Resuscitation Guidelines Chapter 49 RESUSCITATION GUIDELINES † NICHOLAS T. TARMEY, FRCA,* AND R. SCOTT FRAZER, FFARCSI INTRODUCTION EXISTING GUIDELINES Cardiac Arrest Guidelines Trauma Resuscitation Guidelines Prehospital Resuscitation Guidelines EVIDENCE FOR MILITARY TRAUMATIC CARDIORESPIRATOry ARREST AREAS OF CONTROVERSY Epinephrine and Other Vasopressors Intubation, Ventilation, and Chest Compressions Capnometry as a Guide to Resuscitation SUMMARY *Lieutenant Colonel, Royal Army Medical Corps, Department of Critical Care, Ministry of Defence Hospital Unit Portsmouth, Queen Alexandra Hospital, Southwick Hill Road, Portsmouth PO6 3LY, United Kingdom †Colonel, Late Royal Army Medical Corps, Consultant in Anaesthesia, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham B15 2WB, United Kingdom 551 Combat Anesthesia: The First 24 Hours INTRODUCTION Cardiorespiratory arrest following trauma occurs still, although these two phases may be indistinguish- in 1% to 4% of patients transported to major civilian able on initial examination. trauma centers, where it is associated with a very poor There is a lack of robust evidence for the optimal overall prognosis.1–4 Resuscitation from cardiorespi- management of TCRA, in both civilian and mili- ratory arrest in the military setting presents a unique tary settings. In the absence of widely accepted, challenge, with a number of important differences evidence-based guidelines, military practice has from civilian practice. The military population suffers been guided by a combination of generic guide- a high incidence of blast and penetrating trauma as the lines for cardiac arrest, limited civilian guidelines cause of arrest,5 and care is often delivered in a range on prehospital resuscitation, and guidelines for of hostile environments. The military setting may also resuscitative thoracotomy. A recent observational have significant constraints on medical resources, study from a United Kingdom (UK) field hospital in limiting the extent of available treatment. In enduring Afghanistan has provided some additional evidence operations, however, resources may sometimes exceed on predictors of survivability following TCRA.7 those available to the civilian sector. Although survival is rare for these patients, as in Traumatic cardiorespiratory arrest (TCRA), defined civilian practice, good outcomes can be achieved as the loss of central pulses and respiratory effort fol- with timely, appropriate interventions, but these lowing trauma, represents the final common pathway require access to significant resources. This chapter before death due to exsanguination, pneumothorax, will review the evidence for current guidelines and, cardiac injury, brain injury, or asphyxia.6 In the case in the context of experience from current conflicts, of exsanguination, a period of profound hypotension suggest modifications to these guidelines for mil- with nonpalpable pulses may precede cardiac stand- itary TCRA. EXISTING GUIDELINES Cardiac Arrest Guidelines • Do not delay transfer for unproven interven- tions such as spinal immobilization. Currently, the only internationally recognized • Standard cardiopulmonary resuscitation guidelines for the treatment of cardiac arrest are those (CPR) should not delay the treatment of re- produced by the European Resuscitation Council versible causes. and adopted by both the Resuscitation Council (UK) • Chest compressions are still considered “the and the American Heart Association.6 Although the standard of care in cardiac arrest irrespective core adult resuscitation algorithm (Figure 49-1) offers of aetiology,” but they are of limited value in simplicity and standardization, it was produced prin- hypovolemia and cardiac tamponade. cipally for cardiac arrest from primary cardiac causes, • Pericardiocentesis is not recommended, not from trauma (the pediatric algorithm is also shown, because it is usually ineffective and delays in Figure 49-2, for reference). Consequently, the guide- thoracotomy. lines are mostly based on evidence from nontrauma • For tension pneumothorax, anterior or lateral resuscitation and place the greatest emphasis on early thoracostomy is more effective than needle defibrillation for ventricular fibrillation or pulseless decompression and quicker than inserting a ventricular tachycardia, cardiac rhythms rarely en- chest tube. countered in TCRA.7 • For assisted ventilation, it may be useful to The 2010 update of the European Resuscitation limit tidal volumes and respiratory rate in or- Council guidelines does, however, include a useful der to reduce the effect of raised intrathoracic discussion of TCRA in the “Special Circumstances” pressure on venous return. section.8 Here, the authors recognize the lack of ro- • The role of vasopressors in TCRA remains bust evidence for the treatment of TCRA and make unclear. a number of recommendations relevant to military resuscitation, including: Trauma Resuscitation Guidelines • Undertake only life-saving interventions at the A number of sources of guidelines are available scene, with immediate transfer to the nearest to military clinical staff; however, it must be rec- hospital. ognized that even the currently published military 552 Resuscitation Guidelines Unresponsive? Not breathing or only occasional gasps Call Resuscitation Team CPR 30:2 Attach defibrillator/monitor Minimise interruptions Assess rhythm Shockable Non-shockable (VF/Pulseless VT) (PEA/Asystole) Return of 1 Shock Spontaneous Circulation • IMMEDIATE POST CARDIAC Immediately resume: Immediately resume: • ARREST TREATMENT CPR for 2 min CPR for 2 min • Use ABCDE approach Minimise interruptions • Controlled oxygenation and Minimise interruptions • ventilation • 12-lead ECG • Treat precipitating cause • Temperature control/ • Therapeutic hypothermia • DURING CPR • REVERSIBLE CAUSES • Ensure high-quality CPR: rate, depth, recoil • Hypoxia • Plan actions before interrupting CPR • Hypovolaemia • Give oxygen • Hypo-/hyperkalaemia/metabolic • Consider advanced airway and capnography • Hypothermia • Continuous chest compressions when advanced • Thrombosis - coronary or pulmonary • airway in place • Tamponade - cardiac • Vascular access (intravenous, intraosseous) • Toxins • Give adrenaline every 3–4 min • Tension pneumothorax • Correct reversible causes Figure 49-1. Adult Advanced Life Support algorithm. Copyright European Resuscitation Council—www.erc.edu—2012/003. ABCDE: airway, breathing, circulation, disability, exposure CPR: cardiopulmonary resuscitation ECG: electrocardiogram VF: ventricular fibrillation VT: ventricular tachycardia PEA: pulseless electrical activity Reproduced with permission from: Nolan JP, Soar J, Zideman DA, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation. 2010;81:1232. 553 Combat Anesthesia: The First 24 Hours Unresponsive? Not breathing or only occasional gasps CPR (5 initial breaths then 15:2) Call Attach defibrillator/monitor Resuscitation Team Minimise interruptions (1 min CPR first, if alone) Assess rhythm Shockable Non-shockable (VF/Pulseless VT) (PEA/Asystole) Return of 1 Shock 4 J/Kg spontaneous circulation Immediately resume: • IMMEDIATE POST CARDIAC Immediately resume: CPR for 2 min • ARREST TREATMENT CPR for 2 min Minimise interruptions • Use ABCDE approach Minimise interruptions • Controlled oxygenation and • ventilation • Investigations • Treat precipitating cause • Temperature control • Therapeutic hypothermia? • DURING CPR • REVERSIBLE CAUSES • Ensure high-quality CPR: rate, depth, recoil • Hypoxia • Plan actions before interrupting CPR • Hypovolaemia • Give oxygen • Hypo-/hyperkalaemia/metabolic • Vascular access (intravenous, intraosseous) • Hypothermia • Give adrenaline every 3–5 min • Tension pneumothorax • Consider advanced airway and capnography • Toxins • Continuous chest compressions when advanced • Tamponade - cardiac • airway in place • Thromboembolism • Correct reversible causes Figure 49-2. Pediatric Advanced Life Support algorithm. Copyright European Resuscitation Council—www.erc.edu— 2012/003. ABCDE: airway, breathing, circulation, disability, exposure CPR: cardiopulmonary resuscitation ECG: electrocardiogram VF: ventricular fibrillation VT: ventricular tachycardia PEA: pulseless electrical activity Reproduced with permission from: Nolan JP, Soar J, Zideman DA, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation. 2010;81:1249. 554 Resuscitation Guidelines guidance is based on civilian data. Sources include Write Walking yes injured T3 the following: Or if in combat no not Survivor return to The American College of Surgeons’ Advanced injured reception Trauma Life Support (ATLS) fighting force Breathing Airway no Under ATLS is a well-recognized approach to trauma opening effective DEAD resuscitation, aimed at members of a civilian emer- no procedures enemy fire gency department trauma team.9 Although the course NOT under effective enemy fire: provides a widely accepted paradigm for managing yes OK Call for assistance to carry out BLS trauma patients, there is little specific guidance on the management of TCRA. Starts to breathe: Write 3 T1 Roll to /4 prone position Battlefield Advanced Trauma Life Support (BATLS) Catastrophic Write T1 BATLS is a course designed by the UK Defence limb bleeding yes use tourniquet Medical Services (UK DMS) to provide standardized no training in emergency trauma care for military prac- 10 Write titioners. BATLS adapts civilian practice for the