To the Editor,
It was with great interest we read the paper by Lott et al. presenting the European Resuscitation Council (ERC) Guidelines 2021: Cardiac arrest in special circumstances.
1We like to express our gratitude to this collaboration group describing the treatment of traumatic cardiac arrest (TCA) as a specific modality, needing prompt and targeted action. Different, trauma related, causes of the arrest specific intervention strategies are described. Emphasizing TCA as a unique disease, with approaches that differ from the standard advanced life support sequences.
- Lott C.
- et al.
European Resuscitation Council Guidelines 2021: cardiac arrest in special circumstances.
Resuscitation. 2021; 161: 152-219
Time is of essence in a cardiac arrest and causes must be identified and treated accordingly in a very limited time frame. In the proposed TCA algorithm (figure 2) a “secured airway” is prioritized to actual treatment of the underlying causes of arrest, for instance the release of a tension pneumothorax of cardiac tamponade. The term “secured airway”, in our opinion, refers to a endotracheal tube with inflated cuff placed under the vocal cords. Of course oxygenation is needed for the patient to survive, but a secured airway is not as urgent as the treatment of a tamponade or tension pneumothorax. Intubation and consequent positive pressure ventilation in this phase of resuscitation might even be disadvantageous.
- Hudson A.J.
- et al.
Airway and ventilation management strategies for hemorrhagic shock. To tube, or not to tube, that is the question!.
J Trauma Acute Care Surg. 2018; 84: S77-S82
We like to propose to change the algorithm and use the sentence used in the ECR pediatric TCA section: “airway opening and ventilation with (high flow) oxygen”.
3This action takes less time and less resources, increasing the possibility to identify and treat the underlying cause of TCA.
- Perkins G.D.
- et al.
European Resuscitation Council Guidelines 2021: executive summary.
Resuscitation. 2021; 161: 1-60
In case of traumatic cardiac tamponade there is very limited evidence, and place, for (ultrasound guided) needle pericardiocentesis as proposed in the guidelines. This skill is not without risks and demands training and skills.
4Even when the needle is in the correct position, it is debatable if the cumulated clotted blood can be aspirated adequately. Needle pericardiocentesis provides no definitive treatment unlike clot removal by thoracotomy.
- Loukas M.
- et al.
Pericardiocentesis: a clinical anatomy review.
Clin Anat. 2012; 25: 872-881
5In a scenario with adequate resources and skilled professionals, a (guided) pericardiocentesis will only delay a resuscitative thoracotomy and must therefore not be included in a TCA guideline.
- Lee T.H.
- et al.
Pericardiocentesis in trauma: a systematic review.
J Trauma Acute Care Surg. 2013; 75: 543-549
Conflicts of interest
- European Resuscitation Council Guidelines 2021: cardiac arrest in special circumstances.Resuscitation. 2021; 161: 152-219
- Airway and ventilation management strategies for hemorrhagic shock. To tube, or not to tube, that is the question!.J Trauma Acute Care Surg. 2018; 84: S77-S82
- European Resuscitation Council Guidelines 2021: executive summary.Resuscitation. 2021; 161: 1-60
- Pericardiocentesis: a clinical anatomy review.Clin Anat. 2012; 25: 872-881
- Pericardiocentesis in trauma: a systematic review.J Trauma Acute Care Surg. 2013; 75: 543-549
Published online: May 21, 2021
Received: April 8, 2021
© 2021 Elsevier B.V. All rights reserved.
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- European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstancesResuscitationVol. 161
- PreviewThese European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
- Reply to: Suggestions to improve the traumatic cardiac arrest guidelines based on practical prehospital experienceResuscitationVol. 164