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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
