in hospital cardiac arrest michael parr...increased hands-off time in comparison with insertion of a...

In hospital cardiac arrest Michael Parr

Liverpool Hospital, UNSW

Macquarie University Hospital, MQ Health

• Interrupted time series (2007–2013)

• 9,799,081 admissions in all 232 public

hospitals in NSW

46% reduction in cardiac arrest rates 54% reduction in cardiac arrest related mortality rates

19% reduction in hospital mortality 35% decrease in failure to rescue rates

(all Ps < 0.001)

20% (p < 0.001) mortality reduction among LMDRG patients (2013 vs 2007).

• Aimed at health care professionals who are likely to be the first to respond to an in-hospital CA or medical emergency

• ARC document: Standards for Resuscitation: Clinical Practice and Education supports the implementation of this guideline.

Shout for help and rapidly assess

Handover and assist RRT Handover and assist RRT

In hospital CA

• Personal safety and protective equipment

• Background evidence for health care professionals (previous Guideline 11.1.1-CPR for ALS providers) • Cardiorespiratory arrest is recognised immediately • Help is summoned using number/call systems • CPR is started immediately and, if indicated, defibrillation is attempted

as soon as possible (ideally within 3 min) • All in-hospital cardiac arrests should be reviewed as part of an audit

and quality improvement process • Focus on quality and rationale • Emphasis: Quality and some technology

Defibrillation:

• ANZCOR suggests if the first shock is not successful and the defibrillator is capable of delivering shocks of higher energy, it is reasonable to increase the energy to the maximum available for subsequent shocks [CoSTR 2015, weak recommendation, very low quality evidence].

Values and preferences • Escalating shock energy may prevent the risk of

refibrillation.

Airway, oxygenation, and ventilation

• ANZCOR suggests using either an advanced airway or a bag-mask device for airway management during CPR for cardiac arrest in any setting (CoSTR 2015, weak recommendation, very-low-quality evidence).

Values and preferences • The choice of airway used should depend on the skills and training

of the healthcare provider. Tracheal intubation may result in increased hands-off time in comparison with insertion of a supraglottic airway (e.g. LMA, laryngeal tube) or a bag-mask device. Both a bag-mask device and an advanced airway are frequently used in the same patient as part of a stepwise approach to airway management, but this has not been formally assessed.

Capnography • ANZCOR recommends using waveform capnography to confirm and

continuously monitor the position of a tracheal tube during CPR in addition to clinical assessment (CoSTR 2015, strong recommendation, low-quality evidence).

• It is also recommended that if waveform capnography is not available, a non-waveform carbon dioxide detector, esophageal detector device or ultrasound, in addition to clinical assessment, are alternatives (CoSTR 2015, strong recommendation, low quality evidence).

Values and Preferences • These are strong recommendations despite the low quality evidence, as a

high value is placed on avoiding unrecognised oesophageal intubation. In 11 studies assessed, the mean incidence of unrecognised oesophageal intubation in cardiac arrest was 4.3% (range 0–14%).

Waveform capnography

Confirm circulation Confirm tube placement Monitor ventilation rate - avoids hyperventilation Quality of chest compressions during CPR (CO2 values are associated with compression depth and ventilation rate) Identifying ROSC during CPR (increased CO2 ) Assess prognosis during CPR (low CO2 may indicate a poor prognosis and less chance of ROSC). Failure to achieve a CO2 value >10 mmHg after 20 min of CPR is associated with a poor outcome in observational studies.

• If cardiac ultrasound is available and can be performed without interfering with standard ALS, it may be considered to try and identify potentially reversible causes of cardiac arrest (CoSTR 2015, weak recommendation, very low quality evidence).

Ultrasound

US

• Pneumothorax • Hypovolaemia • Tamponade • PE

77% sensitivity, 94%specificitfy, PPV 71%, NPV 96%

Automated mechanical chest compression devices (ACTs)

LUCAS AutoPulse

Automated mechanical chest compression devices (ACTs)

• ANZCOR suggests against the routine use of automated mechanical chest compression devices to replace manual chest compressions (CoSTR 2015 weak recommendation, moderate quality of evidence).

• ANZCOR suggests that automated mechanical chest compression devices are a reasonable alternative to high-quality manual chest compressions in situations where sustained high-quality manual chest compressions are impractical or compromise provider safety (CoSTR 2015, weak recommendation, low quality evidence).

Automated mechanical chest compression devices (ACTs)

Mechanical CPR devices

• For prolonged CPR • For CPR during transport • During imaging and bridge

to PCI during refractory CA • Bridge to Extracorporeal

CPR (E-CPR)

Extracorporeal CPR (eCPR)

Early coronary reperfusion

Special circumstances

• Anaphylaxis • Asthma • Avalanches • Cardiac surgery • Percutaneous coronary interventions • Pericardial tamponade • Pregnancy • Pulmonary embolus • Toxicology

Cardiac arrest under anaesthesia

• Anaphylaxis • Haemorrhage • Airway disasters • Air embolism • Fat embolism • Cement embolism syndrome

Cardiac arrest in radiology

• Anaphyalxis • Ventilatory failure

Cardiac arrest in the ICU

• Air embolism after CVC removal • Disconnection of NIV • Disconnection of VAD

Cardiac arrest in the psychiatry unit

• Asphyxia • Drug overdose

From 2006-2012

• Reliance on national guidelines does not necessarily translate to evidence based care at a local level, so strategies to ensure effective guideline implementation are urgently required.