguish between bronchial and tracheal place- ance. Intra-aortic balloon pumps (IABP) have not been shown to
ment). It permits monitoring of ventilation rate during resuscita- improve 30 day mortality in patients with cardiogenic shock.
tion, provides monitoring of the quality of chest compressions, Cooling reduces cerebral metabolism and oxygen free radical
provides an early indicator of ROSC, and allows for a certain de- production, inhibits excitatory amino acid release, attenuates the
gree of prognostication during CPR. Modern portable monitoring immune response during reperfusion, and inhibits apoptosis.
equipment includes waveform capnography. Therapeutic hypothermia was recommended in the 2010 guide-
In the event of a failure to establish an airway and ventilate lines for all unconscious patients with ROSC. The original 2002
an apnoeic patient, needle or surgical cricothyroidotomy can trials showed improved neurological outcomes with cooling to
Patients suspected of having a cardiac cause after OHCA need MEDIC): a pragmatic, cluster randomised controlled trial.
urgent referral for coronary catheterization. Lancet 2015; 385: 94755
Although guidelines are under constant review and develop- 7. SOS-KANTO Study Group. Cardiopulmonary resuscitation by
ment, recent studies from the American Heart Association pub- bystanders with chest compression only (SOS-KANTO): an
lished in the British Medical Journal in April 2016 show that observational study. Lancet 2007; 369: 9206
adherence to them is not consistent. 8. Flato UA, Paiva EF, Carballo MT et al. Echocardiography for
The National Cardiac Arrest Audit (NCAA) continues to moni- prognostication during the resuscitation of intensive care
tor in-hospital cardiac arrests while the National Out of Hospital unit patients with non-shockable rhythm cardiac arrest.
Cardiac Arrest project measures outcome variables from OHCA. Resuscitation 2015; 92: 16
Both foster quality improvement initiatives with the hope of 9. Lee DH, Han M, An JY et al. Video laryngoscopy versus
improving outcomes. direct laryngoscopy for tracheal intubation during in-
hospital cardiopulmonary resuscitation. Resuscitation 2015;
89: 1959
Declaration of interest 10. Jacobs IG, Finn JC, Jelinek GA et al. Effect of adrenaline on sur-
vival in out-of-hospital cardiac arrest. A randomized double-
None declared.
blind placebo-controlled trial. Resuscitation 2011; 82: 113843
11. Kudenchuk PJ, Brown SP, Daya M et al. Resuscitation
Outcomes Consortium-Amiodarone, Lidocaine or Placebo
References Study (ROC-ALPS): rationale and methodology behind an