Friday, April 28, 2017

In-Hospital Cardiac Arrest

R.E.B.E.L. EM - Emergency Medicine Blog
R.E.B.E.L.EM - April 27, 2017
"Background: Over the past few years there has been a shift in cardiac arrest from the mantra of ABC (Airway, Breathing, Circulation) to CAB (Circulation, Airway, Breathing). There has been increased emphasis on circulation and a de-emphasis of airway management in cardiac arrest. Physiologically, this makes sense as the only two interventions in cardiac arrest that have been shown to make a difference in neurological outcomes are early, high quality CPR and defibrillation. The reason for this is increased coronary and cerebral perfusion pressure, which improve oxygenation to ischemic tissue. The less ischemic cardiomyocytes are the more likely they will convert to a perfusing rhythm. Similarly, the less ischemic neurons are, the more likely we will have a better neurologic outcome for our patients. It has been fairly well established in the peer reviewed literature that advanced airway management in the prehospital setting is associated with decreased survival with good neurologic outcome. There is considerably less literature exploring this area in in-hospital cardiac arrest...
Author Conclusion: “Among adult patients with in-hospital cardiac arrest, initiation of tracheal intubation within any given minute during the first 15 minutes of resuscitation, compared with no intubation during that minute, was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding by indication, these findings do not support early tracheal intubation for adult in-hospital cardiac arrest.”
Clinical Take Home Point: As there are currently no RCTs evaluating intubation during the first 15 minutes of an in-hospital cardiac arrest, this study may be some of the current best evidence that supports focusing on the interventions that matter most early on: High-Quality CPR and Defibrillation."