Bernd W. Böttiger | University Hospital of Cologne, Germany
Sudden cardiac death following unsuccessful out-of-hospital cardiopulmonary resuscitation (CPR) is most probably the third leading cause of death in industrialized nations, and is responsible for more than 350,000 deaths every year in Europe. In addition, many patients are dying following in-hospital cardiac arrest.
Since 15 October 2015, the new European Resuscitation Council (ERC) Guidelines on Cardiopulmonary Resuscitation (CPR) and Postresuscitation Care are available at www.erc.edu. For consistency, we have kept many messages from 2010 – and the most important new 2015 recommendations focus on a marked increase in lay resuscitation including school children’s education in CPR, ‘telephone CPR’, First responder systems, Cardiac Arrest Centres and prognostication.
CPR 2015 at a glance
The new guidelines recommend a CPR compression depth in adults of 5 cm – and not more than 6 cm, with a frequency of 100-120/min. The compression to ventilation ratio is still 30:2; any pauses of more than 5-10 sec must be avoided. For ventilation, experts should use a tracheal tube. For less experienced providers, the alternative is a supraglottic airway device. Capnography is without any exception mandatory. No major changes have been made for drugs. Possibly reversible causes of cardiac arrest (‘4 H´s and 4 HITS’) should always be actively considered. Team debriefing is clearly recommended now – it leads to better performance and an increase in survival rates. Automatic external defibrillators (AEDs) should be available on any commercial airplane. Mechanical chest compression devices are not recommended for routine use; however they may be useful during transport, prolonged CPR, and cardiac catheterization.
In the out-of-hospital setting, the start of CPR by lay bystanders is associated with a 2–4-fold increase in survival rates. For the first minutes, ‘compression only’ lay CPR is often enough. Telephone CPR by the dispatch centre, First responder systems, and education of school children in CPR are now recommended. School children should be trained for two hours per year starting before puberty. This approach is also endorsed by the World Health Organization (WHO).
‘Rapid Response Teams’ and in-hospital cardiac arrest
We now recommend Rapid Response Teams (RRTs) and Medical Emergency Teams (METs). They are activated if vital signs of patients are outside a specific range, and they are associated with better in-hospital outcomes. The competences and skills needed here are the typical competences and skills of our specialty.
Cardiac Arrest Centres
Cardiac Arrest Centres are in the guidelines now. Since coronary events are the most important causes for out-of-hospital cardiac arrests, these centres should provide acute percutaneous cardiac interventions (PCI), temperature management, and up-to-date prognostication. Following out-of-hospital and in-hospital cardiac arrest of any initial rhythm, the 2015 guidelines recommend that unconscious patients should be treated with a constant temperature between 32°C and 36°C for 24 hours. Fever must be avoided for 72 hours, and normoxia is associated with better survival.
Prognostication – All new
Some of the most relevant changes have been made in the field of prognostication (see Figure 1). Any decision following prognostication to withdraw further therapy should not be executed within the first 72–96 hours.
Figure 1.: 2015 European Resuscitation Council (ERC) and European Society of Intensive Care Medicine (ESICM) guidelines prognostication strategy. EEG, electroencephalography; NSE, neuron specific enolase; SSEP, somatosensory evoked potentials; ROSC, return of spontaneous circulation; FPR, false positive rate; CI, confidence interval
Great opportunities for anaesthesiologists
With the new 2015 guidelines, we can save more lives, and anaesthesiologists can get high levels of in-hospital and public visibility with implementation of these new guidelines, with RRTs and METs, and with educating lay people and particularly school children in CPR. This year’s motto of the ERC-initiated ‘European Restart a Heart Day’ is ‘Kids Save Lives’, training school children in CPR. For three years now, this was always on 16 October, the ‘World Anaesthesia Day’. Because 16 October is a Sunday in 2016, it has been decided to train the school children in Europe this year on Tuesday, October 18 – and everybody is cordially invited to participate (www.erc.edu/www.restartaheart.eu).