Resuscitation highlights in 2021.

BACKGROUND: This review is the latest in a series of regular annual reviews undertaken by the editors and aims to highlight some of the key papers published in Resuscitation during 2021. METHODS: Hand-searching by the editors of all papers published in Resuscitation during 2021. Papers were selected based on then general interest and novelty and were categorised into themes. RESULTS: 98 papers were selected for brief mention. CONCLUSIONS: Resuscitation science continues to evolve and incorporates all links in the chain of survival.

Resuscitation highlights in 2020.

BACKGROUND: This review is the latest in a series of regular annual reviews undertaken by the editors and aims to highlight some of the key papers published in Resuscitation during 2020. The number of papers submitted to the Journal in 2020 increased by 25% on the previous year.MethodsHand-searching by the editors of all papers published in Resuscitation during 2020. Papers were selected based on then general interest and novelty and were categorised into general themes.ResultsA total of 103 papers were selected for brief mention in this review.ConclusionsResuscitation science continues to evolve rapidly and incorporate all links in the chain of survival.

Airway management during in-hospital cardiac arrest: An international, multicentre, retrospective, observational cohort study.

AIM: To determine the type of airway devices used during in-hospital cardiac arrest (IHCA) resuscitation attempts. METHODS: International multicentre retrospective observational study of in-patients aged over 18 years who received chest compressions for cardiac arrest from April 2016 to September 2018. Patients were identified from resuscitation registries and rapid response system databases. Data were collected through review of resuscitation records and hospital notes. Airway devices used during cardiac arrest were recorded as basic (adjuncts or bag-mask), or advanced, including supraglottic airway devices, tracheal tubes or tracheostomies. Descriptive statistics and multivariable regression modelling were used for data analysis. RESULTS: The final analysis included 598 patients. No airway management occurred in 36 (6%), basic airway device use occurred at any time in 562 (94%), basic airway device use without an advanced airway device in 182 (30%), tracheal intubation in 301 (50%), supraglottic airway in 102 (17%), and tracheostomy in 1 (0.2%). There was significant variation in airway device use between centres. The intubation rate ranged between 21% and 90% while supraglottic airway use varied between 1% and 45%. The choice of tracheal intubation vs. supraglottic airway as the second advanced airway device was not associated with immediate survival from the resuscitation attempt (odds ratio 0.81; 95% confidence interval 0.35-1.8). CONCLUSION: There is wide variation in airway device use during resuscitation after IHCA. Only half of patients are intubated before return of spontaneous circulation and many are managed without an advanced airway. Further investigation is needed to determine optimal airway device management strategies during resuscitation following IHCA.

Survival and outcome prediction using the Apache III and the out-of-hospital cardiac arrest (OHCA) score in patients treated in the intensive care unit (ICU) following out-of-hospital, in-hospital or ICU cardiac arrest.

BACKGROUND: There are few data comparing outcome and the utility of severity of illness scoring systems following intensive care after out-of-hospital (OHCA), in-hospital (IHCA) and intensive care unit (ICUCA) cardiac arrest. We investigated survival, factors associated with survival and the correlation and accuracy of general and specific scoring systems, including the Apache III score and the OHCA score in OHCA, IHCA and ICUCA patients. MATERIAL AND METHODS: Prospective analysis of data on all cardiac arrest patients treated in a tertiary hospital between August 1st 2008 and July 30th 2010. Collected data included resuscitation and post-resuscitation care data as defined by the Utstein Guidelines, Apache III on admission and the OHCA score on admission in OHCA and IHCA patients and after the arrest in ICUCA patients. Statistical methods were used to identify factors associated with outcome and the predictive ability and correlation of the aforementioned scores. RESULTS: Of a total of 3931 patients treated in the ICU, 51 were admitted following OHCA, 50 following IHCA and 22 suffered an ICUCA and had sustained return of spontaneous circulation (ROSC). Survival at 30 days was highest among ICUCAs (67%) followed by IHCAs (38%) and OHCAs (29%). Using multivariate analysis delay ROSC was the only independent predictor of survival. The OHCA score performed with moderate accuracy for predicting 30-day mortality (area under the curve 0.77 [0.69-0.86] and was slightly better than the Apache III score 0.71 (0.61-0.80). Using multiple logistic regression the Apache III and the OHCA score were both independent predictors of hospital survival and correlation between these two scores was weak (correlation coefficient of 0.244). CONCLUSIONS: Latency to ROSC seems to be the most important determinant of survival in patients following ICU care after a cardiac arrest in this single center trial. The OHCA score and the Apache III score offer moderate predictive accuracy in ICU cardiac arrest patients but correlated weakly with each other. Illness severity adjustment for cardiac arrest patients in ICU should include features of both these scoring systems.

Comparison of Helsinki and European Resuscitation Council "do not attempt to resuscitate" guidelines, and a termination of resuscitation clinical prediction rule for out-of-hospital cardiac arrest patients found in asystole or pulseless electrical activity.

BACKGROUND: The outcome of out-of-hospital cardiac arrest (OHCA) with a non-shockable rhythm is poor. For patients found in asystole or pulseless electrical activity (PEA), recent guidelines or rules that may be used include "do not attempt to resuscitate" (DNAR) guidelines from Helsinki, discontinuing resuscitation in the guidelines of the European Resuscitation Council and a clinical prediction rule from Canada. We compared these guidelines and the rule using a large Scandinavian dataset. MATERIALS AND METHODS: The Swedish Cardiac Arrest Registry includes prospectively collected data on 44121 OHCA patients. We identified patients with asystole or PEA as the initial rhythm and excluded cases caused by trauma or drowning. The specificities and positive predictive values (PPVs) were calculated for the guidelines, and the clinical prediction rule for comparison. RESULTS: A total of 20484 patients with non-shockable rhythms were identified; 85% had asystole and 15% PEA. The overall survival to hospital admission was 9% (n=1.861) and 1% (n=231) were alive at 1 month from the arrest. The specificity of the Helsinki guidelines in identifying non-survivors was 71% (95% confidence interval (CI): 65-77%) and the PPV was 99.4% (95% CI: 99.3-99.5), while the corresponding values for the European Resuscitation Council (ERC) was 95% (95% CI: 91.3-97.5) and 99.9% (95% CI: 99.9-99.9) and, for the prediction rule, 99.1% (95% CI: 96.7-99.9) and 99.9% (95% CI: 99.9-100.00), respectively. CONCLUSION: In this comparison study, the Helsinki DNAR guidelines did not perform well enough in a general OHCA material to be widely adopted. The main reason for this was the unpredicted survival of patients with unwitnessed asystole. The clinical prediction rule and the recommendations of the ERC Guidelines worked well.

Potential cervical spine injury and difficult airway management for emergency intubation of trauma adults in the emergency department--a systematic review.

BACKGROUND: Emergency airway management for trauma adults is practised by physicians from a range of training backgrounds and with differing levels of experience. The indications for intubation and technique employed are factors that vary within EDs and between hospitals. OBJECTIVES: To provide practical evidence based guidance for airway management in trauma resuscitation: first for the trauma adult with potential cervical spine injury and second the management when a difficult airway is encountered at intubation. SEARCH STRATEGY AND METHODOLOGY: Full literature search for relevant articles in Medline (1966-2003), EMBASE (1980-2003), and the Cochrane Central Register of Controlled Trials. Relevant articles relating to adults and written in English language were appraised. English language abstracts of foreign articles were included. Studies were critically appraised on a standardised data collection sheet to assess validity and quality of evidence. The level of evidence was allocated using the methods of the Australian National Health and Medical Research Council.

Recombinant activated factor VIIa use in massive transfusion and coagulopathy unresponsive to conventional therapy.

We report a retrospective analysis of patients admitted to a tertiary intensive care unit who received recombinant activated factor VIIa (rFVIIa) in an effort to control life-threatening haemorrhage and coagulopathy. Data extracted included: demographics, diagnoses and clinical course, dosage of rFVIIa, blood product requirements and coagulation tests prior to and after rFVIIa, pH, base deficit and temperature. During the study period rFVIIa was given to nine patients with refractory coagulopathy in imminent danger of death. Three patients were post cardiac surgery, three patients had multiple blunt trauma, one patient had a close range shotgun wound to the abdomen, one patient had a ruptured iliac artery aneurysm and one patient was post caesarean section with acute fatty liver of pregnancy. Improvements in prothrombin time (PT) (median 17s pre vs 10.6s post rFVIIa (P < 0.05)) were seen in all nine cases. Reduced requirements for red blood cells, fresh frozen plasma, platelets and cryoprecipitate followed rFVIIa administration in eight cases. One patient died after 48 hours of complications unrelated to the initial pathology. Seven patients were discharged from hospital; one remains in hospital. rFVIIa provided improvement in coagulopathy unresponsive to conventional therapy.

The Medical Emergency Team: 21st century critical care.

In-hospital cardiac arrests, intensive care unit (ICU) admissions and unexpected deaths are commonly preceded by warning signs up to 24 hours prior to the event. As a result, some of these critical events are potentially preventable. Critical care physicians are increasingly familiar with patient care systems; trauma systems have become well established in most health services, and the chain of survival provides a system response to out of hospital cardiac arrests. We now need to build on experience with systems to extend critical care services to all hospital patients at risk, whatever their location and on a continuous basis to prevent these critical events from occurring. In fact, if critical care medicine is to take up the challenge and move forward into the 21st century, we need to engage in a re-orientation from individual to system thinking. We know that the majority of in-hospital cardiac arrests occurring on the general wards represent failures in the system. These events are not the fault of one or two individual practitioners that failed to provide adequate care, but a consequence of organisational factors that result in failures in recognition and response involving more than one department, professional group or area of the hospital. There is also potential to reduce morbidity. Morbidity caused by failure to adequately treat hypoxemia and hypovolemia on the wards, results in preventable cases of renal and respiratory failure, requiring prolonged, uncomfortable and expensive admissions to intensive care, along with the invasive therapy that ICU admission entails. The Medical Emergency Team (MET) system provides a potential solution.

Therapeutic approaches in trauma-induced coagulopathy.

Coagulopathy is a phenomenon which is a life threatening complication in the trauma patient who has sustained significant injuries and blood loss. With our increasing understanding of the mechanisms which drive the coagulopathy and the availability of new treatment options, most notably recombinant factor VIIa (rFVIIa), we are now able to treat those patients who have had a massive traumatic haemorrhage with greater efficacy. This paper reviews the current considerations in dealing with patients with trauma-induced coagulopathy and offers a strategy for their management.

Blunt cardiac injury.

Blunt cardiac injury (BCI) is a common complication of chest trauma. With improvements in pre-hospital care and rapid regional transport, more patients with severe BCI may arrive at the hospital with signs of life. Prompt recognition and expeditious surgical and critical care treatment may increase the number of survivors. This paper reviews current clinical considerations in dealing with patients suffering BCI.