Cardiac arrest management: what’s new?
Dr Jonathan Ball
Cardiac arrest is a final common pathway of a wide variety of acute events. Indeed, it is the underlying cause that is the first and arguably the most important determinant of outcome, in concert with the duration and degree of physiological perturbation associated with the prodrome of the cardiac arrest. Time to recognition and initiation of effective chest compressions form the next link in the chain of survival. Expert and fully equipped responders have a growing body of evidence to support postponing definitive airway interventions and (probably) avoiding adrenaline boluses, whilst identifying and treating the underlying cause. Mechanical chest compression devices hold promise but lack evidence. Intra-arrest monitoring is (perhaps) coming of age. The useful duration of resuscitation efforts, especially in the in-hospital scenario, has gained some sobering clarity. Extracorporeal support is possibly effective in rescuing a tiny minority, but the cost and logistics of timely delivery raise practical and ethical questions. Early brain / whole body cooling remains controversial, with waning evidence and enthusiasm. The role of percutaneous coronary revascularisation for the “fortunate few” is well established though the management of persistent cardiogenic shock remains challenging and associated with poor outcomes. For the non-cardiogenic majority, the prognosis remains very poor, taking us back to the underlying cause and the still neglected need for advanced care planning. The optimal temperature and supportive care management of post-arrest patients remains a pragmatic art with a shrinking group of polarised evangelists. The timing and methodology for neurological prognostication in early survivors may just be emerging from dogmatic stipulations. In summary, some old and some new controversies to discuss.