Cardiopulmonary resuscitation standards: The 1992 Dartmouth experience in review

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1 Cardiopulmonary resuscitation standards: The 1992 Dartmouth experience in review JUDITH BOEHM, RN MARK GREENBERG, MD STANLEY LIANG, EMT RAY OBAR, RN TORUNN T. RHODES, MD NORMAN YANOFSKY, MD Lebanon, New Hampshire The following information comes from the Cardiopulmonary Resuscitation Team at the Dartmouth-Hitchcock Medical Center, in Lebanon, New Hampshire. The AANA Journal is grateful to the above individuals for their expertise and willingness to share their experience with our readers. Key words: Advanced cardiac life support (ACLS) guidelines, cardiopulmonary resuscitation, outcomes, resuscitation guidelines. The Dartmouth-Hitchcock Medical Center Cardiopulmonary Resuscitation (CPR) Team handled 150 arrests in 138 patients in 1992 at the newly constructed hospital in Lebanon, New Hampshire. Given that there were 15,311 admissions during this year, the number of patients who underwent CPR represents 0.9% of the total patients admitted. In 1990, the last full year at the old and now vacated hospital, 42% of initial resuscitative efforts were successful, and 22.9% of patients were discharged home. These values for 1992 were 43% and 15.9%, respectively. The latter value, the lowest since a 14.3% discharge rate in 1984, is not statistically different (chi square P>0.10) from the 22.9% value in Interestingly, 50 published reports of in-hospital cardiac arrests during the past 30 years have demonstrated an overall discharge rate of about 15%, without notable improvement over the last three decades.' Unlike Dartmouth's statistics, some of these studies eliminated arrests in the emergency room from analysis, a group with a poor overall survival. The Dartmouth Team response time for 50 arrests examined over the last 8 months of 1992 indicated an average response time of 2.7 minutes. See Table I for demographics of the cardiopulmonary arrests. New American Heart Association Guidelines In 1992, the American Heart Association released an update of its "Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care," initially published in 1974 and updated in 1980 and The October 28, 1992 issue of the Journal of the American Medical Association was essentially devoted to these guidelines. 2 For the first time, graded recommendations for therapeutic modalities have been utilized: Class 1 (indicated, helpful), Class 2 (acceptable, of uncertain efficacy), and Class 3 (not indicated, may be harmful). Class 2 recommendations are further divided into 2A and 2B, probably helpful and possibly helpful, respectively. Although none of the previous guidelines were felt to be dangerous or to require immediate withdrawal, the use of graded recommendations and more extensive algorithms emphasizes that emergency personnel are expected to take a total view of the patient and depend more on clinical judgment and flexible decision making rather than October 1993/Vol. 61/No

2 Table I Summary of cardiopulmonary arrests-january 1, 1992 through December 31,1992 (number of arrests: 150; number of patients: 138) Percent of Patients Arrests Patient deaths arrests survived Survival by number of arrests Patient Age 0-1 month months years years years years years years years Patient sex Male Female Primary service Emergency Medicine Pediatrics Surgery Visitor Unit in which arrest occurred Critical care unit Cardiothoracic intensive care unit Dialysis Emergency department Intensive coronary care unit Intensive care nursery Intensive care unit Lobby Medical specialties/ dermatology Medicine/hematology/oncology Neuroscience Operating room Orthopedics/ urology Postanesthesia care unit Radiology Surgery Surgical specialities Journal of the American Association of Nurse Anesthetists

3 Table I (cont'd.) Percent of Patients Arrests Patient deaths arrests survived Basic life support started by Emergency medical technician Fast squad Lay person Medical doctor Registered nurse Unknown Type of arrest Asystole Bradycardia Electromechanical dissociation Respiratory Ventricular fibrillation Ventricular tachycardia CPR team called No Yes Duration of CPR 1-10 minutes minutes minutes minutes Patient outcomes Patients Arrests Number Percentage Number Percentage Deaths at resuscitation Successful resuscitations Patients discharged home Patients still in hospital Patients died subsequently ordering a drug by rote for a specific rhythm. Specifics in advanced cardiac life support are listed below: 1. The more widespread use of automated external defibrillators has been emphasized. For example LIFEPAK 9P with its shock advisory module gives the Dartmouth Team the ability to teach semiautomatic defibrillation to nurses on general hospital units. Therefore, all Dartmouth Team members should be sure they are familiar with the "hands-off" defibrillation technique. 2. Pulseless electrical activity has replaced the former algorithm for electromechanical dissociation. This algorithm emphasizes identification of possible reversible causes such as hypovolemia, tension pneumothorax, cardiac tamponade, hypothermia, drug overdose, hyperkalemia, etc. 3. The standard dose of epinephrine has been increased from mg given intravenously (IV) every 5 minutes to 1 mg every 3-5 minutes. If this approach fails, several Class 2B dosing regimens can be considered (2-5 mg IV every 3-5 minutes, escalating doses of 1 mg to 3 mg to 5 mg 3 minutes apart, and high doses of 0.1 mg/kg IV every 3-5 minutes). 4. Atropine when used for asystole has been increased from 1 mg IV with a single repeat dose in 5 minutes to a full vagal blockade dose of 1 mg every 3-5 minutes up to a total of 0.04 mg/kg. 5. Lidocaine for ventricular fibrillation is now used more aggressively (1.5 mg/kg IV repeated in 5-10 minutes to a total of 3 mg/kg IV. Previously, 1 mg/kg was administered initially with 0.5 mg/kg given every 8 minutes to the same total dose). For persistent fibrillation, other medications of probable benefit (Class 2A) include bretylium, magnesium, and procainamide. Sodium bicarbonate is generally not recommended (Class 3 for hypoxic lactic acidosis) but is considered possibly helpful and acceptable (Class 2B) for a continued long arrest once the patient has been intubated. 6. Adenosine has replaced verapamil as the October VoL 61/No

4 first drug recommended for paroxysmal supraventricular tachycardia; it is also acceptable for widecomplex tachycardia of undetermined etiology. 7. Isoproterenol has been downgraded for the therapy of symptomatic bradycardia, due mainly to its vasodilatory properties. The recommended intervention sequence is atropine, transcutaneous pacing, dopamine infusion, epinephrine infusion (2-10,ug/min) and then isoproterenol (if used at all, should be used in low doses). Previously, isoproterenol and transcutaneous pacing were both considered acceptable second choices after atropine. 8. For endotracheal drug administration, doses should be times the recommended intravenous dose. 9. If central venous access is not utilized to administer medication, it may take 1-2 minutes for drugs to reach the central circulation in an arrested patient. If drugs are given through a peripheral IV, the drugs should be given rapidly, flushed with ml, and the extremity elevated. Glucosecontaining fluids are discouraged due to the possible deleterious effects of hyperglycemia on cerebral preservation. Basic life support update Changes in the performance of basic life support which are recommended in the October 1993 issue of the Journal of the American Medical Association are as follows:-' 1. Since survival is strongly linked to early defibrillation, the first step for rescuers encountering an adult who has collapsed is to activate the emergency medical system (EMS) by dialing 911 outside of the hospital or pushing the code blue button inside the hospital. Previous guidelines called for the single rescuer to perform CPR for one minute prior to activating the EMS. The sequence for a child or infant is unchanged since most often the arrest is respiratory in nature: perform CPR for one minute, and then notify the EMS. 2. To minimize gastric distention, the inspiratory time during ventilations has been increased from seconds to seconds. The rescuer should pause after the first breath to take a breath. Thus, oxygen content is maximized and carbon dioxide concentration is minimized in the next delivered breath. 3. Rescue breathing for infants and children has been made similar: a rate of 20 breaths per minute or every 3 seconds. Again, keeping the inspiratory time slow (1-1.5 seconds) will decrease gastric distention.the ratio of compressions to ventilations during CPR remains the same at 5:1. To increase the cardiac output, the rate of compression for the child and the infant should now be at least 100 compressions per minute. 5. In the obstructed airway sequences, the regimen is simplified. Five abdominal thrusts are now called for in adults and children, and five back blows alternating with five chest thrusts in infants. What's new in pediatric and neonatal resuscitation? Below is a short outline of changes in pediatric and neonatal CPR based on recommendations of the 1992 National Conference on Cardiopulmonary Resuscitation and Emergency Medical Care held in Dallas, Texas, in February * Pediatric advanced life support 1. Vascular access. Central venous access has been deemphasized. Peripheral venous access and interosseous (10) access are considered adequate. Avoid glucose-containing fluids during cardiac arrest as it can cause hyperglycemia and worsen the neurological outcome. 2. Medications. Epinephrine remains the firstline drug for resuscitation. All endotracheal doses have been changed to 0.1 mg/kg (1:1,000). For bradycardia, the dose IV/IO remains 0.01 mg/kg (1:10,000). In cardiac arrest orpulseless arrest, the first dose is 0.01 mg/kg (1:10,000), but second and subsequent doses are 0.1 mg/kg (1:1,000). Although calcium, glucose and sodium bicarbonate have their uses, they are not considered first-line drugs. Adenosine (0.1 mg/kg IV) is considered the firstline drug for symptomatic supraventricular tachycardia. Isoproterenol is no longer recommended. 3. Trauma. A new section on advanced life support for the pediatric trauma victim has been added. It includes an illustration of two-person cervical spine stabilization and intubation. * The neonatal program 1. Preparation for delivery. Universal precautions should be taken. 2. Initial stabilization. The Trendelenburg position is no longer recommended. Suctioning should be limited to 3-5 seconds. 3. Evaluation. Evaluation should be started immediately; do not wait until after the initial steps have been taken. 4. Ventilation. Gasping is added to the indications for positive pressure ventilation. The recommended ventilation rate is increased from 40 to breaths per minute. Continue ventilation until the infant has adequate spontaneous respiration. 5. Cardiac compression. Chest compressions interposed with ventilation in a 3:1 ratio are now recommended. The preferred method is "fingers 466 Journal of the American Association of Nurse Anesthetists

5 encircling the chest" with the thumbs place on the sternum. 6. Medications. The recommended dose of epinephrine has not been changed. 7. Meconium. The recommendation for endotracheal suctioning has been changed from all meconium-stained fluid to thick or particulate meconium and/or a depressed infant. 8. Preterm infants. Discussion of high-risk preterm neonates has been integrated into the appropriate sections in the next version of the ACLS textbook. High-dose epinephrine During the past several years there has been considerable interest in the use of high-dose epinephrine in cardiac arrest. This interest was initially sparked by animal studies which showed increased survival using doses of epinephrine 5-10 times greater than those usually employed in resuscitation attempts. This was further supported by some early studies showing an increased return of pulse and circulation in patients receiving highdose epinephrine, as well as some anecdotal reports of patients recovering from prolonged cardiac arrest only after receiving high-dose epinephrine when all other interventions had failed. More than 2 years ago, an observational study was begun at Dartmouth-Hitchcock Medical Center which looked at the effect on outcome of using high-dose epinephrine. (Following the initial standard dose, all subsequent doses would be 5 mg at a time.) The data shows no evidence for increased survival for patients who received high-dose epinephrine. In addition, two large multi-institutional studies were published in the New England Journal of Medicine, both of which showed no benefit for high-dose epinephrine in adult cardiac arrest victims. 3 ' 4 There is one small study which suggests some benefit in the pediatric patient who may respond differently to high-dose epinephrine compared to the adult. 5 The latest American Heart Association guidelines recommend the use of standard dose epinephrine (1 mg) every 3-5 minutes during the resuscitation attempt. 2 High-dose epinephrine is considered acceptable and possibly helpful but is not part of the standard algorithm. Psychological aspects of resuscitation The revised CPR guidelines place more emphasis on the psychological aspects of resuscitation. Below are some thoughts which emerge from those guidelines. * Telling the family. A local ambulance calls the triage nurse in a busy emergency department to report that a patient in cardiac arrest is enroute. After all attempts at resuscitating the patient have been unsuccessful, the CPR Team decides to stop. Telling family members and/or friends about the death of a loved one is very difficult. Meet with the family in a quiet and private room. Having clergy or social workers present with the family can be helpful. Introduce yourself to the family and maintain good eye contact with them while talking. Briefly describe to them the resuscitation attempt and inform them of the death-use the word death or died. After the initial shock, allow as much time as necessary for questions and discussion. To facilitate the grief reaction, allow the family to view their loved one, encouraging them to spend as much time as necessary. * Helping the helpers. Being aware of the needs of the grieving person can help to facilitate the grieving process. But what about the needs of the staff after an unsuccessful resuscitation? Often, there are feelings of failure and inadequacy. An important intervention is a debriefing of the event. The debriefing should be held as soon as possible after the event. Bring the group together and review the events. The CPR Team members should be allowed to freely discuss the event. The group should be asked for recommendations or suggestions for future resuscitative attempts. All team members should be allowed to share their feelings, anxieties, and anger. The group leader should encourage team members to contact him/her if questions arise later. Addressing the psychological issues associated with sudden death is important to both families and the medical workers. The knowledge of these issues and using appropriate interventions will greatly enable families and professionals to work through the grieving process. REFERENCES (1) Jastremski MS. In-hospital cardiac arrest. Ann Emerg Med. 1993;22: (2) Guidelines for cardiopulmonary resuscitation and emergency cardiac care. JAMA. 1993;268: (3) Stiell IG, Hebert PC, Weitzman BN, ct al. High-dose epinephrine in adult cardiac arrest. NEngl Med. 1992;327: (4) Brown CG, Martin DR, Pepe PE, et al. A comparison of standarddose and high-dose epinephrine in cardiac arrest outside the hospital. The Multicenter High-Dose Epinephrine Study Group. N Engli] Med. 1992;327: (5) Goetting MG, Paradis NA. High-dose epinephrine improves outcomes from pediatric cardiac arrest. Ann Emerg Med ;20: AUTHORS The authors of this article are members of the D)artmouth- Hitchcock Medical Center's CPR Team and represent a variety of disciplines. October 1993/ Vol. 61/No

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