Update on in hospital resuscitation

Pallás Beneyto, Luis Alberto; Rodríguez Luis, Olga; Bayarri, Vicente Miguel
doi:10.1016/j.medcle.2016.12.047
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Initial in-hospital resuscitation algorithm&#46; ABCD&#58; first aid sequence that includes A&#58; opening the airway&#44; B&#58; ventilation&#44; C&#58; circulatory support and D&#58; differential diagnosis&#59; CPA&#58; cardiopulmonary arrest&#59; ROSC&#58; recovery of spontaneous circulation&#59; CPR&#58; cardiopulmonary resuscitation&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">New recommendations on cardiopulmonary resuscitation guidelines have been recently published&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> incorporating various changes and emphasizing various care measures for patients with deterioration and cardiopulmonary arrest &#40;CPA&#41; during their hospital stay&#46; The update in this article is intended to review and update the current recommendations from a practical and easy-to-follow point of view in order to promote a correct clinical intervention among professionals&#44; should this situation arise&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Cardiac arrest &#40;CA&#41; is the cessation of cardiac mechanical activity&#44; which is diagnosed by the absence of consciousness and pulse&#46; Cardiopulmonary resuscitation &#40;CPR&#41; includes all the manoeuvres to reverse this situation&#44; and its main objective is to reverse clinical death&#44; minimize the consequences and improve neurological outcome&#44; basic pillars in the current concept of cardiocerebral resuscitation&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> Currently&#44; early recognition of deterioration in a patient and CA prevention is the first link in the chain of supervenience&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> Hospitals should have a system based on the recognition of patients at high risk of CA&#44; establishing staff training on identifying signs of patient deterioration&#44; frequent and appropriate monitoring of vital signs in these patients&#44; a homogeneous warning system of aid calls and clear guidelines on the initial procedure in patients with signs of deterioration or dying as basic pillars&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Successful resuscitation of a patient with CA in a hospital setting depends on a set of manoeuvres to restore effective ventilation&#44; oxygenation and circulation through a series of advanced resuscitation measures including early defibrillation&#44; external chest compressions&#44; actions on the airway&#44; ventilation&#44; intravenous medication&#44; <span class="elsevierStyleItalic">etc&#46;</span> performed by specialized personnel&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In-hospital CA has an incidence of between 0&#46;4 and 2&#37; of hospitalized patients&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> Once that occurs&#44; only about 20&#37; survive&#44; and those who survive&#44; up to 30&#37; have significant neurological sequelae&#44; with permanent brain damage&#44; known as post-anoxic encephalopathy<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a>&#59; hence the insistence of this in-hospital CPR update on enhancing&#44; implementing and improving advanced CPR techniques&#44; as well as introducing new postresuscitation measures aimed to minimize that permanent brain damage&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Definitions</span><p id="par0025" class="elsevierStylePara elsevierViewall">By CPA we understand the abrupt and unexpected cessation of breathing and&#47;or circulation&#44; potentially reversible vital signs&#46; As a result of CPA&#44; there is a tissue oxygenation inability&#44; the brain being the most sensitive organ to anoxia&#46; If resuscitation is initiated before 4<span class="elsevierStyleHsp" style=""></span>min have elapsed&#44; the probability of survival doubles&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#44;8</span></a> Some concepts should be clarified&#44; for example&#44; <span class="elsevierStyleItalic">respiratory arrest</span> is the cessation of spontaneous breathing&#44; with heartbeat remaining during 3&#8211;4<span class="elsevierStyleHsp" style=""></span>min&#46; The most common causes are poisoning&#44; airflow obstruction&#44; disorders of the central nervous system and chest trauma&#46; <span class="elsevierStyleItalic">CA</span> usually follows respiratory arrest or appears in the context of serious&#44; life-threatening arrhythmias&#44; such as ventricular fibrillation &#40;VF&#41;&#44; pulseless ventricular tachycardia &#40;PVT&#41; as well as pulseless electrical activity&#46; <span class="elsevierStyleItalic">in-hospital CPR</span> refers to advanced resuscitation carried out by qualified professionals with the necessary equipment to perform defibrillation&#44; besides optimizing the respiratory and circulatory support&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Resuscitation ethics and end-of-life decisions</span><p id="par0030" class="elsevierStylePara elsevierViewall">If an in-hospital CPA occurs unexpectedly&#44; the usual protocol involves the immediate establishment of life support measures&#44; and given the difficulty in knowing or predicting patient survival&#44; comorbidities and baseline condition&#44; the patient often receives simultaneous treatment interventions in order to restore life and minimize neurological sequelae&#44; but this is not always appropriate&#46; In this sense&#44; we must acknowledge some ethical aspects&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0035" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">principle of autonomy</span> refers to respecting patient preferences and making decisions in harmony with his&#47;her values and beliefs&#46; The application of this principle during CA is difficult&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">principle of beneficence</span> implies that the interventions established should benefit the patient&#44; deciding what treatment strategies are most appropriate and with a lower risk for the patient&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall">CPR is an invasive procedure with a low probability of success&#44; so&#44; CPR should not be performed in futile cases&#46; This action falls within the concept of <span class="elsevierStyleItalic">principle of non-maleficence</span>&#44; understanding that resuscitation is considered futile when the chances of survival with a good quality of life are minimal&#46; The decision not to attempt resuscitation does not require the consent of the patient or their relatives&#44; who often have unrealistic expectations&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#41;</span><p id="par0050" class="elsevierStylePara elsevierViewall">A <span class="elsevierStyleItalic">living will</span> involves treatment decisions previously taken by an individual foreseeing a possible scenario where the patient is unable to participate directly in making medical decisions sometime in the future&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Therefore&#44; after an in-hospital CA&#44; the default position is to start resuscitation unless a decision has been made regarding not to perform CPR&#44; having to review the decisions on resuscitation and the consequences of the same&#44; taking into account the difficulty of determining when CPR is likely to fail or be futile&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resuscitation indications&#44; cessation and contraindications</span><p id="par0060" class="elsevierStylePara elsevierViewall">In a hospital environment&#44; when facing a CPA situation and CPR initiation&#44; it is important to try to establish the cause that led to the arrest and know the patient&#39;s prognosis as soon as possible&#46; This will help in deciding the intensity and continuity of the manoeuvres&#46; Unless the patient has expressly left in writing a &#8220;Do Not Resuscitate&#8221; &#40;DNR&#41; order as part of his&#47;her living will&#44; CPR must be started&#44; as this situation is considered of extreme urgency&#46; Once resuscitation is established&#44; the decision to suspend efforts is difficult and it will never be an isolated time interval&#59; clinical judgement and human dignity must be taken into account in this process &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The resuscitation team should review the quality of this and ensure that they have successfully carried out an adequate and high-quality CPR&#44; a defibrillation in the presence of shockable rhythms&#44; vascular access and drug administration in an appropriate manner&#44; effective ventilation and identification and treatment of the reversible causes&#46; However&#44; there are some situations that contraindicate starting resuscitation<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Immediate in-hospital resuscitation &#40;the chain of survival&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall">After an in-hospital CA&#44; the division between basic life support and advanced life support is arbitrary&#44; and it should be a continuous process in clinical practice&#46; This requires organization and a set of integrated actions ranging from the site where CPA takes place to the patient&#39;s admission in the critical care unit&#44; where postresuscitation care will be given&#46; The <span class="elsevierStyleItalic">American Heart Association</span> defined this set of actions as <span class="elsevierStyleItalic">Chain of Survival</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a> a metaphoric term to denote the interdependence of a global response when facing a CA&#46; This response comprises four links&#58; &#40;a&#41; early recognition of a dying patient in a situation of cardiocirculatory pre-arrest or arrest and request for help&#44; being necessary to implement simple identification scales for this group of patients by health workers in order to recognize the patient at high risk of CPA and prioritize prevention<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a>&#59; &#40;b&#41; early application of life support techniques &#40;early CPR&#41;&#59; &#40;c&#41; early defibrillation&#44; and &#40;d&#41; establish advanced care and postresuscitation&#46; If any of the links is lost&#44; the chance of survival decreases&#44; hence the importance of an updated knowledge and continuous training&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The first step is to establish early identification and early action&#59; therefore&#44; targeted action guidelines will be established&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">When <span class="elsevierStyleItalic">the patient has clinical signs of severity</span>&#44; with a high risk of CPA&#44; an urgent medical evaluation based on the hospital&#39;s own protocols is required&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">If the patient does not respond or has an agonal breathing</span> &#40;sign of arrest&#44; which should not be mistaken as a sign of life&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; help should be simultaneously requested&#44; keep the airway open &#40;look&#44; listen and feel&#44; no more than 10<span class="elsevierStyleHsp" style=""></span>s&#41; and&#44; if absent&#44; begin chest compressions without having to feeling the pulse&#44;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;12&#44;13</span></a> because delays in CA diagnosis and the beginning of CPR will negatively affect survival&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> It is unlikely that performing chest compressions to a patient with a heartbeat will cause any harm&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> As one member of staff begins CPR&#44; others call the resuscitation team and get the resuscitation equipment and a defibrillator&#46; In the latest resuscitation recommendations&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> it is advisable to apply <span class="elsevierStyleItalic">30 chest compressions followed by 2 ventilations</span>&#44; compressing to a <span class="elsevierStyleItalic">depth of about 5</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">cm</span>&#44; but not more than 6<span class="elsevierStyleHsp" style=""></span>cm &#40;novelty regarding the 2010 recommendations&#41;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a>&#44; with a <span class="elsevierStyleItalic">100&#8211;120<span class="elsevierStyleHsp" style=""></span>min</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">&#8722;1</span></span><span class="elsevierStyleItalic">frequency&#44; allowing the chest to re-expand completely after each compression</span>&#44; without resting on the chest&#46; Disruptions should be minimized&#44; ensuring high quality compressions&#46; If possible&#44; the person performing the chest compressions should be <span class="elsevierStyleItalic">relieved every 2</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">min</span>&#44; but without interrupting chest compressions&#46; CPR start and end times should be recorded&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Managing shockable rhythms</span><p id="par0085" class="elsevierStylePara elsevierViewall">In general&#44; how to manage shockable rhythms &#40;VF&#47;PVT&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; has not been modified since the 2010 recommendations regarding the use and indications of defibrillation&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">16&#44;17</span></a> Without interrupting chest compressions&#44; another resuscitating technician charges the defibrillator and&#44; once charged&#44; chest compressions pause&#44; making sure all resuscitating technicians are clear of the patient&#44; then the first shock is performed with an intensity of at least 150 J for biphasic defibrillators &#40;360 J monophasic&#41;&#46; The defibrillation shock levels have not changed from the 2010 recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> In manual defibrillators&#44; it is considered appropriate to increase the energy of successive shocks after an unsuccessful shock and in patients in which refibrillation occurs&#46; <span class="elsevierStyleItalic">Without stopping to check for rhythm or feeling the pulse&#44; CPR will resume</span> &#40;CV ratio 30&#58;2&#41; immediately after the shock during <span class="elsevierStyleItalic">2</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">min</span>&#59; then a <span class="elsevierStyleItalic">short pause should be made to assess the rhythm</span> and&#44; if VF&#47;PVT persists&#44; give a <span class="elsevierStyleItalic">second shock</span> &#40;150&#8211;360<span class="elsevierStyleHsp" style=""></span>J biphasic&#41; and&#44; without stopping to reassess the rhythm or feeling the pulse&#44; <span class="elsevierStyleItalic">resume CPR</span> &#40;CV ratio 30&#58;2&#41; immediately after the shock&#46; CPR must <span class="elsevierStyleItalic">continue during 2</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">min</span>&#44; then pause briefly to assess the rhythm&#59; if VF&#47;PVT persists&#44; give a <span class="elsevierStyleItalic">third shock</span> &#40;150&#8211;360<span class="elsevierStyleHsp" style=""></span>J biphasic&#41;&#46; Without reassessing the rhythm or feeling the pulse&#44; <span class="elsevierStyleItalic">resume CPR</span> &#40;CV ratio 30&#58;2&#41; immediately after the shock&#44; starting with chest compressions&#46; If intravenous access is achieved&#44; <span class="elsevierStyleItalic">epinephrine 1</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mg</span> and <span class="elsevierStyleItalic">amiodarone 300</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mg</span> should be administered <span class="elsevierStyleItalic">during the next 2</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">min</span> of CPR &#40;intraosseous access can be used with the same level of effectiveness if a peripheral vein access is not achieved&#59; administering drugs intratracheally is not currently recommended&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;16</span></a> If the return of spontaneous circulation &#40;ROSC&#41; has not been achieved with the third shock&#44; adrenaline can improve myocardial blood flow and increase the likelihood of successful defibrillation with the next shock&#46; After each 2<span class="elsevierStyleHsp" style=""></span>min resuscitation cycle&#44; if the rhythm changes to asystole or pulseless electrical activity&#44; the measures described in the <span class="elsevierStyleItalic">non-shockable rhythms</span> algorithm will be applied and if ROSC has been achieved&#44; postresuscitation care should begin&#46; Regardless of the arrest rhythm&#44; after the initial dose of adrenaline has been given&#44; <span class="elsevierStyleItalic">1</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mg of adrenaline must be administered every 3&#8211;5</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">min</span> until ROSC is achieved&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Managing non-shockable rhythms &#40;asystole&#47;pulseless electrical activity&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Pulseless electrical activity and asystole require CPR &#40;30&#58;2&#41; initiation in patients without airway isolation&#46; Those patients with an advanced airway device may be ventilated without interrupting chest compressions&#44; at a rate of 100&#8211;120<span class="elsevierStyleHsp" style=""></span>lpm and ventilatory ratio of 10<span class="elsevierStyleHsp" style=""></span>bpm&#46; After 2<span class="elsevierStyleHsp" style=""></span>min of CPR&#44; the rhythm will be checked through the monitor&#44; and if asystole persists&#44; CPR will restart immediately&#46; If an organized rhythm appears&#44; check for central pulse evidence&#46; If no pulse &#40;or if there is any doubt about the presence of pulse&#41;&#44; continue CPR&#46; 1<span class="elsevierStyleHsp" style=""></span>mg of adrenaline should be given as soon as venous or intraosseous access is achieved&#44; and repeat at every other cycle of CPR &#40;about every 3&#8211;5<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; During any CA&#44; an assessment of potential causes or aggravating factors for which specific treatment exists should be considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18&#44;19</span></a> The 4H&#39;s reversible causes rule&#58; Hypoxia&#44; Hypovolemia&#44; Hypo-hyperkalaemia&#44; Hypo-hyperthermia&#44; and 4T&#39;s&#58; Thrombosis &#40;coronary or pulmonary&#41;&#44; Tension Pneumothorax&#44; Tamponade &#40;cardiac&#41;&#44; Toxins&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Resuscitation when faced with hemodynamically unstable slow rhythms</span><p id="par0095" class="elsevierStylePara elsevierViewall">Patients with bradycardia accompanied by haemodynamic consequences should receive 500<span class="elsevierStyleHsp" style=""></span>&#956;g of atropine IV&#59; if they do not respond or there is a risk of asystole&#44; another 500<span class="elsevierStyleHsp" style=""></span>&#956;g will be administered&#46; This may be repeated up to 3<span class="elsevierStyleHsp" style=""></span>mg&#46; In the absence of an appropriate response to atropine&#44; isoproterenol can be used together with transcutaneous pacing as a step towards the implantation of a temporary pacemaker&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Fluids and drugs in cardiac arrest</span><p id="par0100" class="elsevierStylePara elsevierViewall">Hypovolemia is a potentially reversible cause&#46; Fluids should be infused rapidly&#46; Balanced crystalloid solutions are recommended&#46; Hypotonic fluids should be avoided because they can quickly spread outside the intravascular space and may worsen the neurological outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> There is no placebo-controlled study showing that the systematic use of vasopressors during CA increases survival to hospital discharge&#46; The current recommendation is to continue using adrenaline during CPR&#44; per the 2010 recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> Evidence that antiarrhythmic drugs are beneficial in the CA is limited&#46; No antiarrhythmic drug administered during CA in humans has been shown to increase survival to hospital discharge&#46; Despite the lack of data on long-term outcomes in humans&#44; the balance of evidence favours the use of antiarrhythmic drugs for the treatment of arrhythmias in CA&#46; After 3 initial shocks&#44; in VF refractory to shock&#44; amiodarone improves short-term survival to hospital admission compared to placebo<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> or lidocaine&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Lidocaine is recommended when amiodarone is not available&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a><span class="elsevierStyleItalic">Sodium bicarbonate</span> should not be administered systematically during CA and CPR or after ROSC&#46; Its use may be considered in the treatment for CA associated with hyperkalaemia and tricyclic antidepressants overdose&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Fibrinolytic therapy</span> should not be used routinely in CA&#44; and should be considered when this is caused by proven or suspected acute pulmonary embolism&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> If a fibrinolytic drug is administered in these circumstances&#44; performing CPR should be considered for at least 60&#8211;90<span class="elsevierStyleHsp" style=""></span>min before the end of resuscitation attempts&#44; because cases of survival and good neurological outcome have been reported after fibrinolysis for pulmonary embolism during CPR which required more than 60<span class="elsevierStyleHsp" style=""></span>min of CPR&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Some relevant considerations in the new guidelines</span><p id="par0110" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0115" class="elsevierStylePara elsevierViewall">Pauses in chest compressions should be minimized&#46; Pre- and post-shock pauses should last less than 10<span class="elsevierStyleHsp" style=""></span>s&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0120" class="elsevierStylePara elsevierViewall">CPR should be performed on a firm surface&#46; Evidence on the use of boards is inconclusive&#44; and if used&#44; interrupting CPR and losing venous access&#44; probes and ventilation and oxygenation devices should be avoided&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Defibrillation</span>&#46; The pre-shock pause should be reduced to less than 5<span class="elsevierStyleHsp" style=""></span>s&#44; continuing compressions during defibrillator charge&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Oxygenation</span>&#46; During CPA&#44; supplemental oxygen should be administered as soon as possible&#44; providing a higher concentration of inspired oxygen&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Airway management</span>&#46; The airway must be sustained and the lungs must be immediately ventilated with the most appropriate equipment at hand&#46; Ventilation should be started with the use of a mask or ambu-mask by 2 technicians&#44; which can be supplemented with an oropharyngeal airway&#46;</p></li></ul></p><p id="par0140" class="elsevierStylePara elsevierViewall">Tracheal intubation provides the most reliable airway&#44; but should only be attempted if the health professional is properly trained and experienced in the technique&#46; Tracheal intubation should not delay defibrillation attempts&#46; Laryngoscopy and intubation should be attempted without interrupting chest compressions&#44; although a brief pause in chest compressions may be required while the tube passes through the vocal cords&#44; but this pause should be less than 5<span class="elsevierStyleHsp" style=""></span>s&#46; No randomized controlled trial has shown that tracheal intubation increases survival after CA&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Alternatively&#44; a supraglottic airway device &#40;SAD&#41; and a self-inflating balloon can be used&#46; Once a SAD is inserted&#44; continuous chest compressions should be performed without interruption during ventilation&#46; A resuscitation should be established with a ratio 30&#58;2 if excessive gas leakage causes inadequate ventilation&#46;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Ventilation</span>&#46; The volume required for ventilation in adult CPR should make the chest rise visibly &#40;500&#8211;600<span class="elsevierStyleHsp" style=""></span>ml or 6&#8211;7<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#41;&#44; with an insufflation duration of about a second&#46; The maximum chest compressions interruption for 2 ventilations &#40;30&#58;2&#41; should not exceed 10<span class="elsevierStyleHsp" style=""></span>s&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">Current importance of <span class="elsevierStyleItalic">waveform capnography</span>&#46; Waveform capnography enables continuous real-time CO<span class="elsevierStyleInf">2</span> monitoring during CPR at the end of expiration&#46; During CPR&#44; CO<span class="elsevierStyleInf">2</span> values at the end of expiration are low&#44; reflecting the low cardiac output generated by chest compression&#46; The role of the waveform capnography during CPR includes<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">23&#8211;25</span></a>&#58; &#40;a&#41; confirmation of proper tracheal tube placement&#59; &#40;b&#41; monitors the quality of chest compressions during CPR &#40;greater depth of chest compression increases values&#41;&#59; &#40;c&#41; monitors ventilation during CPR&#44; avoiding hyperventilation&#59; &#40;d&#41; identifies ROSC during CPR &#40;an increase in CO<span class="elsevierStyleInf">2</span> at the end of exhalation during CPR may indicate ROSC&#41;&#44; &#40;e&#41; prognosis during CPR &#40;very low values of CO<span class="elsevierStyleInf">2</span> at the end of expiration may indicate a poor prognosis and a lower probability of ROSC&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Vascular access&#46;</span> Most interventions can be carried out without chest compression interruptions&#46; Peripheral venous cannulation is quicker&#44; easier to perform and safer than central venous cannulation&#46; Drugs injected peripherally should be followed by a bolus of at least 20<span class="elsevierStyleHsp" style=""></span>ml of fluid and a limb elevation during 10&#8211;20<span class="elsevierStyleHsp" style=""></span>s to facilitate delivery of the drug to the central circulation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Interosseous access&#46;</span> Intraosseous insertion devices should be available&#59; staff should be trained in its use&#44; because if intravenous access is difficult or impossible&#44; the intraosseous administration of pharmacotherapy in adults is effective&#44; achieving appropriate plasma concentrations in a time interval which can be compared to intravenous administration&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a></p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">CPA in pregnant women</span> is a challenge&#44; recommending early and high-quality CPR with uterine manual displacement&#44; advanced life support and early removal of the foetus if the ROSC is not achieved&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">There is currently a greater emphasis on the need <span class="elsevierStyleItalic">of urgent coronary catheterization and percutaneous coronary intervention</span> in cases of resuscitation after a VF or PVT in the context of a probable cardiac cause&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Mechanical chest compression devices</span> do not provide or increase survival advantages over manual chest compression&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a></p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Postresuscitation care</span>&#46; Success in ROSC is the first step to achieve the goal of complete recovery from CA&#46; Depending on the cause of the CPA&#44; many patients will require multiple organ support and the treatment they receive during postresuscitation significantly influences the overall outcome and particularly the quality of neurological recovery&#46; This is what is called post-cardiac arrest syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> Regarding neurological recovery&#44; induced mild hypothermia is neuroprotective and improves outcome after a period of global cerebral hypoxia-ischemia&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a></p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="par0190" class="elsevierStylePara elsevierViewall">Despite technical advances introduced for in-hospital CPR protocols since 2010&#44; survival remains low&#44; especially if the CPA occurs in hospital areas where the staff are not trained to deal with the problem&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> Within Spanish hospitals&#44; emergency medical equipment or arrest equipment have been introduced&#44; even though CPA treatment outcomes are considered an indicator of the quality of the health system&#46; It would be essential to promote continuous training courses for both&#44; basic and advanced CPR&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflict of interests</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Pall&#225;s Beneyto LA&#44; Rodr&#237;guez Luis O&#44; Bayarri VM&#46; Actualizaci&#243;n en la reanimaci&#243;n intrahospitalaria&#46; Med Clin &#40;Barc&#41;&#46; 2016&#59;147&#58;558&#8211;563&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Initial in-hospital resuscitation algorithm&#46; ABCD&#58; first aid sequence that includes A&#58; opening the airway&#44; B&#58; ventilation&#44; C&#58; circulatory support and D&#58; differential diagnosis&#59; CPA&#58; cardiopulmonary arrest&#59; ROSC&#58; recovery of spontaneous circulation&#59; CPR&#58; cardiopulmonary resuscitation&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">VF&#58; ventricular fibrillation&#59; CPA&#58; cardiopulmonary arrest&#59; CPR&#58; cardiopulmonary resuscitation&#59; PVT&#58; pulseless ventricular tachycardia&#46;</p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Recovery of spontaneous circulation and breathing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Knowledge that initiated CPR is futile &#40;irreversible disease&#41;&#46; Confirmation that the CPA occurred as a result of the natural evolution of an incurable process&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Presentation of &#8220;Do Not Resuscitate&#8221; order&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Confirmation that resuscitation manoeuvres were initiated with more than 10<span class="elsevierStyleHsp" style=""></span>min delay &#40;except in cases of drowning&#44; accidental hypothermia or poisoning&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Absence for more than 20<span class="elsevierStyleHsp" style=""></span>min of spontaneous heartbeat despite adequate CPR&#44; and in the absence of electrical activity&#46; To be continued as long as PVT&#47;VF persists&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In-hospital resuscitation suspension indications&#46;</p>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">CPA&#58; cardiopulmonary arrest&#59; CPR&#58; cardiopulmonary resuscitation&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">If the patient has been more than 10<span class="elsevierStyleHsp" style=""></span>min in CPA without resuscitation&#44; CPR can be started if the patient is a potential organ donor&#46;</p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Presence of indisputable signs of death &#40;<span class="elsevierStyleItalic">lividity</span>&#44; <span class="elsevierStyleItalic">rigour mortis</span>&#44; <span class="elsevierStyleItalic">etc</span>&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evolution of a terminal process or dignified life expectancy highly unlikely&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CPA with more than 10<span class="elsevierStyleHsp" style=""></span>min of progression &#40;well documented&#41; without having started basic CPR&#44; except in patients with hypothermia&#44; drowning or poisoning by barbiturates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">When there is a risk to the resuscitation team&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Contraindications for in-hospital resuscitation initiation&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
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                      "Revista" => array:6 [
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                  "host" => array:1 [
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