Part 4: Advanced life support
Section snippets
Causes and prevention
Rescuers may be able to identify some noncardiac causes of arrest and tailor the sequence of attempted resuscitation. Most patients sustaining in-hospital cardiac arrest display signs of deterioration for several hours before the arrest. Early identification of these high-risk patients and the immediate arrival of a MET (also known as Rapid Response Team in the United States) to care for them may help prevent cardiac arrest. Hospitals in many countries are introducing early warning systems such
Airway and ventilation
Consensus conference topics related to the management of airway and ventilation are categorised as (1) basic airway devices, (2) advanced airway devices, (3) confirmation of advanced airway placement, (4) strategies to secure advanced airways, and (5) strategies for ventilation.
Drugs and fluids for cardiac arrest
Questions related to the use of drugs during cardiac arrest that were discussed during the 2005 Consensus Conference are categorised as (1) vasopressors, (2) antiarrhythmics, (3) other drugs and fluids, and (4) alternative routes of delivery.
Monitoring and assisting the circulation
Specific questions related to the use of techniques and devices to (1) monitor the performance of CPR during cardiac arrest or (2) assist the circulation (alternatives to standard CPR) during cardiac arrest were discussed during the 2005 Consensus Conference. They are listed below.
Narrow-complex tachycardia
There are four options for the treatment of narrow-complex tachycardia in the periarrest setting: electrical conversion, physical manoeuvers, pharmacological conversion, or rate control. The choice depends on the stability of the patient and the rhythm. In a haemodynamically unstable patient, narrow-complex tachycardia is best treated with electrical cardioversion.
Cardiac arrest in special circumstances
In some circumstances modification of the standard resuscitation technique is required to maximize the victim's chance of survival. In many of these special circumstances recognition of the critically ill patient may enable early treatment to prevent cardiac arrest. The special circumstances reviewed during the consensus process can be categorised as environmental (hypothermia, submersion, electrocution), pregnancy, asthma, and drug overdose/poisoning.
Postresuscitation care
ROSC is just the first step toward the goal of complete recovery from cardiac arrest. Interventions in the postresuscitation period are likely to significantly influence the final outcome, yet there are relatively few data relating to this phase. In the absence of firm guidelines, approaches to postresuscitation care are heterogeneous. Postresuscitation interventions are categorised into the following areas: (1) ventilation, (2) temperature control (therapeutic hypothermia and prevention and
Consensus on science
Five studies (LOE 4532, 533; LOE 5534, 535, 536) documented some ability to predict outcome in adults when neurological examination is undertaken during cardiac arrest, but there is insufficient negative predictive value for this assessment to be used clinically.
Treatment recommendation
Relying on the neurological exam during cardiac arrest to predict outcome is not recommended and should not be used.
Consensus on science
In eight human prospective studies (LOE 3537, 538; LOE 4241, 539, 540, 541, 542, 543) of the value of biomarkers in
References (601)
- et al.
Evaluation of a medical emergency team one year after implementation
Resuscitation
(2004) - et al.
How do you size a nasopharyngeal airway
Resuscitation
(2003) - et al.
Field trial of endotracheal intubation by basic EMTs
Ann Emerg Med
(1998) - et al.
Misplaced endotracheal tubes by paramedics in an urban emergency medical services system
Ann Emerg Med
(2001) - et al.
Ability of paramedics to use the Combitube in prehospital cardiac arrest
Ann Emerg Med
(1993) - et al.
Ventilation with the esophageal tracheal combitube in cardiopulmonary resuscitation: promptness and effectiveness
Chest
(1988) - et al.
Comparison of a conventional tracheal airway with the Combitube in an urban emergency medical services system run by physicians
Resuscitation
(2003) - et al.
Endotracheal intubation and esophageal tracheal Combitube insertion by regular ambulance attendants: a comparative trial
Prehosp Emerg Care
(2004) - et al.
Emergency intubation with the Combitube: comparison with the endotracheal airway
Ann Emerg Med
(1993) - et al.
Use of the esophageal tracheal combitube by basic emergency medical technicians
Resuscitation
(2002)
Successful prehospital airway management by EMT-Ds using the combitube
Prehosp Emerg Care
Piriform sinus perforation during Esophageal-Tracheal Combitube placement
J Emerg Med
Laryngeal mask airway and tracheal tube insertion by unskilled personnel
Lancet
Comparison of placement of the laryngeal mask airway with endotracheal tube by paramedics and respiratory therapists
Ann Emerg Med
Airway management training using the laryngeal mask airway: a comparison of two different training programmes
Resuscitation
The incidence of regurgitation during cardiopulmonary resuscitation: a comparison between the bag valve mask and laryngeal mask airway
Resuscitation
The role of laryngeal mask airway in cardiopulmonary resuscitation
Resuscitation
The use of the laryngeal mask airway in CPR
Resuscitation
The laryngeal mask in cardiopulmonary resuscitation in a district general hospital: a preliminary communication
Resuscitation
Use of the laryngeal tube for out-of-hospital resuscitation
Resuscitation
Randomized comparison of laryngeal tube with classic laryngeal mask airway for anaesthesia with controlled ventilation
Br J Anaesth
Efficacy of the laryngeal tube by inexperienced personnel
Resuscitation
Capnography alone is imperfect for endotracheal tube placement confirmation during emergency intubation
J Emerg Med
A disposable end-tidal CO2 detector to verify endotracheal intubation
Ann Emerg Med
Validity of a disposable end-tidal CO2 detector in verifying endotracheal tube placement in infants and children
Ann Emerg Med
Verification of endotracheal tube placement with colorimetric end-tidal CO2 detection
Ann Emerg Med
Multicenter study of a portable, hand-size, colorimetric end-tidal carbon dioxide detection device
Ann Emerg Med
The assessment of three methods to verify tracheal tube placement in the emergency setting
Resuscitation
End-tidal CO2 measurement in the detection of esophageal intubation during cardiac arrest
Ann Emerg Med
Evaluation of an end-tidal carbon dioxide detector in the aeromedical setting
J Air Med Transp
Esophageal detector device versus detection of end-tidal carbon dioxide level in emergency intubation
Ann Emerg Med
A comparative study of oral endotracheal tube securing methods
Chest
Out-of-hospital cardiac arrests of non-cardiac origin: epidemiology and outcome
Eur Heart J
Presentation, management, and outcome of out of hospital cardiopulmonary arrest: comparison by underlying aetiology
Heart (British Cardiac Society)
A prospective before-and-after trial of a medical emergency team
Med J Aust
Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study
BMJ
Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial
Lancet
Rates of in-hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team
Med J Aust
The patient-at-risk team: identifying and managing seriously ill ward patients
Anaesthesia
Out of our reach? Assessing the impact of introducing a critical care outreach service
Anaesthesia
Effect of introducing the Modified Early Warning score on clinical outcomes, cardio-pulmonary arrests and intensive care utilisation in acute medical admissions
Anaesthesia
Comparison of nasal trauma associated with nasopharyngeal airway applied by nurses and experienced anesthesiologists
Changgeng Yi Xue Za Zhi
The nasopharyngeal airway. Assessment of position by fibreoptic laryngoscopy
Anaesthesia
Intracranial malposition of nasopharyngeal airway
J Trauma
Complication from a nasopharyngeal airway in a patient with a basilar skull fracture
Anesthesiology
Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial
JAMA
Paramedics and technicians are equally successful at managing cardiac arrest outside hospital
BMJ
Advanced cardiac life support in out-of-hospital cardiac arrest
N Engl J Med
Emergency physician-verified out-of-hospital intubation: miss rates by paramedics
Acad Emerg Med
Cited by (207)
Recent developments and controversies in therapeutic hypothermia after cardiopulmonary resuscitation: A narrative review
2023, American Journal of Emergency MedicineUse of supraglottic airway devices under capnography monitoring during cardiopulmonary resuscitation: A systematic review
2021, Australian Critical CareCitation Excerpt :During the initial care of patients in cardiac arrest by healthcare personnel, bag-valve-mask (BVM) ventilation with devices to open the airway (oropharyngeal or nasopharyngeal cannulas) is often the technique used until the establishment of advanced devices.2 There has been controversy about the ideal, definitive device for airway management during cardiopulmonary resuscitation (CPR); orotracheal intubation (OTI) has been the recommended standard.3,4 The International Liaison Committee on Resuscitation (ILCOR), in the latest recommendations (2015),5 raised reasonable doubts about the superiority of advanced airway management (by means of OTI or extraglottic airway devices [EADs]) in comparison with ventilation with BVMs, referring to the improvement of results obtained after cardiac arrest in various published observational studies.
The Role of Post-Resuscitation Electrocardiogram in Patients With ST-Segment Changes in the Immediate Post-Cardiac Arrest Period
2017, JACC: Cardiovascular Interventions