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Optimizing Survival Outcomes for Adult Patients with Nontraumatic

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Optimizing Survival Outcomes for Adult Patients with Nontraumatic October 2016 Optimizing Survival Outcomes Volume 18, Number 10 Author For Adult Patients With Julianna Jung, MD, FACEP Associate Professor and Director of Undergraduate Medical Education, Department of Emergency Medicine, Johns Hopkins University School of Nontraumatic Cardiac Arrest Medicine, Baltimore, MD Peer Reviewers Abstract William J. Brady, MD Professor of Emergency Medicine and Medicine; Chair, Medical Patient survival after cardiac arrest can be improved significantly Emergency Response Committee; Medical Director, Emergency Management, University of Virginia Medical Center, Charlottesville, VA with prompt and effective resuscitative care. This systematic Faheem Guirgis, MD, FACEP review analyzes the basic life support factors that improve survival Assistant Professor of Emergency Medicine, University of Florida Health outcome, including chest compression technique and rapid defi- Jacksonville, Department of Emergency Medicine, Division of Research, brillation of shockable rhythms. For patients who are successfully Jacksonville, FL resuscitated, comprehensive postresuscitation care is essential. Tar- CME Objectives geted temperature management is recommended for all patients Upon completion of this article, you should be able to: who remain comatose, in addition to careful monitoring of oxygen- 1. Describe the elements of high-quality basic life support. 2. Discuss the evidentiary basis and current guidelines for advanced ation, hemodynamics, and cardiac rhythm. Management of cardiac life support interventions. arrest in circumstances such as pregnancy, pulmonary embolism, 3. Describe essential considerations in postresuscitation care following opioid overdose and other toxicologic causes, hypothermia, and restoration of spontaneous circulation. coronary ischemia are also reviewed. 4. List modifications to standard resuscitation protocols that may be considered in special resuscitation situations. Prior to beginning this activity, see “Physician CME Information” on the back page. Editor-In-Chief Daniel J. Egan, MD Eric Legome, MD Robert Schiller, MD International Editors Associate Professor, Department Chief of Emergency Medicine, Chair, Department of Family Medicine, Andy Jagoda, MD, FACEP Peter Cameron, MD of Emergency Medicine, Program King’s County Hospital; Professor of Beth Israel Medical Center; Senior Professor and Chair, Department of Academic Director, The Alfred Director, Emergency Medicine Clinical Emergency Medicine, SUNY Faculty, Family Medicine and Emergency Medicine, Icahn School Emergency and Trauma Centre, Residency, Mount Sinai St. Luke's Downstate College of Medicine, Community Health, Icahn School of of Medicine at Mount Sinai, Medical Monash University, Melbourne, Roosevelt, New York, NY Brooklyn, NY Medicine at Mount Sinai, New York, NY Director, Mount Sinai Hospital, New Australia York, NY Nicholas Genes, MD, PhD Keith A. Marill, MD Scott Silvers, MD, FACEP Giorgio Carbone, MD Assistant Professor, Department of Research Faculty, Department of Chair, Department of Emergency Associate Editor-In-Chief Emergency Medicine, University Medicine, Mayo Clinic, Jacksonville, FL Chief, Department of Emergency Emergency Medicine, Icahn School Medicine Ospedale Gradenigo, Kaushal Shah, MD, FACEP of Medicine at Mount Sinai, New of Pittsburgh Medical Center, Associate Professor, Department of Pittsburgh, PA Corey M. Slovis, MD, FACP, FACEP Torino, Italy York, NY Professor and Chair, Department Emergency Medicine, Icahn School Suzanne Y.G. Peeters, MD Charles V. Pollack Jr., MA, MD, of Emergency Medicine, Vanderbilt of Medicine at Mount Sinai, New Michael A. Gibbs, MD, FACEP Emergency Medicine Residency FACEP University Medical Center, Nashville, TN York, NY Professor and Chair, Department Director, Haga Teaching Hospital, of Emergency Medicine, Carolinas Professor and Senior Advisor for Interdisciplinary Research and Ron M. Walls, MD The Hague, The Netherlands Editorial Board Medical Center, University of North Professor and Chair, Department of Clinical Trials, Department of Hugo Peralta, MD Carolina School of Medicine, Chapel Emergency Medicine, Brigham and Saadia Akhtar, MD Emergency Medicine, Sidney Kimmel Chair of Emergency Services, Hospital Hill, NC Women's Hospital, Harvard Medical Associate Professor, Department of Medical College of Thomas Jefferson Italiano, Buenos Aires, Argentina Emergency Medicine, Associate Dean Steven A. Godwin, MD, FACEP University, Philadelphia, PA School, Boston, MA for Graduate Medical Education, Professor and Chair, Department Dhanadol Rojanasarntikul, MD Program Director, Emergency of Emergency Medicine, Assistant Michael S. Radeos, MD, MPH Critical Care Editors Attending Physician, Emergency Medicine Residency, Mount Sinai Assistant Professor of Emergency Medicine, King Chulalongkorn Dean, Simulation Education, William A. Knight IV, MD, FACEP Beth Israel, New York, NY Medicine, Weill Medical College Memorial Hospital, Thai Red Cross, University of Florida COM- Associate Professor of Emergency Jacksonville, Jacksonville, FL of Cornell University, New York; Thailand; Faculty of Medicine, William J. Brady, MD Research Director, Department of Medicine and Neurosurgery, Medical Chulalongkorn University, Thailand Professor of Emergency Medicine Gregory L. Henry, MD, FACEP Emergency Medicine, New York Director, EM Midlevel Provider and Medicine; Chair, Medical Clinical Professor, Department of Hospital Queens, Flushing, NY Program, Associate Medical Director, Stephen H. Thomas, MD, MPH Emergency Response Committee; Emergency Medicine, University Neuroscience ICU, University of Professor & Chair, Emergency Ali S. Raja, MD, MBA, MPH Medical Director, Emergency of Michigan Medical School; CEO, Cincinnati, Cincinnati, OH Medicine, Hamad Medical Corp., Vice-Chair, Emergency Medicine, Management, University of Virginia Medical Practice Risk Assessment, Weill Cornell Medical College, Qatar; Massachusetts General Hospital, Scott D. Weingart, MD, FCCM Medical Center, Charlottesville, VA Inc., Ann Arbor, MI Associate Professor of Emergency Emergency Physician-in-Chief, Boston, MA Hamad General Hospital, Doha, Qatar John M. Howell, MD, FACEP Medicine, Director, Division of ED Calvin A. Brown III, MD Robert L. Rogers, MD, FACEP, Clinical Professor of Emergency Critical Care, Icahn School of Medicine Edin Zelihic, MD Director of Physician Compliance, FAAEM, FACP Medicine, George Washington at Mount Sinai, New York, NY Head, Department of Emergency Credentialing and Urgent Care Assistant Professor of Emergency University, Washington, DC; Director Medicine, Leopoldina Hospital, Services, Department of Emergency Medicine, The University of Medicine, Brigham and Women's of Academic Affairs, Best Practices, Senior Research Editors Schweinfurt, Germany Inc, Inova Fairfax Hospital, Falls Maryland School of Medicine, Hospital, Boston, MA James Damilini, PharmD, BCPS Church, VA Baltimore, MD Clinical Pharmacist, Emergency Peter DeBlieux, MD Shkelzen Hoxhaj, MD, MPH, MBA Alfred Sacchetti, MD, FACEP Room, St. Joseph’s Hospital and Professor of Clinical Medicine, Chief of Emergency Medicine, Baylor Assistant Clinical Professor, Medical Center, Phoenix, AZ Interim Public Hospital Director College of Medicine, Houston, TX Department of Emergency Medicine, of Emergency Medicine Services, Thomas Jefferson University, Joseph D. Toscano, MD Louisiana State University Health Philadelphia, PA Chairman, Department of Emergency Science Center, New Orleans, LA Medicine, San Ramon Regional Medical Center, San Ramon, CA Case Presentations Survival to hospital discharge is better overall for shockable rhythms, with more than 33% of patients Shortly after starting your night shift, you get STAT surviving VF/VT arrests compared to approximate- 8,9 paged to bed 34. You rush to the room and find the nurses ly 10% for PEA and asystole. giving chest compressions. You wrack your brain to remember sign-out – wasn’t this the man who came in Critical Appraisal Of The Literature with chest pain, no ECG changes, but a concerning his- tory? He was stable, just waiting on an inpatient bed! The body of literature on cardiac arrest is vast, with Not anymore, you sigh. You hold compressions to take a more than 40,000 articles in PubMed. Fortunately, look at the monitor, and see V-fib. “Charge to 200 joules,” the International Liaison Committee on Resuscita- you say. “Clear!” calls the tech. The patient jumps with tion (ILCOR) regularly reviews the literature and the force of the electricity. The nurse resumes compres- synthesizes it into practice guidelines for its member sions, but a few moments later, the patient moans, moving organizations, including the American Heart Associ- his hand to his chest. As you hold on compressions and ation (AHA). The AHA publishes guideline updates continue to stabilize the patient, you wonder if he would every 5 years, and these are the “gold standard” in be a good candidate to go to the cath lab . cardiac arrest science. The guidelines summarize Shortly afterward, you get a call from paramedics clinical resuscitation protocols and their evidentiary about a young man who collapsed suddenly while danc- basis, as well as noting areas where scientific evi- ing at a nightclub. “He’s in full cardiac arrest,” they say, dence is lacking. The 2015 updates, published on and you rush back to the critical care bay. You arrive in October 15, 2015 in the journal Circulation, served the resuscitation bay just as EMS arrives. “It’s V-fib,” as the starting point for this review, with additional the paramedic
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