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CHAPTER 13 Cardiac arrest: clinical management
Jon C. Rittenberger and Vincent N. Mosesso, Jr.
Introduction
Detailed algorithms and consensus guidelines, often referred to as basic life support (BLS) and advanced cardiac life support (ACLS), exist for cardiac arrest management. However, there are unique practical and scientific considerations that may affect the execution of resuscitation efforts in the out‐of‐hospital setting. EMS medical directors and field personnel including EMS physicians must be aware of these factors when developing protocols for prehospital resuscitation. They must also understand the scientific basis for, and the controversies surrounding, recommended resuscitation actions.
This chapter reviews scientific and practical considerations for carrying out BLS and ACLS in the prehospital setting. For specific treatment algorithms, the reader is referred to the American Heart Association (AHA) Emergency Cardiac Care (ECC) Guidelines [1].
Specific interventions
Chest compressions
Chest compressions are essential in cardiac arrest resuscitation. In consideration of ECMO, chest compressions generate coronary perfusion pressure (CPP), and a CPP of at least 20 mmHg is important for achieving return of spontaneous circulation (ROSC) [2]. Multiple studies highlight the role of early chest compressions in survival from cardiac arrest [3–6].
The most recent BLS and ACLS guidelines emphasize the delivery of continuous chest compressions with as few interruptions as possible [1]. Several consecutive chest compressions are necessary to generate adequate CPP [7]. CPP drops off immediately when chest compressions are discontinued [8]. The proportion of resuscitation time without chest compressions, termed hands‐off time or no‐flow fraction, is inversely associated with cardiac arrest survival [9]. Compression depth, rate, and full recoil are also critical characteristics for effectiveness.
Prior work has highlighted the often‐substandard CPR performed by prehospital and in‐hospital clinicians. In a series of prehospital cardiac arrests in Europe, chest compressions were delivered on average only half of the time while the patient was in arrest, and most compressions were too shallow [10]. There have been similar observations made in analyses of in‐hospital resuscitations [11].
Delivering chest compressions during cardiac arrest resuscitation poses practical challenges. The treating EMS team must provide