Tuesday, December 28, 2010

What's new in CPR and emergency cardiac care in 2010 and what does it mean for hospital systems of care?

St. Louis City Hospital

New ACLS guidelines came out last fall. I posted a brief discussion with links to the original document here. For the management of cardiac arrest the guideline changes fell short and remain years behind the best resuscitation science. Welcome changes, though, came in the recommendations for post resuscitation care and stroke care.

In the past, new ACLS guidelines merely meant more material for providers to learn. Not so in 2010. Now, for the first time, ACLS guidelines mean major system changes for hospitals.

A post resuscitation bundle to include applied hypothermia and urgent PCI in many patients is now a class I recommendation:

A comprehensive, structured, multidisciplinary system of care should be implemented in a consistent manner for the treatment of post–cardiac arrest patients (Class I, LOE B). Programs should include as part of structured interventions therapeutic hypothermia; optimization of hemodynamics and gas exchange; immediate coronary reperfusion when indicated for restoration of coronary blood flow with percutaneous coronary intervention (PCI); glycemic control; and neurological diagnosis, management, and prognostication.

Neurological prognostication following return of spontaneous circulation (ROSC) has been turned upside down in the hypothermia era. Traditional clinical rules apply for patients not treated with hypothermia. For those patients treated with hypothermia all bets are off, and here's the new class I recommendation:

There is a paucity of data about the utility of physical examination, EEG, and evoked potentials in patients who have been treated with induced hypothermia. Physical examination (motor response, pupillary light and corneal reflexes), EEG, SSEP, and imaging studies are less reliable for predicting poor outcome in patients treated with hypothermia. Durations of observation greater than 72 hours after ROSC should be considered before predicting poor outcome in patients treated with hypothermia (Class I, Level C).

Part 9 of the new guidelines is a useful reference on many aspects of post resuscitation management.

The section on stroke care (part 11 of the guidelines) also calls for system changes. Transport of stroke patients to a designated center and admission to a stroke unit are class I recommendations.

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