ERC Guidelines for resuscitation 2010

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Journal: Resuscitation

European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary

Jerry P. Nolan, Jasmeet Soar, David A. Zideman, Dominique Biarent, Leo L. Bossaert, Charles Deakin, Rudolph W. Koster, Jonathan Wyllie, Bernd Böttiger, on behalf of the ERC Guidelines Writing Group 1 .

Published online 19 October 2010, pages 1219 - 1276

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References

Label Authors Title Source Year
1

References in context

  • The publication of these European Resuscitation Council (ERC) Guidelines for cardiopulmonary resuscitation (CPR) updates those that were published in 2005 and maintains the established 5-yearly cycle of guideline changes.1 Like the previous guidelines, these 2010 guidelines are based on the most recent International Consensus on CPR Science with Treatment Recommendations (CoSTR),2 which incorporated the results of systematic reviews of a wide range of topics relating to CPR.
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J. Nolan. European Resuscitation Council Guidelines for resuscitation 2005. Section 1. Introduction. Resuscitation 67 (Suppl. 1) (2005) (S3 - S6) 2005
2

References in context

  • The publication of these European Resuscitation Council (ERC) Guidelines for cardiopulmonary resuscitation (CPR) updates those that were published in 2005 and maintains the established 5-yearly cycle of guideline changes.1 Like the previous guidelines, these 2010 guidelines are based on the most recent International Consensus on CPR Science with Treatment Recommendations (CoSTR),2 which incorporated the results of systematic reviews of a wide range of topics relating to CPR.
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  • The International Liaison Committee on Resuscitation (ILCOR) includes representatives from the American Heart Association (AHA), the European Resuscitation Council (ERC), the Heart and Stroke Foundation of Canada (HSFC), the Australian and New Zealand Committee on Resuscitation (ANZCOR), Resuscitation Council of Southern Africa (RCSA), the Inter-American Heart Foundation (IAHF), and the Resuscitation Council of Asia (RCA).
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  • During the 3 years leading up to this conference, 356 worksheet authors reviewed thousands of relevant, peer-reviewed publications to address 277 specific resuscitation questions, each in standard PICO (Population, Intervention, Comparison Outcome) format.2 Each science statement summarised the experts’ interpretation of all relevant data on a specific topic and consensus draft treatment recommendations were added by the relevant ILCOR task force.
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  • During the 3 years leading up to this conference, 356 worksheet authors reviewed thousands of relevant, peer-reviewed publications to address 277 specific resuscitation questions, each in standard PICO (Population, Intervention, Comparison Outcome) format.2 Each science statement summarised the experts’ interpretation of all relevant data on a specific topic and consensus draft treatment recommendations were added by the relevant ILCOR task force.
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Nolan JP, Hazinski MF, Billi JE, et al. International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 1. Executive Summary. Resuscitation; doi:10.1016/j.resuscitation.2010.08.002 , in press.
3

References in context

  • The publication of these European Resuscitation Council (ERC) Guidelines for cardiopulmonary resuscitation (CPR) updates those that were published in 2005 and maintains the established 5-yearly cycle of guideline changes.1 Like the previous guidelines, these 2010 guidelines are based on the most recent International Consensus on CPR Science with Treatment Recommendations (CoSTR),2 which incorporated the results of systematic reviews of a wide range of topics relating to CPR.
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  • The actions linking the victim of sudden cardiac arrest with survival are called the Chain of Survival (Fig. 1.1).
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  • The post-cardiac arrest syndrome, which comprises post-cardiac arrest brain injury, post-cardiac arrest myocardial dysfunction, the systemic ischaemia/reperfusion response, and the persistent precipitating pathology, often complicates the post-resuscitation phase.3 The severity of this syndrome will vary with the duration and cause of cardiac arrest.
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J.P. Nolan, R.W. Neumar, C. Adrie, et al.. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation 79 (2008) (350 - 379) 2008
4

References in context

 R.W. Koster, M.A. Baubin, A. Caballero, et al.. European Resuscitation Council Guidelines for Resuscitation 2010. Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation 81 (2010) (1277 - 1292) 2010
5

References in context

 C.D. Deakin, J.P. Nolan, K. Sunde, R.W. Koster. European Resuscitation Council Guidelines for Resuscitation 2010. Section 3. Electrical therapies: automated external defibrillators, defibrillation, cardioversion and pacing. Resuscitation 81 (2010) (1293 - 1304) 2010
6

References in context


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  • The actions linking the victim of sudden cardiac arrest with survival are called the Chain of Survival (Fig. 1.1).
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  • When defibrillation is warranted, give a single shock and resume chest compressions immediately following the shock.
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  • Consider pacing in patients with symptomatic bradycardia refractory to anti-cholinergic drugs or other second line therapy (see Advanced life support).6 Immediate pacing is indicated especially when the block is at or below the His-Purkinje level.
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  • Treat life-threatening tachyarrhythmias with cardioversion according to the peri-arrest arrhythmia guidelines (see Advanced life support).6 This includes correction of electrolyte and acid-base abnormalities.
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C.D. Deakin, J.P. Nolan, J. Soar, et al.. European Resuscitation Council Guidelines for Resuscitation 2010. Section 4. Adult advanced life support. Resuscitation 81 (2010) (1305 - 1352) 2010
7

References in context

 H.R. Arntz, L. Bossaert, N. Danchin, N. Nikolaou. European Resuscitation Council Guidelines for Resuscitation 2010. Section 5. Initial management of acute coronary syndromes. Resuscitation 81 (2010) (1353 - 1363) 2010
8

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  • For children, rescuers should be encouraged to use whichever adult sequence they have been taught, as outcome is worse if they do nothing.
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D. Biarent, R. Bingham, C. Eich, et al.. European Resuscitation Council Guidelines for Resuscitation 2010. Section 6. Paediatric life support. Resuscitation 81 (2010) (1364 - 1387) 2010
9

References in context

 J. Wyllie, S. Richmond. European Resuscitation Council Guidelines for Resuscitation 2010. Section 7. Resuscitation of babies at birth. Resuscitation 81 (2010) (1388 - 1398) 2010
10

References in context


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  • If VF/VT occurs during cardiac catheterisation or in the early post-operative period following cardiac surgery (when chest compressions could disrupt vascular sutures), consider delivering up to three-stacked shocks before starting chest compressions (see Special circumstances).10 This three-shock strategy may also be considered for an initial, witnessed VF/VT cardiac arrest if the patient is already connected to a manual defibrillator.
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  • Potential causes or aggravating factors for which specific treatment exists must be considered during any cardiac arrest.
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  • The World Health Organisation (WHO) estimates that, worldwide, drowning accounts for approximately 450,000 deaths each year and drowning is a common cause of accidental death in Europe.
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  • The patient with severe asthma requires aggressive medical management to prevent deterioration.
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J. Soar, G.D. Perkins, G. Abbas, et al.. European Resuscitation Council Guidelines for Resuscitation 2010. Section 8. Cardiac arrest in special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 81 (2010) (1399 - 1431) 2010
11

References in context

 J. Soar, K.G. Monsieurs, J. Ballance, et al.. European Resuscitation Council Guidelines for Resuscitation. Section 9. Principles of education in resuscitation. Resuscitation 81 (2010) (1432 - 1442) 2010
12

References in context

 F.K. Lippert, V. Raffay, M. Georgiou, P.A. Steen, L. Bossaert. European Resuscitation Council Guidelines for Resuscitation 2010. Section 10. The ethics of resuscitation and end-of-life decisions. Resuscitation 81 (2010) (1443 - 1449) 2010
13

References in context

  • In many situations however, standard CPR (which includes ventilation/rescuer breathing) is better, for example in children,84 asphyxial arrests, and when bystander CPR is required for more than a few minutes.13 A simplified, education-based approach is therefore suggested:•Ideally, full CPR skills (compressions and ventilation using a 30:2 ratio) should be taught to all citizens.
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Koster RW, Sayre MR, Botha M, et al. International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 5. Adult basic life support. Resuscitation; doi:10.1016/j.resuscitation.2010.08.005 , in press.
14

References in context

  • There is limited evidence from case reports of unexpected ROSC in patients with suspected gas trapping when the tracheal tube is disconnected.613–617 If dynamic hyperinflation of the lungs is suspected during CPR, compression of the chest wall and/or a period of apnoea (disconnection from the tracheal tube) may relieve gas trapping if dynamic hyperinflation occurs.
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Sunde K, Jacobs I, Deakin CD, et al. International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 6. Defibrillation. Resuscitation; doi:10.1016/j.resuscitation.2010.08.025 , in press.
15

References in context

  • Many imaging modalities (magnetic resonance imaging [MRI], computed tomography [CT], single photon emission computed tomography [SPECT], cerebral angiography, transcranial Doppler, nuclear medicine, near infra-red spectroscopy [NIRS]) have been studied to determine their utility for prediction of outcome in adult cardiac arrest survivors.15 There are no high-level studies that support the use of any imaging modality to predict outcome of comatose cardiac arrest survivors.
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  • There is limited evidence from case reports of unexpected ROSC in patients with suspected gas trapping when the tracheal tube is disconnected.613–617 If dynamic hyperinflation of the lungs is suspected during CPR, compression of the chest wall and/or a period of apnoea (disconnection from the tracheal tube) may relieve gas trapping if dynamic hyperinflation occurs.
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Deakin CD, Morrison LJ, Morley PT, et al. International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 8. Advanced life support. Resuscitation; doi:10.1016/j.resuscitation.2010.08.027 , in press.
16
Bossaert L, O’Connor RE, Arntz H-R, et al. International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 9. Acute coronary syndromes. Resuscitation; doi:10.1016/j.resuscitation.2010.09.001 , in press.
17
de Caen AR, Kleinman ME, Chameides L, et al. International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 10. Pediatric basic and advanced life support. Resuscitation; doi:10.1016/j.resuscitation.2010.08.028 , in press.
18
Wyllie J, Perlman JM, Kattwinkel J, et al. International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 11. Neonatal resuscitation. Resuscitation; doi:10.1016/j.resuscitation.2010.08.029 , in press.
19

References in context

  • The key issues identified by the Education, Implementation and Teams (EIT) task force of ILCOR during the Guidelines 2010 evidence evaluation process are19:•Educational interventions should be evaluated to ensure that they reliably achieve the learning objectives.
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  • Ideally all citizens should have some knowledge of CPR.
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Soar J, Mancini ME, Bhanji F, et al. International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 12. Education, implementation, and teams. Resuscitation; doi:10.1016/j.resuscitation.2010.08.030 , in press.
20

References in context

  • Ischaemic heart disease is the leading cause of death in the world.20 In Europe, cardiovascular disease accounts for around 40% of all deaths under the age of 75 years.21 Sudden cardiac arrest is responsible for more than 60% of adult deaths from coronary heart disease.22 Summary data from 37 communities in Europe indicate that the annual incidence of EMS-treated out-of-hospital cardiopulmonary arrests (OHCAs) for all rhythms is 38 per 100,000 population.22a Based on these data, the annual incidence of EMS-treated ventricular fibrillation (VF) arrest is 17 per 100,000 and survival to hospital discharge is 10.7% for all-rhythm and 21.2% for VF cardiac arrest.
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C.J. Murray, A.D. Lopez. Mortality by cause for eight regions of the world: global burden of disease study. Lancet 349 (1997) (1269 - 1276) 1997
21

References in context

  • Ischaemic heart disease is the leading cause of death in the world.20 In Europe, cardiovascular disease accounts for around 40% of all deaths under the age of 75 years.21 Sudden cardiac arrest is responsible for more than 60% of adult deaths from coronary heart disease.22 Summary data from 37 communities in Europe indicate that the annual incidence of EMS-treated out-of-hospital cardiopulmonary arrests (OHCAs) for all rhythms is 38 per 100,000 population.22a Based on these data, the annual incidence of EMS-treated ventricular fibrillation (VF) arrest is 17 per 100,000 and survival to hospital discharge is 10.7% for all-rhythm and 21.2% for VF cardiac arrest.
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S. Sans, H. Kesteloot, D. Kromhout. The burden of cardiovascular diseases mortality in Europe. Task force of the European Society of Cardiology on cardiovascular mortality and morbidity statistics in Europe. Eur Heart J 18 (1997) (1231 - 1248) 1997
22

References in context

  • Ischaemic heart disease is the leading cause of death in the world.20 In Europe, cardiovascular disease accounts for around 40% of all deaths under the age of 75 years.21 Sudden cardiac arrest is responsible for more than 60% of adult deaths from coronary heart disease.22 Summary data from 37 communities in Europe indicate that the annual incidence of EMS-treated out-of-hospital cardiopulmonary arrests (OHCAs) for all rhythms is 38 per 100,000 population.22a Based on these data, the annual incidence of EMS-treated ventricular fibrillation (VF) arrest is 17 per 100,000 and survival to hospital discharge is 10.7% for all-rhythm and 21.2% for VF cardiac arrest.
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Z.J. Zheng, J.B. Croft, W.H. Giles, G.A. Mensah. Sudden cardiac death in the United States, 1989 to 1998. Circulation 104 (2001) (2158 - 2163) 2001
22a

References in context

  • Ischaemic heart disease is the leading cause of death in the world.20 In Europe, cardiovascular disease accounts for around 40% of all deaths under the age of 75 years.21 Sudden cardiac arrest is responsible for more than 60% of adult deaths from coronary heart disease.22 Summary data from 37 communities in Europe indicate that the annual incidence of EMS-treated out-of-hospital cardiopulmonary arrests (OHCAs) for all rhythms is 38 per 100,000 population.22a Based on these data, the annual incidence of EMS-treated ventricular fibrillation (VF) arrest is 17 per 100,000 and survival to hospital discharge is 10.7% for all-rhythm and 21.2% for VF cardiac arrest.
    Go to context

C. Atwood, M.S. Eisenberg, J. Herlitz, T.D. Rea. Incidence of EMS-treated out-of-hospital cardiac arrest in Europe. Resuscitation 67 (2005) (75 - 80) 2005
23

References in context

  • Ischaemic heart disease is the leading cause of death in the world.20 In Europe, cardiovascular disease accounts for around 40% of all deaths under the age of 75 years.21 Sudden cardiac arrest is responsible for more than 60% of adult deaths from coronary heart disease.22 Summary data from 37 communities in Europe indicate that the annual incidence of EMS-treated out-of-hospital cardiopulmonary arrests (OHCAs) for all rhythms is 38 per 100,000 population.22a Based on these data, the annual incidence of EMS-treated ventricular fibrillation (VF) arrest is 17 per 100,000 and survival to hospital discharge is 10.7% for all-rhythm and 21.2% for VF cardiac arrest.
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  • Studies indirectly comparing resuscitation outcomes between physician-staffed and other systems are difficult to interpret because of the extremely high variability between systems, independent of physician-staffing.23 Given the inconsistent evidence, the inclusion or exclusion of physicians among prehospital personnel responding to cardiac arrests will depend largely on existing local policy.
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G. Nichol, E. Thomas, C.W. Callaway, et al.. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA 300 (2008) (1423 - 1431) 2008
24
J. Hollenberg, J. Herlitz, J. Lindqvist, et al.. Improved survival after out-of-hospital cardiac arrest is associated with an increase in proportion of emergency crew—witnessed cases and bystander cardiopulmonary resuscitation. Circulation 118 (2008) (389 - 396) 2008
25
T. Iwami, G. Nichol, A. Hiraide, et al.. Continuous improvements in “chain of survival” increased survival after out-of-hospital cardiac arrests: a large-scale population-based study. Circulation 119 (2009) (728 - 734) 2009
26
L.A. Cobb, C.E. Fahrenbruch, M. Olsufka, M.K. Copass. Changing incidence of out-of-hospital ventricular fibrillation, 1980–2000. JAMA 288 (2002) (3008 - 3013) 2002
27
T.D. Rea, R.M. Pearce, T.E. Raghunathan, et al.. Incidence of out-of-hospital cardiac arrest. Am J Cardiol 93 (2004) (1455 - 1460) 2004
28
C. Vaillancourt, A. Verma, J. Trickett, et al.. Evaluating the effectiveness of dispatch-assisted cardiopulmonary resuscitation instructions. Acad Emerg Med 14 (2007) (877 - 883) 2007
29
D.A. Agarwal, E.P. Hess, E.J. Atkinson, R.D. White. Ventricular fibrillation in Rochester, Minnesota: experience over 18 years. Resuscitation 80 (2009) (1253 - 1258) 2009
30
M. Ringh, J. Herlitz, J. Hollenberg, M. Rosenqvist, L. Svensson. Out of hospital cardiac arrest outside home in Sweden, change in characteristics, outcome and availability for public access defibrillation. Scand J Trauma Resusc Emerg Med 17 (2009) (18) 2009
31
R. Cummins, W. Thies. Automated external defibrillators and the Advanced Cardiac Life Support Program: a new initiative from the American Heart Association. Am J Emerg Med 9 (1991) (91 - 93) 1991
32
R.A. Waalewijn, M.A. Nijpels, J.G. Tijssen, R.W. Koster. Prevention of deterioration of ventricular fibrillation by basic life support during out-of-hospital cardiac arrest. Resuscitation 54 (2002) (31 - 36) 2002
33

References in context

  • Ischaemic heart disease is the leading cause of death in the world.20 In Europe, cardiovascular disease accounts for around 40% of all deaths under the age of 75 years.21 Sudden cardiac arrest is responsible for more than 60% of adult deaths from coronary heart disease.22 Summary data from 37 communities in Europe indicate that the annual incidence of EMS-treated out-of-hospital cardiopulmonary arrests (OHCAs) for all rhythms is 38 per 100,000 population.22a Based on these data, the annual incidence of EMS-treated ventricular fibrillation (VF) arrest is 17 per 100,000 and survival to hospital discharge is 10.7% for all-rhythm and 21.2% for VF cardiac arrest.
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M.L. Weisfeldt, C.M. Sitlani, J.P. Ornato, et al.. Survival after application of automatic external defibrillators before arrival of the emergency medical system: evaluation in the resuscitation outcomes consortium population of 21 million. J Am Coll Cardiol 55 (2010) (1713 - 1720) 2010
34

References in context

  • Ischaemic heart disease is the leading cause of death in the world.20 In Europe, cardiovascular disease accounts for around 40% of all deaths under the age of 75 years.21 Sudden cardiac arrest is responsible for more than 60% of adult deaths from coronary heart disease.22 Summary data from 37 communities in Europe indicate that the annual incidence of EMS-treated out-of-hospital cardiopulmonary arrests (OHCAs) for all rhythms is 38 per 100,000 population.22a Based on these data, the annual incidence of EMS-treated ventricular fibrillation (VF) arrest is 17 per 100,000 and survival to hospital discharge is 10.7% for all-rhythm and 21.2% for VF cardiac arrest.
    Go to context

A.P. van Alem, R.H. Vrenken, R. de Vos, J.G. Tijssen, R.W. Koster. Use of automated external defibrillator by first responders in out of hospital cardiac arrest: prospective controlled trial. BMJ 327 (2003) (1312) 2003
35

References in context

  • The reported incidence of in-hospital cardiac arrest is more variable, but is in the range of 1–5 per 1000 admissions.35 Recent data from the American Heart Association's National Registry of CPR indicate that survival to hospital discharge after in-hospital cardiac arrest is 17.6% (all rhythms).36 The initial rhythm is VF or pulseless VT in 25% of cases and, of these, 37% survive to leave hospital; after PEA or asystole, 11.5% survive to hospital discharge.
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C. Sandroni, J. Nolan, F. Cavallaro, M. Antonelli. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Med 33 (2007) (237 - 245) 2007
36

References in context

  • The reported incidence of in-hospital cardiac arrest is more variable, but is in the range of 1–5 per 1000 admissions.35 Recent data from the American Heart Association's National Registry of CPR indicate that survival to hospital discharge after in-hospital cardiac arrest is 17.6% (all rhythms).36 The initial rhythm is VF or pulseless VT in 25% of cases and, of these, 37% survive to leave hospital; after PEA or asystole, 11.5% survive to hospital discharge.
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  • The first monitored rhythm is VF/VT in approximately 25% of cardiac arrests, both in-36 or out-of-hospital.24,25,146 VF/VT will also occur at some stage during resuscitation in about 25% of cardiac arrests with an initial documented rhythm of asystole or PEA.36 Having confirmed cardiac arrest, summon help (including the request for a defibrillator) and start CPR, beginning with chest compressions, with a CV ratio of 30:2.
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  • The first monitored rhythm is VF/VT in approximately 25% of cardiac arrests, both in-36 or out-of-hospital.24,25,146 VF/VT will also occur at some stage during resuscitation in about 25% of cardiac arrests with an initial documented rhythm of asystole or PEA.36 Having confirmed cardiac arrest, summon help (including the request for a defibrillator) and start CPR, beginning with chest compressions, with a CV ratio of 30:2.
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P.A. Meaney, V.M. Nadkarni, K.B. Kern, J.H. Indik, H.R. Halperin, R.A. Berg. Rhythms and outcomes of adult in-hospital cardiac arrest. Crit Care Med 38 (2010) (101 - 108) 2010
37
Proceedings of the 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care science with Treatment Recommendations. Resuscitation 67 (2005) (157 - 341) 2005
38
International Liaison Committee on Resuscitation. International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 112 (Suppl. III) (2005) (III-1 - III-136) 2005
39

References in context

  • The literature reviews followed a standardised ‘worksheet’ template including a specifically designed grading system to define the level of evidence of each study.39 When possible, two expert reviewers were invited to undertake independent evaluations for each topic.
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Morley PT, Atkins DL, Billi JE, et al. International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 3. Evidence evaluation process. Resuscitation; doi:10.1016/j.resuscitation.2010.08.023 , in press.
40

References in context

  • The comprehensive conflict of interest (COI) policy that was created for the 2005 International Consensus Conference40 was revised for 2010.41 Representatives of manufacturers and industry did not participate in either of the 2005 and the 2010 conferences.
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J.E. Billi, D.A. Zideman, B. Eigel, J.P. Nolan, W.H. Montgomery, V.M. Nadkarni. Conflict of interest management before, during, and after the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 67 (2005) (171 - 173) 2005
41

References in context

  • The comprehensive conflict of interest (COI) policy that was created for the 2005 International Consensus Conference40 was revised for 2010.41 Representatives of manufacturers and industry did not participate in either of the 2005 and the 2010 conferences.
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Shuster M, Billi JE, Bossaert L, et al. International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 4. Conflict of interest management before, during, and after the 2010 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation; doi:10.1016/j.resuscitation.2010.08.024 , in press.
42
T.D. Valenzuela, D.J. Roe, S. Cretin, D.W. Spaite, M.P. Larsen. Estimating effectiveness of cardiac arrest interventions: a logistic regression survival model. Circulation 96 (1997) (3308 - 3313) 1997
43
M. Holmberg, S. Holmberg, J. Herlitz. Factors modifying the effect of bystander cardiopulmonary resuscitation on survival in out-of-hospital cardiac arrest patients in Sweden. Eur Heart J 22 (2001) (511 - 519) 2001
44
M. Holmberg, S. Holmberg, J. Herlitz, B. Gardelov. Survival after cardiac arrest outside hospital in Sweden. Swedish Cardiac Arrest Registry. Resuscitation 36 (1998) (29 - 36) 1998
45
R.A. Waalewijn, J.G. Tijssen, R.W. Koster. Bystander initiated actions in out-of-hospital cardiopulmonary resuscitation: results from the Amsterdam Resuscitation Study (ARREST). Resuscitation 50 (2001) (273 - 279) 2001
46
SOS-KANTO Study Group. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study. Lancet 369 (2007) (920 - 926) 2007
47
T. Iwami, T. Kawamura, A. Hiraide, et al.. Effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest. Circulation 116 (2007) (2900 - 2907) 2007
48
W.D. Weaver, D. Hill, C.E. Fahrenbruch, et al.. Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. N Engl J Med 319 (1988) (661 - 666) 1988
49
T.E. Auble, J.J. Menegazzi, P.M. Paris. Effect of out-of-hospital defibrillation by basic life support providers on cardiac arrest mortality: a metaanalysis. Ann Emerg Med 25 (1995) (642 - 658) 1995
50
I.G. Stiell, G.A. Wells, B.J. Field, et al.. Improved out-of-hospital cardiac arrest survival through the inexpensive optimization of an existing defibrillation program: OPALS study phase II. Ontario Prehospital Advanced Life Support. JAMA 281 (1999) (1175 - 1181) 1999
51
I.G. Stiell, G.A. Wells, V.J. DeMaio, et al.. Modifiable factors associated with improved cardiac arrest survival in a multicenter basic life support/defibrillation system: OPALS Study Phase I results. Ontario Prehospital Advanced Life Support. Ann Emerg Med 33 (1999) (44 - 50) 1999
52

References in context

  • Automated external defibrillator programmes should be actively considered for implementation in public places such as airports,52 sport facilities, offices, in casinos55 and on aircraft,53 where cardiac arrests are usually witnessed and trained rescuers are quickly on scene.
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S. Caffrey. Feasibility of public access to defibrillation. Curr Opin Crit Care 8 (2002) (195 - 198) 2002
53

References in context

  • Automated external defibrillator programmes should be actively considered for implementation in public places such as airports,52 sport facilities, offices, in casinos55 and on aircraft,53 where cardiac arrests are usually witnessed and trained rescuers are quickly on scene.
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M.F. O’Rourke, E. Donaldson, J.S. Geddes. An airline cardiac arrest program. Circulation 96 (1997) (2849 - 2853) 1997
54
R.L. Page, M.H. Hamdan, D.K. McKenas. Defibrillation aboard a commercial aircraft. Circulation 97 (1998) (1429 - 1430) 1998
55

References in context

  • Automated external defibrillator programmes should be actively considered for implementation in public places such as airports,52 sport facilities, offices, in casinos55 and on aircraft,53 where cardiac arrests are usually witnessed and trained rescuers are quickly on scene.
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T.D. Valenzuela, D.J. Roe, G. Nichol, L.L. Clark, D.W. Spaite, R.G. Hardman. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med 343 (2000) (1206 - 1209) 2000
56
R.A. Waalewijn, R. de Vos, J.G. Tijssen, R.W. Koster. Survival models for out-of-hospital cardiopulmonary resuscitation from the perspectives of the bystander, the first responder, and the paramedic. Resuscitation 51 (2001) (113 - 122) 2001
57
J. Engdahl, P. Abrahamsson, A. Bang, J. Lindqvist, T. Karlsson, J. Herlitz. Is hospital care of major importance for outcome after out-of-hospital cardiac arrest? Experience acquired from patients with out-of-hospital cardiac arrest resuscitated by the same Emergency Medical Service and admitted to one of two hospitals over a 16-year period in the municipality of Goteborg. Resuscitation 43 (2000) (201 - 211) 2000
58
A. Langhelle, S.S. Tyvold, K. Lexow, S.A. Hapnes, K. Sunde, P.A. Steen. In-hospital factors associated with improved outcome after out-of-hospital cardiac arrest. A comparison between four regions in Norway. Resuscitation 56 (2003) (247 - 263) 2003
59
B.G. Carr, M. Goyal, R.A. Band, et al.. A national analysis of the relationship between hospital factors and post-cardiac arrest mortality. Intensive Care Med 35 (2009) (505 - 511) 2009
60
J.M. Liu, Q. Yang, R.G. Pirrallo, J.P. Klein, T.P. Aufderheide. Hospital variability of out-of-hospital cardiac arrest survival. Prehosp Emerg Care 12 (2008) (339 - 346) 2008
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 B.G. Carr, J.M. Kahn, R.M. Merchant, A.A. Kramer, R.W. Neumar. Inter-hospital variability in post-cardiac arrest mortality. Resuscitation 80 (2009) (30 - 34) 2009
62
J. Herlitz, J. Engdahl, L. Svensson, K.A. Angquist, J. Silfverstolpe, S. Holmberg. Major differences in 1-month survival between hospitals in Sweden among initial survivors of out-of-hospital cardiac arrest. Resuscitation 70 (2006) (404 - 409) 2006
63
S.P. Keenan, P. Dodek, C. Martin, F. Priestap, M. Norena, H. Wong. Variation in length of intensive care unit stay after cardiac arrest: where you are is as important as who you are. Crit Care Med 35 (2007) (836 - 841) 2007
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J. Bahr, H. Klingler, W. Panzer, H. Rode, D. Kettler. Skills of lay people in checking the carotid pulse. Resuscitation 35 (1997) (23 - 26) 1997
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J. Nyman, M. Sihvonen. Cardiopulmonary resuscitation skills in nurses and nursing students. Resuscitation 47 (2000) (179 - 184) 2000
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J. Tibballs, P. Russell. Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation 80 (2009) (61 - 64) 2009
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M. Ruppert, M.W. Reith, J.H. Widmann, et al.. Checking for breathing: evaluation of the diagnostic capability of emergency medical services personnel, physicians, medical students, and medical laypersons. Ann Emerg Med 34 (1999) (720 - 729) 1999
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G.D. Perkins, B. Stephenson, J. Hulme, K.G. Monsieurs. Birmingham assessment of breathing study (BABS). Resuscitation 64 (2005) (109 - 113) 2005
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  • Checking the carotid pulse (or any other pulse) is an inaccurate method of confirming the presence or absence of circulation, both for lay rescuers and for professionals.64–66 Healthcare professionals, as well as lay rescuers, have difficulty determining the presence or absence of adequate or normal breathing in unresponsive victims.67,68 This may be because the victim is making occasional (agonal) gasps, which occur in the first minutes after onset in up to 40% of cardiac arrests.69 Laypeople should be taught to begin CPR if the victim is unconscious (unresponsive) and not breathing normally.
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B.J. Bobrow, M. Zuercher, G.A. Ewy, et al.. Gasping during cardiac arrest in humans is frequent and associated with improved survival. Circulation 118 (2008) (2550 - 2554) 2008
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  • During CPR, blood flow to the lungs is substantially reduced, so an adequate ventilation–perfusion ratio can be maintained with lower tidal volumes and respiratory rates than normal.70 Hyperventilation is harmful because it increases intrathoracic pressure, which decreases venous return to the heart and reduces cardiac output.
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R.B. Taylor, C.G. Brown, T. Bridges, H.A. Werman, J. Ashton, R.L. Hamlin. A model for regional blood flow measurements during cardiopulmonary resuscitation in a swine model. Resuscitation 16 (1988) (107 - 118) 1988
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  • During CPR, the optimal tidal volume, respiratory rate and inspired oxygen concentration to achieve adequate oxygenation and CO2 removal is unknown.
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  • Interruptions in external chest compression reduces the chances of converting VF to another rhythm.71 Studies have shown a significantly lower hands-off-ratio with a one-shock instead of a three-stacked shock protocol148 and some,149–151 but not all,148,152 have suggested a significant survival benefit from this single-shock strategy.
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T. Eftestol, K. Sunde, P.A. Steen. Effects of interrupting precordial compressions on the calculated probability of defibrillation success during out-of-hospital cardiac arrest. Circulation 105 (2002) (2270 - 2273) 2002
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T.P. Aufderheide, R.G. Pirrallo, D. Yannopoulos, et al.. Incomplete chest wall decompression: a clinical evaluation of CPR performance by EMS personnel and assessment of alternative manual chest compression–decompression techniques. Resuscitation 64 (2005) (353 - 362) 2005
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D. Yannopoulos, S. McKnite, T.P. Aufderheide, et al.. Effects of incomplete chest wall decompression during cardiopulmonary resuscitation on coronary and cerebral perfusion pressures in a porcine model of cardiac arrest. Resuscitation 64 (2005) (363 - 372) 2005
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J.P. Ornato, L.F. Hallagan, S.B. McMahan, E.H. Peeples, A.G. Rostafinski. Attitudes of BCLS instructors about mouth-to-mouth resuscitation during the AIDS epidemic. Ann Emerg Med 19 (1990) (151 - 156) 1990
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P. Hew, B. Brenner, J. Kaufman. Reluctance of paramedics and emergency medical technicians to perform mouth-to-mouth resuscitation. J Emerg Med 15 (1997) (279 - 284) 1997
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N.C. Chandra, K.G. Gruben, J.E. Tsitlik, et al.. Observations of ventilation during resuscitation in a canine model. Circulation 90 (1994) (3070 - 3075) 1994
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K.B. Kern, R.W. Hilwig, R.A. Berg, A.B. Sanders, G.A. Ewy. Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario. Circulation 105 (2002) (645 - 649) 2002
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R.A. Berg, K.B. Kern, R.W. Hilwig, et al.. Assisted ventilation does not improve outcome in a porcine model of single-rescuer bystander cardiopulmonary resuscitation. Circulation 95 (1997) (1635 - 1641) 1997
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R.A. Berg, K.B. Kern, R.W. Hilwig, G.A. Ewy. Assisted ventilation during ‘bystander’ CPR in a swine acute myocardial infarction model does not improve outcome. Circulation 96 (1997) (4364 - 4371) 1997
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I. Turner, S. Turner, V. Armstrong. Does the compression to ventilation ratio affect the quality of CPR: a simulation study. Resuscitation 52 (2002) (55 - 62) 2002
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E. Dorph, L. Wik, T.A. Stromme, M. Eriksen, P.A. Steen. Oxygen delivery and return of spontaneous circulation with ventilation:compression ratio 2:30 versus chest compressions only CPR in pigs. Resuscitation 60 (2004) (309 - 318) 2004
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K. Bohm, M. Rosenqvist, J. Herlitz, J. Hollenberg, L. Svensson. Survival is similar after standard treatment and chest compression only in out-of-hospital bystander cardiopulmonary resuscitation. Circulation 116 (2007) (2908 - 2912) 2007
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  • In many situations however, standard CPR (which includes ventilation/rescuer breathing) is better, for example in children,84 asphyxial arrests, and when bystander CPR is required for more than a few minutes.13 A simplified, education-based approach is therefore suggested:•Ideally, full CPR skills (compressions and ventilation using a 30:2 ratio) should be taught to all citizens.
    Go to context

T. Kitamura, T. Iwami, T. Kawamura, et al.. Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study. Lancet (2010) 2010
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  • The incidence of adverse effects (muscle strain, back symptoms, shortness of breath, hyperventilation) on the rescuer from CPR training and actual performance is very low.86 Several manikin studies have found that, as a result of rescuer fatigue, chest compression depth can decrease as little as 2min after starting chest compressions.87 Rescuers should change about every 2min to prevent a decrease in compression quality due to rescuer fatigue.
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M.A. Peberdy, L.V. Ottingham, W.J. Groh, et al.. Adverse events associated with lay emergency response programs: the public access defibrillation trial experience. Resuscitation 70 (2006) (59 - 65) 2006
87

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  • The incidence of adverse effects (muscle strain, back symptoms, shortness of breath, hyperventilation) on the rescuer from CPR training and actual performance is very low.86 Several manikin studies have found that, as a result of rescuer fatigue, chest compression depth can decrease as little as 2min after starting chest compressions.87 Rescuers should change about every 2min to prevent a decrease in compression quality due to rescuer fatigue.
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N.T. Sugerman, D.P. Edelson, M. Leary, et al.. Rescuer fatigue during actual in-hospital cardiopulmonary resuscitation with audiovisual feedback: a prospective multicenter study. Resuscitation 80 (2009) (981 - 984) 2009
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  • There are several variations of the recovery position, each with its own advantages.
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Anon.. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care—an international consensus on science. Resuscitation 46 (2000) (1 - 447) 2000
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  • Foreign-body airway obstruction (FBAO) is an uncommon but potentially treatable cause of accidental death.96 The signs and symptoms enabling differentiation between mild and severe airway obstruction are summarised in Table 1.1.
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L.A. Fingerhut, C.S. Cox, M. Warner. International comparative analysis of injury mortality. Findings from the ICE on injury statistics. International Collaborative Effort on Injury Statistics. Adv Data (1998) (1 - 20) 1998
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R.D. White, T.J. Bunch, D.G. Hankins. Evolution of a community-wide early defibrillation programme experience over 13 years using police/fire personnel and paramedics as responders. Resuscitation 65 (2005) (279 - 283) 2005
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V.N. Mosesso Jr., E.A. Davis, T.E. Auble, P.M. Paris, D.M. Yealy. Use of automated external defibrillators by police officers for treatment of out-of-hospital cardiac arrest. Ann Emerg Med 32 (1998) (200 - 207) 1998
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  • Public access defibrillation (PAD) and first responder AED programmes may increase the number of victims who receive bystander CPR and early defibrillation, thus improving survival from out-of-hospital SCA.99 Recent data from nationwide studies in Japan and the USA33,100 showed that when an AED was available, victims were defibrillated much sooner and with a better chance of survival.
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The Public Access Defibrillation Trial Investigators. Public-access defibrillation and survival after out-of-hospital cardiac arrest. N Engl J Med 351 (2004) (637 - 646) 2004
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T. Kitamura, T. Iwami, T. Kawamura, K. Nagao, H. Tanaka, A. Hiraide. Nationwide public-access defibrillation in Japan. N Engl J Med 362 (2010) (994 - 1004) 2010
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  • The full potential of AEDs has not yet been achieved, because they are used mostly in public settings, yet 60–80% of cardiac arrests occur at home.
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G.H. Bardy, K.L. Lee, D.B. Mark, et al.. Home use of automated external defibrillators for sudden cardiac arrest. N Engl J Med 358 (2008) (1793 - 1804) 2008
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  • An effective system for training and retraining should be in place.104 Enough healthcare providers should be trained to enable the first shock to be given within 3min of collapse anywhere in the hospital.
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K.G. Spearpoint, P.C. Gruber, S.J. Brett. Impact of the Immediate Life Support course on the incidence and outcome of in-hospital cardiac arrest calls: an observational study over 6 years. Resuscitation 80 (2009) (638 - 643) 2009
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  • The semi-automatic mode has been shown to reduce time to first shock when used both in-hospital105 and pre-hospital106 settings, and results in higher VF conversion rates,106 and delivery of fewer inappropriate shocks.107 Conversely, semi-automatic modes result in less time spent performing chest compressions,107,108 mainly because of a longer pre-shock pause associated with automated rhythm analysis.
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R.O. Cummins, M.S. Eisenberg, P.E. Litwin, J.R. Graves, T.R. Hearne, A.P. Hallstrom. Automatic external defibrillators used by emergency medical technicians: a controlled clinical trial. JAMA 257 (1987) (1605 - 1610) 1987
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  • The semi-automatic mode has been shown to reduce time to first shock when used both in-hospital105 and pre-hospital106 settings, and results in higher VF conversion rates,106 and delivery of fewer inappropriate shocks.107 Conversely, semi-automatic modes result in less time spent performing chest compressions,107,108 mainly because of a longer pre-shock pause associated with automated rhythm analysis.
    Go to context

  • The semi-automatic mode has been shown to reduce time to first shock when used both in-hospital105 and pre-hospital106 settings, and results in higher VF conversion rates,106 and delivery of fewer inappropriate shocks.107 Conversely, semi-automatic modes result in less time spent performing chest compressions,107,108 mainly because of a longer pre-shock pause associated with automated rhythm analysis.
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K.R. Stults, D.D. Brown, R.E. Kerber. Efficacy of an automated external defibrillator in the management of out-of-hospital cardiac arrest: validation of the diagnostic algorithm and initial clinical experience in a rural environment. Circulation 73 (1986) (701 - 709) 1986
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  • The semi-automatic mode has been shown to reduce time to first shock when used both in-hospital105 and pre-hospital106 settings, and results in higher VF conversion rates,106 and delivery of fewer inappropriate shocks.107 Conversely, semi-automatic modes result in less time spent performing chest compressions,107,108 mainly because of a longer pre-shock pause associated with automated rhythm analysis.
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J. Kramer-Johansen, D.P. Edelson, B.S. Abella, L.B. Becker, L. Wik, P.A. Steen. Pauses in chest compression and inappropriate shocks: a comparison of manual and semi-automatic defibrillation attempts. Resuscitation 73 (2007) (212 - 220) 2007
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  • The negligible risk of a rescuer receiving an accidental shock is minimised even further if all rescuers wear gloves.113 The post-shock pause is minimised by resuming chest compressions immediately after shock delivery (see below).
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M.S. Lloyd, B. Heeke, P.F. Walter, J.J. Langberg. Hands-on defibrillation: an analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation 117 (2008) (2510 - 2514) 2008
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  • A review of evidence for the 2005 guidelines resulted in the recommendation that it was reasonable for EMS personnel to give a period of about 2min of CPR before defibrillation in patients with prolonged collapse (>5min).140 This recommendation was based on clinical studies, which showed that when response times exceeded 4–5min, a period of 1.5–3min of CPR before shock delivery improved ROSC, survival to hospital discharge141,142 and 1 year survival142 for adults with out-of-hospital VF or VT compared with immediate defibrillation.
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C.D. Deakin, J.P. Nolan. European Resuscitation Council guidelines for resuscitation 2005. Section 3. Electrical therapies: automated external defibrillators, defibrillation, cardioversion and pacing. Resuscitation 67 (Suppl. 1) (2005) (S25 - S37) 2005
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L. Wik, T.B. Hansen, F. Fylling, et al.. Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial. JAMA 289 (2003) (1389 - 1395) 2003
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S.M. Bradley, E.E. Gabriel, T.P. Aufderheide, et al.. Survival Increases with CPR by Emergency Medical Services before defibrillation of out-of-hospital ventricular fibrillation or ventricular tachycardia: observations from the resuscitation outcomes consortium. Resuscitation 81 (2010) (155 - 162) 2010
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  • Interruptions in external chest compression reduces the chances of converting VF to another rhythm.71 Studies have shown a significantly lower hands-off-ratio with a one-shock instead of a three-stacked shock protocol148 and some,149–151 but not all,148,152 have suggested a significant survival benefit from this single-shock strategy.
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T.M. Olasveengen, E. Vik, A. Kuzovlev, K. Sunde. Effect of implementation of new resuscitation guidelines on quality of cardiopulmonary resuscitation and survival. Resuscitation 80 (2009) (407 - 411) 2009
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L.J. Morrison, P. Dorian, J. Long, et al.. Out-of-hospital cardiac arrest rectilinear biphasic to monophasic damped sine defibrillation waveforms with advanced life support intervention trial (ORBIT). Resuscitation 66 (2005) (149 - 157) 2005
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J.J. Ambler, C.D. Deakin. A randomized controlled trial of efficacy and ST change following use of the Welch-Allyn MRL PIC biphasic waveform versus damped sine monophasic waveform for external DC cardioversion. Resuscitation 71 (2006) (146 - 151) 2006
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B.E. Gliner, D.B. Jorgenson, J.E. Poole, et al.. Treatment of out-of-hospital cardiac arrest with a low-energy impedance-compensating biphasic waveform automatic external defibrillator. The LIFE Investigators. Biomed Instrum Technol 32 (1998) (631 - 644) 1998
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R.D. White, T.H. Blackwell, J.K. Russell, D.E. Snyder, D.B. Jorgenson. Transthoracic impedance does not affect defibrillation, resuscitation or survival in patients with out-of-hospital cardiac arrest treated with a non-escalating biphasic waveform defibrillator. Resuscitation 64 (2005) (63 - 69) 2005
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I.G. Stiell, R.G. Walker, L.P. Nesbitt, et al.. BIPHASIC trial: a randomized comparison of fixed lower versus escalating higher energy levels for defibrillation in out-of-hospital cardiac arrest. Circulation 115 (2007) (1511 - 1517) 2007
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S.J. Walsh, A.J. McClelland, C.G. Owens, et al.. Efficacy of distinct energy delivery protocols comparing two biphasic defibrillators for cardiac arrest. Am J Cardiol 94 (2004) (378 - 380) 2004
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S.L. Higgins, J.M. Herre, A.E. Epstein, et al.. A comparison of biphasic and monophasic shocks for external defibrillation. Physio-control biphasic investigators. Prehosp Emerg Care 4 (2000) (305 - 313) 2000
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R.A. Berg, R.A. Samson, M.D. Berg, et al.. Better outcome after pediatric defibrillation dosage than adult dosage in a swine model of pediatric ventricular fibrillation. J Am Coll Cardiol 45 (2005) (786 - 789) 2005
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C.R. Killingsworth, S.B. Melnick, F.W. Chapman, et al.. Defibrillation threshold and cardiac responses using an external biphasic defibrillator with pediatric and adult adhesive patches in pediatric-sized piglets. Resuscitation 55 (2002) (177 - 185) 2002
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W. Tang, M.H. Weil, S. Sun, et al.. The effects of biphasic waveform design on post-resuscitation myocardial function. J Am Coll Cardiol 43 (2004) (1228 - 1235) 2004
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J. Xie, M.H. Weil, S. Sun, et al.. High-energy defibrillation increases the severity of postresuscitation myocardial dysfunction. Circulation 96 (1997) (683 - 688) 1997
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  • If electrical cardioversion is used to convert atrial or ventricular tachyarrhythmias, the shock must be synchronised to occur with the R wave of the electrocardiogram rather than with the T wave: VF can be induced if a shock is delivered during the relative refractory portion of the cardiac cycle.170 Biphasic waveforms are more effective than monophasic waveforms for cardioversion of AF.156–159 Commencing at high energy levels does not improve cardioversion rates compared with lower energy levels.156,171–176 An initial synchronised shock of 120–150J, escalating if necessary is a reasonable strategy based on current data.
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B. Lown. Electrical reversion of cardiac arrhythmias. Br Heart J 29 (1967) (469 - 489) 1967
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L. Boodhoo, A.R. Mitchell, G. Bordoli, G. Lloyd, N. Patel, N. Sulke. DC cardioversion of persistent atrial fibrillation: a comparison of two protocols. Int J Cardiol 114 (2007) (16 - 21) 2007
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C. Boos, M.D. Thomas, A. Jones, E. Clarke, G. Wilbourne, R.S. More. Higher energy monophasic DC cardioversion for persistent atrial fibrillation: is it time to start at 360 joules?. Ann Noninvasive Electrocardiol 8 (2003) (121 - 126) 2003
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B.M. Glover, S.J. Walsh, C.J. McCann, et al.. Biphasic energy selection for transthoracic cardioversion of atrial fibrillation. The BEST AF Trial. Heart 94 (2008) (884 - 887) 2008
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E.J. Rashba, M.R. Gold, F.A. Crawford, R.B. Leman, R.W. Peters, S.R. Shorofsky. Efficacy of transthoracic cardioversion of atrial fibrillation using a biphasic, truncated exponential shock waveform at variable initial shock energies. Am J Cardiol 94 (2004) (1572 - 1574) 2004
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  • Atrial flutter and paroxysmal SVT generally require less energy than atrial fibrillation for cardioversion.175 Give an initial shock of 100J monophasic or 70–120J biphasic.
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S.L. Pinski, E.B. Sgarbossa, E. Ching, R.G. Trohman. A comparison of 50-J versus 100-J shocks for direct-current cardioversion of atrial flutter. Am Heart J 137 (1999) (439 - 442) 1999
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F. Alatawi, O. Gurevitz, R. White. Prospective, randomized comparison of two biphasic waveforms for the efficacy and safety of transthoracic biphasic cardioversion of atrial fibrillation. Heart Rhythm 2 (2005) (382 - 387) 2005
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  • Give subsequent shocks using stepwise increases in energy.177 The energy required for cardioversion of VT depends on the morphological characteristics and rate of the arrhythmia.178 Use biphasic energy levels of 120–150J for the initial shock.
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R.E. Kerber, J.B. Martins, M.G. Kienzle, et al.. Energy, current, and success in defibrillation and cardioversion: clinical studies using an automated impedance-based method of energy adjustment. Circulation 77 (1988) (1038 - 1046) 1988
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  • Give subsequent shocks using stepwise increases in energy.177 The energy required for cardioversion of VT depends on the morphological characteristics and rate of the arrhythmia.178 Use biphasic energy levels of 120–150J for the initial shock.
    Go to context

  • Give subsequent shocks using stepwise increases in energy.177 The energy required for cardioversion of VT depends on the morphological characteristics and rate of the arrhythmia.178 Use biphasic energy levels of 120–150J for the initial shock.
    Go to context

R.E. Kerber, M.G. Kienzle, B. Olshansky, et al.. Ventricular tachycardia rate and morphology determine energy and current requirements for transthoracic cardioversion. Circulation 85 (1992) (158 - 163) 1992
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  • Discharge of an ICD may cause pectoral muscle contraction in the patient, and shocks to the rescuer have been documented.179 In view of the low energy levels discharged by ICDs, it is unlikely that any harm will come to the rescuer, but the wearing of gloves and minimising contact with the patient while the device is discharging is prudent.
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B. Stockwell, G. Bellis, G. Morton, et al.. Electrical injury during “hands on” defibrillation—a potential risk of internal cardioverter defibrillators?. Resuscitation 80 (2009) (832 - 834) 2009
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C.L. Gwinnutt, M. Columb, R. Harris. Outcome after cardiac arrest in adults in UK hospitals: effect of the 1997 guidelines. Resuscitation 47 (2000) (125 - 135) 2000
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M.A. Peberdy, W. Kaye, J.P. Ornato, et al.. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 58 (2003) (297 - 308) 2003
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  • Hospitals should provide a system of care that includes: (a) staff education about the signs of patient deterioration, and the rationale for rapid response to illness, (b) appropriate and regular vital signs monitoring of patients, (c) clear guidance (e.g., via calling criteria or early warning scores) to assist staff in the early detection of patient deterioration, (d) a clear, uniform system of calling for assistance, and (e) an appropriate and timely clinical response to calls for assistance.183 The following strategies may prevent avoidable in-hospital cardiac arrests:1.Provide care for patients who are critically ill or at risk of clinical deterioration in appropriate areas, with the level of care provided matched to the level of patient sickness.
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G.B. Smith. In-hospital cardiac arrest: is it time for an in-hospital ‘chain of prevention’?. Resuscitation (2010) 2010
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T.J. Hodgetts, G. Kenward, I. Vlackonikolis, et al.. Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital. Resuscitation 54 (2002) (115 - 123) 2002
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J. Kause, G. Smith, D. Prytherch, M. Parr, A. Flabouris, K. Hillman. A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom—the ACADEMIA study. Resuscitation 62 (2004) (275 - 282) 2004
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R. Bellomo, D. Goldsmith, S. Uchino, et al.. A prospective before-and-after trial of a medical emergency team. Med J Aust 179 (2003) (283 - 287) 2003
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R. Bellomo, D. Goldsmith, S. Uchino, et al.. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med 32 (2004) (916 - 921) 2004
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D.R. Goldhill, L. Worthington, A. Mulcahy, M. Tarling, A. Sumner. The patient-at-risk team: identifying and managing seriously ill ward patients. Anaesthesia 54 (1999) (853 - 860) 1999
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T.J. Hodgetts, G. Kenward, I.G. Vlachonikolis, S. Payne, N. Castle. The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team. Resuscitation 54 (2002) (125 - 131) 2002
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C.P. Subbe, R.G. Davies, E. Williams, P. Rutherford, L. Gemmell. Effect of introducing the modified early warning score on clinical outcomes, cardio-pulmonary arrests and intensive care utilisation in acute medical admissions. Anaesthesia 58 (2003) (797 - 802) 2003
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  • The response to patients who are critically ill or who are at risk of becoming critically ill is usually provided by medical emergency teams (MET), rapid response teams (RRT), or critical care outreach teams (CCOT).198–200 These teams replace or coexist with traditional cardiac arrest teams, which typically respond to patients already in cardiac arrest.
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  • The response to patients who are critically ill or who are at risk of becoming critically ill is usually provided by medical emergency teams (MET), rapid response teams (RRT), or critical care outreach teams (CCOT).198–200 These teams replace or coexist with traditional cardiac arrest teams, which typically respond to patients already in cardiac arrest.
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P.S. Chan, R. Jain, B.K. Nallmothu, R.A. Berg, C. Sasson. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med 170 (2010) (18 - 26) 2010
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M.J. Parr, J.H. Hadfield, A. Flabouris, G. Bishop, K. Hillman. The Medical Emergency Team: 12 month analysis of reasons for activation, immediate outcome and not-for-resuscitation orders. Resuscitation 50 (2001) (39 - 44) 2001
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  • One high-quality, prospective study has demonstrated that application of a ‘basic life support termination of resuscitation rule’ is predictive of death when applied by defibrillation-only emergency medical technicians.219 The rule recommends termination when there is no ROSC, no shocks are administered, and the arrest is not witnessed by EMS personnel.
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L.J. Morrison, L.M. Visentin, A. Kiss, et al.. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med 355 (2006) (478 - 487) 2006
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  • The use of adhesive electrode pads or a ‘quick-look’ paddles technique will enable rapid assessment of heart rhythm compared with attaching ECG electrodes.222 Pause briefly to assess the heart rhythm.
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M. Holmberg, S. Holmberg, J. Herlitz. Low chance of survival among patients requiring adrenaline (epinephrine) or intubation after out-of-hospital cardiac arrest in Sweden. Resuscitation 54 (2002) (37 - 45) 2002
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  • Without reassessing the rhythm or feeling for a pulse, resume CPR (CV ratio 30:2) immediately after the shock, starting with chest compressions.
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K. Sunde, T. Eftestol, C. Askenberg, P.A. Steen. Quality assessment of defibrillation and advanced life support using data from the medical control module of the defibrillator. Resuscitation 41 (1999) (237 - 247) 1999
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  • Without reassessing the rhythm or feeling for a pulse, resume CPR (CV ratio 30:2) immediately after the shock, starting with chest compressions.
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T.D. Rea, S. Shah, P.J. Kudenchuk, M.K. Copass, L.A. Cobb. Automated external defibrillators: to what extent does the algorithm delay CPR?. Ann Emerg Med 46 (2005) (132 - 141) 2005
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  • Without reassessing the rhythm or feeling for a pulse, resume CPR (CV ratio 30:2) immediately after the shock, starting with chest compressions.
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A.P. van Alem, B.T. Sanou, R.W. Koster. Interruption of cardiopulmonary resuscitation with the use of the automated external defibrillator in out-of-hospital cardiac arrest. Ann Emerg Med 42 (2003) (449 - 457) 2003
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  • In animal studies, peak plasma concentrations of adrenaline occur at about 90s after a peripheral injection.233 If ROSC has been achieved after the 3rd shock it is possible that the bolus dose of adrenaline will cause tachycardia and hypertension and precipitate recurrence of VF.
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M. Pytte, J. Kramer-Johansen, J. Eilevstjonn, et al.. Haemodynamic effects of adrenaline (epinephrine) depend on chest compression quality during cardiopulmonary resuscitation in pigs. Resuscitation 71 (2006) (369 - 378) 2006
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  • However, naturally occurring adrenaline plasma concentrations are high immediately after ROSC,234 and any additional harm caused by exogenous adrenaline has not been studied.
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A.W. Prengel, K.H. Lindner, H. Ensinger, A. Grunert. Plasma catecholamine concentrations after successful resuscitation in patients. Crit Care Med 20 (1992) (609 - 614) 1992
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  • A single precordial thump has a very low success rate for cardioversion of a shockable rhythm237–239 and is likely to succeed only if given within the first few seconds of the onset of a shockable rhythm.240 There is more success with pulseless VT than with VF.
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T. Pellis, F. Kette, D. Lovisa, et al.. Utility of pre-cordial thump for treatment of out of hospital cardiac arrest: a prospective study. Resuscitation 80 (2009) (17 - 23) 2009
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  • A single precordial thump has a very low success rate for cardioversion of a shockable rhythm237–239 and is likely to succeed only if given within the first few seconds of the onset of a shockable rhythm.240 There is more success with pulseless VT than with VF.
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P. Kohl, A.M. King, C. Boulin. Antiarrhythmic effects of acute mechanical stimulation. P. Kohl, F. Sachs, M.R. Franz (Eds.) Cardiac mechano-electric feedback and arrhythmias: form pipette to patient (Elsevier Saunders, Philadelphia, 2005) (304 - 314) 2005
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G. Caldwell, G. Millar, E. Quinn, R. Vincent, D.A. Chamberlain. Simple mechanical methods for cardioversion: defence of the precordial thump and cough version. BMJ (Clin Res Ed) 291 (1985) (627 - 630) 1985
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  • Establish intravenous access if this has not already been achieved.
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  • In comparison with placebo244 and lidocaine,245 the use of amiodarone in shock-refractory VF improves the short-term outcome of survival to hospital admission.
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P.J. Kudenchuk, L.A. Cobb, M.K. Copass, et al.. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med 341 (1999) (871 - 878) 1999
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  • Fibrinolytic therapy should not be used routinely in cardiac arrest.257 Consider fibrinolytic therapy when cardiac arrest is caused by proven or suspected acute pulmonary embolus.
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B.W. Bottiger, H.R. Arntz, D.A. Chamberlain, et al.. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med 359 (2008) (2651 - 2662) 2008
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D.F. Niendorff, A.J. Rassias, R. Palac, M.L. Beach, S. Costa, M. Greenberg. Rapid cardiac ultrasound of inpatients suffering PEA arrest performed by nonexpert sonographers. Resuscitation 67 (2005) (81 - 87) 2005
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P.A. van der Wouw, R.W. Koster, B.J. Delemarre, R. de Vos, A.J. Lampe-Schoenmaeckers, K.I. Lie. Diagnostic accuracy of transesophageal echocardiography during cardiopulmonary resuscitation. J Am Coll Cardiol 30 (1997) (780 - 783) 1997
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C. Hernandez, K. Shuler, H. Hannan, C. Sonyika, A. Likourezos, J. Marshall. C.A.U.S.E.: cardiac arrest ultra-sound exam—a better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation 76 (2008) (198 - 206) 2008
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  • Cardiac activity can be rapidly visualised527 and pericardial tamponade diagnosed.268 However, appropriately skilled operators must be available and its use should be balanced against the interruption to chest compressions during examination.
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H.V. Steiger, K. Rimbach, E. Muller, R. Breitkreutz. Focused emergency echocardiography: lifesaving tool for a 14-year-old girl suffering out-of-hospital pulseless electrical activity arrest because of cardiac tamponade. Eur J Emerg Med 16 (2009) (103 - 105) 2009
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M. Blaivas, J.C. Fox. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardiogram. Acad Emerg Med 8 (2001) (616 - 621) 2001
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  • There are animal data273 and some observational clinical data indicating an association between high SaO2 after ROSC and worse outcome.274 Initially, give the highest possible oxygen concentration.
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  • Several animal studies indicate that hyperoxaemia causes oxidative stress and harms post-ischaemic neurones.273,312–315 A clinical registry study documented that post-resuscitation hyperoxaemia was associated with worse outcome, compared with both normoxaemia and hypoxaemia.274 In clinical practice, as soon as arterial blood oxygen saturation can be monitored reliably (by blood gas analysis and/or pulse oximetry), it may be more practicable to titrate the inspired oxygen concentration to maintain the arterial blood oxygen saturation in the range of 94–98%.
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H.E. Wang, S.J. Simeone, M.D. Weaver, C.W. Callaway. Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation. e1 Ann Emerg Med 54 (2009) (645 - 652) 2009
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  • However, a device or technique which provides good quality CPR when used by a highly trained team or in a test setting may show poor quality and frequent interruptions when used in an uncontrolled clinical setting.286 While no circulatory adjunct is currently recommended for routine use instead of manual CPR, some circulatory adjuncts are being routinely used in both out-of-hospital and in-hospital resuscitation.
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L. Cabrini, P. Beccaria, G. Landoni, et al.. Impact of impedance threshold devices on cardiopulmonary resuscitation: a systematic review and meta-analysis of randomized controlled studies. Crit Care Med 36 (2008) (1625 - 1632) 2008
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A. Hallstrom, T.D. Rea, M.R. Sayre, et al.. Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial. JAMA 295 (2006) (2620 - 2628) 2006
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M.E. Ong, J.P. Ornato, D.P. Edwards, et al.. Use of an automated, load-distributing band chest compression device for out-of-hospital cardiac arrest resuscitation. JAMA 295 (2006) (2629 - 2637) 2006
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S. Wirth, M. Korner, M. Treitl, et al.. Computed tomography during cardiopulmonary resuscitation using automated chest compression devices—an initial study. Eur Radiol 19 (2009) (1857 - 1866) 2009
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K. Sunde, M. Pytte, D. Jacobsen, et al.. Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation 73 (2007) (29 - 39) 2007
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  • In adult patients who are comatose after cardiac arrest, and who have not been treated with hypothermia and who do not have confounding factors (such as hypotension, sedatives or muscle relaxants), the absence of both pupillary light and corneal reflex at ≥72h reliably predicts poor outcome (FPR 0%; 95% CI 0–9%).330 Absence of vestibulo-ocular reflexes at ≥24h (FPR 0%; 95% CI 0–14%)366,367 and a GCS motor score of 2 or less at ≥72h (FPR 5%; 95% CI 2–9%)330 are less reliable.
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  • In adult patients who are comatose after cardiac arrest, and who have not been treated with hypothermia and who do not have confounding factors (such as hypotension, sedatives or muscle relaxants), the absence of both pupillary light and corneal reflex at ≥72h reliably predicts poor outcome (FPR 0%; 95% CI 0–9%).330 Absence of vestibulo-ocular reflexes at ≥24h (FPR 0%; 95% CI 0–14%)366,367 and a GCS motor score of 2 or less at ≥72h (FPR 5%; 95% CI 2–9%)330 are less reliable.
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E.G. Zandbergen, A. Hijdra, J.H. Koelman, et al.. Prediction of poor outcome within the first 3 days of postanoxic coma. Neurology 66 (2006) (62 - 68) 2006
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  • There is a strong association between high blood glucose after resuscitation from cardiac arrest and poor neurological outcome.58,332–338 A large randomised trial of intensive glucose control (4.5–6.0mmoll−1) versus conventional glucose control (10mmoll−1 or less) in general ICU patients reported increased 90-day mortality in patients treated with intensive glucose control.339 Another recent study and two meta-analyses of studies of tight glucose control versus conventional glucose control in critically ill patients showed no significant difference in mortality but found tight glucose control was associated with a significantly increased risk of hypoglycaemia.340–342 Severe hypoglycaemia is associated with increased mortality in critically ill patients,343 and comatose patients are at particular risk from unrecognised hypoglycaemia.
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S. Finfer, D.R. Chittock, S.Y. Su, et al.. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 360 (2009) (1283 - 1297) 2009
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  • There is some evidence that, irrespective of the target range, variability in glucose values is associated with mortality.344 Based on the available data, following ROSC blood glucose should be maintained at ≤10mmoll−1 (180mgdl−1).345 Hypoglycaemia should be avoided.
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G. Meyfroidt, D.M. Keenan, X. Wang, P.J. Wouters, J.D. Veldhuis, G. Van den Berghe. Dynamic characteristics of blood glucose time series during the course of critical illness: effects of intensive insulin therapy and relative association with mortality. Crit Care Med 38 (2010) (1021 - 1029) 2010
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  • There is some evidence that, irrespective of the target range, variability in glucose values is associated with mortality.344 Based on the available data, following ROSC blood glucose should be maintained at ≤10mmoll−1 (180mgdl−1).345 Hypoglycaemia should be avoided.
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  • Fever is common following cardiopulmonary resuscitation and is associated with a poor neurological outcome,346,348,349 the risk increasing for each degree of body temperature greater than 37°C.349 There are limited experimental data suggesting that the treatment of fever with antipyretics and/or physical cooling reduces neuronal damage.567,568 Antipyretics and accepted drugs to treat fever are safe; therefore, use them to treat fever aggressively.
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  • There are no specific studies on cardiac arrest in hyperthermia.
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M. Strueber, M.M. Hoeper, S. Fischer, et al.. Bridge to thoracic organ transplantation in patients with pulmonary arterial hypertension using a pumpless lung assist device. Am J Transplant 9 (2009) (853 - 857) 2009
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P.D. Gluckman, J.S. Wyatt, D. Azzopardi, et al.. Selective head cooling with mild systemic hypothermia after neonatal encephalopathy: multicentre randomised trial. Lancet 365 (2005) (663 - 670) 2005
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M.R. Battin, J. Penrice, T.R. Gunn, A.J. Gunn. Treatment of term infants with head cooling and mild systemic hypothermia (35.0 degrees C and 34.5 degrees C) after perinatal asphyxia. Pediatrics 111 (2003) (244 - 251) 2003
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G. Compagnoni, L. Pogliani, G. Lista, F. Castoldi, P. Fontana, F. Mosca. Hypothermia reduces neurological damage in asphyxiated newborn infants. Biol Neonate 82 (2002) (222 - 227) 2002
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A.J. Gunn, T.R. Gunn, M.I. Gunning, C.E. Williams, P.D. Gluckman. Neuroprotection with prolonged head cooling started before postischemic seizures in fetal sheep. Pediatrics 102 (1998) (1098 - 1106) 1998
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T. Debillon, P. Daoud, P. Durand, et al.. Whole-body cooling after perinatal asphyxia: a pilot study in term neonates. Dev Med Child Neurol 45 (2003) (17 - 23) 2003
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S. Shankaran, A.R. Laptook, R.A. Ehrenkranz, et al.. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. N Engl J Med 353 (2005) (1574 - 1584) 2005
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  • Hypothermia is common in the child following cardiopulmonary resuscitation.350 Central hypothermia (32–34°C) may be beneficial, whereas fever may be detrimental to the injured brain.
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D.R. Doherty, C.S. Parshuram, I. Gaboury, et al.. Hypothermia therapy after pediatric cardiac arrest. Circulation 119 (2009) (1492 - 1500) 2009
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C. Coimbra, F. Boris-Moller, M. Drake, T. Wieloch. Diminished neuronal damage in the rat brain by late treatment with the antipyretic drug dipyrone or cooling following cerebral ischemia. Acta Neuropathol 92 (1996) (447 - 453) 1996
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H. Losert, F. Sterz, R.O. Roine, et al.. Strict normoglycaemic blood glucose levels in the therapeutic management of patients within 12 h after cardiac arrest might not be necessary. Resuscitation 76 (2008) (214 - 220) 2008
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T. Oksanen, M.B. Skrifvars, T. Varpula, et al.. Strict versus moderate glucose control after resuscitation from ventricular fibrillation. Intensive Care Med 33 (2007) (2093 - 2100) 2007
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C. Palme-Kilander. Methods of resuscitation in low-Apgar-score newborn infants—a national survey. Acta Paediatr 81 (1992) (739 - 744) 1992
572

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  • Compromised babies are particularly vulnerable.572 Exposure of the newborn to cold stress will lower arterial oxygen tension573 and increase metabolic acidosis.574 Prevent heat loss:•Protect the baby from draughts.
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L.S. Dahm, L.S. James. Newborn temperature and calculated heat loss in the delivery room. Pediatrics 49 (1972) (504 - 513) 1972
573

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J. Stephenson, J. Du, T.K. Oliver. The effect of cooling on blood gas tensions in newborn infants. J Pediatr 76 (1970) (848 - 852) 1970
574

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  • Compromised babies are particularly vulnerable.572 Exposure of the newborn to cold stress will lower arterial oxygen tension573 and increase metabolic acidosis.574 Prevent heat loss:•Protect the baby from draughts.
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G.M. Gandy, K. Adamsons Jr., N. Cunningham, W.A. Silverman, L.S. James. Thermal environment and acid–base homeostasis in human infants during the first few hours of life. J Clin Invest 43 (1964) (751 - 758) 1964
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  • The Apgar score was proposed as a “simple, common, clear classification or grading of newborn infants” to be used “as a basis for discussion and comparison of the results of obstetric practices, types of maternal pain relief and the effects of resuscitation” (our emphasis).577 It was not designed to be assembled and ascribed in order to then identify babies in need of resuscitation.578 However, individual components of the score, namely respiratory rate, heart rate and tone, if assessed rapidly, can identify babies needing resuscitation.577 Furthermore, repeated assessment particularly of heart rate and, to a lesser extent breathing, can indicate whether the baby is responding or whether further efforts are needed.
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  • The Apgar score was proposed as a “simple, common, clear classification or grading of newborn infants” to be used “as a basis for discussion and comparison of the results of obstetric practices, types of maternal pain relief and the effects of resuscitation” (our emphasis).577 It was not designed to be assembled and ascribed in order to then identify babies in need of resuscitation.578 However, individual components of the score, namely respiratory rate, heart rate and tone, if assessed rapidly, can identify babies needing resuscitation.577 Furthermore, repeated assessment particularly of heart rate and, to a lesser extent breathing, can indicate whether the baby is responding or whether further efforts are needed.
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  • The Apgar score was proposed as a “simple, common, clear classification or grading of newborn infants” to be used “as a basis for discussion and comparison of the results of obstetric practices, types of maternal pain relief and the effects of resuscitation” (our emphasis).577 It was not designed to be assembled and ascribed in order to then identify babies in need of resuscitation.578 However, individual components of the score, namely respiratory rate, heart rate and tone, if assessed rapidly, can identify babies needing resuscitation.577 Furthermore, repeated assessment particularly of heart rate and, to a lesser extent breathing, can indicate whether the baby is responding or whether further efforts are needed.
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  • This is assessed best by listening to the apex beat with a stethoscope.
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C.J. Owen, J.P. Wyllie. Determination of heart rate in the baby at birth. Resuscitation 60 (2004) (213 - 217) 2004
580

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  • This is assessed best by listening to the apex beat with a stethoscope.
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C.O. Kamlin, J.A. Dawson, C.P. O’Donnell, et al.. Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room. J Pediatr 152 (2008) (756 - 760) 2008
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R. David. Closed chest cardiac massage in the newborn infant. Pediatrics 81 (1988) (552 - 554) 1988
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J.J. Menegazzi, T.E. Auble, K.A. Nicklas, G.M. Hosack, L. Rack, J.S. Goode. Two-thumb versus two-finger chest compression during CRP in a swine infant model of cardiac arrest. Ann Emerg Med 22 (1993) (240 - 243) 1993
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588

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  • If there has been suspected blood loss or the infant appears to be in shock (pale, poor perfusion, weak pulse) and has not responded adequately to other resuscitative measures then consider giving fluid.588 This is a rare event.
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589

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  • Life-threatening arrhythmias are associated most commonly with potassium disorders, particularly hyperkalaemia, and less commonly with disorders of serum calcium and magnesium.
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J. Soar, C.D. Deakin, J.P. Nolan, et al.. European Resuscitation Council guidelines for resuscitation 2005. Section 7. Cardiac arrest in special circumstances. Resuscitation 67 (Suppl. 1) (2005) (S135 - S170) 2005
590

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  • Poisoning rarely causes cardiac arrest, but is a leading cause of death in victims younger than 40 years of age.590 Poisoning by therapeutic or recreational drugs and by household products are the main reasons for hospital admission and poison centre calls.
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A.C. Bronstein, D.A. Spyker, L.R. Cantilena Jr., J.L. Green, B.H. Rumack, S.L. Giffin. 2008 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 26th Annual Report. Clin Toxicol (Phila) 47 (2009) (911 - 1084) 2009
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592

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  • Interventions such as decontamination, enhanced elimination and antidotes may be indicated and are usually second line interventions.592 Alcohol excess is often associated with self-poisoning.
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593

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594

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  • Hypothermia can be classified arbitrarily as mild (35–32°C), moderate (32–28°C) or severe (less than 28°C).594 In a hypothermic patient, no signs of life alone is unreliable for declaring death.
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595

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  • Drug metabolism is slowed, leading to potentially toxic plasma concentrations of any drugs given repeatedly.595 Withold adrenaline and other CPR drugs until the patient has been warmed to a temperature higher than approximately 30°C.
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P. Paal, W. Beikircher, H. Brugger. Avalanche emergencies. Review of the current situation. Anaesthesist 55 (2006) (314 - 324) 2006
596

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  • As the body core temperature decreases, sinus bradycardia tends to give way to atrial fibrillation followed by VF and finally asystole.596 Once in hospital, severely hypothermic victims in cardiac arrest should be rewarmed with active internal methods.
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A. Mattu, W.J. Brady, A.D. Perron. Electrocardiographic manifestations of hypothermia. Am J Emerg Med 20 (2002) (314 - 326) 2002
597

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  • If VF is detected, give a shock at the maximum energy setting; if VF/VT persists after three shocks, delay further defibrillation attempts until the core temperature is above 30°C.597 If an AED is used, follow the AED prompts while rewarming the patient.
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M.R. Ujhelyi, J.J. Sims, S.A. Dubin, J. Vender, A.W. Miller. Defibrillation energy requirements and electrical heterogeneity during total body hypothermia. Crit Care Med 29 (2001) (1006 - 1011) 2001
598

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A. Bouchama. The 2003 European heat wave. Intensive Care Med 30 (2004) (1 - 3) 2004
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E.E. Coris, A.M. Ramirez, D.J. Van Durme. Heat illness in athletes: the dangerous combination of heat, humidity and exercise. Sports Med 34 (2004) (9 - 16) 2004
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  • Heat stroke is a systemic inflammatory response with a core temperature above 40.6°C, accompanied by mental state change and varying levels of organ dysfunction.
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H. Grogan, P.M. Hopkins. Heat stroke: implications for critical care and anaesthesia. Br J Anaesth 88 (2002) (700 - 707) 2002
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E. Hadad, A.A. Weinbroum, R. Ben-Abraham. Drug-induced hyperthermia and muscle rigidity: a practical approach. Eur J Emerg Med 10 (2003) (149 - 154) 2003
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M. Masoli, D. Fabian, S. Holt, R. Beasley. The global burden of asthma: executive summary of the GINA Dissemination Committee report. Allergy 59 (2004) (469 - 478) 2004
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Global Strategy for Asthma Management and Prevention 2009 [accessed 24.06.10].
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J.W. Leatherman, C. McArthur, R.S. Shapiro. Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma. Crit Care Med 32 (2004) (1542 - 1545) 2004
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S.E. Lapinsky, R.S. Leung. Auto-PEEP and electromechanical dissociation. N Engl J Med 335 (1996) (674) 1996
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P.L. Rogers, R. Schlichtig, A. Miro, M. Pinsky. Auto-PEEP during CPR. An “occult” cause of electromechanical dissociation?. Chest 99 (1991) (492 - 493) 1991
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P.L. Rosengarten, D.V. Tuxen, L. Dziukas, C. Scheinkestel, K. Merrett, G. Bowes. Circulatory arrest induced by intermittent positive pressure ventilation in a patient with severe asthma. Anaesth Intensive Care 19 (1991) (118 - 121) 1991
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J. Sprung, K. Hunter, G.M. Barnas, D.L. Bourke. Abdominal distention is not always a sign of esophageal intubation: cardiac arrest due to “auto-PEEP”. Anesth Analg 78 (1994) (801 - 804) 1994
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R. Harrison. Chest compression first aid for respiratory arrest due to acute asphyxic asthma. Emerg Med J 27 (2010) (59 - 61) 2010
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C.D. Deakin, R.M. McLaren, G.W. Petley, F. Clewlow, M.J. Dalrymple-Hay. Effects of positive end-expiratory pressure on transthoracic impedance—implications for defibrillation. Resuscitation 37 (1998) (9 - 12) 1998
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A. Galbois, H. Ait-Oufella, J.L. Baudel, et al.. Pleural ultrasound compared to chest radiographic detection of pneumothorax resolution after drainage. Chest (2010) 2010
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N. Mabuchi, H. Takasu, S. Ito, et al.. Successful extracorporeal lung assist (ECLA) for a patient with severe asthma and cardiac arrest. Clin Intensive Care 2 (1991) (292 - 294) 1991
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A. Pottle, I. Bullock, J. Thomas, L. Scott. Survival to discharge following Open Chest Cardiac Compression (OCCC). A 4-year retrospective audit in a cardiothoracic specialist centre – Royal Brompton and Harefield NHS Trust, United Kingdom. Resuscitation 52 (2002) (269 - 272) 2002
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J.H. Mackay, S.J. Powell, J. Osgathorp, C.J. Rozario. Six-year prospective audit of chest reopening after cardiac arrest. Eur J Cardiothorac Surg 22 (2002) (421 - 425) 2002
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I. Birdi, N. Chaudhuri, K. Lenthall, S. Reddy, S.A. Nashef. Emergency reinstitution of cardiopulmonary bypass following cardiac surgery: outcome justifies the cost. Eur J Cardiothorac Surg 17 (2000) (743 - 746) 2000
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A. el-Banayosy, C. Brehm, L. Kizner, et al.. Cardiopulmonary resuscitation after cardiac surgery: a two-year study. J Cardiothorac Vasc Anesth 12 (1998) (390 - 392) 1998
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J.F. Rhodes, A.D. Blaufox, H.S. Seiden, et al.. Cardiac arrest in infants after congenital heart surgery. Circulation 100 (1999) (II194 - II199) 1999
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Y. Li, H. Wang, J.H. Cho, et al.. Defibrillation delivered during the upstroke phase of manual chest compression improves shock success. Crit Care Med 38 (2010) (910 - 915) 2010
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Y. Li, T. Yu, G. Ristagno, et al.. The optimal phasic relationship between synchronized shock and mechanical chest compressions. Resuscitation 81 (2010) (724 - 729) 2010
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A.S. Rosemurgy, P.A. Norris, S.M. Olson, J.M. Hurst, M.H. Albrink. Prehospital traumatic cardiac arrest: the cost of futility. J Trauma 35 (1993) (468 - 473) 1993
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B.J. Maron, T.E. Gohman, S.B. Kyle, N.A. Estes 3rd, M.S. Link. Clinical profile and spectrum of commotio cordis. JAMA 287 (2002) (1142 - 1146) 2002
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B.J. Maron, N.A. Estes 3rd, M.S. Link. Task Force 11: commotio cordis. J Am Coll Cardiol 45 (2005) (1371 - 1373) 2005
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Article information

PII: S0300-9572(10)00447-8
DOI: 10.1016/j.resuscitation.2010.08.021
© 2010 Published by Elsevier B.V.

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