Best practices in resuscitation – interim updates for 5-Year ILCOR recommendations
Over the past decade, resuscitation has become one of the fastest growing areas in emergency medical care. The drivers for growth include portable, remote monitoring equipment as well as real time video-consultation. The focus of attention is on cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC), and includes all responses to sudden life-threatening events impacting on the cardiovascular and respiratory system.
Local practices continue to drive growth of best practice in resuscitation. However, there is also substantial cooperation at the global level. The International Liaison Committee on Resuscitation (ILCOR) was founded in 1993 and currently includes representatives from the American Heart Association, the Heart and Stroke Foundation of Canada, the European Resuscitation Council, the Australian and New Zealand Committee on Resuscitation, the Resuscitation Council of Asia, the Resuscitation Council of Southern Africa and the InterAmerican Heart Foundation.
ILCOR members seek to both optimize and minimize international differences in resuscitation practices, but also leave space for geographic, economic, and other real-world differences in practice and the availability of medical devices and drugs.
In 1999, the American Heart Association (AHA) hosted the first ILCOR conference to evaluate best practices and chart resuscitation guidelines. The ILCOR recommendations, formally known as International Consensus on CPR and ECC Science With Treatment Recommendations (CoSTR), were published in 2000. Over the years, ILCOR task forces have evaluated and published CoSTR recommendations in 5-year cycles.
The most recent ILCOR Consensus Conference was held in Dallas in February 2015, and attended by over 230 participants from some 40 countries. Almost two-thirds of participants came from outside the US – giving weight to ILCOR’s position as a global group. The Conference focused, as before, on CPR and ECC, but also covered first aid topics.
One good recent example of the pace of evolution in resuscitation practices is ILCOR’s observation that five years (the task force recommendation cycle) was far too long a period to inform healthcare professionals of therapeutic advances in the field. As a result, it plans to systematically review new science and publish interim advisories on treatment guidelines. The aim is to give resuscitation practitioners access to providing state-of-the-art patient care.
ILCOR’s 2015 CoSTR consensus statements summarize the results of task forces in several areas:
BLS or basic life support (covers quality of CPR and the use of an automated external defibrillator), ALS or advanced life support (post-cardiac arrest care), ACS or acute coronary syndromes, along with education, implementation and teams (EIT), and, for the first time, first aid.
Although dedicated specific task forces cover pediatric BLS and ALS as well as neonatal resuscitation, this review of the 2015 ILCOR guidelines is restricted to adults.
ILCOR task forces perform detailed systematic reviews, evaluate evidence and make recommendations. Task forces identify and prioritize questions using the PICO (population, intervention, comparator, outcome) format, accompanied by a call for public comments. This is followed by a search (with detailed inclusion/exclusion and screening) of relevant articles in three major online databases (PubMed, Embase and the Cochrane Library).
The quality of evidence is tabulated as high, moderate, low, or very low, based on five core domains of risk of bias, inconsistency, indirectness, imprecision, and publication bias (and occasionally other considerations). Together, they follow the so-called GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology for drafting guidelines.
The final wording ranges from ‘we suggest…’ for weak recommendations to ‘we recommend…’ for the strong ones… .’
One of ILCOR’s major goals is continuously-updated and high-quality research into CPR and ECC. An online platform known as SEERS (Scientific Evaluation and Evidence Review System) guides task forces and their individual reviewers, as well as public comments and suggestions. (https://volunteer.heart.org/apps/pico/Pages/default.aspx).
On the other hand, ILCOR also avoids giving attention to areas where there is little development in technology or evidence on practices.
Developments in resuscitation (2010-2015)
The 2015 CoSTR notes that post-OHCA (out-of-hospital cardiac arrest) survival rates are rising, especially when the first monitored rhythm is shockable’ – that is, associated with ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT). However, survival rates from non-shockable rhythms are also improving. These developments directly correlate with an increased emphasis on improving basic life support (BLS) and advanced life support (ALS).
Given below is a summary of evidence-based recommendations by ILCOR task forces, covering developments since 2010.
Basic life support
EMS dispatchers play the critical role in identifying cardiac arrest, providing CPR instructions to the caller, and activating emergency response. In drowning, it appears that submersion time is a key prognostic factor for outcomes. However, fundamental metrics of high-quality CPR remain the same, with an emphasis on compressions of adequate rate and depth, allowing full chest recoil after each compression, minimizing pauses in compressions, and avoiding excessive ventilation. It is also noted that public access programmes which provide early defibrillation can save many more lives if the programmes are carefully planned and coordinated.
Advanced life support
Post-cardiac arrest care is probably the resuscitation segment undergoing the greatest evolution since 2010, with substantial potential to improve survival from cardiac arrest.
Key recent developments in ALS include results from three major trials on mechanical CPR devices, drug therapy, and insertion of advanced airway devices. In addition, the ALS task force evaluated several studies regarding post-cardiac arrest care and the use of targeted temperature management (TTM).
. Mechanical devices
The three mechanical compression device trials enrolled over 7,500 patients. However, it yielded outcomes similar to those from manual compressions. ILCOR concludes that mechanical CPR devices should not be seen as replacements, but may play a role in conditions where high-quality manual compressions are not feasible.
. Drug therapy
The 2010 CoSTR had pointed to insufficient evidence about drug administration improving survival from cardiac arrest. In 2015, a systematic review identified large observational studies that also challenged routine use of advanced airways and the use of epinephrine for ALS. Since observational studies are known to carry a risk of bias, the findings did not result in a recommendation to change practice. However, they do indicate a need for large randomized controlled trials to assess whether epinephrine and advanced airways are helpful during CPR.
. Targeted Temperature Management
Recent developments in ALS also include greater delineation of the timing and effects of TTM and the need to take account of controlling oxygenation/ventilation and optimizing cardiovascular function. Nevertheless, one high quality TTM trial could not demonstrate an advantage to a temperature goal of either 33C or 36C, while five other trials failed to identify benefits from pre-hospital hypothermia initiation via cold intravenous fluids. Though none of the trials dispelled with the view that post-cardiac arrest patients need a care plan taking account of TTM, there is still little consensus about optimal target temperature and its duration.
Acute coronary syndromes
There are several evidence-based recommendations for ACS since 2010.
. Catheterization, ADP and UFH, troponins
Firstly, pre-hospital ST-segment elevation myocardial infarction (STEMI) activation of a catheterization laboratory treatment delays and improves outcomes.
Secondly, adenosine diphosphate (ADP) receptor antagonists, along with unfractionated heparin (UFH) can be part of a planned percutaneous coronary intervention (PCI) approach and be administered either pre-hospital or in-hospital for suspected STEMI patients. In the pre-hospital setting, enoxaparin is an alternative to UFH. This is not the case with bivalirudin, for which there is insufficient evidence.
Thirdly, the 2015 CoSTR discourages the use of troponins at zero and 2 hours as a standalone measure to exclude ACS diagnosis. Instead, it suggests that negative high-sensitivity troponin I (hs-cTnI) at zero and 2 hours may be used together with low-risk stratification or negative cardiac troponin I (cTnI) or cardiac troponin T (cTnT) measured at zero and 3-6 hours to identify patients at low risk of a major adverse high-sensitivity cardiac troponin I (hs-cTnI) cardiac event (MACE).
. PCI and STEMI
ILCOR’s 2015 CoSTR also has several comments on PCI and STEMI. Its find primary PCI to be generally preferable to fibrinolysis for STEMI reperfusion. However, such decisions must be individualized’ based on time from symptom onset, anticipated delay to PCI, relative contraindications to fibrinolysis, and other patient factors.
Patients with STEMI in the emergency department (ED) of a non-PCI-capable hospital should either be transported rapidly for primary PCI (without fibrinolysis) or be administered fibrinolysis and transported for routine angiography in the first 3-6 hours.
Education, implementation, and teams
One of the most noteworthy areas of attention by ILCOR since 2010 concerns training and continuous quality improvement.
ILCOR states that, although more evidence is needed, it is ‘now recognized’ that training should be more frequent and less time consuming to prevent skill degradation. On the other hand, retraining cycles of 1-2 years are inadequate to maintain competence in resuscitation skills. Though ‘optimal retraining intervals’ remain to be defined, it is clear that more frequent training may help providers likely to encounter a cardiac arrest.
ILCOR also suggests replacing standard manikins with high-fidelity manikins at training centres with the infrastructure and resources to maintain the programme.
Performance and quality metrics, social media
Another challenge is that though the role of performance measurement and feedback in cardiac arrest response systems (both in-hospital and out-of-hospital) is recognized, supporting data is of low quality. Closely coupled to improvements in the performance of resuscitation teams is the need for data-driven, performance-focused debriefing.
Finally, ILCOR also notes the rapidly-growing role of social media for notifying suspected OHCA to hospitals and for sourcing bystanders with CPR skills.
The First Aid Task Force considered stroke assessment, hypoglycemia treatment in diabetics, as well as treatment of open chest wounds and severe bleeding and the identification of concussion.
. Stroke assessment
Observers consider one of the most important recommendations from the First Aid task force is to use stroke assessment systems to improve early identification of possible stroke and enable subsequent referral for definitive treatment. Specific recommendations are made on the FAST (Face, Arm, Speech, Time) tool as well as the Cincinnati Prehospital Stroke Scale, alongside an important observation, that blood glucose measurement could improve the specificity of recognition.
ILCOR’s 2015 CoSTR observes that first aid providers often face symptoms of hypoglycemia, and a failure to identify and treat it can lead to loss of consciousness and seizures. It recommends administration of glucose tablets for conscious individuals who can swallow, or substitute forms of dietary sugars should glucose tablets not be immediately available.
. Open chest wounds, bleeding, concussion
The 2015 CoSTR recommends that occlusive dressings or devices, or those which might become occlusive, be avoided in the case of open chest wounds in order to avoid engendering a tension pneumothorax.
Recommendations for severe bleeding include using direct pressure, hemostatic dressings and tourniquets – after formal training to ensure effective application and use.
The 2015 First Aid Task Force also recommends developing a simple validated concussion scoring system to accurately identify and manage concussion (minor traumatic brain injury or TBI), which is a condition often encountered by prehospital first-aid providers.