Jason Smith Royal College of Emergency Medicine Professor · to admission (OR 3.6; 2.2 –5.9) •...

TOP 10 PAPERS ON RESUSCITATION

Jason Smith

Consultant in Emergency Medicine, Plymouth, UK

Royal College of Emergency Medicine Professor

2016

2017

THE AVERAGE SHIFT..

1. NO RHYME NOR REASON

Gaspari R et al. Emergency department point-of-care ultrasound in out-of-

hospital and in-ED cardiac arrest. Resuscitation 2016;109:33-39.

REASON TRIAL

• 20 sites in US and Canada

• prospective observational study

• 793 patients in OH cardiac arrest (PEA or

asystole)

• ROSC, survival to admission (primary outcome)

and survival to discharge

REASON TRIAL

• Cardiac activity associated with increased survival

to admission (OR 3.6; 2.2 – 5.9)

• Cardiac activity associated with increased survival

to hospital discharge (OR 5.7; 1.5 – 21.9)

• Overall survival to discharge = 1.5%

• 3 patients with no cardiac activity on US

SURVIVED

CLINICAL BOTTOM LINE

• Patients more likely to survive if cardiac

activity on US

• Clinical decision making still necessary

• Even if no movement on ultrasound,

some patients survive

2. HOW ABOUT INTUBATION?

Andersen LW, et al. Association Between Tracheal Intubation During

Adult In-Hospital Cardiac Arrest and Survival. JAMA 2017;317(5):494-

506.

GET WITH THE GUIDELINES

REGISTRY STUDY

• 86,628 adult in-hospital cardiac arrests

• 15 year propensity matched cohort study

using registry data

GET WITH THE GUIDELINES

REGISTRY STUDY

• tracheal intubation associated with

significantly worse outcome

• survival to hospital discharge 16.3%

(intubated) vs 19.4% (not intubated)

• worse neurological outcome when intubated

CLINICAL BOTTOM LINE

• This study does not support the practice

of intubation for patients sustaining in-

hospital cardiac arrest

PRE-HOSPITAL

INTUBATION?

AIRWAYS-2

3. COOL AND THE GANG

Chan PS, et al. Association Between Therapeutic Hypothermia and

Survival After In-Hospital Cardiac Arrest. JAMA 2016;316(13):1375-

1382.

TH - GWTG-R REGISTRY

• 26,183 patients with in-hospital cardiac

arrest

• 6% received TH

• propensity matched cohort study

TH

• TH-treated patients had lower rates of hospital

survival (27.4% vs 29.2%)

• TH-treated patients had less favourable

neurological recovery (17.0% vs 20.5%)

• TH was associated with worse outcomes

regardless of whether the initial rhythm was

shockable or non-shockable

4. THE BLUE RINSE

Bernard SA, et al. Induction of Therapeutic Hypothermia During Out-of-

Hospital Cardiac Arrest Using a Rapid Infusion of Cold Saline: The RINSE

Trial (Rapid Infusion of Cold Normal Saline). Circulation 2016;134(11):797-

805.

RINSE

• prospective randomised controlled trial

• adults with OHCA

• infusion of 2 litres cold saline or standard

care

RINSE

• 1198 patients - 618 randomised to

hypothermia

• survival to hospital discharge worse in the

cooling group (10.2% vs 11.4%; p=0.71)

• ROSC in 41.2% cooling vs 50.6% standard

care; p=0.03

CLINICAL BOTTOM LINE

• Therapeutic hypothermia might not be

the best thing for your patients with

ROSC after cardiac arrest

• Avoid hyperthermia - is TTM the answer?

5. DRUGS IN CARDIAC ARREST

Kudenchuk PJ, et al. Amiodarone, Lidocaine, or Placebo in Out-of-

Hospital Cardiac Arrest. N Engl J Med 2016;375(8):802-3.

ALPS

• randomised, double-blind multicentre trial

• IV amiodarone, lidocaine, or saline (placebo) in

adults with non-traumatic OHCA

• shock refractory VF or pulseless VT

• amiodarone 300 mg v lidocaine 120mg v

placebo

ALPS

• 3026 patients

• amiodarone and lidocaine showed better

short term outcomes (ROSC, conversion to

sinus rhythm, admission to hospital)

• no significant difference in survival to

discharge

24.4% v 23.7% v 21.0%

CLINICAL BOTTOM LINE

• in OHCA patients with refractory VF/VT,

drugs give short term benefit but no

evidence of ultimate survival benefit

6. AMIODARONE

Laina A, et al. Amiodarone and cardiac arrest: Systematic review and

meta-analysis. Int J Cardiol 2016;221:780-8.

• Systematic review and meta-analysis

• 4 RCTs and 6 observational studies

AMIODARONE

• significantly increases survival to hospital

admission (OR 1.40)

• no significant effect on survival to hospital

discharge (OR 0.85)

• no significant effect on good neurological

outcome (OR 1.11)

CLINICAL BOTTOM LINE

• Amiodarone may increase survival to

hospital admission but does not improve

long term survival or function

7. TCA

Barnard EBG et al. Epidemiology and aetiology of traumatic

cardiac arrest in England and Wales - A retrospective database

analysis. Resuscitation 2017;110:90-94.

TRAUMATIC CARDIAC

ARREST

• 705 patients in TARN database with TCA

• 30 day survival 7.5%

Lockey DJ et al.

Resuscitation 2013;

84(6):738-742

TCA RECIPE

Control of external haemorrhage

Oxygenate and ventilate

Bilateral open thoracostomy

(Pelvic binder)

Rapid blood product

administration

Consider resuscitative

thoracotomy

CLINICAL BOTTOM LINE

• TCA is survivable

• similar results to OOH medical cardiac

arrest

• protocols probably help

8. REACT-ION TIME

Sierink JC, et al. Immediate total-body CT scanning versus

conventional imaging and selective CT scanning in patients with

severe trauma (REACT-2): a randomised controlled trial. Lancet

2016;388(10045):673-83.

REACT 2

• 5 level 1 trauma centres in Europe

(Netherlands and Switzerland)

• RCT of pan CT versus selective CT

REACT 2

• 1083 patients

• no difference in survival between groups

CLINICAL BOTTOM LINE

• CT defines injury in trauma

• pan CT versus selective CT has pros and

cons

9. FRAGILITY INDEX

Ridgeon EE et al. The fragility index in

multicenter randomised controlled critical care

trials. Crit Care Med 2016; 44(7):1278-84.

P VALUES

FRAGILITY INDEX

• the number of events a trial depends on

FRAGILITY INDEX

• 56 trials identifying improvement in

mortality

• calculated fragility index

THE GLASS JAW OF EBM

• median fragility index 2

• >40% of trials had fragility index 1

• loss to follow up > fragility index

CLINICAL BOTTOM LINE

• trust no-one

• believe nothing

10. LOVE THY NEIGHBOUR

Riskin AR et al. Rudeness and medical team performance.

Pediatrics 2017;139(2):e20162305.

RUDE KID ON THE BLOCK

• 39 NICU teams involved in simulation

training

• those exposed to rudeness did worse in

diagnostic, therapeutic, procedural and

process measures

CLINICAL BOTTOM LINE

• being rude kills people

• be nice

• look after your oppo

• smile more

SUMMARY

• ensure oxygenation not intubation

• targeted temperature management rather than

TH

• TCA is not futile

• CT is OK in trauma patients

• be nice to each other

TOP 10 PAPERS ON RESUSCITATION

jasonesmith@nhs.net

@DefProfEM