Resuscitation (2005) 67, 213—247 Part 4: Advanced life support International Liaison Committee on Resuscitation The topics reviewed by the InternationalLiaison • Evidence to identify the most effective vasopres- Committee on Resuscitation (ILCOR) Advanced Life sor or if any vasopressor is better than placebo for Support Task Force are grouped as follows: (1) cardiac arrest causes and prevention, (2) airway and ventilation, • Randomised controlled trials on several new (3) drugs and fluids given during cardiac arrest, (4) devices to assist circulation during CPR techniques and devices to monitor and assist the • Randomised controlled trial data on several circulation, (5) periarrest arrhythmias, (6) cardiac postresuscitation care therapies, such as control arrest in specialcircumstances, (7) postresuscita- of ventilation, sedation, and glucose tion care, and (8) prognostication. Defibrillation • The precise role of, and method for implement- topics are discussed in Part 3. ing, therapeutic hypothermia: patient selection, The most important developments in advanced externalversus internalcooling,optimum target life support (ALS) since the last ILCOR review in temperature and duration of therapy 2000 include • The emergence of medicalemergency teams Causes and prevention (METs) as a means of preventing in-hospitalcar- diac arrest Rescuers may be able to identify some noncar- • Additionalclinicaldataon the use of vasopressin diac causes of arrest and tailor the sequence of in cardiac arrest attempted resuscitation. Most patients sustaining • Severalnew devices to assist circulationduring in-hospitalcardiac arrest displaysigns of deteri- CPR oration for severalhours before the arrest. Early • The use of therapeutic hypothermia to improve identification of these high-risk patients and the neurological outcome after ventricular fibrilla- immediate arrivalof a MET (alsoknown as Rapid tion (VF) cardiac arrest Response Team in the United States) to care for • The potentialimportance of glucosecontrolafter them may help prevent cardiac arrest. Hospitals in cardiac arrest many countries are introducing early warning sys- For many topics there were insufficient data with tems such as METs. which to make firm treatment recommendations. The following interventions in particular need fur- Identification of the aetiology of cardiac ther research: arrest W119A,W120,W121 • The impact of METs on the incidence of cardiac arrest Consensus on science. Very few data address the • Outcome data to define the most appropriate aetiology of cardiac arrest directly. One prospective advanced airway adjunct study (LOE 3)1 and one retrospective study (LOE 4)2 0300-9572/$ — see front matter © 2005 InternationalLiaison Committee on Resuscitation, European Resuscitation Counciland American Heart Association. All Rights Reserved. Published by Elsevier Ireland Ltd. doi:10.1016/j.resuscitation.2005.09.018 214 Part 4: Advanced life support suggested that rescuers can identify some noncar- Treatment recommendation. Introduction of a diac causes of some arrests. MET system for adult hospital in-patients should be considered, with specialattention to detailsof Treatment recommendation. The physicalcir- implementation (e.g. composition and availability cumstances, history, or precipitating events may of the team, calling criteria, education and aware- enable the rescuer to determine a noncardiac cause ness of hospitalstaff, and method of activation of of the cardiorespiratory arrest. Under these circum- the team). Introduction of an EWS system for adult stances the rescuer should undertake interventions in-hospitalpatients may be considered. based on the presumed noncardiac aetiology. Airway and ventilation Impact of medical emergency teams W128A, W128B, W129A, W129B, W130A, W130B, Consensus conference topics related to the man- W195A, W195B, W195C, W195D, W195E agement of airway and ventilation are categorised as (1) basic airway devices, (2) advanced airway The METs studied were composed generally of a devices, (3) confirmation of advanced airway place- doctor and nurse with critical-care training who ment, (4) strategies to secure advanced airways, were available at all times, responded immediately and (5) strategies for ventilation. when called, and had specific, well-defined calling criteria. The MET system normally includes a strat- egy for educating ward staff about early recogni- Basic airway devices tion of critical illness. Variations of the MET system Nasopharyngeal airway include critical-care outreach teams and patient- W45,W46A,W46B at-risk teams; all such variants use early warning scoring (EWS) systems to indicate patients who may Consensus on science. Despite frequent success- be critically ill or at risk of cardiac arrest. fuluse of nasopharyngealairways by anaesthetists, there are no published data on the use of these Consensus on science. Two supportive before-and- airway adjuncts during CPR. One study in anaes- 3,4 after single-center studies (LOE 3) documented thetised patients showed that nurses inserting significant reductions in cardiac arrest rates and nasopharyngeal airways were no more likely than improved outcomes following cardiac arrest (e.g. anaesthesiologists to cause nasopharyngeal trauma survivaland lengthof stay in the intensive care (LOE 7).12 One LOE 5 study13 showed that the tra- unit [ICU]) after introduction of a MET. One cluster ditionalmethods of sizing a nasopharyngealairway randomised controlled trial documented no differ- (measurement against the patient’s little finger or ence in the composite primary outcome (cardiac anterior nares) do not correlate with the airway arrest, unexpected death, unplanned ICU admis- anatomy and are unreliable. In one report inser- sion) between 12 hospitals in which a MET system tion of a nasopharyngealairway caused some air- was introduced and 11 hospitals that continued to way bleeding in 30% of cases (LOE 7).14 Two case 5 function as normal(LOE 2). In this study, however, reports involve inadvertent intracranial placement the MET system increased significantly the rate of of a nasopharyngealairway in patients with basal emergency team calling. Two neutral studies doc- skull fractures (LOE 7).15,16 umented a trend toward reduction in the rates of adult in-hospital cardiac arrest and overall mortal- Treatment recommendation. In the presence of a ity (LOE 3)6 and a reduction in unplanned admis- known or suspected basalskullfracture,an oralair- sions to the ICU (LOE 3).7 A before-and-after study way is preferred, but if this is not possible and the documented reductions in cardiac arrest and death airway is obstructed, gentle insertion of a nasopha- in children after introduction of a MET service into ryngealairway may be lifesaving(i.e. the benefits a children’s hospital,8 but these did not reach sta- may far outweigh the risks). tisticalsignificance. Two before-and-after studies (LOE 3)9,10 showed Advanced airway devices reduced mortality among unplanned ICU admissions after the introduction of an EWS system. Another The tracheal tube has generally been considered before-and-after in-hospitalstudy (LOE 3) 11 failed the optimalmethod of managing the airway dur- to show any significant reduction in the incidence ing cardiac arrest. There is evidence that without of cardiac arrest or unplanned ICU admissions when adequate training and experience, the incidence of an EWS system was used to identify and treat adult complications, such as unrecognised oesophageal patients at risk of deterioration. intubation, is unacceptably high. Alternatives to Part 4: Advanced life support 215 the trachealtube that have been studied during sions, providers may defer an intubation attempt CPR include the bag-valve mask and advanced air- untilreturn of spontaneous circulation(ROSC). To way devices such as the laryngeal mask airway ensure competence, healthcare systems that pro- (LMA) and Combitube. There are no data to support vide advanced airways should address factors such the routine use of any specific approach to airway as adequacy of training and experience and quality management during cardiac arrest. The best tech- assurance. Providers must confirm tube placement nique depends on the precise circumstances of the and ensure that the tube is adequately secured (see cardiac arrest and the competence of the rescuer. below). Tracheal intubation versus ventilation with Tracheal intubation versus the bag-valve mask Combitube/laryngeal mask airway W57 W42A,W42B,W43A,W43B,W44A,W44B Consensus on science. There were no randomised Consensus on science. In some communities tra- trials that assessed the effect of airway and ventila- chealintubation is not permitted or practitioners tion management with bag-valve mask (BVM) alone have inadequate opportunity to maintain their intu- versus airway management that includes tracheal bation skills. Under these circumstances several intubation in adult victims of cardiac arrest. studies indicate a high incidence of unrecognised The only published randomised controlled trial oesophagealintubation misplacementand unrecog- identified (LOE 7)17 that compared trachealintuba- nised dislodgment. Prolonged attempts at tracheal tion with BVM ventilation was performed in children intubation are harmful: the cessation of chest com- who required airway management out-of-hospital. pressions during this time will compromise coro- In this study there was no difference in survival- nary and cerebralperfusion. Severalalternative to-discharge rates, but it is unclear how applica- airway devices have been considered