Introduction
Adult advanced life support (ALS) includes advanced interventions after basic life support has started and when appropriate an automated external defibrillator (AED) has been used. Adult basic life support (BLS) and use of AEDs is addressed in Section 2. The transition between basic and advanced life support should be seamless as BLS will continue during and overlap with ALS interventions. This section on ALS includes the prevention of cardiac arrest, specific aspects of prehospital ALS, starting in-hospital resuscitation, the ALS algorithm, manual defibrillation, airway management during CPR, drugs and their delivery during CPR, and the treatment of peri-arrest arrhythmias. There are two changes in the presentation of these guidelines since European Resuscitation Council (ERC) Guidelines 2010.
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There is no longer a separate section on electrical therapies2
and the ALS aspects are now part of this section. Post-resuscitation care guidelines are presented in a new section (Section 5) that recognises the importance of the final link in the Chain of Survival.3
These Guidelines are based on the International Liaison Committee on Resuscitation (ILCOR) 2015 Consensus on Science and Treatment Recommendations (CoSTR) for ALS.
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The 2015 ILCOR review focused on 42 topics organised in the approximate sequence of ALS interventions: defibrillation, airway, oxygenation and ventilation, circulatory support, monitoring during CPR, and drugs during CPR. For these Guidelines the ILCOR recommendations were supplemented by focused literature reviews undertaken by the ERC ALS Writing Group for those topics not reviewed in the 2015 ILCOR CoSTR. Guidelines were drafted and agreed by the ALS Writing Group members before final approval by the ERC General Assembly and ERC Board.Summary of changes since 2010 Guidelines
The 2015 ERC ALS Guidelines have a change in emphasis aimed at improved care and implementation of these guidelines in order to improve patient focused outcomes.
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The 2015 ERC ALS Guidelines do not include any major changes in core ALS interventions since the previous ERC guidelines published in 2010.1
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The key changes since 2010 are:- •Continuing emphasis on the use of rapid response systems for care of the deteriorating patient and prevention of in-hospital cardiac arrest.
- •Continued emphasis on minimally interrupted high-quality chest compressions throughout any ALS intervention: chest compressions are paused briefly only to enable specific interventions. This includes minimising interruptions in chest compressions to attempt defibrillation.
- •Keeping the focus on the use of self-adhesive pads for defibrillation and a defibrillation strategy to minimise the preshock pause, although we recognise that defibrillator paddles are used in some settings.
- •There is a new section on monitoring during ALS with an increased emphasis on the use of waveform capnography to confirm and continually monitor tracheal tube placement, quality of CPR and to provide an early indication of return of spontaneous circulation (ROSC).
- •There are a variety of approaches to airway management during CPR and a stepwise approach based on patient factors and the skills of the rescuer is recommended.
- •The recommendations for drug therapy during CPR have not changed, but there is greater equipoise concerning the role of drugs in improving outcomes from cardiac arrest.
- •The routine use of mechanical chest compression devices is not recommended, but they are a reasonable alternative in situations where sustained high-quality manual chest compressions are impractical or compromise provider safety.
- •Peri-arrest ultrasound may have a role in identifying reversible causes of cardiac arrest.
- •Extracorporeal life support techniques may have a role as a rescue therapy in selected patients where standard ALS measures are not successful.
3a – Prevention of in-hospital cardiac arrest
Early recognition of the deteriorating patient and prevention of cardiac arrest is the first link in the chain of survival.
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Once cardiac arrest occurs, only about 20% of patients who have an in-hospital cardiac arrest will survive to go home.6
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The key recommendations for the prevention of in-hospital cardiac arrest are unchanged since the previous guidance in 2010.
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We suggest an approach to prevention of in-hospital cardiac arrest that includes staff education, monitoring of patients, recognition of patient deterioration, a system to call for help and an effective response – the chain of prevention.8
The problem
Cardiac arrest in patients in unmonitored ward areas is not usually a sudden unpredictable event.
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Patients often have slow and progressive physiological deterioration, involving hypoxaemia and hypotension that is unnoticed or poorly managed by ward staff.10
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The initial cardiac arrest rhythm is usually non-shockable6
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and survival to hospital discharge is poor, particularly in patients with preceding signs of respiratory depression or shock.7
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Early and effective treatment might prevent some cardiac arrests, deaths and unanticipated ICU admissions. Studies conducted in hospitals with traditional cardiac arrest teams have shown that patients attended by the team but who were found not to have a cardiac arrest, have a high morbidity and mortality.14
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Registry data from the US suggests that hospitals with lowest incidence of IHCA also have the highest CA survival.17
Nature of the deficiencies in the recognition and response to patient deterioration
These include infrequent, late or incomplete vital signs assessments; lack of knowledge of normal vital signs values; poor design of vital signs charts; poor sensitivity and specificity of ‘track and trigger’ systems; failure of staff to increase monitoring or escalate care, and staff workload.
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Problems with assessing and treating airway, breathing and circulation abnormalities as well organisational problems such as poor communication, lack of teamwork and insufficient use of treatment limitation plans are not infrequent.10
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Education in acute care
Several studies show that medical and nursing staff lack knowledge and skills in acute care,
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e.g. oxygen therapy,30
fluid and electrolyte balance,31
analgesia,32
issues of consent,33
pulse oximetry,30
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and drug doses.36
Staff education is an essential part of implementing a system to prevent cardiac arrest but to date, randomised controlled studies addressing the impact of specific educational interventions are lacking.37
In one study, virtually all the improvement in the hospital cardiac arrest rate occurred during the educational phase of implementation of a medical emergency team (MET) system.
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Rapid response teams, such as METs, play a role in educating and improving acute care skills of ward personnel.37
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The introduction of specific, objective calling criteria,41
referral tools42
and feedback to caregivers43
has resulted in improved MET use and a significant reduction in cardiac arrests. Another study found that the number of cardiac arrest calls decreased while pre-arrest calls increased after implementing a standardised educational programme44
in two hospitals45
; this was associated with a decrease in CA incidence and improved CA survival. Other research suggests that multi-professional education did not alter the rate of mortality or staff awareness of patients at risk on general wards.46
Monitoring and recognition of the critically ill patient
Clinical signs of acute illness are similar whatever the underlying process, as they reflect failing respiratory, cardiovascular and neurological systems. Alterations in physiological variables, singly or in combination are associated with, or can be used to predict the occurrence of cardiac arrest,
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hospital death20
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and unplanned ICU admission,47
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and with increasing magnitude and number of derangements the likelihood of death is increased.18
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Even though abnormal physiology is common on general wards,80
the measurement and documentation of vital signs is suboptimal.9
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To assist in the early detection of critical illness, each patient should have a documented plan for vital signs monitoring including which physiological measurements needs no be undertaken and frequency.24
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Many hospitals use early warning scores (EWS) or calling criteria to identify ward patients needing escalation of care,
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and this increases vital signs monitoring.82
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These calling criteria or ‘track and trigger’ systems include single-parameter systems, multiple-parameter systems, aggregate weighted scoring systems or combination systems.90
Aggregate weighted track and trigger systems offer a graded escalation of care, whereas single parameter track and trigger systems provide an all-or-nothing response. Simpler systems may have advantages over more complex ones.91
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Nurse concern may also be an important predictor of patient deterioration.93
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The use of an aggregate score based on a number of vital sign abnormalities appears more important than abnormalities in a single criteria.
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Aggregate-weighted scoring systems vary in their performance and in which endpoint they predict.20
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In older (>65 year) patients, who represent the largest group of IHCA patients,99
signs of deterioration before cardiac arrest are often blunted, and the predictive value of the Modified Early Warning Score (MEWS) progressively decreases with increasing patient age.100
The design of vital signs charts
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or the use of technology102
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may have an important role in the detection of deterioration and the escalation of care, but these require further study. Possible benefits include increased vital signs recording,105
improved identification of signs of deterioration,19
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reduced time to team activation103
and improved patient outcomes.103
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Calling for help and the response to critical illness
Nursing staff and junior doctors often find it difficult to ask for help or escalate treatment as they feel their clinical judgement may be criticised.
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In addition, there is a common belief, especially amongst younger staff, that the patient's primary team should be capable of dealing with problems close to their area of specialty.- Shearer B.
- Marshall S.
- Buist M.D.
- et al.
What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service.
BMJ Qual Saf. 2012; 21: 569-575
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It is logical that hospitals should ensure all staff are empowered to call for help and also trained to use structured communication tools such as RSVP (reason-story-vital signs-plan)- Shearer B.
- Marshall S.
- Buist M.D.
- et al.
What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service.
BMJ Qual Saf. 2012; 21: 569-575
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or SBAR (situation-background-assessment-recommendation)112
tools to ensure effective inter-professional communication. However, recent research suggests that structured communication tools are rarely used in clinical practice.113
The response to patients who are critically ill or who are at risk of becoming critically ill is now usually provided by a medical emergency team (MET), rapid response team (RRT), or critical care outreach team (CCOT).
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These replace or coexist with traditional cardiac arrest teams, which typically respond to patients already in cardiac arrest. MET/RRT usually comprise medical and nursing staff from intensive care and general medicine, who respond to specific calling criteria. Any member of the healthcare team can initiate a MET/RRT/CCOT call. In some hospitals, the patient, and their family and friends, are also encouraged to activate the team.118
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Team interventions often involve simple tasks such as starting oxygen therapy and intravenous fluids.121
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However, post-hoc analysis of the MERIT study data suggests that nearly all MET calls required ‘critical care-type’ interventions.126
The MET, RRT or CCOT is often also involved in discussions regarding ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) or end-of-life plans.127
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Recently, attempts have been made to develop a screening tool to identify patients at the end of life and quantify the risk of death in order to minimise prognostic uncertainty and avoid potentially harmful and futile treatments.134
Studying the effect of the MET/RRT/CCOT systems on patient outcomes is difficult because of the complex nature of the intervention. During the period of most studies of rapid response teams, there has been a major international focus on improving other aspects of patient safety, e.g. hospital acquired infections, earlier treatment of sepsis and better medication management, all of which have the potential to influence patient deterioration and may have a beneficial impact on reducing cardiac arrests and hospital deaths. Most studies on RRT/MET systems to date originate from the USA and Australia and the systems effectiveness in other health care systems in not clear.
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A well-designed, cluster-randomised controlled trial of the MET system (MERIT study) involving 23 hospitals
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did not show a reduction in cardiac arrest rate after introduction of a MET when analysed on an intention-to-treat basis. Both the control and MET groups demonstrated improved outcome compared to baseline. Post hoc analysis of the MERIT study showed there was a decrease in cardiac arrest and unexpected mortality rate with increased activation of the MET system.136
The evidence from predominantly single centre observational studies is inconclusive, with some studies showing reduced numbers of cardiac arrests after MET/RRT implementation38
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and some studies failing to show a reduction121
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. However, systematic reviews, meta-analyses and multicentre studies do suggest that RRT/MET systems reduce rates of cardiopulmonary arrest and lower hospital mortality rates.164
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Concern has been expressed about MET activity leading to potential adverse events resulting from staff leaving normal duties to attend MET calls. Research suggests that although MET calls may cause disruption to normal hospital routines and inconvenience to staff, no major patient harm follows.167
Appropriate placement of patients
Ideally, the sickest patients should be admitted to an area that can provide the greatest supervision and the highest level of organ support and nursing care. International organisations have offered definitions of levels of care and produced admission and discharge criteria for high dependency units (HDUs) and ICUs.
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