Download Cardiopulmonary resuscitation standards: The 1992 Dartmouth

Cardiopulmonary resuscitation standards:
The 1992 Dartmouth experience in review
JUDITH BOEHM, RN
MARK GREENBERG, MD
STANLEY LIANG, EMT
RAY OBAR, RN
TORUNN T. RHODES, MD
NORMAN YANOFSKY, MD
Lebanon, New Hampshire
The following information comes from the
CardiopulmonaryResuscitation Team at the
Dartmouth-HitchcockMedical Center, in
Lebanon, New Hampshire. The AANA
Journal is grateful to the above individuals
for their expertise and willingness to share
their experience with our readers.
Key words: Advanced cardiac life support
(ACLS) guidelines, cardiopulmonary
resuscitation, outcomes, resuscitation
guidelines.
The Dartmouth-Hitchcock Medical Center Cardiopulmonary Resuscitation (CPR) Team handled
150 arrests in 138 patients in 1992 at the newly
constructed hospital in Lebanon, New Hampshire.
Given that there were 15,311 admissions during
this year, the number of patients who underwent
CPR represents 0.9% of the total patients admitted.
In 1990, the last full year at the old and now
vacated hospital, 42% of initial resuscitative efforts
were successful, and 22.9% of patients were discharged home. These values for 1992 were 43% and
15.9%, respectively. The latter value, the lowest
since a 14.3% discharge rate in 1984, is not statistically different (chi square P>0.10) from the 22.9%
value in 1990. Interestingly, 50 published reports
of in-hospital cardiac arrests during the past 30
years have demonstrated an overall discharge rate
October 1993/Vol. 61/No. 5
of about 15%, without notable improvement over
the last three decades.'
Unlike Dartmouth's statistics, some of these
studies eliminated arrests in the emergency room
from analysis, a group with a poor overall survival.
The Dartmouth Team response time for 50 arrests
examined over the last 8 months of 1992 indicated
an average response time of 2.7 minutes. See Table
I for demographics of the cardiopulmonary arrests.
New American Heart Association Guidelines
In 1992, the American Heart Association released an update of its "Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac
Care," initially published in 1974 and updated in
1980 and 1986. The October 28, 1992 issue of the
Journal of the American Medical Association was essentially devoted to these guidelines. 2 For the first
time, graded recommendations for therapeutic modalities have been utilized: Class 1 (indicated, helpful), Class 2 (acceptable, of uncertain efficacy), and
Class 3 (not indicated, may be harmful). Class 2
recommendations are further divided into 2A and
2B, probably helpful and possibly helpful, respectively.
Although none of the previous guidelines
were felt to be dangerous or to require immediate
withdrawal, the use of graded recommendations
and more extensive algorithms emphasizes that
emergency personnel are expected to take a total
view of the patient and depend more on clinical
judgment and flexible decision making rather than
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Table I
Summary of cardiopulmonary arrests-January
1, 1992 through December
31,1992
(number of arrests: 150; number of patients: 138)
Percent of
arrests survived
Arrests
Patient deaths
136
11
3
77
3
3
43
73
0
30
18
4
4
1
2
12
23
50
36
18
2
3
0
0
8
11
33
16
10
50
25
100
100
33
52
34
56
44
81
57
88
62
49
44
34
45
Emergency
Medicine
Pediatrics
43
64
8
31
35
5
28
45
37
Surgery
34
12
65
1
0
100
32
19
41
9
1
44
2
1
31
78
0
30
7
7
3
5
57
29
17
1
9
0
47
100
7
4
7
2
4
2
4
0
43
50
43
100
Patients
Survival by number of arrests
1
2
3
Patient Age
0-1 month
1-11 months
1-11 years
31-40 years
41-50 years
51-60 years
61-70 years
71-80 years
81-95 years
Patient sex
Male
Female
4
4
1
2
12
18
49
Primary service
Visitor
Unit in which arrest occurred
Critical care unit
Cardiothoracic
intensive care unit
Dialysis
Emergency department
Intensive coronary care unit
Intensive care nursery
Intensive care unit
Lobby
Medical specialties/
dermatology
Medicine/hematology/oncology
Neuroscience
Operating room
Orthopedics/ urology
2
1
150
Postanesthesia care unit
Radiology
2
1
0
1
100
0
Surgery
6
1
83
Surgical specialities
1
0
100
464
464
Journalof the American Association of Nurse Anesthetists
Table I (cont'd.)
Patients
Patient deaths
21
1
5
43
48
32
16
1
5
17
26
18
24
0
0
60
46
44
31
17
47
9
32
14
19
7
30
1
22
4
39
59
36
89
31
71
14
136
11
72
21
47
26
67
40
17
6
46
24
7
77
31
40
59
Basic life support started by
Emergency medical technician
Fast squad
Lay person
Medical doctor
Registered nurse
Unknown
Type of arrest
Asystole
Bradycardia
Electromechanical dissociation
Respiratory
Ventricular fibrillation
Ventricular tachycardia
CPR team called
No
Yes
Duration of CPR
1-10 minutes
11-30 minutes
31-60 minutes
61 + minutes
Patient outcomes
Patients
Deaths at resuscitation
Successful resuscitations
Patients discharged home
Patients still in hospital
Patients died subsequently
Arrests
Number
83
Percentage
60.1
22
1
32
138
15.9
0.7
23.2
ordering a drug by rote for a specific rhythm. Specifics in advanced cardiac life support are listed
below:
1. The more widespread use of automated external defibrillators has been emphasized. For example LIFEPAK 9P® with its shock advisory module gives the Dartmouth Team the ability to teach
semiautomatic defibrillation to nurses on general
hospital units. Therefore, all Dartmouth Team
members should be sure they are familiar with the
"hands-off" defibrillation technique.
2. Pulseless electrical activity has replaced the
former algorithm for electromechanical dissociation. This algorithm emphasizes identification of
possible reversible causes such as hypovolemia,
tension pneumothorax, cardiac tamponade, hypothermia, drug overdose, hyperkalemia, etc.
3. The standard dose of epinephrine has been
increased from 0.5-1.0 mg given intravenously (IV)
every 5 minutes to 1 mg every 3-5 minutes. If this
approach fails, several Class 2B dosing regimens
October 19931 VoL 61/No. 5
Percent of
arrests survived
Arrests
Number
83
67
Percentage
55.3
44.7
150
can be considered (2-5 mg IV every 3-5 minutes,
escalating doses of 1 mg to 3 mg to 5 mg 3 minutes
apart, and high doses of 0.1 mg/kg IV every 3-5
minutes).
4. Atropine when used for asystole has been
increased from 1 mg IV with a single repeat dose
in 5 minutes to a full vagal blockade dose of 1 mg
every 3-5 minutes up to a total of 0.04 mg/kg.
5. Lidocaine for ventricular fibrillation is now
used more aggressively (1.5 mg/kg IV repeated in
5-10 minutes to a total of 3 mg/kg IV. Previously,
1 mg/kg was administered initially with 0.5 mg/kg
given every 8 minutes to the same total dose). For
persistent fibrillation, other medications of probable benefit (Class 2A) include bretylium, magnesium, and procainamide. Sodium bicarbonate is
generally not recommended (Class 3 for hypoxic
lactic acidosis) but is considered possibly helpful
and acceptable (Class 2B) for a continued long arrest once the patient has been intubated.
6. Adenosine has replaced verapamil as the
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first drug recommended for paroxysmal supraventricular tachycardia; it is also acceptable for widecomplex tachycardia of undetermined etiology.
7. Isoproterenol has been downgraded for the
therapy of symptomatic bradycardia, due mainly
to its vasodilatory properties. The recommended
intervention sequence is atropine, transcutaneous
pacing, dopamine infusion, epinephrine infusion
(2-10 ,ug/min) and then isoproterenol (if used at
all, should be used in low doses). Previously,
isoproterenol and transcutaneous pacing were both
considered acceptable second choices after
atropine.
8. For endotracheal drug administration,
doses should be 2-2.5 times the recommended intravenous dose.
9. If central venous access is not utilized to
administer medication, it may take 1-2 minutes for
drugs to reach the central circulation in an arrested
patient. If drugs are given through a peripheral
IV, the drugs should be given rapidly, flushed with
20-30 mL, and the extremity elevated. Glucosecontaining fluids are discouraged due to the possible deleterious effects of hyperglycemia on cerebral preservation.
Basic life support update
Changes in the performance of basic life support
which are recommended in the October 1993 issue
of the Journalof the American Medical Association are
as follows:-'
1. Since survival is strongly linked to early
defibrillation, the first step for rescuers encountering an adult who has collapsed is to activate the
emergency medical system (EMS) by dialing 911
outside of the hospital or pushing the code blue
button inside the hospital. Previous guidelines
called for the single rescuer to perform CPR for
one minute prior to activating the EMS. The sequence for a child or infant is unchanged since
most often the arrest is respiratory in nature: perform CPR for one minute, and then notify the
EMS.
2. To minimize gastric distention, the inspiratory time during ventilations has been increased
from 1-1.5 seconds to 1.5-2 seconds. The rescuer
should pause after the first breath to take a breath.
Thus, oxygen content is maximized and carbon
dioxide concentration is minimized in the next delivered breath.
3. Rescue breathing for infants and children has
been made similar: a rate of 20 breaths per minute
or every 3 seconds. Again, keeping the inspiratory
time slow (1-1.5 seconds) will decrease gastric
distention.The ratio of compressions to ventilations during CPR remains the same at 5:1.
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To increase the cardiac output, the rate of compression for the child and the infant should now be
at least 100 compressions per minute.
5. In the obstructed airway sequences, the regimen is simplified. Five abdominal thrusts are now
called for in adults and children, and five back
blows alternating with five chest thrusts in infants.
What's new in pediatric and neonatal
resuscitation?
Below is a short outline of changes in pediatric and neonatal CPR based on recommendations
of the 1992 National Conference on Cardiopulmonary Resuscitation and Emergency Medical Care
held in Dallas, Texas, in February 1992.
* Pediatricadvanced life support
1. Vascular access. Central venous access has
been deemphasized. Peripheral venous access and
interosseous (10) access are considered adequate.
Avoid glucose-containing fluids during cardiac
arrest as it can cause hyperglycemia and worsen the
neurological outcome.
2. Medications. Epinephrine remains the firstline drug for resuscitation. All endotracheal doses
have been changed to 0.1 mg/kg (1:1,000). For
bradycardia, the dose IV/IO remains 0.01 mg/kg
(1:10,000). In cardiacarrest orpulseless arrest,the first
dose is 0.01 mg/kg (1:10,000), but second and subsequent doses are 0.1 mg/kg (1:1,000). Although
calcium, glucose and sodium bicarbonate have their
uses, they are not considered first-line drugs.
Adenosine (0.1 mg/kg IV) is considered the firstline drug for symptomatic supraventricular tachycardia. Isoproterenol is no longer recommended.
3. Trauma. A new section on advanced life support for the pediatric trauma victim has been
added. It includes an illustration of two-person cervical spine stabilization and intubation.
* The neonatalprogram
1. Preparationfor delivery. Universal precautions should be taken.
2. Initial stabilization. The Trendelenburg position is no longer recommended. Suctioning should
be limited to 3-5 seconds.
3. Evaluation. Evaluation should be started immediately; do not wait until after the initial steps
have been taken.
4. Ventilation. Gasping is added to the indications for positive pressure ventilation. The recommended ventilation rate is increased from 40 to
40-60 breaths per minute. Continue ventilation
until the infant has adequate spontaneous respiration.
5. Cardiaccompression. Chest compressions interposed with ventilation in a 3:1 ratio are now
recommended. The preferred method is "fingers
Journalof the American Association of Nurse Anesthetists
encircling the chest" with the thumbs place on the
sternum.
6. Medications. The recommended dose of epinephrine has not been changed.
7. Meconium. The recommendation for endotracheal suctioning has been changed from all
meconium-stained fluid to thick or particulate meconium and/or a depressed infant.
8. Preterm infants. Discussion of high-risk
preterm neonates has been integrated into the appropriate sections in the next version of the ACLS
textbook.
High-dose epinephrine
During the past several years there has been
considerable interest in the use of high-dose epinephrine in cardiac arrest. This interest was initially sparked by animal studies which showed increased survival using doses of epinephrine 5-10
times greater than those usually employed in resuscitation attempts. This was further supported
by some early studies showing an increased return
of pulse and circulation in patients receiving highdose epinephrine, as well as some anecdotal
reports of patients recovering from prolonged cardiac arrest only after receiving high-dose epinephrine when all other interventions had failed.
More than 2 years ago, an observational study
was begun at Dartmouth-Hitchcock Medical Center which looked at the effect on outcome of using
high-dose epinephrine. (Following the initial standard dose, all subsequent doses would be 5 mg at a
time.) The data shows no evidence for increased
survival for patients who received high-dose epinephrine. In addition, two large multi-institutional
studies were published in the New EnglandJournal
of Medicine, both of which showed no benefit for
high-dose epinephrine in adult cardiac arrest
victims. 3' 4 There is one small study which suggests
some benefit in the pediatric patient who may respond differently to high-dose epinephrine compared to the adult. 5
The latest American Heart Association guidelines recommend the use of standard dose epinephrine (1 mg) every 3-5 minutes during the resuscitation attempt. 2 High-dose epinephrine is considered acceptable and possibly helpful but is not
part of the standard algorithm.
Psychological aspects of resuscitation
The revised CPR guidelines place more emphasis on the psychological aspects of resuscitation. Below are some thoughts which emerge from
those guidelines.
* Telling the family. A local ambulance calls
the triage nurse in a busy emergency department
October1993/ Vol. 61/No. 5
to report that a patient in cardiac arrest is enroute.
After all attempts at resuscitating the patient have
been unsuccessful, the CPR Team decides to stop.
Telling family members and/or friends about
the death of a loved one is very difficult. Meet with
the family in a quiet and private room. Having
clergy or social workers present with the family
can be helpful. Introduce yourself to the family
and maintain good eye contact with them while
talking. Briefly describe to them the resuscitation
attempt and inform them of the death-use the
word death or died. After the initial shock, allow
as much time as necessary for questions and discussion. To facilitate the grief reaction, allow the
family to view their loved one, encouraging them
to spend as much time as necessary.
* Helping the helpers. Being aware of the needs
of the grieving person can help to facilitate the
grieving process. But what about the needs of the
staff after an unsuccessful resuscitation? Often,
there are feelings of failure and inadequacy. An
important intervention is a debriefing of the event.
The debriefing should be held as soon as possible after the event. Bring the group together and
review the events. The CPR Team members should
be allowed to freely discuss the event. The group
should be asked for recommendations or suggestions for future resuscitative attempts. All team
members should be allowed to share their feelings,
anxieties, and anger. The group leader should encourage team members to contact him/her if questions arise later.
Addressing the psychological issues associated
with sudden death is important to both families
and the medical workers. The knowledge of these
issues and using appropriate interventions will
greatly enable families and professionals to work
through the grieving process.
REFERENCES
(1)
Jastremski MS. In-hospital cardiac arrest. Ann Emerg Med.
1993;22:113-117.
(2)
Guidelines for cardiopulmonary resuscitation and emergency car-
diac care. JAMA. 1993;268:2171-2302.
(3) Stiell IG, Hebert PC, Weitzman BN, ct al. High-dose epinephrine
in adult cardiac arrest. NEngl Med. 1992;327:1045-1050.
(4) Brown CG, Martin DR, Pepe PE, et al. A comparison of standarddose and high-dose epinephrine in cardiac arrest outside the hospital.
The Multicenter High-Dose Epinephrine Study Group. N Engli] Med.
1992;327:1051-1055.
(5) Goetting MG, Paradis NA. High-dose epinephrine improves outcomes from pediatric cardiac arrest. Ann Emerg Med. 1991 ;20:22-26.
AUTHORS
The authors of this article are members of the D)artmouthHitchcock Medical Center's CPR Team and represent a variety of
disciplines.
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