Diagnosis and treatment
Update on in hospital resuscitation
Actualización en la reanimación intrahospitalaria
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"documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Clin. 2016;147:554-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "The reliability of clinical trials. The risky way towards drug deregulation" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "554" "paginaFinal" => "557" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fiabilidad de los ensayos clínicos. 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ABCD: first aid sequence that includes A: opening the airway, B: ventilation, C: circulatory support and D: differential diagnosis; CPA: cardiopulmonary arrest; ROSC: recovery of spontaneous circulation; CPR: cardiopulmonary resuscitation.</p>" ] ] ] "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,<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 (CPA) during their hospital stay. 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, should this situation arise.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Cardiac arrest (CA) is the cessation of cardiac mechanical activity, which is diagnosed by the absence of consciousness and pulse. Cardiopulmonary resuscitation (CPR) includes all the manoeuvres to reverse this situation, and its main objective is to reverse clinical death, minimize the consequences and improve neurological outcome, basic pillars in the current concept of cardiocerebral resuscitation.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> Currently, early recognition of deterioration in a patient and CA prevention is the first link in the chain of supervenience.<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, establishing staff training on identifying signs of patient deterioration, frequent and appropriate monitoring of vital signs in these patients, 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.</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, oxygenation and circulation through a series of advanced resuscitation measures including early defibrillation, external chest compressions, actions on the airway, ventilation, intravenous medication, <span class="elsevierStyleItalic">etc.</span> performed by specialized personnel.<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 0.4 and 2% of hospitalized patients.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> Once that occurs, only about 20% survive, and those who survive, up to 30% have significant neurological sequelae, with permanent brain damage, known as post-anoxic encephalopathy<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a>; hence the insistence of this in-hospital CPR update on enhancing, implementing and improving advanced CPR techniques, as well as introducing new postresuscitation measures aimed to minimize that permanent brain damage.</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/or circulation, potentially reversible vital signs. As a result of CPA, there is a tissue oxygenation inability, the brain being the most sensitive organ to anoxia. If resuscitation is initiated before 4<span class="elsevierStyleHsp" style=""></span>min have elapsed, the probability of survival doubles.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7,8</span></a> Some concepts should be clarified, for example, <span class="elsevierStyleItalic">respiratory arrest</span> is the cessation of spontaneous breathing, with heartbeat remaining during 3–4<span class="elsevierStyleHsp" style=""></span>min. The most common causes are poisoning, airflow obstruction, disorders of the central nervous system and chest trauma. <span class="elsevierStyleItalic">CA</span> usually follows respiratory arrest or appears in the context of serious, life-threatening arrhythmias, such as ventricular fibrillation (VF), pulseless ventricular tachycardia (PVT) as well as pulseless electrical activity. <span class="elsevierStyleItalic">in-hospital CPR</span> refers to advanced resuscitation carried out by qualified professionals with the necessary equipment to perform defibrillation, besides optimizing the respiratory and circulatory support.</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, the usual protocol involves the immediate establishment of life support measures, and given the difficulty in knowing or predicting patient survival, comorbidities and baseline condition, the patient often receives simultaneous treatment interventions in order to restore life and minimize neurological sequelae, but this is not always appropriate. In this sense, we must acknowledge some ethical aspects:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1)</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/her values and beliefs. The application of this principle during CA is difficult.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2)</span><p id="par0040" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">principle of beneficence</span> implies that the interventions established should benefit the patient, deciding what treatment strategies are most appropriate and with a lower risk for the patient.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3)</span><p id="par0045" class="elsevierStylePara elsevierViewall">CPR is an invasive procedure with a low probability of success, so, CPR should not be performed in futile cases. This action falls within the concept of <span class="elsevierStyleItalic">principle of non-maleficence</span>, understanding that resuscitation is considered futile when the chances of survival with a good quality of life are minimal. The decision not to attempt resuscitation does not require the consent of the patient or their relatives, who often have unrealistic expectations.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4)</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.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Therefore, after an in-hospital CA, the default position is to start resuscitation unless a decision has been made regarding not to perform CPR, having to review the decisions on resuscitation and the consequences of the same, taking into account the difficulty of determining when CPR is likely to fail or be futile.</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resuscitation indications, cessation and contraindications</span><p id="par0060" class="elsevierStylePara elsevierViewall">In a hospital environment, when facing a CPA situation and CPR initiation, it is important to try to establish the cause that led to the arrest and know the patient's prognosis as soon as possible. This will help in deciding the intensity and continuity of the manoeuvres. Unless the patient has expressly left in writing a “Do Not Resuscitate” (DNR) order as part of his/her living will, CPR must be started, as this situation is considered of extreme urgency. Once resuscitation is established, the decision to suspend efforts is difficult and it will never be an isolated time interval; clinical judgement and human dignity must be taken into account in this process (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The resuscitation team should review the quality of this and ensure that they have successfully carried out an adequate and high-quality CPR, a defibrillation in the presence of shockable rhythms, vascular access and drug administration in an appropriate manner, effective ventilation and identification and treatment of the reversible causes. However, there are some situations that contraindicate starting resuscitation<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</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 (the chain of survival)</span><p id="par0065" class="elsevierStylePara elsevierViewall">After an in-hospital CA, the division between basic life support and advanced life support is arbitrary, and it should be a continuous process in clinical practice. This requires organization and a set of integrated actions ranging from the site where CPA takes place to the patient's admission in the critical care unit, where postresuscitation care will be given. The <span class="elsevierStyleItalic">American Heart Association</span> defined this set of actions as <span class="elsevierStyleItalic">Chain of Survival</span>,<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. This response comprises four links: (a) early recognition of a dying patient in a situation of cardiocirculatory pre-arrest or arrest and request for help, 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>; (b) early application of life support techniques (early CPR); (c) early defibrillation, and (d) establish advanced care and postresuscitation. If any of the links is lost, the chance of survival decreases, hence the importance of an updated knowledge and continuous training.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The first step is to establish early identification and early action; therefore, targeted action guidelines will be established:<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>, with a high risk of CPA, an urgent medical evaluation based on the hospital's own protocols is required.</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> (sign of arrest, which should not be mistaken as a sign of life) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), help should be simultaneously requested, keep the airway open (look, listen and feel, no more than 10<span class="elsevierStyleHsp" style=""></span>s) and, if absent, begin chest compressions without having to feeling the pulse,<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1,12,13</span></a> because delays in CA diagnosis and the beginning of CPR will negatively affect survival.<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.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> As one member of staff begins CPR, others call the resuscitation team and get the resuscitation equipment and a defibrillator. In the latest resuscitation recommendations,<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>, compressing to a <span class="elsevierStyleItalic">depth of about 5</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">cm</span>, but not more than 6<span class="elsevierStyleHsp" style=""></span>cm (novelty regarding the 2010 recommendations)<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a>, with a <span class="elsevierStyleItalic">100–120<span class="elsevierStyleHsp" style=""></span>min</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">−1</span></span><span class="elsevierStyleItalic">frequency, allowing the chest to re-expand completely after each compression</span>, without resting on the chest. Disruptions should be minimized, ensuring high quality compressions. If possible, 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>, but without interrupting chest compressions. CPR start and end times should be recorded.</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, how to manage shockable rhythms (VF/PVT) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) has not been modified since the 2010 recommendations regarding the use and indications of defibrillation.<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">16,17</span></a> Without interrupting chest compressions, another resuscitating technician charges the defibrillator and, once charged, chest compressions pause, making sure all resuscitating technicians are clear of the patient, then the first shock is performed with an intensity of at least 150 J for biphasic defibrillators (360 J monophasic). The defibrillation shock levels have not changed from the 2010 recommendations.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> In manual defibrillators, it is considered appropriate to increase the energy of successive shocks after an unsuccessful shock and in patients in which refibrillation occurs. <span class="elsevierStyleItalic">Without stopping to check for rhythm or feeling the pulse, CPR will resume</span> (CV ratio 30:2) immediately after the shock during <span class="elsevierStyleItalic">2</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">min</span>; then a <span class="elsevierStyleItalic">short pause should be made to assess the rhythm</span> and, if VF/PVT persists, give a <span class="elsevierStyleItalic">second shock</span> (150–360<span class="elsevierStyleHsp" style=""></span>J biphasic) and, without stopping to reassess the rhythm or feeling the pulse, <span class="elsevierStyleItalic">resume CPR</span> (CV ratio 30:2) immediately after the shock. CPR must <span class="elsevierStyleItalic">continue during 2</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">min</span>, then pause briefly to assess the rhythm; if VF/PVT persists, give a <span class="elsevierStyleItalic">third shock</span> (150–360<span class="elsevierStyleHsp" style=""></span>J biphasic). Without reassessing the rhythm or feeling the pulse, <span class="elsevierStyleItalic">resume CPR</span> (CV ratio 30:2) immediately after the shock, starting with chest compressions. If intravenous access is achieved, <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 (intraosseous access can be used with the same level of effectiveness if a peripheral vein access is not achieved; administering drugs intratracheally is not currently recommended).<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1,16</span></a> If the return of spontaneous circulation (ROSC) has not been achieved with the third shock, adrenaline can improve myocardial blood flow and increase the likelihood of successful defibrillation with the next shock. After each 2<span class="elsevierStyleHsp" style=""></span>min resuscitation cycle, if the rhythm changes to asystole or pulseless electrical activity, the measures described in the <span class="elsevierStyleItalic">non-shockable rhythms</span> algorithm will be applied and if ROSC has been achieved, postresuscitation care should begin. Regardless of the arrest rhythm, after the initial dose of adrenaline has been given, <span class="elsevierStyleItalic">1</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mg of adrenaline must be administered every 3–5</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">min</span> until ROSC is achieved.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Managing non-shockable rhythms (asystole/pulseless electrical activity) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>)</span><p id="par0090" class="elsevierStylePara elsevierViewall">Pulseless electrical activity and asystole require CPR (30:2) initiation in patients without airway isolation. Those patients with an advanced airway device may be ventilated without interrupting chest compressions, at a rate of 100–120<span class="elsevierStyleHsp" style=""></span>lpm and ventilatory ratio of 10<span class="elsevierStyleHsp" style=""></span>bpm. After 2<span class="elsevierStyleHsp" style=""></span>min of CPR, the rhythm will be checked through the monitor, and if asystole persists, CPR will restart immediately. If an organized rhythm appears, check for central pulse evidence. If no pulse (or if there is any doubt about the presence of pulse), continue CPR. 1<span class="elsevierStyleHsp" style=""></span>mg of adrenaline should be given as soon as venous or intraosseous access is achieved, and repeat at every other cycle of CPR (about every 3–5<span class="elsevierStyleHsp" style=""></span>min). During any CA, an assessment of potential causes or aggravating factors for which specific treatment exists should be considered.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18,19</span></a> The 4H's reversible causes rule: Hypoxia, Hypovolemia, Hypo-hyperkalaemia, Hypo-hyperthermia, and 4T's: Thrombosis (coronary or pulmonary), Tension Pneumothorax, Tamponade (cardiac), Toxins.</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>μg of atropine IV; if they do not respond or there is a risk of asystole, another 500<span class="elsevierStyleHsp" style=""></span>μg will be administered. This may be repeated up to 3<span class="elsevierStyleHsp" style=""></span>mg. In the absence of an appropriate response to atropine, isoproterenol can be used together with transcutaneous pacing as a step towards the implantation of a temporary pacemaker.</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. Fluids should be infused rapidly. Balanced crystalloid solutions are recommended. Hypotonic fluids should be avoided because they can quickly spread outside the intravascular space and may worsen the neurological outcome.<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. The current recommendation is to continue using adrenaline during CPR, per the 2010 recommendations.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> Evidence that antiarrhythmic drugs are beneficial in the CA is limited. No antiarrhythmic drug administered during CA in humans has been shown to increase survival to hospital discharge. Despite the lack of data on long-term outcomes in humans, the balance of evidence favours the use of antiarrhythmic drugs for the treatment of arrhythmias in CA. After 3 initial shocks, in VF refractory to shock, amiodarone improves short-term survival to hospital admission compared to placebo<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> or lidocaine.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Lidocaine is recommended when amiodarone is not available.<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. Its use may be considered in the treatment for CA associated with hyperkalaemia and tricyclic antidepressants overdose.</p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Fibrinolytic therapy</span> should not be used routinely in CA, and should be considered when this is caused by proven or suspected acute pulmonary embolism.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> If a fibrinolytic drug is administered in these circumstances, performing CPR should be considered for at least 60–90<span class="elsevierStyleHsp" style=""></span>min before the end of resuscitation attempts, 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.<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. Pre- and post-shock pauses should last less than 10<span class="elsevierStyleHsp" style=""></span>s.</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. Evidence on the use of boards is inconclusive, and if used, interrupting CPR and losing venous access, probes and ventilation and oxygenation devices should be avoided.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Defibrillation</span>. The pre-shock pause should be reduced to less than 5<span class="elsevierStyleHsp" style=""></span>s, continuing compressions during defibrillator charge.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Oxygenation</span>. During CPA, supplemental oxygen should be administered as soon as possible, providing a higher concentration of inspired oxygen.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Airway management</span>. The airway must be sustained and the lungs must be immediately ventilated with the most appropriate equipment at hand. Ventilation should be started with the use of a mask or ambu-mask by 2 technicians, which can be supplemented with an oropharyngeal airway.</p></li></ul></p><p id="par0140" class="elsevierStylePara elsevierViewall">Tracheal intubation provides the most reliable airway, but should only be attempted if the health professional is properly trained and experienced in the technique. Tracheal intubation should not delay defibrillation attempts. Laryngoscopy and intubation should be attempted without interrupting chest compressions, although a brief pause in chest compressions may be required while the tube passes through the vocal cords, but this pause should be less than 5<span class="elsevierStyleHsp" style=""></span>s. No randomized controlled trial has shown that tracheal intubation increases survival after CA.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Alternatively, a supraglottic airway device (SAD) and a self-inflating balloon can be used. Once a SAD is inserted, continuous chest compressions should be performed without interruption during ventilation. A resuscitation should be established with a ratio 30:2 if excessive gas leakage causes inadequate ventilation.<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>. The volume required for ventilation in adult CPR should make the chest rise visibly (500–600<span class="elsevierStyleHsp" style=""></span>ml or 6–7<span class="elsevierStyleHsp" style=""></span>ml/kg), with an insufflation duration of about a second. The maximum chest compressions interruption for 2 ventilations (30:2) should not exceed 10<span class="elsevierStyleHsp" style=""></span>s.</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>. Waveform capnography enables continuous real-time CO<span class="elsevierStyleInf">2</span> monitoring during CPR at the end of expiration. During CPR, CO<span class="elsevierStyleInf">2</span> values at the end of expiration are low, reflecting the low cardiac output generated by chest compression. The role of the waveform capnography during CPR includes<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">23–25</span></a>: (a) confirmation of proper tracheal tube placement; (b) monitors the quality of chest compressions during CPR (greater depth of chest compression increases values); (c) monitors ventilation during CPR, avoiding hyperventilation; (d) identifies ROSC during CPR (an increase in CO<span class="elsevierStyleInf">2</span> at the end of exhalation during CPR may indicate ROSC), (e) prognosis during CPR (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).</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Vascular access.</span> Most interventions can be carried out without chest compression interruptions. Peripheral venous cannulation is quicker, easier to perform and safer than central venous cannulation. 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 10–20<span class="elsevierStyleHsp" style=""></span>s to facilitate delivery of the drug to the central circulation.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Interosseous access.</span> Intraosseous insertion devices should be available; staff should be trained in its use, because if intravenous access is difficult or impossible, the intraosseous administration of pharmacotherapy in adults is effective, achieving appropriate plasma concentrations in a time interval which can be compared to intravenous administration.<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, recommending early and high-quality CPR with uterine manual displacement, advanced life support and early removal of the foetus if the ROSC is not achieved.</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.</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.<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>. Success in ROSC is the first step to achieve the goal of complete recovery from CA. Depending on the cause of the CPA, 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. This is what is called post-cardiac arrest syndrome.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> Regarding neurological recovery, induced mild hypothermia is neuroprotective and improves outcome after a period of global cerebral hypoxia-ischemia.<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, survival remains low, especially if the CPA occurs in hospital areas where the staff are not trained to deal with the problem.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> Within Spanish hospitals, emergency medical equipment or arrest equipment have been introduced, even though CPA treatment outcomes are considered an indicator of the quality of the health system. It would be essential to promote continuous training courses for both, basic and advanced CPR.</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.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Definitions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Resuscitation ethics and end-of-life decisions" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Resuscitation indications, cessation and contraindications" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Immediate in-hospital resuscitation (the chain of survival)" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Managing shockable rhythms" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Managing non-shockable rhythms (asystole/pulseless electrical activity) (Fig. 2)" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Resuscitation when faced with hemodynamically unstable slow rhythms" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Fluids and drugs in cardiac arrest" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Some relevant considerations in the new guidelines" ] 10 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusions" ] 11 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflict of interests" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-09-28" "fechaAceptado" => "2016-10-06" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pallás Beneyto LA, Rodríguez Luis O, Bayarri VM. Actualización en la reanimación intrahospitalaria. Med Clin (Barc). 2016;147:558–563.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2172 "Ancho" => 2170 "Tamanyo" => 228770 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Initial in-hospital resuscitation algorithm. ABCD: first aid sequence that includes A: opening the airway, B: ventilation, C: circulatory support and D: differential diagnosis; CPA: cardiopulmonary arrest; ROSC: recovery of spontaneous circulation; CPR: cardiopulmonary resuscitation.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3847 "Ancho" => 3045 "Tamanyo" => 815184 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Algorithm for advanced in-hospital cardiopulmonary resuscitation. ADR: adrenaline; DF: defibrillator; PEA: pulseless electrical activity; VF: ventricular fibrillation; CPR: cardiopulmonary resuscitation; PVT: pulseless ventricular tachycardia.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">VF: ventricular fibrillation; CPA: cardiopulmonary arrest; CPR: cardiopulmonary resuscitation; PVT: pulseless ventricular tachycardia.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \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 \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 (irreversible disease). Confirmation that the CPA occurred as a result of the natural evolution of an incurable process \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 “Do Not Resuscitate” order \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 (except in cases of drowning, accidental hypothermia or poisoning) \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, and in the absence of electrical activity. To be continued as long as PVT/VF persists \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1338496.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In-hospital resuscitation suspension indications.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">CPA: cardiopulmonary arrest; CPR: cardiopulmonary resuscitation.</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, CPR can be started if the patient is a potential organ donor.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \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 (<span class="elsevierStyleItalic">lividity</span>, <span class="elsevierStyleItalic">rigour mortis</span>, <span class="elsevierStyleItalic">etc</span>.) \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 \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 (well documented) without having started basic CPR, except in patients with hypothermia, drowning or poisoning by barbiturates \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 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1338495.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Contraindications for in-hospital resuscitation initiation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "European resuscitation council guidelines for resuscitation 2015. 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