Thursday, September 23, 2010

More on the new CPR (CCR) from the 36th Annual Tutorials in the Tetons Update in Cardiovascular Disease

I'm usually a strong advocate for guideline based care. Almost all the studies I've examined on the effects of guideline adherence show outcomes to be improved. There's one notable exception: the AHA guidelines for CPR and emergency cardiac care. Dr. Ewy spoke at the 2010 Tutorials on this topic and I mentioned his talk briefly here.

Many folks are familiar with Ewy's recommendations for chest compression only bystander CPR which has been more widely adopted since publication of the AHA Science Advisory allowing it as an option for out of hospital cardiac arrest.

Less well known, and thus far adopted in portions of only three states, is Ewy's protocol for ACLS. This paper in Current Opinion in Cardiology summarizes the protocol. It applies to adult patients with out of hospital cardiac arrest (not pediatric or suspected respiratory arrest) who are believed to be in the circulatory phase (down for greater than 5 minutes). It features no rescue breathing, intubation delayed until at least three CPR cycles and use of the AED only after 200 compressions.

The protocol has yielded rates of survival to hospital discharge of almost 40%. Rates for patients treated according to the 2005 guidelines have been much lower, on the order of 20-25%. Using statistics on the number of out of hospital cardiac arrests in the US and the improved survival rates using his protocol Dr. Ewy did a little math and estimated that 63,000 lives could be saved each year in America by implementing the changes.

Ewy briefly mentioned post resuscitation care, specifically the post resuscitation bundle which includes therapeutic hypothermia and early cardiac catheterization (within 24 hours), even during coma while the patient is being cooled and even in patients lacking classic electrocardiographic findings of STEMI. In some communities fire departments are diverting codes to hospitals that employ the bundle even when it involves some delay in getting them there.

So what do the new protocols mean for the hospitalist? In-hospital arrests are different and Ewy's protocol changes may not be as applicable. First, many in-hospital arrests, at least those in the ER and the ICU, can be treated in the electrical phase (first 5 minutes) during which time prompt defibrillation remains paramount, just as recommended in the guidelines. Second, the epidemiology of arrests in the hospital is different, with more codes being respiratory codes, in which Ewy's protocol does not apply.

The new ACLS guidelines are due out very soon. What will they look like? It's hard to say, although historically they have stayed years behind the best resuscitation science.

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