Editorial

Time for change?

International guidelines for basic life support and defibrillation are identical for lay people and healthcare professionals. In 2002, a small meeting hosted by the Resuscitation Council (UK) debated recent advances in resuscitation science, along with the possibility of more demanding procedures for treating out of hospital cardiac arrest (OHCA) that could take advantage of the expertise available with professional use. The resulting algorithm known as Protocol C could not be tested in a randomized trial for reasons relating to consent, but was introduced by one ambulance service as an observational study. Results from a 2-year period from one city within the service area are presented, using the Utstein style of reporting to show the recommended ‘comparator’ group whilst also providing epidemiological data on the frequency of cardiac arrest within the community and the outcome of all resuscitation attempts.

Manual methods were used to collect data from 2009 and 2010 for cases of cardiac arrest treated by crews from the two ambulance stations within the city of Brighton and Hove. All transported patients were tracked individually through the hospital because no official method of data linkage is available. Outcome data were obtained for survival to hospital discharge, or to 30 days for the few who remained in hospital care for that duration.

In the epidemiological analysis, 454 patients with OHCA were treated over 2 years, of whom 151 (33%) had sustained return of spontaneous circulation (ROSC) at hospital handover and 59 (13%) survived to discharge or for 30 days. Within the ‘comparator’ group of 79 patients, 47 (59%) achieved sustained ROSC to hospital handover and 24 (30%) survived.

The use of Protocol C has been associated with rates of sustained ROSC to hospital and of survival to discharge that have reached the range of international best practice. The improvement noted in this observational study cannot be ascribed to the new protocol alone; any wider use should await randomized trials to test the impact of this single variable. Meanwhile, wider adoption of the Utstein system to compare results for treatment of OHCA will provide a potent stimulus for emergency services to seek ways of improving outcome.

The science and practice of resuscitation is recognised and endorsed on an international level, yet for more than a decade it has appeared in the literature alongside words such as witnessing or witnessed to signify the practice of family presence during a resuscitation attempt. This paper explores the meaning of witnessed resuscitation using the process for concept analysis proposed by Rodgers [1989. Concepts, analysis and the development of nursing knowledge: the evolutionary cycle. Journal of Advanced Nursing 14, 330–335; 1991. Using concept analysis to enhance clinical practice and research. Dimensions of Critical Care Nursing 10(1), 28–34]. The term resuscitation is explored, followed by identification of relevant uses of the concept of witnessed resuscitation. The reader is introduced to conceptual variations that challenge the way in which the concept has become associated with family or relatives presence in the resuscitation room of an accident and emergency department. Conceptual clarity is further enhanced through the identification of references, antecedents and consequences of witnessed resuscitation and by providing a model case of the concept that includes its defining attributes.

Lund University Cardiopulmonary Assist System (LUCAS) is a new gas-driven CPR device providing automatic chest compression and active decompression. This is a report of the first 100 consecutive cases treated with LUCAS due to out-of-hospital cardiac arrest (58% asystole, 42% ventricular fibrillation (VF)). Safety aspects were also investigated and it was found that LUCAS can be used safely regarding noise levels and oxygen concentrations within the ambulance. A crash test (10 G) showed no displacement of the device from the manikin. Of the 71 patients with witnessed cardiac arrest, 39% received bystander CPR. In those 28 patients where LUCAS-CPR was initiated more than 15 min after the ambulance alarm and in the 29 unwitnessed cases, none survived for 30 days. Of the 43 witnessed cases treated with LUCAS within 15 min, 24 had VF and 15 (63%) of these cases achieved a stable return of spontaneous circulation (ROSC) and 6 (25%) of them survived with a good neurological recovery after 30 days; 5 (26%) of the 19 patients with asystole achieved ROSC and 1 (5%) survived for over 30 days. One patient where ROSC could not be achieved was transported with on-going LUCAS-CPR to the catheter laboratory and after PCI for an occluded LAD a stable ROSC occurred, but the patient never regained consciousness and died 15 days later.

To conclude, establishment of an adequate cerebral circulation as quickly as possible after cardiac arrest is mandatory for a good outcome. In this report patients with a witnessed cardiac arrest receiving LUCAS-CPR within 15 min from the ambulance call had a 30-day survival of 25% in VF and 5% in asystole, but if the interval was more than 15 min, there were no 30-day survivors.

Maximizing cardiopulmonary resuscitation (CPR) during resuscitation may improve survival. Resuscitation protocols stack up to 3 shocks to achieve defibrillation, followed by an immediate postdefibrillation pulse check. The purpose of this study is to evaluate outcomes of rhythm reanalyses immediately after shock, stacked shocks, and initial postshock pulse checks in relation to achieving a pulse and initiating CPR.

We conducted an observational study of patients with ventricular fibrillation treated by first-tier emergency medical services (EMS). We collected data from EMS, dispatch, and hospital records. Additionally, we analyzed automatic external defibrillator recordings to determine the proportion of cardiac arrest victims who were defibrillated and achieved a pulse according to shock number (single versus stacked shock), proportion of victims with a pulse during the initial postdefibrillation pulse check, and interval from initial shock to CPR.

The study included 481 cardiac arrest subjects. Automatic external defibrillators terminated ventricular fibrillation with the initial shock in 83.6% (n=402) of cases. A second shock terminated ventricular fibrillation in an additional 7.5% (n=36) of cases, and a third shock terminated ventricular fibrillation in 4.8% (n=23) of cases. The initial sequence of 3 shocks failed to terminate ventricular fibrillation in 4.1% (n=20) of cases. In total, automatic external defibrillators performed 560 rhythm reanalyses during the initial shock sequence and delivered 122 “stacked” shocks. Termination of ventricular fibrillation was not synonymous with return of a pulse. The initial shock produced a pulse that was eventually detected in 21.8% (105/481) of cases. Stacked shocks produced a pulse in 10.7% (13/122) of cases. For the 24.5 % (n=118) of cases in which a pulse returned, the pulse was detected during the initial postshock pulse check only 12 times, or 2.5% of all cases. The median interval from initial shock until CPR was 29 (23,41) seconds.

Rhythm reanalyses, stacked shocks, and postshock pulse checks had low yield for achieving or detecting return of a pulse. CPR was not initiated until 29 seconds after the initial shock.