Jason Smith Royal College of Emergency Medicine Professor · to admission (OR 3.6; 2.2 –5.9) •...
Transcript of Jason Smith Royal College of Emergency Medicine Professor · to admission (OR 3.6; 2.2 –5.9) •...
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TOP 10 PAPERS ON RESUSCITATION
Jason Smith
Consultant in Emergency Medicine, Plymouth, UK
Royal College of Emergency Medicine Professor
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2016
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2017
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THE AVERAGE SHIFT..
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1. NO RHYME NOR REASON
Gaspari R et al. Emergency department point-of-care ultrasound in out-of-
hospital and in-ED cardiac arrest. Resuscitation 2016;109:33-39.
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REASON TRIAL
• 20 sites in US and Canada
• prospective observational study
• 793 patients in OH cardiac arrest (PEA or
asystole)
• ROSC, survival to admission (primary outcome)
and survival to discharge
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REASON TRIAL
• Cardiac activity associated with increased survival
to admission (OR 3.6; 2.2 – 5.9)
• Cardiac activity associated with increased survival
to hospital discharge (OR 5.7; 1.5 – 21.9)
• Overall survival to discharge = 1.5%
• 3 patients with no cardiac activity on US
SURVIVED
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CLINICAL BOTTOM LINE
• Patients more likely to survive if cardiac
activity on US
• Clinical decision making still necessary
• Even if no movement on ultrasound,
some patients survive
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2. HOW ABOUT INTUBATION?
Andersen LW, et al. Association Between Tracheal Intubation During
Adult In-Hospital Cardiac Arrest and Survival. JAMA 2017;317(5):494-
506.
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GET WITH THE GUIDELINES
REGISTRY STUDY
• 86,628 adult in-hospital cardiac arrests
• 15 year propensity matched cohort study
using registry data
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GET WITH THE GUIDELINES
REGISTRY STUDY
• tracheal intubation associated with
significantly worse outcome
• survival to hospital discharge 16.3%
(intubated) vs 19.4% (not intubated)
• worse neurological outcome when intubated
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CLINICAL BOTTOM LINE
• This study does not support the practice
of intubation for patients sustaining in-
hospital cardiac arrest
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PRE-HOSPITAL
INTUBATION?
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AIRWAYS-2
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3. COOL AND THE GANG
Chan PS, et al. Association Between Therapeutic Hypothermia and
Survival After In-Hospital Cardiac Arrest. JAMA 2016;316(13):1375-
1382.
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TH - GWTG-R REGISTRY
• 26,183 patients with in-hospital cardiac
arrest
• 6% received TH
• propensity matched cohort study
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TH
• TH-treated patients had lower rates of hospital
survival (27.4% vs 29.2%)
• TH-treated patients had less favourable
neurological recovery (17.0% vs 20.5%)
• TH was associated with worse outcomes
regardless of whether the initial rhythm was
shockable or non-shockable
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4. THE BLUE RINSE
Bernard SA, et al. Induction of Therapeutic Hypothermia During Out-of-
Hospital Cardiac Arrest Using a Rapid Infusion of Cold Saline: The RINSE
Trial (Rapid Infusion of Cold Normal Saline). Circulation 2016;134(11):797-
805.
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RINSE
• prospective randomised controlled trial
• adults with OHCA
• infusion of 2 litres cold saline or standard
care
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RINSE
• 1198 patients - 618 randomised to
hypothermia
• survival to hospital discharge worse in the
cooling group (10.2% vs 11.4%; p=0.71)
• ROSC in 41.2% cooling vs 50.6% standard
care; p=0.03
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CLINICAL BOTTOM LINE
• Therapeutic hypothermia might not be
the best thing for your patients with
ROSC after cardiac arrest
• Avoid hyperthermia - is TTM the answer?
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5. DRUGS IN CARDIAC ARREST
Kudenchuk PJ, et al. Amiodarone, Lidocaine, or Placebo in Out-of-
Hospital Cardiac Arrest. N Engl J Med 2016;375(8):802-3.
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ALPS
• randomised, double-blind multicentre trial
• IV amiodarone, lidocaine, or saline (placebo) in
adults with non-traumatic OHCA
• shock refractory VF or pulseless VT
• amiodarone 300 mg v lidocaine 120mg v
placebo
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ALPS
• 3026 patients
• amiodarone and lidocaine showed better
short term outcomes (ROSC, conversion to
sinus rhythm, admission to hospital)
• no significant difference in survival to
discharge
24.4% v 23.7% v 21.0%
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CLINICAL BOTTOM LINE
• in OHCA patients with refractory VF/VT,
drugs give short term benefit but no
evidence of ultimate survival benefit
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6. AMIODARONE
Laina A, et al. Amiodarone and cardiac arrest: Systematic review and
meta-analysis. Int J Cardiol 2016;221:780-8.
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• Systematic review and meta-analysis
• 4 RCTs and 6 observational studies
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AMIODARONE
• significantly increases survival to hospital
admission (OR 1.40)
• no significant effect on survival to hospital
discharge (OR 0.85)
• no significant effect on good neurological
outcome (OR 1.11)
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CLINICAL BOTTOM LINE
• Amiodarone may increase survival to
hospital admission but does not improve
long term survival or function
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7. TCA
Barnard EBG et al. Epidemiology and aetiology of traumatic
cardiac arrest in England and Wales - A retrospective database
analysis. Resuscitation 2017;110:90-94.
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TRAUMATIC CARDIAC
ARREST
• 705 patients in TARN database with TCA
• 30 day survival 7.5%
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Lockey DJ et al.
Resuscitation 2013;
84(6):738-742
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TCA RECIPE
Control of external haemorrhage
Oxygenate and ventilate
Bilateral open thoracostomy
(Pelvic binder)
Rapid blood product
administration
Consider resuscitative
thoracotomy
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CLINICAL BOTTOM LINE
• TCA is survivable
• similar results to OOH medical cardiac
arrest
• protocols probably help
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8. REACT-ION TIME
Sierink JC, et al. Immediate total-body CT scanning versus
conventional imaging and selective CT scanning in patients with
severe trauma (REACT-2): a randomised controlled trial. Lancet
2016;388(10045):673-83.
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REACT 2
• 5 level 1 trauma centres in Europe
(Netherlands and Switzerland)
• RCT of pan CT versus selective CT
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REACT 2
• 1083 patients
• no difference in survival between groups
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CLINICAL BOTTOM LINE
• CT defines injury in trauma
• pan CT versus selective CT has pros and
cons
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9. FRAGILITY INDEX
Ridgeon EE et al. The fragility index in
multicenter randomised controlled critical care
trials. Crit Care Med 2016; 44(7):1278-84.
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P VALUES
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FRAGILITY INDEX
• the number of events a trial depends on
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FRAGILITY INDEX
• 56 trials identifying improvement in
mortality
• calculated fragility index
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THE GLASS JAW OF EBM
• median fragility index 2
• >40% of trials had fragility index 1
• loss to follow up > fragility index
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CLINICAL BOTTOM LINE
• trust no-one
• believe nothing
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10. LOVE THY NEIGHBOUR
Riskin AR et al. Rudeness and medical team performance.
Pediatrics 2017;139(2):e20162305.
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RUDE KID ON THE BLOCK
• 39 NICU teams involved in simulation
training
• those exposed to rudeness did worse in
diagnostic, therapeutic, procedural and
process measures
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CLINICAL BOTTOM LINE
• being rude kills people
• be nice
• look after your oppo
• smile more
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SUMMARY
• ensure oxygenation not intubation
• targeted temperature management rather than
TH
• TCA is not futile
• CT is OK in trauma patients
• be nice to each other