Articles at the Top. Take home messages from 2017 (part 2).

19 Gen

Welcome to our annual review of the best articles from the finishing year.

This will be a weekly (or so..) appointment with the top (or so…) articles of 2017 divided by topic and chosen by me.

Here is the best (for me) about:

 Advanced Life Support

Here are the best 2017 articles:

My take home messages:

Pathophysiological bases in experimental swine models

  • In a swine model following primary cardiac arrest the respiration continues at least for 1 minute. and after that Gasping starts lasting for another minute.
  • In a swine model following primary cardiac arrest the blood shifts from high pressure compartment (arteries) to low pressure compartment (veins). 
  • In a swine model the PaO2 following primary cardiac untreated VF arrests PaO2 results 70 mmHg after 9 min with a saturation of 93% and decrease at 44 mmHg with a saturation of 61% after 14 min of CPR. In this period airway management with possible interruption of chest compressions and starting positive pressure ventilation (with decreased return to the thorax end depression of cardiac output) is not mandatory due to the low cost/beneficial ratio and the potential detrimental effect. 

Chest compressions

  • Chest compressione only CPR is associated with worst outcome in children under 8 yers. Always perform chest compression/ventilation (ratio 15:2) in children <8 years of age (only exception if the cardiac arrest is due to primitive cardiac causes). 
  • Chest compressione only CPR can be a valuable option in adult witnessed VF/pulseless VT primary cardiac arrest (delayed airway management and passive O2 administration is reasonable).
  • Mechanical chest compression (MCC) is the future of CPR. They still do not demonstrated evident superiority in terms of outcome respect to manual chest compressions, but are evidently not inferior with a similar rate of life treating lesions. For sure MCC avoid variability in quality and allows good quality CC during transport. 

Ventilation

  • Lower Tidal volumes following OHCA is independently associated with favourable neurocognitive outcome
  • Weak evidences demonstrate that the ideal rate for ventilation of intubated patients  during CPR is 10/min

Airway management

  • There is not beneficial effect on outcome with early intubation in Cardiac Arrest (CA)
  • Privilege High Quality CPR and Defibrillation (if needed).
  • Use Supraglottic Airway Devices (SAD) in first part (15 min) of resuscitation 
  • If Mechanical Chest Compressions is used, to optimise ventilation with SAD, use 30:2 ratio (because the intrathoracic pressure generated during MCC overrules that generated from SAD and impaires ventilation).
  • In prolonged Cardiac Arrest management converting SAD to Endotracheal Tube can be considered.
  • Experience provider only can perform endotracheal intubation in CA. They have a better chance of first passage rate, without interruption in chest compressions. First pass success rate is positively associated to survival and good neurological outcome.

Defibrillation

  • Escalating bilevel energy (150-200-360 Joule) is associated with more efficacy in termination of shock resistant VF/pulselessVT cardiac arrest
  • Dual Sequential Defibrillation is feasible and safe. Although the evidences on its beneficial effect on outcome are still lacking it has to be considered in case of CA with refractory shockable rhythm. 

Antiarrhythmics drugs

  • There has been no conclusive evidence that any antiarrhythmic agents improve rates of ROSC, survival to admission, survival to discharge or neurological outcomes.

Ultrasound

  • Ultrasound in PEA is a key tool to detect CA causes improving survivival.

Post Resuscitation Care

  • In post resuscitation phase avoid any arterial oxygen and carbon dioxide abnormality because are associated to increased mortality.
  • Centralisation of resuscitated patients toward an acute PCI/CABG capable Center  is associated to better outcome.

Targeted Temperature Management

  • Prehospital cooling does not improve faster in-hospital target temperature achieving and due to its costs is not recommended.
If you are interested on a daily update about the best emergency medicine literature follow me on Facebook, Twitter or give your like to MEDEST Facebook page.

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