Re: Cardiopulmonary resuscitation
Dr Samuel highlights the difficulties of producing a comprehensive review given the diverse readership of the BMJ. We were commissioned to provide a general overview of current guidelines, introduce recent developments and highlight areas of current controversy. We included links to the in-depth international CPR guidelines for those readers seeking additional information.
To address the specific queries raised by Dr Samuel, we refer readers to the International Liaison Committee for Resuscitation (ILCOR) systematic review on treatment of cardiac arrest secondary to pulmonary embolus (PE).1 In brief, ﬁbrinolytic therapy should be considered when PE causes cardiac arrest.2 Survival and good neurological outcome have been reported in cases requiring over 60 min of CPR.1 Consider performing CPR for at least 60–90 min before terminating resuscitation attempts. Detailed information on other reversible causes are contained within these guidelines.1,2
We agree that effective team leadership skills are required for optimal team performance. Recent data link better team leadership with improved technical skills performance in simulated cardiac arrest setting.3 Non-technical skill training is now included in the Resuscitation Council (UK) ALS Course.
The decision about when to stop CPR is challenging. Although termination rules have been validated for out of hospital cardiac arrest, the ILCOR systematic review of CPR termination rules found limited evidence supporting in-hospital termination rules.4 In our practice, termination of resuscitation efforts is based on ruling out reversible causes, the duration of the resuscitation and information about co-morbidities and functional status prior to cardiac arrest. Recent data indicate better outcomes (higher likelihood of return of spontaneous circulation (adjusted risk ratio 1·12, 95% CI 1·06–1·18; p<0·0001) and survival to discharge (1·12, 1·02–1·23; 0·021) in hospitals in the quartile with the longest median duration of resuscitation attempts in non-survivors (25 min [IQR 25–28]) compared with hospitals in the quartile with the shortest median resuscitation attempts (16 min [IQR 15–17]).5
1. Deakin CD, Nolan JP, Soar J, Sunde K, Koster RW, Smith GB, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2010;81(10):1305-52.
2. Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, et al. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2010;81 Suppl 1:e93-e174.
3. Yeung JH, Ong GJ, Davies RP, Gao F, Perkins GD. Factors affecting team leadership skills and their relationship with quality of cardiopulmonary resuscitation. Crit Care Med 2012;40(9):2617-21.
4. Soar J, Mancini ME, Bhanji F, Billi JE, Dennett J, Finn J, et al. Part 12: Education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2010;81 Suppl 1:e288-330.
5. Goldberger ZD, Chan PS, Berg RA, Kronick SL, Cooke CR, Lu M, et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet 2012;380:1473-81.
Competing interests: JPN, JS and GDP are members of the Executive Committee of the Resuscitation Council (UK). All were authors of the 2010 cardiopulmonary resuscitation guidelines (RC (UK) and European Resuscitation Council).