Source: http://sofia.medicalistes.org/spip/spip.php?article562
Timestamp: 2017-08-23 23:00:55+00:00
Document Index: 256626335

Matched Legal Cases: ['arrêt ', 'arrêt ', 'arrêt ', 'arrêt ', 'arrêt ', 'arrêt ', 'arrêt ', 'arrêt ', 'arrêt ', 'arrêt ', 'arrêt ', 'arrêt ', 'arrêt ', 'art 1', 'art 1', 'art 2', 'art 2', 'art 3', 'art 4', 'art 4', 'art 5', 'art 5', 'art 6', 'art 6', 'art 7', 'art 7', 'art 8', 'art 8', 'art 9', 'art 9', 'art 2', 'arrêt ', 'arrêt ', 'arrêt ', 'arrêt ', 'art 5', 'arrêt ', 'arrêt ', 'arrêt ', 'art 7', 'arrêt ', 'arrêt ', 'arrêt ', 'arrêt ', 'arrêt ', 'arrêt ', 'arrêt ']

[Société Française des Infirmier(e)s Anesthésistes] Réanimation cardio respiratoire guidelines ILCOR-ERC 2015-2020
On les attendait le 15 octobre 2015, elles sont à l’heure. Les nouvelles recommandations de l’ILCOR et de l’ERC pour la prise en charge des arrêts cardio-respiratoires.
Elles font suite aux recommandations 2010-2015, et 2005-2010.
Les nouvelles recommandations sont le fruit d’un travail international sur l’arrêt cardio-respiratoire.
D’un côté les recommandations américaines, visées par l’American Heart Association (AHA), de l’autre, les recommandations européennes visées par l’European Resuscitation Council (ERC), en français.
Directives 2015 du Conseil Européen de Réanimation
En français ; traduction par le conseil Belge de réanimation
Rappelons le calendrier
Novembre 2011 Ilcor meeting Orlando
Octobre 2012 Ilcor meeting Vienna
18-20 Avril 2013 Spark Of Life Conference Melbourne
21-22 Avril2013 Ilcor meeting Melbourne
23 Avril 2013 Utstein meeting Melbourne
29-30 Avril 2014 ILCOR meeting Canada
2-5 Février 2015 International Consensus Conference
15 Octobre 2015 ILCOR CoSTR and Guidelines published
Ces publications sont basées sur un processus international coordonné par l’ International Liaison Committee on Resuscitation (ILCOR) créée en 1993 et qui comprend : « the American Heart Association (AHA), the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Australian and New Zealand Committee on Resuscitation, the Resuscitation Council of Southern Africa, the InterAmerican Heart Foundation, and the Resuscitation Council of Asia. »
La mission de l’ILCOR est d’identifier et d’examiner la science internationale et des informations pertinentes à la réanimation cardio-respiratoire et les soins cardiovasculaires d’urgence et offrir un consensus sur des recommandations de traitement.
Pour suivre les évolutions de la réanimation cardio respiratoire aux USA. On notera le premier enseignement "de masse" en 1972 à Seattle, les indications de la réanimation par téléphone en 1981, et en 1990 les DAE accessibles au grand public quand en France on réservait toujours ce geste à la caste médicale. D’où peut-être un retard certain que l’on tente de compenser actuellement.
On peut juste regretter le bouche à bouche, qui s’il n’est pas interdit, n’est toutefois pas recommandé.
Ici viendront s’agglomérer les publications récentes et actualisées, sur la thématique de l’arrêt cardio respiratoire et sa prise en charge. Que ces publications soient en français ou en anglais.
Alain Cariou – Chaine de survie
Alain CARIOU – Comment je pronostique le devenir neurologique
Anne PESKINE – Devenir à long therme des arrêts cardiaques
Florence DUMAS – Aspects épidémiologiques
Nicolas PICHON – Le point sur arrêt cardiaque et Hypothermie
Pascal DANG MINGH – Comment améliorer la qualité de la RCP de Base
Patricia JABRE – Présence de la famille durant la réanimation pré-hospitalière
Pierre-Yves GUEUGNIAUD – Comment améliorer la qualité de la RCP spécialisée
Xavier JOUVEN – Arrêt cardiaque du jeune sportif
Actualités 2015 RCP de l’adulte en dehors de l’hôpital (Dr Meyran)
L’optimisation du massage cardiaque Pascal CASSAN (Paris), Marie GODET (Paris)
L’arrêt cardiaque réfractaire Didier DOREZ (Metz Tessy), Virginie DELANNOY (Annecy)
Arrêt cardiaque au bloc. Des situations moins critiques (Dr Adrien Bouglé - novembre 2016)
Compressions entre 5 et 6cm. On permute toutes les deux minutes pas trois. Si on est au bloc, on a un patient scopé. Donc on voit son rythme. Si c’est une asystolie, la pose du DAE est à discuter de par le fait...
Arrêt cardiaque intrahospitalier
Deeper chest compression – More complications for cardiac arrest patients ?
Fiches techniques des principaux défibrillateurs
Comparatif des défibrillateurs grand public
AFGSU pour le personnel hospitalier (soignant et non soignant)
Est-il nécessaire de présenter la base de données PubMed du NCBI (National Center for Biotechnology Information) “THE” référence. Vous y trouverez des articles en recherchant par thème, par auteur. Un exemple en tapant cardiac arrest review
Les posters 2015 de l’ERC
Points saillants de la mise à jour 2015 des lignes directrices
Points saillants de la mise à jour 2015 des lignes directrices (American Heart Association (AHA). Editées par la Fondation des maladies du coeur et de l’AVC du Canada. En français)
Les recommandations en français :
Recommandations - ERC 2015-2020 Principales modifications concernant la réanimation des arrêts cardiaques de l’adulte
Les nouvelles procédures scientifiques qui ont été mise en place par l’ERC pendant les cinq dernières années ont permis de remaniées ces recommandations en ce qui concerne :
L’utilisation des médias sociaux et de la technologie mobile pourrait accélérer la mise en œuvre de la réanimation cardio-pulmonaire (RCP) en permettant d’alerter des intervenants, formés à la RCP et volontaires, lorsqu’une personne se trouvant à proximité du lieu où il se trouve est victime d’un arrêt cardiaque. Des études indique que les technologies mobiles émergentes peuvent entrainer un « taux accru de RCP pratiquée par les témoins ».
L’importance cruciale des échanges entre le régulateur médical et le témoin de l’arrêt cardiaque qui réalise la RCP et la mise en œuvre rapide d’un défibrillateur externe : véritable « coaching » des premiers témoins par téléphone pour la recherche d’une respiration agonique et la pratique des compressions thoraciques. Les régulateurs devaient être formés pour apporter une telle assistance.
L’identification d’un arrêt cardiaque devant une victime inconsciente et qui ne respire pas ou qui ne respire pas normalement doit faire immédiatement débuter la RCP. Cette respiration anormale est appelée gasp, c’est un mouvement respiratoire inefficace d’origine réflexe, phénomène terminal de l’agonie. Dans les secondes qui suivent l’arrêt cardiaque, le débit sanguin parvenant au cerveau est pratiquement nul. Cela peut provoquer des épisodes de crise qui peuvent être confondus avec de l’épilepsie. Les témoins, ainsi que les services d’urgence, doivent suspecter un arrêt cardiaque avec les patients présentant ce type de crise, et évaluer soigneusement si la victime respire normalement.
Les compressions thoraciques (MCE) débutée sans délais sont, plus que jamais, importantes et doivent être interrompues le moins souvent possible… La qualité de la RCP repose sur la qualité des compressions thoraciques que tout le monde peut apprendre à réaliser. Chez l’adulte, il est souhaitable que les compressions thoraciques aient une profondeur d’au moins 5 cm sans dépasser 6 cm. Le rythme des compressions doit être d’au moins 100 par minute, avec un maximum de 120. Le talon de la première main doit être positionné au milieu des deux mamelons, l’autre main par-dessus. Après chaque compression, il faut laisser le thorax se relâcher totalement. Les interruptions doivent être minimisées autant que possible. Pour minimiser ces interruptions lors de la RCP, on ne vérifie plus la présence d’un pouls et immédiatement après le choc et on reprend les compressions thoraciques. Les sauveteurs entraînés à réaliser des insufflations doivent ajouter aux compressions thoraciques les insufflations, car cela peut améliorer le pronostic.
La défibrillation… avec un défibrillateur automatique externe (DAE) est toujours plus que jamais indispensable. En raison des preuves indiscutables de l’importance pour la survie, les recommandations insistent sur l’utilisation des DAE dans le traitement de l’arrêt cardiaque. Les recommandations ne préconisent plus de débuter une RCP, pendant un certain temps, avant de délivrer un premier choc par défibrillation. Si un défibrillateur, qu’il soit manuel ou automatique, est disponible, il faudra immédiatement installer le défibrillateur, lui permettre d’analyser le rythme cardiaque et délivrer un choc, et seulement ensuite réaliser la RCP. Toutefois, pendant que le DAE est installé, il faut poursuivre la RCP autant que possible. Pour cela, pendant que les électrodes sont appliquées sur le thorax, si un deuxième sauveteur est disponible, il continue le massage jusqu’au dernier moment, lorsque le défibrillateur ordonne de reculer pour l’analyse. Une défibrillation réalisée rapidement dans les 3 à 5 minutes après l’arrêt cardiaque est susceptible d’améliorer les chances de survie de 50 à 70 %. La défibrillation peut être réalisée par les témoins en utilisant des défibrillateurs se trouvant sur place et en libre accès. La poursuite de l’implantation des DAE dans les lieux publics ayant une forte densité de population, comme les aéroports, les gares ferroviaires et routières, les enceintes sportives, les centres commerciaux, les bureaux et les casinos doit être une priorité mais aussi dans le domaine résidentiel où 60 à 70 % des arrêts cardiaques ont lieu. L’enregistrement des défibrillateurs dans une base de données pourrait permettre au régulateur médical de guide le sauveteur vers le défibrillateur le plus proche.
Les insufflations restent utiles… notamment dans le cas des enfants, des noyés ou d’autres personnes souffrant d’un arrêt cardiaque ayant des causes respiratoires. Même dans le cas d’un arrêt cardiaque primaire s’expliquant par une arythmie, une RCP de qualité devrait comporter des compressions thoraciques et des insufflations. Mais si l’on ne peut pas réaliser les insufflations, réaliser au moins les compressions thoraciques est préférable à ne rien faire. Les insufflations doivent interrompre la RCP le moins possible : les deux insufflations doivent être réalisées en cinq secondes (pour interrompre le massage cardiaque externe le moins longtemps possible), chaque insufflations étant réalisée en environ une seconde. Le volume d’air insufflé doit être suffisant pour seulement permettre au thorax de se soulever visiblement. Le ratio entre les compressions et la ventilation reste de 30 compressions thoraciques pour deux insufflations soit 30/2.
L’intérêt d’une formation courte pour le grand public confirmée par plusieurs retours d’expérience. Idéalement les citoyens devraient être formés à la RCP classique incluant compressions et ventilations. Toutefois, il y a des circonstances où la formation aux compressions seules est appropriée (par exemple formation adaptée sur un temps très limité). Les mannequins dits de haute-fidélité sont à privilégier sans abandonner les mannequins moins sophistiqués. L’utilisation de dispositifs de formation délivrant un feedback améliore significativement la qualité de la RCP pratiquée, tant pour la fréquence, la profondeur, le relâchement et la position des mains. Un recyclage pour maintenir les compétences optimales des personnes formées est nécessaire après moins d’une année ; formations plus courtes mais beaucoup plus fréquentes sont préconisées.
Petit rappel actualisé sur les dernières données de la RCP (d’après les lundis du SAMU (samu 75) du 11 janvier 2016
Le ou les premiers intervenants
Dr Pascal CASSAN (croix rouge française)
La position des mains situées soit entre le milieu de la poitrine et le 1/3 moyen inférieur : Le 1/3 moyen serait de meilleur pronostic Si appui supérieur à 6 cm, risque de dommage traumatique
11 % avant "push hard and fast
37 % après "push hard and fast"
< 5 cm on retrouve 29 % de dommages
5-6 cm 33 % de dommages
> 6 cm 63 % de dommages
L’idéal se situe dans un enfoncement de 40,3 et 55 mm et un rythme entre 100 et 120/ minute en terme de "recovery"
Le relâchement n’est pas si important que ça dans l’absolu. Il faut masser au moindre doute (n’entraîne pas de problème majeur : douleur = 6%, traumatisme = 1,7%)
Le gold standard reste le massage cardiaque externe (MCE) et la ventilation sur une alternance 30/2
Si inconscient sur le dos : ne serait pas un problème. Vomissements peu avérés
Si traumatisme, on ne le tourne pas, même si inconscient.
Dr Daniel JOST (BSPP)
Les fibrillations récidivantes : reviennent après 5 secondes Réfractaires : ne s’arrêtent pas
Le choc avec un défibrillateur bi phasique est le mieux d’après l’étude de Morisson qui date de 2005. Le DSA est plus sûr qu’un médecin qui choque de façon inappropriée.
Les nouveaux DSA sont opérationnels entre 8 et 10 secondes. Ils sont aussi rapides en bi phasique qu’en monophasique qui ne sont plus construits et doivent disparaître.
Pas de supériorité du DEA vs DSA. En France on utilise les DSA.
MCE + choc vs choc + MCE ne donne pas de différence notable. Mais au vu des délais d’intervention, il vaut mieux MCE + DSA
Le choc commence par 120 à 150 Joules puis 150 à 200 Joules.
Sur une minute, 70 à 80 % des personnes re fibrillent après avoir été massés, car le massage tombe sur la période réfractaire du myocarde en phase de repolarisation. Cela induit une fibrillation ventriculaire. Plus le temps passe, plus le risque est grand. USA vs Europe
USA RCP 30 secondes -> choc->RCP pendant 1’30 -> choc->RCP pendant 1’30 ->
Europe Analyse choc->RCP pendant 2’ -> analyse-choc ->RCP pendant 2’
L’asthme augmente l’impédance, donc augmente le niveau de charge. Si ily a un pace maker l’électrode du DSA doit être posée à une distance > à 8cm
Ne pas interompre les compressions sternales si possible. Pas d’utrilisation de filtre mécanique. (masser pendant l’analyse).
Pr Carli (SAMU 75)
La méthodologie GRADE (The Grading of Recommendations Assessment, Development and Evaluation) est insuffisamment connu en France. Cet outil permet d’évaluer le niveau de preuve des études, et de proposer la force des recommandations. Il a été adopté par de nombreux groupes ou organisations qui produisent des recommandations de pratique clinique. Plus de 65 organisations nationales et internationales ont adopté GRADE (mais personne en France).
Outcome (pronostic)
Grande évolution depuis 1998. L’importance du no flow est prioritaire.
Réduire la pause avant le choc électrique du DSA.
Reprendre immédiatement après le choc.
L’adrénaline 1mg après le er choc.
Cordarone si fibrillation ventriculaire réfractaire. 300 mg puis 150 mg
Si Augmentation de l’Etco2 et/ :ou signe de vie, on arrête le MCE
Si rythme non choquable : Adrénaline dès que possible. Mauvais pronostic
La ventilation pas plus de 10/minute.
Capnie : obligatoire
Voie intra osseuse est aussi bonne que la voie IV
L’adrénaline aggrave le pronostic neurologique à forte dose
La cordarone : ne pas dépasser 1 mg en tout.
Il faut traiter les causes réversibles.
L’échographie peut être utile pour détecter des problèmes de remplissage, d’embolie pulmonaire, de tamponnade, de bradycardie extrême.
Les machines à massage automatisés.
Pas de pronostic en faveur, mais utile car facilite le massage sur équipe réduite.
Faire approche ABCDE
L’ECMO (Extra Corporeal Membrane Oxygenation, Oxygénation par membrane extra-corporelle)
ACR réfractaire
Dr Lamhaut (SAMU 75)
L’ECPR ou extra corporeal cardio pulmonary resuscitation favorise le retour à un meilleur retour neurologique à 6 mois. Le choix du patient est fondamental en terme de pronostic neuro favorable : hypothermie, (noyade, avalanché)
Hypothermie asphyxique et non asphyxique
Intoxication neuroprotection possible
Les SCA + ? exclure les absences de signes de vie et les ACR
Détection : pupilles, respiration, mouvements (signes de vie+++)
On peut poser une ECPR à partir de la 20’ minute de RCP avec DAE. Idéalement mis en place dans les 60 minutes.
L’apport excessif d’oxygène est délétère. Le manque aussi…il faut maintenir une normoxie et une normocapnie. Relationship between supranormal oxygen tension and outcome after resuscitation from cardiac arrest.
Traitement par hypothermie : 33 ou 36° = aucune différence. Commencer tôt : pas prouvé, au contraire (étude de Seattle).
Ci-dessous les publications de l’ERC (European Resuscitation Council)
ERC guidelines 2015. Section 1. Executive summary
ERC guidelines 2015. Section 2 Adult basic life support and automated external defibrillation
ERC guidelines 2015. Section 3. Adult advanced life support
ERC guidelines 2015. Section 4. Cardiac arrest in special circumstances
ERC and European society of intensive care medecine guidelines for post-resuscitation care 2015. Section 5 for 2015
ERC guidelines 2015. section 6. Paediatric life support
ERC guidelines 2015. Section 7. Resuscitation and support of transition of babies at birth
ERC guidelines 2015. Section 8. Initial management of acute coronary syndromes
ERC guidelines 2015. Section 9. First aid
NDLR : Les auteurs affirment que les colliers cervicaux rigides font plus de dégâts que de réels bénéfices. D’ailleurs les recommandations pour l’afgsu ne préconisent plus la pose d’un collier cervical, mais plutôt le maintien de la tête, sans mobilisation.
Récemment l’ILCOR a publié des guides de bonne pratique sur les colliers cervicaux : la pose systématique de colliers cervicaux rigides n’est pas recommandée, car les preuves d’une réduction de mouvement de tête après l’application de colliers cervicaux rigides ne proviennent que sur des études sur cadavres.
source : scancrit.com
The ERC, the European Resuscitation Council, have issued new guidelines for first aid, section 9 of their guidelines. And it includes an interesting and rather controversial take on cervical collars and spinal immobilisation that’s similar to what we have been propagating for some years now. They say : “The routine application of a cervical collar by a first aid provider is not recommended”, and comment on limitations of the current view of cervical collars as a good routine device in trauma. Read the out-take.
Here’s the full section on spinal immobilisation. The rest of the guideline is – as always – also worth a read.
• Spinal immobilisation is defined as the process of immobilising
the spine using a combination of devices (e.g. backboard and cervical
collar) intended to restrict spinal motion.
• Cervical spinal motion restriction is defined as the reduction or
limitation of cervical spine movement using mechanical cervical
devices including cervical collars and sandbags with tape.
• Spinal stabilisation is defined as physical maintenance of the
spine in a neutral position prior to applying spinal motion restriction
In suspected cervical spine injury it has been routine to apply cervical collars to the neck, in order to avoid further injury from spinal movement. However, this intervention has been based on consensus and opinion rather than on scientific evidence. Furthermore, clinically significant adverse effects, such as raised intracranial pressure, have been shown to occur following the application of a cervical collar.
2015 First Aid Guideline The routine application of a cervical collar by a first aid provider is not recommended.
Moving away from the collar ?
So the cervical collar might still be placed, but they’re saying it’s not worth it for inexperienced first aid providers. They might get the benefit/harm ratio wrong, and they might not apply it correctly. But they are also mentioning serious harms from cervical collars, and pointing to the lack of evidence for them in general. It’s worth quoting this little part again :
“In suspected cervical spine injury it has been routine to apply cervical collars to the neck, in order to avoid further injury from spinal movement. However, this intervention has been based on consensus and opinion rather than on scientific evidence.”
The conclusion seems to be that we need to take care of the spine, but there are several ways to reduce spine movement and keep the head/neck in a neutral position. Other techniques might be just as good. We’ll be back with more when the Norwegian national guidelines that specifically speaks on spinal stabilisation are released.
ERC guidelines 2015. Section 10 education and implementation of resuscitation
ERC guidelines 2015. Section 11. The ethics of resuscitation and end of life decisions
ERC Summary of the main changes in the resuscitation guidelines 2015
Ci-dessous les publications de l’AHA (American Heart Association)
Consensus on Resuscitation Science and. Treatment Recommendations (CoSTR)
Part 1 : Executive Summary : 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
Part 1. Executive Summary 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
Part 2 : Evidence Evaluation and Management of Conflicts of Interest : 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With TreatmentRecommendations
Part 2. Evidence Evaluation and Management of Conflicts of Interest. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
Part 3. Adult Basic Life Support and Automated External Defibrillation. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
Part 4 : Advanced Life Support : 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
Part 4. Advanced Life Support. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
Part 5 : Acute Coronary Syndromes : 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
Part 5. Acute Coronary Syndromes. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
Part 6 : Pediatric Basic Life Support and Pediatric Advanced Life Support : 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
Part 6. Pediatric Basic Life Support and Pediatric Advanced Life Support. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
Part 7 : Neonatal Resuscitation : 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
Part 7. Neonatal Resuscitation. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
Part 8 : Education, Implementation, and Teams : 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
Part 8. Education, Implementation, and Teams. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
Part 9 : First Aid : 2015 International Consensus on First Aid Science With Treatment Recommendations
Part 9. First Aid. 2015 International Consensus on First Aid Science With Treatment Recommendations
Alternative Techniques and Ancillary Devices for Cardiopulmonary Resuscitation : 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
These new guidelines are the culmination of many years of international collaboration to improve the practice and teaching of resuscitation medicine in order to improve survival from cardiorespiratory arrest.1,2 English ambulance services initiate resuscitation on about 28,000 people who sustain an OHCA each year (52 cases per 100,000 inhabitants) and approximately 8% survive to leave hospital.3 Data from the UK National Cardiac Arrest Audit (NCAA) indicate that in-hospital cardiac arrest occurs in 1.6 per 1000 hospital admissions with rate of survival to hospital discharge of 18.4%.4 Recent international data suggest that survival rates after both in- and out-of-hospital cardiac arrest are slowly improving.5-7 It is hoped that refinements in resuscitation guidelines will continue to contribute to increasing survival rates.
The process used to produce the Resuscitation Council (UK) Guidelines 2015 has been accredited by the National Institute for Health and Care Excellence (NICE). The guidelines process includes : Systematic reviews with grading of the quality of evidence and strength of recommendations (detailed below). These reviews formed the basis of the 2015 International Liaison Committee on Resuscitation (ILCOR) Consensus on Cardiopulmonary Resuscitation (CPR) Science with Treatment Recommendations (CoSTR).1,2 The involvement of stakeholders from around the world including members of the public and cardiac arrest survivors. Collaboration with the European Resuscitation Council (ERC) and adaption of the ERC Guidelines for use in the UK.8 Details of the guidelines development process can be found in the Resuscitation Council (UK) Guidelines Development Process Manual.
2. The ILCOR evidence evaluation process
For the 2015 evidence evaluation process ILCOR formed seven task forces : basic life support (BLS), advanced life support (ALS), acute coronary syndromes (ACS), paediatric BLS and ALS, neonatal resuscitation, education implementation and teams (EIT), and, for the first time, first aid. Using the PICO [population, intervention, comparator, outcome] format, each task force identified and prioritised the questions to be addressed and then performed detailed systematic reviews. The task forces used the methodological approach for evidence evaluation and development of recommendations proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group.9 A detailed search for relevant articles was performed in each of three online databases (MEDLINE, Embase, and the Cochrane Library).2 The quality of the evidence (or confidence in the estimate of the effect) was categorised as high, moderate, low, or very low,10 based on the study methodologies and the risk of bias, inconsistency, indirectness, imprecision, and publication bias. Written summaries of evidence for each outcome (the Consensus on Science statements) were drafted by the evidence reviewers and then discussed, debated and refined by the task forces until consensus was reached. Whenever possible, consensus-based treatment recommendations were created. These recommendations (designated as strong or weak and either for or against a therapy or diagnostic test) were accompanied by an overall assessment of the evidence, and a statement from the task force about the values and preferences that underpinned the recommendations. There was open public and stakeholder consultation at several stages during this process.
3. From science to guidelines
The 2015 CoSTR summarises the science supporting CPR ; although this includes treatment recommendations these are generally broad and do not provide sufficient practical detail for clinical implementation. These Resuscitation Council (UK) guidelines have been adapted from the 2015 ERC Guidelines and are tailored specifically to clinical practice in the UK. The guidelines have been peer reviewed by the Executive Committee of the Resuscitation Council (UK), which comprises 25 individuals and includes lay representation and representation of the key stakeholder groups.
4. Summary of main changes since the 2010 Guidelines
Main changes in the 2015 Guidelines are summarised at the beginning of each guideline topic and are listed below.
Guidelines 2015 highlights the critical importance of the interactions between the emergency medical dispatcher, the bystander who provides CPR and the timely deployment of an automated external defibrillator (AED).
There is increased emphasis on minimally interrupted high quality chest compressions throughout any ALS intervention.
The ALS algorithm has been modified slightly to show these changes.
There is a greater emphasis on the need for urgent coronary catheterisation and percutaneous coronary intervention (PCI) following out-of-hospital cardiac arrest of likely cardiac cause.
Targeted temperature management remains important but the target temperature can be either 36°C or 33°C according to local policy. There was a preference for 36°C among the guidelines group because it is easier to implement and there is no evidence that it is inferior to 33°C.
Prognostication is now undertaken using a multimodal strategy and there is emphasis on allowing sufficient time for neurological recovery and to enable sedatives to be cleared.
For chest compressions, depress the lower sternum by at least one-third the anterior-posterior diameter of the chest, or by 4 cm for the infant and 5 cm for the child.
In the presence of a febrile illness, if there are no signs of septic shock, children should be given fluid cautiously and then reassessed. In some forms of septic shock, restricted fluid resuscitation with isotonic crystalloid may be more beneficial than the liberal use of fluids.
For cardioversion of a supraventricular tachycardia (SVT), the initial dose has been revised to 1 J kg-1.
Prevent fever in children who have turn of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest.
In children, targeted temperature management can be with normothermia or mild hypothermia.
For uncompromised term and preterm infants, a delay in cord clamping of at least one minute from the complete delivery of the infant, is now recommended. As yet there is insufficient evidence to recommend an appropriate time for clamping the cord in infants who are severely compromised at birth. For infants requiring resuscitation, resuscitative intervention remains the immediate priority.
The temperature of newly born infants should be actively maintained between 36.5°C and 37.5°C after birth unless a decision has been taken to start therapeutic hypothermia.
Preterm infants of less than 32 weeks gestation may benefit from a combination of interventions to maintain their body temperature between 36.5°C and 37.5°C after delivery, through stabilisation and neonatal unit admission.
An ECG, if available, can give a rapid accurate and continuous heart rate reading during newborn resuscitation. It does not, however, indicate the presence of a cardiac output and should not be the sole means of monitoring the infant.
Resuscitation of term infants should commence in air. For preterm infants, a low concentration of oxygen (21–30%) should be used initially for resuscitation at birth. If, despite effective ventilation, oxygenation (ideally guided by oximetry) remains unacceptable, use of a higher concentration of oxygen should be considered.
Attempts to aspirate meconium from the nose and mouth of the unborn infant, while the head is still on the perineum, are not recommended.
Nasal continuous positive airways pressure (CPAP) rather than routine intubation may be used to provide initial respiratory support of all spontaneously breathing preterm infants with respiratory distress.
The recommended compression : ventilation ratio for CPR remains at 3:1 for newborn resuscitation. Asynchronous compressions are not recommended.
The team approach is emphasised.
Supraglottic airways often provide an ideal airway and should be used as part of a stepwise airway management pathway. Tracheal intubation is attempted only by those with adequate training and only if simpler airways prove inadequate.
There is no evidence that a pre-defined period of CPR before defibrillation improves success rates. Mechanical chest compression devices are a reasonable alternative to high quality manual chest compressions in situations where sustained high quality manual chest compressions are impractical or compromise provider safety.
The use of waveform capnography is emphasised not only to indicate placement of a tracheal tube in the airway (and not the oesophagus), but also as a useful indicator of cardiac output and the effectiveness of chest compressions. A sudden increase in end-tidal CO2 may be an early indicator of ROSC.
After ROSC is achieved passive cooling is recommended in the prehospital phase.
In patients with evidence of ST elevation, transfer to a cardiac arrest centre capable of performing PCI is the optimal care pathway.
Prevention of in-hospital cardiac arrest requires staff education, monitoring of patients, recognition of patient deterioration, a system to call for help and an effective response.
Ensure that all clinical staff are trained in the recognition, monitoring, and management of critically ill patients, and that they know their role in the rapid response system.
Ensure that all policies on CPR decisions are based on current national guidance, and ensure that all clinical personnel understand it.
Identify those fully informed patients who do not wish to receive CPR, those patients for whom cardiorespiratory arrest is an anticipated terminal event and for whom CPR would be inappropriate, and those patients who have lost capacity in whom a decision not to attempt CPR is in their best interests.
There is continuing emphasis on the use of rapid response systems for care of the deteriorating patient and prevention of in-hospital cardiac arrest.
There is continued emphasis on minimally interrupted high quality chest compressions throughout CPR : chest compressions are paused briefly only to enable specific interventions. This includes minimising interruptions in chest compressions to attempt defibrillation.
Peri-arrest arrhythmia
The basic principles of assessment and treatment of a suspected cardiac arrhythmia are unchanged.
Use of oxygen therapy is not recommended unless the patient is hypoxic, in which situation the concentration of oxygen delivered should be guided by monitoring arterial oxygen saturation whenever possible.
There is stronger emphasis on the use of antithrombotic therapy in atrial fibrillation (AF) and the importance of assessing thromboembolic risk in people with AF.
All school children should be taught how to perform CPR and should be made aware of how to use an AED.
Frequent ‘low-dose’ training may be a beneficial method for providing CPR/AED retraining.
The changes in the new Guidelines 2015 compared with the previous 2010 Guidelines are relatively subtle. Nevertheless, some of the treatment recommendations in these guidelines will change the way resuscitation is delivered. It will take time for courses and training materials to be updated and for this change in practice to be disseminated to healthcare professionals and laypeople by resuscitation trainers. As this transition is made there will inevitably be some variation in practice between individuals and healthcare organisations. Healthcare organisations should implement those components of Guidelines 2015 relevant to them by the end of 2016. The Resuscitation Council (UK) Quality standards for cardiopulmonary resuscitation practice and training will help with the implementation of these guidelines in health care settings.
Guidelines 2015 do not define the only way that resuscitation should be achieved ; they merely represent a widely accepted view of how resuscitation can be undertaken both safely and effectively. The publication of new treatment recommendations does not imply that current clinical care is either unsafe or ineffective.
The Resuscitation Council (UK) Guidelines undergo a major revision every 5 years (synchronised with the International Consensus on Cardiopulmonary Resuscitation Science Conferences and new ERC Guidelines) with occasional interim amendments to reflect very important new science. These interim amendments are generally made only if delaying guideline changes until a major revision is thought to put patients at risk. The decision to publish interim ‘advisory statements’ is made by the ILCOR delegates and although some experts advocate a more continuous process of science review, the next major review of these guidelines is likely to be in 2020.
These 2015 Guidelines include some changes in practice that reflect new science that has been published since 2010. Consistency in practice among countries provides the basis for the large trials necessary to establish best practice, and the further development of such international collaboration is encouraged. Similarly, consistent collection and reporting of audit data in registries that enable comparison between systems does much to improve practice and ensure that the victims of sudden cardiac arrest are given the best chance of successful resuscitation.3,4
The National Out of Hospital Cardiac Arrest Outcomes project www.warwick.ac.uk/ohcao measures patient, process and outcome variables from out-of-hospital-cardiac arrest in the UK. The project is run in collaboration with the National Ambulance Service Medical Directors Group with support from the British Heart Foundation, Resuscitation Council (UK) and University of Warwick. The project is designed to measure the epidemiology and outcomes from cardiac arrest and to serve as a national resource for continuous quality improvement initiatives for cardiac arrest.
The National Cardiac Arrest Audit (NCAA) https://ncaa.icnarc.org/ is an ongoing, national, comparative outcome audit of in-hospital cardiac arrests.4 It is a joint initiative between the Resuscitation Council (UK) and the Intensive Care National Audit & Research Centre (ICNARC) and is open to all acute hospitals in the UK and Ireland. The audit monitors and reports on the incidence of, and outcome from, in-hospital cardiac arrest in order to inform practice and policy. It aims to identify and foster improvements in the prevention, care delivery and outcomes from cardiac arrest.
All the individuals contributing to the writing of these guidelines have signed and adhered to the Resuscitation Council (UK) Conflict of Interest (COI) Policy. The COI declarations of all authors are listed in Appendix 1.
The process leading to the publication of the guidelines has entailed considerable work by many individuals over a protracted period. The Resuscitation Council (UK) would like to thank all the individuals and organisations that have contributed to the process and made this publication possible.
The following abbreviations have been used in these guidelines :
h	hour, hours
h-1	per hour
min	minute, minutes
min-1	per minute
s	second, seconds
s-1	per second
IV	is intravenous
Nolan JP, Hazinski MF, Aicken R, et al. Part I. Executive Summary : 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2015 ;95:e1-e32. Morley PT, Lang E, Aickin R, et al. Part 2 : Evidence Evaluation and Management of Conflict of Interest for the ILCOR 2015 Consensus on Science and Treatment Recommendations. Resuscitation 2015 ;95:e33-e41. Perkins GD, Lockey AS, de Belder MA, Moore F, Weissberg P, Gray H. National initiatives to improve outcomes from out of hospital cardiac arrest in England. Emergency Medicine Journal 2015. doi : 10.1136/emermed-2015-204847. Nolan JP, Soar J, Smith GB, et al. Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit. Resuscitation 2014 ;85:987-92. Chan PS, McNally B, Tang F, Kellermann A, Group CS. Recent trends in survival from out-of-hospital cardiac arrest in the United States. Circulation 2014 ;130:1876-82. Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013 ;310:1377-84. Girotra S, Nallamothu BK, Spertus JA, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med 2012 ;367:1912-20. Monsieurs K, Nolan JP, Bossaert LL, et al. European Resuscitation Council Guidelines for Resuscitation 2015 Section 1 Executive Summary. Resuscitation 2015 ;95:1-80. Overview of the GRADE Approach. In : GRADE Handbook. Available at : http://www.guidelinedevelopment.org... h.svwngs6pm0f2. Updated October 2013. Accessed May 6, 2015. Schunemann HJ, Oxman AD, Brozek J, et al. Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ 2008 ;336:1106-10.
Connaître les gestes de premiers secours ; ça fait plus que changer la vie… ça la sauve. Et qu’en est-il en France ? Les citoyens sont-ils suffisamment formés ? Quel est votre chance de survie en cas d’arrêt cardiaque dans la rue ?
Un instantané en quelques chiffres.
C’est un peu le chiffre choc : si la France formait 20% de personnes en plus, on estime que 10 000 vies seraient sauvées en plus chaque année. Alors, est-ce que cela veut dire que les français ne connaissent pas assez les gestes qui sauvent ?
Les chiffres sont encore très clairs. 4 minutes : C’est le temps que vous avez pour sauver une personne victime d’un arrêt cardiaque. Alors qu’il faut en moyenne 14 minutes au secours pour arriver …
Ainsi on note également que le taux de survie à un arrêt cardiaque, en France est en moyenne de 5,7%, face à 30% dans certaines villes des Etats-Unis comme Chicago, Seattle ou Las Vegas. Les facteurs ? une mobilisation immédiate des témoins et l’utilisation d’un défibrillateur.
20% des collégiens reçoivent une formation de premier secours en fin de 3ème, ce qui est bien, même si la loi l’impose à tous.** L’âge minimum pour suivre la formation aux premiers secours PSC1 est de 10 ans.
Le coût de cette formation qui dure une journée va de 50 à 72 euros. Les pouvoirs publics ont également pris la mesure des efforts à consentir. Depuis le *4 mai 2007, les personnes lambda (ni secouristes diplômés ni professionnels de santé) peuvent utiliser les DAE (Défibrillateurs Automatisés Externes), compte tenu de la simplicité et de la sécurité de leur utilisation. D’ailleurs, depuis 2008, le nombre de DA a été *multiplié par 40 (entre 60000 et 100000).
Alors n’oubliez pas, formez-vous aux gestes de premiers secours ! D’ailleurs, du 4 au 6 février 2016 : C’est la deuxième édition de "Secours Expo", le salon 100% Secours, soin d’urgence et prévention, à la Porte de Versailles à Paris.
source https://www.newstoprotect.axa
Survival after Perioperative Cardiopulmonary Resuscitation : Providing an Evidence Base for Ethical Management of Do-not-resuscitate Orders
Shona Kalkman, M.D. ; Lotty Hooft, Ph.D. ; Johanne M. Meijerman, B.Sc. ; Johannes T. A. Knape, M.D., Ph.D. ; Johannes J. M. van Delden, M.D., Ph.D.
From the Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (S.K., J.M.M., J.J.M.v.D.) ; Dutch Cochrane Centre, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (L.H.) ; and Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands (J.T.A.K.).
This article is featured in “This Month in Anesthesiology,” page 1A. Figure 1 was enhanced by Annemarie B. Johnson, C.M.I., Medical Illustrator, Vivo Visuals, Winston-Salem, North Carolina. Submitted for publication March 27, 2015. Accepted for publication July 17, 2015.
Address correspondence to Dr. Kalkman : Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, The Netherlands. s.kalkman@umcutrecht.nl.Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Anesthesiology 3 2016, Vol.124, 723-729. doi:10.1097/ALN.0000000000000873 Article has an altmetric score of 1
Automatic suspension of do-not-resuscitate (DNR) orders during general anesthesia does not sufficiently address a patient’s right to self-determination and is a practice still observed among anesthesiologists today. To provide an evidence base for ethical management of DNR orders during anesthesia and surgery, the authors performed a systematic review of the literature to quantify the survival after perioperative cardiopulmonary resuscitation (CPR). Results show that the probability of surviving perioperative CPR ranged from 32.0 to 55.7% when measured within the first 24 h after arrest with a neurologically favorable outcome expectancy between 45.3 and 66.8% at follow-up, which suggests a viable survival of approximately 25%.
Because CPR generally proves successful in less than 15% of out-of-hospital cardiac arrests, the altered outcome probabilities that the conditions in the operating room bring on warrant reevaluation of DNR orders during the perioperative period. By preoperatively communicating the evidence to patients, they can make better informed decisions while reducing the level of moral distress that anesthesiologists may experience when certain patients decide to retain their DNR orders.
Lire l’article sur le site du new england
Joglar, Jose A., Page, Richard L., . Out-of-Hospital Cardiac Arrest — Are Drugs Ever the Answer ?. New England Journal of Medicine 0:0
Peter J. Kudenchuk, M.D., Siobhan P. Brown, Ph.D., Mohamud Daya, M.D., Thomas Rea, M.D., M.P.H., Graham Nichol, M.D., M.P.H., Laurie J. Morrison, M.D., Brian Leroux, Ph.D., Christian Vaillancourt, M.D., Lynn Wittwer, M.D., Clifton W. Callaway, M.D., Ph.D., James Christenson, M.D., Debra Egan, M.Sc., M.P.H., Joseph P. Ornato, M.D., Myron L. Weisfeldt, M.D., Ian G. Stiell, M.D., Ahamed H. Idris, M.D., Tom P. Aufderheide, M.D., James V. Dunford, M.D., M. Riccardo Colella, D.O., M.P.H., Gary M. Vilke, M.D., Ashley M. Brienza, B.S., Patrice Desvigne-Nickens, M.D., Pamela C. Gray, NREMT-P, Randal Gray, M.Ed., NREMT-P, Norman Seals, B.S., Ron Straight, M.Ed., and Paul Dorian, M.D., for the Resuscitation Outcomes Consortium Investigators*
Out-of-hospital cardiac arrest is responsible for more than 300,000 deaths each year in North America.1 Many out-of-hospital cardiac arrests are attributable to ventricular fibrillation or pulseless ventricular tachycardia. Although ventricular fibrillation or pulseless ventricular tachycardia is regarded as the most treatable presentation of out-of-hospital cardiac arrest because of its responsiveness to shock,2 most defibrillation attempts do not result in sustained return of spontaneous circulation.3 Ventricular fibrillation or pulseless ventricular tachycardia commonly persists or recurs after shock, and there is a significant inverse relationship between the duration of ventricular fibrillation or pulseless ventricular tachycardia, or the frequency of acute recurrences, and resuscitation outcome.4-6
Amiodarone and lidocaine are used commonly to promote successful defibrillation of shock-refractory ventricular fibrillation or pulseless ventricular tachycardia and prevent recurrences. In controlled trials involving patients with out-of-hospital cardiac arrest, those who received amiodarone were more likely than those who received placebo or lidocaine to have a return of spontaneous circulation and to survive to be admitted to the hospital,7,8 but the effects of amiodarone on survival to hospital discharge or neurologic outcome remain uncertain. To address this knowledge gap, we compared the effects of amiodarone, lidocaine, and placebo on survival to hospital discharge after out-of-hospital cardiac arrest due to shock-refractory ventricular fibrillation or pulseless ventricular tachycardia.
The background and methods of the trial were described previously.9 Paramedics from 55 emergency medical services (EMS) agencies enrolled patients with out-of-hospital cardiac arrest at 10 North American sites participating in the Resuscitation Outcomes Consortium (ROC).10 The trial was conducted under exception from informed consent in emergency research in accordance with applicable regulatory requirements, oversight by the Food and Drug Administration and Health Canada, approval by institutional review boards in participating communities, and monitoring by an independent data and safety monitoring board appointed by the National Heart, Lung, and Blood Institute (NHLBI).
The trial was sponsored by the NHLBI, the Canadian Institutes of Health Research, and others (see the support statement at the end of the article). In addition, Baxter Healthcare provided the trial drugs without cost and tested the stability of these products over the trial duration but otherwise played no role in the trial. The investigators designed and conducted the trial ; gathered, analyzed, and interpreted the data ; wrote the manuscript draft (the first author) ; and made the decision to submit it for publication. The trial statisticians had full access to all trial data and take responsibility for their integrity, analytic accuracy, and completeness and for the fidelity of this report to the trial protocol, which is available with the full text of this article at NEJM.org.
The trial included patients 18 years of age or older with nontraumatic out-of-hospital cardiac arrest and shock-refractory ventricular fibrillation or pulseless ventricular tachycardia, defined as confirmed persistent (nonterminating) or recurrent (restarting after successful termination) ventricular fibrillation or pulseless ventricular tachycardia after one or more shocks anytime during resuscitation (inclusive of rhythms interpreted as being shockable by an automated external defibrillator). Eligible patients were also required to have intravenous or intraosseous vascular access. We excluded patients who had already received open-label intravenous lidocaine or amiodarone during resuscitation or had known hypersensitivity to these drugs. A complete list of trial inclusion and exclusion criteria is provided in the Supplementary Appendix, available at NEJM.org.
The trial protocol specified that the primary analysis population (the per-protocol population) would include only those randomly assigned participants who actually met the eligibility criteria, who received any dose of a trial drug during shock-refractory ventricular fibrillation or pulseless ventricular tachycardia, and who were confirmed to have an initial (rather than secondary) cardiac-arrest rhythm of ventricular fibrillation or pulseless ventricular tachycardia. Analyses were also performed in all randomly assigned patients (the intention-to-treat population).
The trial evaluated licensed parenteral preparations of lidocaine, normal saline and a recently approved Captisol-based formulation of amiodarone (Nexterone, Baxter Healthcare) that is designed to reduce hypotensive effects.11,12 Trial drugs were packaged in identically appearing, sealed kits each having three identically formulated syringes. Each syringe held 3 ml of colorless fluid containing 150 mg of amiodarone (totaling 450 mg in the amiodarone kit), 60 mg of lidocaine (180 mg in the lidocaine kit), or normal saline. Kits and their syringe contents were indistinguishable except by numerical code and were randomly distributed to EMS providers in a ratio of 1:1:1. Randomization was performed in permuted blocks of concealed size and was stratified according to participating site and agency. Trial drugs were tested regularly for stability and were confirmed to maintain their integrity in the simulated climates of trial communities.9
Patients with out-of-hospital cardiac arrest were treated in accordance with local EMS protocols that complied with American Heart Association (AHA) guidelines for advanced life support.13 Some patients were coenrolled in a concurrent trial comparing continuous chest compressions with interrupted chest compressions during cardiopulmonary resuscitation (CPR).14
After the failure of one or more shocks to terminate ventricular fibrillation or pulseless ventricular tachycardia or prevent its recurrence, eligible patients received a vasopressor and were then enrolled in the trial by the EMS personnel’s act of opening a trial-drug kit whose masked contents (amiodarone, lidocaine, or placebo) determined the patient’s random assignment (details are provided in the Supplementary Appendix). Patients, investigators, and trial personnel were unaware of the trial-drug assignments. The initial dose of a trial drug, approximating current clinical practice, consisted of two syringes (one syringe if the estimated body weight was <100 lb [45.4 kg]) that were administered by rapid bolus.10,15,16 If ventricular fibrillation or pulseless ventricular tachycardia persisted after the initial dose of the trial drug, standard resuscitation measures, and additional shocks, a supplemental dose (one syringe) of the same drug was administered. Thereafter, standard interventions for advanced life support ensued according to local practice, excluding open-label lidocaine or amiodarone before hospitalization.
All trial interventions were completed before hospital arrival. On arrival, hospital care providers were notified of the patient’s enrollment in the trial and encouraged to provide usual post–cardiac arrest care in accordance with published AHA guidelines,17 including open-label amiodarone or lidocaine if necessary. Components of hospital care were monitored but were not standardized by the trial protocol, and their performance was reported back to hospitals periodically. A patient’s trial-drug assignment was not disclosed to care providers, investigators, or site personnel unless emergency unblinding was requested, and then only to the treating physicians.
Data from prehospital patient care records, CPR-process measures, and data from hospital medical records were collected as described in the Supplementary Appendix. The primary outcome of the trial was survival to hospital discharge. The main aim was to compare survival in amiodarone recipients versus placebo recipients, with secondary comparisons of survival in lidocaine recipients versus placebo recipients and in amiodarone recipients versus lidocaine recipients. The secondary outcome was survival with favorable neurologic status at discharge, defined as a score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) of 3 or less, indicating the ability to conduct daily activities independently or with minimal assistance.18 These outcomes were determined in both the per-protocol population (the primary analysis) and in the intention-to-treat population.
Mechanistic outcomes that were assessed for exploratory purposes included the number of defibrillation shocks administered after receipt of the trial drug, return of spontaneous circulation at hospital arrival, hospital admission, hospital treatments, and time to withdrawal of life-sustaining treatments. Prespecified subgroups were defined according to status with respect to witnessing of the cardiac arrest (witnessed by EMS, witnessed by bystander, or unwitnessed), receipt of bystander-initiated CPR (yes or no), location of the arrest (public or private), time to trial-drug administration (<15 or ≥15 minutes), route of trial-drug administration (intravenous or intraosseous), treatment group in the concurrent trial of continuous or interrupted chest compressions during CPR, baseline survival rate at the trial site (in quartiles), and EMS drug-administration practice (see the Supplementary Appendix).
Adverse events were considered to be drug-related if they were reported previously with these medications19,20 (e.g., anaphylaxis, thrombophlebitis requiring therapeutic intervention, clinical seizure activity, and bradycardia requiring temporary cardiac pacing) and if they occurred within 24 hours after trial-drug administration. Serious or unexpected adverse events attributable to trial interventions21 and complications related to vascular access were also assessed. Other adverse events such as pulmonary edema, hypotension, or pneumonia, which are common after out-of-hospital cardiac arrest, were monitored but were not considered to be drug-related unless imbalanced between trial groups.
We estimated that a sample size of 3000 in the per-protocol population (1000 patients per group) would provide 90% power to detect an absolute difference of 6.3 percentage points in the rate of survival to hospital discharge between the amiodarone group and the placebo group (29.7% vs. 23.4%). The baseline survival rate was estimated from patients with a first recorded rhythm of ventricular fibrillation or pulseless ventricular tachycardia who received at least two shocks in previous ROC trials.22,23 The projected difference in survival with amiodarone was estimated from a previous trial database7 and was the comparison for which this trial was powered.
Survival was evaluated across groups with the use of the z-test for comparison of binomial proportions with pooled variance, with a one-sided significance level of 0.025 for comparisons between an active drug and placebo (based on the monitoring plan of the trial) and a two-sided significance level of 0.05 when comparing amiodarone with lidocaine.9 All comparisons in this report, including testing interactions, were recalculated as two-sided with P values of less than or equal to 0.05 considered to indicate statistical significance (as most comparisons were initially performed), which did not substantially change the results.
The data and safety monitoring board performed interim reviews twice a year with the use of group sequential methods with formal stopping boundaries ; final differences and 95% confidence intervals for the primary outcome were adjusted accordingly.9 Apart from this, there were no adjustments for multiple comparisons.
The trial began on May 7, 2012 and completed enrollment on October 25, 2015. Of 37,889 patients with nontraumatic out-of-hospital cardiac arrest, 7051 (18.6%) had shock-refractory ventricular fibrillation or pulseless ventricular tachycardia at some time and were potentially eligible for enrollment in the trial (Figure 1Figure 1Screening and Randomization.). The intention-to-treat population of 4653 patients was composed of 4667 with opened drug kits, excluding 6 with an unknown trial-drug assignment and 8 in protected populations. Of these, 3026 comprised the per-protocol population of trial-eligible patients with out-of-hospital cardiac arrest and initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia who were randomly assigned recipients of amiodarone (974 patients), lidocaine (993), or placebo (1059), excluding 1627 who did not meet the per-protocol criteria (Table S1 in the Supplementary Appendix). Emergency unblinding of the trial-drug assignment was requested in 24 patients (0.8%) and was proportionately similar across trial groups.
The baseline patient characteristics and event characteristics in the per-protocol population were well balanced across trial groups (Table 1Table 1Prerandomization Characteristics of the Per-Protocol Population. and Table 2Table 2Event Characteristics and Treatments Received in the Per-Protocol Population.). The first dose of the trial drugs was given a mean (±SD) of 19.3±7.4 minutes after the initial call to EMS and after a median of three shocks (interquartile range, two to four) had been administered.
Outcomes were available for 99.5% of all patients in the per-protocol population (Figure 1). Among amiodarone recipients in the per-protocol population, 237 (24.4%) survived to hospital discharge (the primary outcome), as compared to 233 (23.7%) who received lidocaine and 222 (21.0%) who received placebo. The absolute risk difference for the primary comparison of amiodarone versus placebo was 3.2 percentage points (95% confidence interval [CI], −0.4 to 7.0 ; P=0.08). For the secondary comparison of lidocaine versus placebo, the risk difference was 2.6 percentage points (95% CI, −1.0 to 6.3 ; P=0.16), and for the secondary comparison of amiodarone versus lidocaine, it was 0.7 percentage points (95% CI, −3.2 to 4.7 ; P=0.70) (Table 3Table 3Outcomes According to Trial Group in the Per-Protocol Population.). Rates of survival with favorable neurologic status (the secondary outcome) were similar in the amiodarone group (182 patients [18.8%]), lidocaine group (172 [17.5%]), and placebo group (175 [16.6%]). The risk difference for the secondary outcome for amiodarone versus placebo was 2.2 percentage points (95% CI, −1.1 to 5.6 ; P=0.19) ; for lidocaine versus placebo, 0.9 percentage points (95% CI, −2.4 to 4.2 ; P=0.59) ; and for amiodarone versus lidocaine, 1.3 percentage points (95% CI, −2.1 to 4.8 ; P=0.44).
There was heterogeneity of treatment effect with respect to whether or not the out-of-hospital cardiac arrest was witnessed (P=0.05 for interaction) ; active drugs were associated with a higher rate of survival to hospital discharge than the rate with placebo among patients with witnessed out-of-hospital cardiac arrest (Table S2 in the Supplementary Appendix). Among 1934 patients with bystander-witnessed arrest, the survival rate was higher with amiodarone (27.7%) or lidocaine (27.8%) than with placebo (22.7%). This absolute risk difference was significant for amiodarone versus placebo (5.0 percentage points ; 95% CI, 0.3 to 9.7 ; P=0.04) and for lidocaine versus placebo (5.2 percentage points ; 95% CI, 0.5 to 9.9 ; P=0.03), but did not differ significantly between amiodarone and lidocaine (−0.1 percentage points ; 95% CI, −5.1 to 4.9 ; P=0.97). The survival rate was also higher among amiodarone recipients than placebo recipients with EMS-witnessed arrest, a risk difference of 21.9 percentage points (95% CI, 5.8 to 38.0 ; P=0.01). Conversely, among 839 patients in whom out-of-hospital cardiac arrest was unwitnessed, survival did not differ significantly between trial groups. No other significant interaction with treatment was found in other prespecified subgroups.
After randomization, placebo recipients were more likely to require an additional dose of blinded trial drug than recipients of amiodarone or lidocaine, and they received a greater number of subsequent shocks and other rhythm-control medications (Table 2). More lidocaine recipients than placebo recipients had sustained return of spontaneous circulation on hospital arrival (Table 3). Patients were more likely to survive to hospital admission after receipt of amiodarone or lidocaine than after receipt of placebo. Fewer recipients of amiodarone or lidocaine than of placebo required CPR during hospitalization (Table S3 in the Supplementary Appendix). Use of open-label antiarrhythmic drugs (particularly open-label amiodarone) during the first 24 hours of hospitalization was also less common in the amiodarone group than in the lidocaine or placebo groups.
In the per-protocol population, the overall frequency of prespecified drug-related adverse events did not differ significantly among patients who received amiodarone, lidocaine, or placebo, nor did serious adverse events (Table 4Table 4Adverse Events in the Per-Protocol Population., and Table S4 in the Supplementary Appendix). There was a greater need for temporary cardiac pacing after receipt of amiodarone (4.9%) than after receipt of lidocaine (3.2%) or placebo (2.7%).
Patients enrolled in the intention-to-treat population had balanced baseline characteristics across trial groups (Table S5 in the Supplementary Appendix). There were no significant differences between the trial groups in the rates of the primary and secondary outcomes (Table S6 in the Supplementary Appendix). There were also no significant differences between the trial groups in the rates of drug-related adverse events or serious adverse events (Tables S7 and S8 in the Supplementary Appendix).
In this randomized, double-blind, placebo-controlled, prehospital trial, we found that treatment with amiodarone or lidocaine did not result in a significantly higher rate of survival to hospital discharge or favorable neurologic outcome at discharge than the rate with placebo after out-of-hospital cardiac arrest caused by shock-refractory initial ventricular fibrillation or pulseless ventricular tachycardia. There were also no significant differences in these outcomes between amiodarone and lidocaine.
Two previous small, randomized trials showed significantly higher rates of return of spontaneous circulation and hospital admission with amiodarone than with placebo or lidocaine after shock-refractory out-of-hospital cardiac arrest.7,8 The current trial, which was larger and performed in the context of well-executed CPR, showed similar benefits with respect to short-term outcomes, but with both drugs. The time to treatment with these drugs was typically late across all the trials, averaging 19 minutes from the initial call to EMS in this trial and 21 to 25 minutes in the others.7,8 Such delays may attenuate the effectiveness of antiarrhythmic interventions as patients progress to the metabolic phase of out-of-hospital cardiac arrest, when cellular injury and physiological derangements may be irreversible despite restored circulation.24
Our results could be interpreted in several ways. First, antiarrhythmic drugs may simply be ineffective in this population because they lack antiarrhythmic or restorative effects on circulation. This explanation seems unlikely, given that both amiodarone and lidocaine facilitated termination of ongoing or recurrent ventricular fibrillation or pulseless ventricular tachycardia with fewer shocks than placebo, were associated with higher rates of hospital admission, and resulted in a lesser need for CPR or antiarrhythmic therapies during hospitalization, which could even be taken as potential mechanisms for improved survival. Drug-related adverse events could also have mitigated survival. This too seems unlikely, because no significant between-group differences were observed in the frequency of adverse events. Conversely, because hospital care was not standardized, treatment imbalances between trial groups might have attenuated the survival benefit from amiodarone or lidocaine. However, the trial was randomized and blinded throughout, and the frequency of coronary catheterization, therapeutic hypothermia, and withdrawal of life-sustaining treatments did not differ significantly across trial groups.
The effectiveness of active treatment could also depend on physiological conditions, timing, and patient characteristics. We observed an interaction of treatment with the witnessed status of out-of-hospital cardiac arrest, which is often taken as a surrogate for early recognition of cardiac arrest, a short interval between the patient’s collapse from cardiac arrest and the initiation of treatment, and a greater likelihood of therapeutic responsiveness. Though prespecified, this subgroup analysis was performed in the context of an insignificant difference for the overall analysis, and the P value for heterogeneity in this subgroup analysis was not adjusted for the number of subgroup comparisons. Nonetheless, the suggestion that survival was improved by drug treatment in patients with witnessed out-of-hospital cardiac arrest, without evidence of harm in those with unwitnessed arrest, merits thoughtful consideration.
Finally, the point estimates of the survival rates in the placebo group and the amiodarone group differed less than anticipated when the trial was designed, which suggests that the trial may have been underpowered. If amiodarone has a true treatment effect of 3 percentage points, approximately 9000 patients across the three trial groups would be needed to establish this difference in outcome with 90% power. Though seemingly small, a confirmed overall difference of 3 percentage points in survival with drug therapy would mean that 1800 additional lives could be saved each year in North America alone after out-of-hospital cardiac arrest.
Several limitations of this trial should be considered. Selection bias could have influenced trial enrollment. However, reasons for nonenrollment were systematically tracked, and questionable instances of exclusion were numerically small. The trial tested only one administration strategy without active-treatment crossover ; other strategies may produce different results. Last, enrollment of patients whose condition at randomization afforded little or no chance of survival irrespective of treatment may have diluted the presence of a more robust treatment effect in others, resulting in a smaller overall benefit than had eligibility been more selective.25
In conclusion, in this randomized trial, we found that overall neither amiodarone nor lidocaine resulted in a significantly higher rate of survival to hospital discharge or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia.
The Resuscitation Outcomes Consortium (ROC) was supported by the NHLBI through a series of cooperative agreements with nine regional clinical centers (spanning 10 North American communities) and one data coordinating center (5U01 HL077863, with the University of Washington Data Coordinating Center ; HL077866, with the Medical College of Wisconsin ; HL077867, with the University of Washington ; HL077871, with the University of Pittsburgh ; HL077872, with St. Michael’s Hospital ; HL077873, with Oregon Health and Science University ; HL077881, with the University of Alabama at Birmingham ; HL077885, with the Ottawa Hospital Research Institute ; HL077887, with the University of Texas Southwestern Medical Center ; and HL077908, with the University of California San Diego). Additional funding was provided by U.S. Army Medical Research and Materiel Command, the Canadian Institutes of Health Research Institute of Circulatory and Respiratory Health, Defence Research and Development Canada, the Heart and Stroke Foundation of Canada, and the American Heart Association. Two authors are employees of the NHLBI ; they helped in the design and conduct of the trial, data analysis and interpretation, and revision of the manuscript. The NHLBI, as the trial funder, also appointed members of the protocol review committee of the ROC and members of the data and safety monitoring board of this trial but otherwise played no role in its conduct.
The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute (NHLBI) or the National Institutes of Health.
This article was published on April 4, 2016, at NEJM.org.
We thank the nurse coordinators, research personnel, and especially the paramedic prehospital care providers across the ROC, whose enthusiasm, professionalism, and dedication to advancing patient care and gaining new knowledge to save lives were the foundation for this endeavor.
From the Department of Medicine (P.J.K., T.R., G.N.) and Division of Cardiology (P.J.K.), University of Washington, the King County Emergency Medical Services, Public Health (P.J.K., T.R.), the Department of Biostatistics, University of Washington Clinical Trial Center (S.P.B., G.N., B.L.), and University of Washington–Harborview Center for Prehospital Emergency Care (G.N.), Seattle, and Clark County Emergency Medical Services, Vancouver (L.W.) — all in Washington ; the Department of Emergency Medicine, Oregon Health and Science University, Portland (M.D.) ; Rescu, Li Ka Shing Knowledge Institute, St. Michael’s Hospital (L.J.M., P.D.), and the Divisions of Emergency Medicine (L.J.M.) and Cardiology (P.D.), Department of Medicine, University of Toronto, Toronto, the Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (C.V., I.G.S.), and the Department of Emergency Medicine, Providence Health Care Research Institute, University of British Columbia Faculty of Medicine (J.C.), and Providence Health Care Research Institute and British Columbia Emergency Health Services (R.S.), Vancouver — all in Canada ; University of Pittsburgh, Pittsburgh (C.W.C., A.M.B.) ; National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda (D.E., P.D.-N.), and Johns Hopkins University, Baltimore (M.L.W.) — both in Maryland ; the Department of Emergency Medicine, Virginia Commonwealth University, Richmond (J.P.O.) ; the Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center (A.H.I.), and Dallas Fire–Rescue Department (N.S.) — both in Dallas ; the Departments of Emergency Medicine (T.P.A.) and Pediatrics (M.R.C.), Medical College of Wisconsin, Milwaukee ; the Department of Emergency Medicine, University of California San Diego (J.V.D., G.M.V.), and San Diego Fire–Rescue Department (J.V.D.) — both in San Diego ; and University of Alabama at Birmingham, Birmingham (P.C.G., R.G.).
Address reprint requests to Dr. Kudenchuk at the Division of Cardiology, University of Washington, 1959 N.E. Pacific St., Box 356422, Seattle, WA 98166.
A complete list of the Resuscitation Outcomes Consortium investigators is provided in the Supplementary Appendix, available at NEJM.org.
RCP continue ou discontinue… De quoi changer les pratiques ?
Publié le 06/07/2016 source : srlf.org
La réanimation cardio-pulmonaire (RCP) a pour objectif le maintien d’un débit sanguin et d’une ventilation pulmonaire suffisante pour assurer une oxygénation tissulaire minimale jusqu’à la restauration d’une activité cardiaque efficace (1). Durant la prise en charge de l’arrêt cardiorespiratoire (ACR) extra hospitalier, l’interruption des compressions thoraciques par des insufflations en pression positive s’accompagnerait d’une réduction du débit sanguin circulant (2) et d’une diminution de la survie chez l’animal (3). Les études observationnelles réalisées chez l’homme dans les ACR présumés de cause cardiaque, suggèrent que la RCP en compression continue est associée à un taux de survie plus élevé (4, 5).
L’objectif de ce travail était de savoir si, durant la RCP par une équipe entrainée, l’interruption régulière du massage cardiaque pour permettre la ventilation comparée à des compressions thoraciques en continu et des insufflations asynchrones pouvait avoir un impact sur la survie et le pronostic neurologique des patients en ACR non hypoxiques.
Essai prospectif, randomisé, contrôlé, multicentrique en ouvert, comparant le groupe interventionnel (RCP avec compressions thoraciques continues à un rythme de 100/min associées à une ventilation pulmonaire asynchrone à un rythme de 10 cycles/min) à la prise en charge de référence (RCP avec compression intermittente selon le ratio 30 compressions thoraciques /2 insufflations).
La population cible regroupait les patients adultes ayant présenté un ACR extra-hospitalier non hypoxique et non traumatique, initialement pris en charge par un membre d’un des services d’urgence participant à l’étude.
Les services d’urgences participant à l’étude étaient répartis en clusters après randomisation avec un schéma d’étude en cross over et un changement de prise en charge attribuée à chaque cluster tous les 6 mois. Une phase dite de « run-in » permettait d’exclure de la population effective les clusters dont les services d’urgences ne réalisaient pas correctement la RCP qui leur avait été assignée, selon les enregistrements continus des scopes-défibrillateurs et des critères d’efficience pré-fixés et évalués par un comité interne à l’étude.
Le critère de jugement principal était la survie à la sortie de l’hôpital. Les principaux critères secondaires étaient la fonction neurologique à la sortie de l’hôpital et le nombre de jours vivant en dehors de l’hôpital dans les 30 jours suivant l’ACR. L’étude était suivie d’une double analyse per protocole visant à exclure les RCP ne suivant pas scrupuleusement le protocole de RCP attribué, d’abord à partir d’un algorithme automatique évaluant l’adhérence des soignants aux manœuvres de RCP selon l’enregistrement des défibrillateurs puis, à partir d’une relecture des RCP inclassables par un comité interne indépendant.
De juin 2011 à mai 2015, 26 148 patients ont été inclus en phase de run-in. Après exclusion des centres non efficients et des données non exploitables, 23 648 patients ont été inclus dans l’analyse principale en intention de traiter : 12 613 patients dans le groupe « compressions thoraciques continues » versus 11 035 patients dans le groupe « compressions thoraciques intermittentes ».
1129 patients du groupe RCP avec compressions continues (9%) sortent vivants de l’hôpital pour 1072 patients du groupe RCP avec compressions intermittentes (9,7%) (Différence -0,7%, IC 95% [-1,5 ; 0,1], p=0,07). 7.0% des patients du groupe RCP avec compressions continues et 7.7% des patients du groupe RCP avec compressions intermittentes présentaient une évolution neurologique favorable défini par un Rankin score < 4 (différence, −0.6 % ; 95% IC, −1.4 to 0.1, P=0.09). Le nombre de jours vivant en dehors de l’hôpital dans les 30 jours suivant l’ACR était significativement plus faible dans le groupe RCP avec compressions continues (différence moyenne, −0.2 jours, 95% IC, −0.3 to −0.1 ; P= 0.004).
L’analyse complémentaire per protocole entraîne l’exclusion de 13479 patients et l’analyse de 10 232 dossiers : 6 545 avec compressions continues et 3 687 avec compressions intermittentes. Dans cette population, il existait une diminution significative du taux de survie dans le groupe RCP avec compressions continues par rapport au groupe RCP avec compressions intermittentes (de -2%, IC95% [-2,9 ;-1,1], p<0,001).
Il s’agit de la première étude interventionnelle sur ce sujet : seules des études observationnelles chez l’humain ou pré cliniques sur des porcs avaient été jusque là réalisées. Cette étude a une forte qualité méthodologique avec un effectif important, une validité interne conforme à l’objectif, une puissance suffisante, peu de biais et une population étudiée représentative de celle ciblée. On peut lui attribuer une forte pertinence clinique et un fort niveau de preuve. Elle répond à une question importante concernant la prise en charge des ACR en pré-hospitalier avec un résultat à l’impact pratique susceptible d’influencer nos prises en charge.
L’analyse complémentaire en per protocole souffre de plusieurs limites. D’abord, en excluant trop de patients au final non classés par l’analyse des données des défibrillateurs (10 232 analysés en per protocole pour 23711 en analyse principale), la validité interne est moindre. D’autre part, les 2 groupes ne sont pas comparables, avec un nombre significativement supérieur d’intubation pré hospitalières et de rythmes choquables dans le groupe contrôle (compressions intermittentes).
Le temps moyen occupé par les compressions thoraciques pour chaque minute de RCP (0.77±0.14 dans le groupe contrôle et 0.83±0.14 dans le groupe interventionnel) est peu différent d’un groupe à l’autre. Il très élevée, au-delà des cibles préconisées par l’AHA et l’ERC, et vraisemblablement au-delà de ce qui se fait dans la « vraie vie » (6). Au final, ces données expliquent peut être l’absence de différence entre les deux groupes sur le critère de jugement principal.
Enfin, les résultats de cette étude ne sont pas extrapolables au système de soins français, compte tenu des différences d’organisation que celui-ci présente avec le système de soins nord-américain. Il faut d’ailleurs noter un délai moyen assez bref entre l’ACR et l’arrivée des secours sur les lieux (en moyenne 6 minutes) et un taux élevé de rythmes choquables (en moyenne 20%) l’ensemble s’associant à un taux de survie globale significatif (>9%). Implications et conclusions
Cet essai clinique va à l’encontre de la notion selon laquelle l’interruption brève des compressions thoraciques diminuerait l’efficacité de la RCP. Il nous incite à poursuivre une réanimation cardio-pulmonaire dont les compressions thoraciques seraient interrompues par de brèves phases de ventilation.
Trial of Continuous or Interrupted Chest Compressions during CPR. Nichol G, Leroux B, Wang H and ROC Investigators. N Engl J Med. 2015 Dec 3 ;373(23):2203-14.
Article commenté par le Dr Coralie Chambrin(a), le Dr Nicholas Sedillot (a), le Pr Antoine Roch (b) pour la Commission de Médecine d’Urgence de la SRLF
(a) Service de Réanimation
(b) Service des Urgences
Les auteurs déclarent n’avoir aucun conflit d’intérêt. Le contenu des fiches REACTU traduit la position de leurs auteurs mais n’engage ni la CERC ni la SRLF.
Envoyez vos commentaires/réactions aux auteurs (Coralie.Chambrin@live.fr, nsedillot@ch-bourg01.fr, antoine.roch@ap-hm.fr) ou à la CERC.
Berg RA, Hemphill R, Abella BS, et al. Part 5 : adult basic life support : 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010 ;122:Suppl 3:S685-705
Berg RA, Sanders AB, Kern KB, et al. Adverse hemodynamic effects of inter- rupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation 2001 ;104:2465-70
Kern KB, Hilwig RW, Berg RA, Sanders AB, Ewy GA. Importance of continuous chest compressions during cardiopulmonary resuscitation : improved outcome during a simulated single lay-rescuer scenario. Circulation 2002 ;105:645-9
Bobrow BJ, Spaite DW, Berg RA, et al. Chest compression-only CPR by lay rescuers and survival from out-of-hospital cardiac arrest. JAMA 2010 ;304:1447-54.
Bobrow BJ, Clark LL, Ewy GA, et al. Minimally interrupted cardiac resuscitation by emergency medical services for out- of-hospital cardiac arrest. JAMA 2008 ;299 : 1158-65.
Christenson J, Andrusiek D, Everson-Stewart S, et al. Chest Compression Fraction Determines Survival in Patients With Out-of-Hospital Ventricular Fibrillation. Circulation. 2009 ;120:1241-47.
Massage cardiaque externe : entre pompes et coups de pompe
Plusieurs études confirment que la fatigue du sauveteur altère déjà la qualité du massage cardiaque externe (MCE), quelques minutes après son début. Afin de vérifier l’hypothèse que le MCE n’est pas qu’une affaire d’intellos et prenant leur courage à deux biceps, des auteurs espagnols de la Mancha ont d’une part étudié la relation entre l’indice de masse corporelle (IMC), la force musculaire (mesurée par dynamométrie ajusté au poids corporel) et la bonne réalisation du MCE. D’autre part, ils ont voulu voir si l’association entre IMC et bonne réalisation du MCE est médiée par la force musculaire (1). Ce deuxième objectif en fait la première étude du genre.
Stayin’ Alive, Stayin’ Alive, ah, ah, ah
Après avoir reçu une formation selon les standards de l’European Resuscitation Council, 63 étudiants en soins infirmiers (19 hommes et 44 femmes âgés de 19 à 43 ans) ayant subi des tests cardiovasculaires maximaux avec succès, ont été inclus dans une étude transversale évaluant leur pratique du MCE sur mannequin (ratio compression-ventilation de 30 pour 2) pendant 20 minutes ou jusqu’à épuisement, Ont été considérés comme adéquats, les MCE effectués à une fréquence de 100 à 120 / minute ; avec 100 % de compressions au centre du thorax ; avec une dépression thoracique de 50 à 60 mm et avec un temps égal de compression et de relaxation du thorax à 100 % du temps. La méthode PROCESS macro de Preacher et Hayes a été utilisée pour rechercher une association entre IMC et MCE médiée par la force musculaire.
Au pays de Don Quichotte et de Sancho Pança
Les étudiants de moindre poids ont obtenu de moins bons résultats que ceux de poids normal ou bien obèses pour plusieurs variables dépendantes telles que la bonne dépression sternale (P < 0,001) et la réalisation adéquate du MCE (P < 0,001). Après réajustement pour la force musculaire, cette différence persiste sauf pour la fréquence des compressions (P = 0,053).
De plus, les étudiants aux plus bas quartiles de force musculaire étaient moins performants en matière de bonne dépression sternale (P = 0,001) et de réalisation adéquate du MCE (P < 0,001) que ceux aux quartiles moyens ou hauts après ajustement des variables confondantes.
Les effets de l’IMC sur la bonne réalisation du MCE étaient partiellement médiés par la force musculaire. Des résultats similaires ont été obtenus par l’analyse du rôle de la force musculaire dans la relation entre l’IMC et la bonne dépression sternale.
Le résultat principal de cette étude menée au pays de Cervantes est qu’il existe une association significative entre poids, force musculaire et bonne réalisation des MCE dans une situation de fatigue extrême ou après 20 minutes de MCE. Au-delà d’une durée de MCE supérieure à 5 minutes, la qualité du MCE et tout particulièrement la profondeur de la dépression sternale dépendent de la force musculaire. Les personnes les plus lourdes de morphotype Sancho Pança produisent des MCE plus efficaces que les morphotypes de faible IMC de type Don Quichotte. Toutefois ces derniers peuvent compenser leur handicap par une plus grande force musculaire des bras.
La survie des arrêts cardio-circulatoires pré hospitaliers dépend de la précocité et de la qualité des manœuvres de réanimation cardio-respiratoires dont le MCE (2), lequel dépend de la force musculaire des bras de celui qui le pratique.
Sans vouloir se battre contre des moulins à vent, la conclusion de cette étude originale, outre le fait qu’elle confirme que tous les ibères ne sont pas rudes dans la Mancha, est que les métiers d’urgentiste, de réanimateur et d’anesthésiste sont les plus complets qui soient, car ils requièrent une bonne condition physique en sus d’une bonne condition mentale et intellectuelle ! CQFD.
Dr Bernard-Alex Gauzère
1) López-González A, Sánchez-López M, Garcia-Hermoso A et coll. : Muscular fitness as a mediator of quality cardiopulmonary resuscitation. Am J Emerg Med., 2016 ; 34 : 1845-9. doi : 10.1016/j.ajem.2016.06.058.
2) GD Perkins, AJ Handley, RW Koster et coll. : European resuscitation council guidelines for resuscitation 2015 : section 2. Adult basic life support and and automated external defibrillation. Resuscitation, 2015 ; 95 : 81–99
Réanimation : une vidéo pour connaitre les bons gestes
L’école de Santé de Suisse Romande a réalisé une petite vidéo qui vise à expliquer simplement et non sans une petite pointe d’humour, les principes de réanimation cardiopulmonaire aux non professionnels de la santé. En général, Les secours mettent en France 14 minutes pour arriver sur le lieu d’un accident, quelqu’il soit. C’est rapide, mais c’est long en cas d’arrêt cardiaque -mais également, en cas d’hémorragie, de réaction allergique ou d’étouffement.
Problème : moins d’une personne sur cinq, témoin d’un arrêt cardiaque, sait comment pratiquer les gestes de premiers secours en France, selon la Fédération française de cardiologie (FFC). L’arrêt cardiaque est pourtant l’exemple même de la situation où chaque minute compte et où un geste de réanimation pratiqué par un témoin peut doubler, voire tripler les chances de survie d’un individu !
Dans ce contexte, l’intervention rapide d’un témoin peut non seulement améliorer les chances de survie de la victime mais aussi réduire ses risques de séquelles… C’est pour cela que l’école de Santé de Suisse Romande a réalisé une petite vidéo (voir ci-dessous) qui vise à expliquer simplement et non sans une petite pointe d’humour, les principes de réanimation cardiopulmonaire aux non professionnels de la santé.
Un homme adulte court le long du Rhône à Genève. Il croise plusieurs passants d’âges différents, dont une vieille dame assise sur un banc. D’un coup il s’écroule, terrassé. Les personnes alentours, notamment les plus jeunes restent sans réagir. Mais la vieille dame aperçue précédemment prend les choses en main… Elle sait ce qu’il faut faire en attendant les secours !
Et vous, sauriez-vous réagir, si un ami ou collègue était victime d’un accident grave ? Rappelons que la réanimation cardiopulmonaire (RCP) désigne l’ensemble des gestes destinés à sauver la vie en cas de malaise grave. Le massage cardiaque ne comporte quasiment aucun risque de complication sérieuse. Au moindre doute, démarrez immédiatement le massage cardiaque, vous n’avez rien à perdre -et encore moins la personne malade- et tout à gagner !
Les différentes étapes de la réanimation :
- Face à la personne qui fait un malaise, regardez si elle vous répond.
- Si la personne ne vous répond pas, regardez si elle respire.
- Si la personne ne respire plus OU que sa respiration ne vous paraît pas normale ? Appelez immédiatement votre numéro d’urgence (112 en Europe)
- Et démarrez immédiatement le massage cardiaque !
source : essr.ch/blog et senioractu.com
Epinephrine : The ’Backboard’ of Cardiac Arrest ?
Amal Mattu, MD Disclosures | October 30, 201
source : http://www.medscape.com/viewarticle...
EPI for Cardiac Arrest : Time to Step Away ?
Part 7 : Adult Advanced Cardiovascular Life Support : 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Link MS, Berkow LC, Kudenchuk PJ, et al. Circulation. 2015 ;132:S444-S464
Every 5 years, the American Heart Association (AHA) releases its update on Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. The 2015 Guidelines were released in October without much fanfare or groundbreaking changes. The latter point is unfortunate, as many of us who follow the emergency resuscitation literature were expecting...hoping...that the AHA would take a step away from its longstanding recommendation regarding routine use of epinephrine (EPI) in patients with cardiac arrest.
The following is a brief summary of the 2015 guidelines as they pertain to the use of EPI :
Standard-dose EPI (1 mg every 3-5 minutes) may be reasonable for patients in cardiac arrest (class IIb — possibly helpful).
High-dose EPI (HDE) is not recommended for routine use in cardiac arrest (class III — harmful).
Vasopressin in combination with EPI offers no advantage as a substitute for standard-dose EPI (class IIb).
It may be reasonable to administer EPI as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm (class IIb).
Although the strength of recommendation for use of EPI by the AHA seems to be weak, the continued endorsement of EPI in patients with cardiac arrest reminds me of the routine use of backboards for spinal immobilization by prehospital providers.
Backboards were introduced into prehospital-care protocols in the 1980s based on virtually no evidence. Nevertheless, they became a dogmatic practice in prehospital medicine. Evidence eventually began to accumulate that the backboards didn’t, in fact, produce better outcomes for patients who are victims of trauma. On the contrary, the evidence began to show that the routine use of backboards was associated with pain, discomfort, pressure sores, respiratory compromise,[1] airway difficulties,[2,3] and occasional neurologic complications.[4]
Despite significant literature published over the past 2+ decades showing that the harm exceeded any benefit for routine use of backboards, it has only been in the past few years that the use of backboards is being discouraged for routine use in prehospital protocols. The use of backboards in selected patients seems reasonable, but routine use just doesn’t make sense. However, as this backboard protocol demonstrates, once a recommendation finds its way into a formal protocol or guideline, no matter how little evidence there was to start, it becomes extremely difficult to remove it from protocols and standard practice.
Such appears to be the case with the use of EPI in cardiac arrest. This and other advanced life support drugs were first introduced into resuscitation protocols in the 1960s based on poorly controlled case series involving asphyxiated healthy young dogs[5] in which a standard 1-mg dose was defined without any weight adjustments or consideration of interspecies variation.[6]
The presumed benefits of EPI were based on the alpha-adrenergic effects that produce increased coronary perfusion pressure, and some benefits in terms of survival were noted in these early dog studies. Soon thereafter, assumptions were made that HDE would be even better. In fact, I was taught to use HDE in the late 1980s and early 1990s. Subsequent studies[7-11] demonstrated that although larger dosages of EPI, whether given in bolus form or cumulative, were associated with an increase in return of spontaneous circulation (ROSC) and survival to hospital admission, they did not produce an increase in survival to discharge or neurologic recovery.
In fact, evidence suggested worse discharge and neurologic outcomes with these higher dosages, presumably related to the beta-adrenergic effect of EPI. The AHA responded by removing HDE from its recommendations, but the guidelines continued to ignore the concerns of cumulative dosing of standard-dose EPI. The recommendation for EPI continued to be 1 mg every 3-5 minutes and ... apparently ... will continue indefinitely. Cardiac arrest victims were continuing to be placed on "backboards" despite mounting concerns and lack of quality evidence of benefit of EPI.
Since the publication of the 2010 Guidelines, further studies have questioned the dogma of repeated dosages of EPI in cardiac arrest.[12,13] These studies again support an increase in early ROSC but demonstrate worse neurologic and functional outcomes, especially with increasing cumulative dosages of EPI. An in-hospital study of cardiac arrest also showed that outcomes were improved with less frequent dosing of EPI than generally recommended in the guidelines.[14] The most optimistic study of EPI was by Jacobs and colleagues in 2011, a randomized, double-blind, placebo-controlled study evaluating EPI vs placebo in cardiac arrest.[15] This study showed at best a trend toward a better outcome with EPI, but the investigators did not find a statistically significant benefit. The investigators also did not evaluate the outcomes associated with cumulative dosages of EPI.
The recent study by Dumas and colleagues[13] and accompanying editorial[16] has proposed what I believe is the most cogent argument to when and how EPI should be used in cardiac arrest. During the first minutes of cardiac arrest, referred to as the "electrical phase," prompt defibrillation and continuous chest compressions should be the priority. It is during the second or "circulatory" phase of cardiac arrest that vasopressors appear to have the best chance of improving outcomes by improving coronary perfusion generated by chest compressions. During the third or "metabolic" phase of cardiac arrest, continuing dosages of EPI appear to be associated with a worse neurologic outcome in survivors. Continued accumulating dosages of EPI produce impaired oxygen utilization, increased myocardial oxygen demand, myocardial and cerebral ischemia, dysrhythmias, impaired lactate clearance, and a prothrombotic state.[6]
In summary, the data suggest that the benefits of EPI are likely to be optimal in the first 10 minutes after cardiac arrest, and EPI may be detrimental beyond that timeframe.
Perhaps it is about time for us to rethink our continued use of the indefinite "every 3-5 minute" dosing of EPI in victims of cardiac arrest. There is possible benefit to the early use of EPI but evidence of harm to the later continued use. It’s time to put the "backboard of cardiac arrest" aside. It’s time to start making more intelligent decisions about how to care for victims of cardiac arrest and use EPI in a more sensible way instead of being strapped to dogmatic longstanding protocols that are bereft of good evidence.
Vickery D. The use of the spinal board after the pre-hospital phase of trauma management. Emerg Med J. 2001 ;18:51-54. Abstract
Butman AM, Schelble DT, Vomacka RW. The relevance of the occult cervical spine controversy and mechanism of injury to prehospital protocols : a review of the issues and literature. Prehospital and Disaster Medicine. 1996 ;11:228-233. Abstract
Scannell GG, Waxman KK, Tominaga GG, et al. Orotracheal intubation in trauma patients with cervical fractures. Arch Surg. 1993 ;128:903-906. Abstract
Thumbikat PP, Hariharan RP, Ravichandran GG, et al. Spinal cord injury in patients with ankylosing spondylitis : a 10-year review. Spine. 2007 ;32:2989-2995. Abstract
Callaham M. Evidence in support of a back-to-basics approach in out-of-hospital cardiopulmonary resuscitation vs. "advanced treatment." JAMA Intern Med. 2015 ;175:205-206.
Callaway CW. Questioning the use of epinephrine to treat cardiac arrest. JAMA. 2012 ;307:1198-1199. Abstract
Stiell IG, Hebert PC, Weitzman BN, et al. High-dose epinephrine in adult cardiac arrest. N Engl J Med. 1992 ;327:1045-1050. Abstract
Brown CG, Martin DR, Pepe PE, et al. A comparison of standard-dose and high-dose epinephrine in cardiac arrest outside the hospital. The Multicenter High-Dose Epinephrine Study Group. N Engl J Med. 1992 ;327:1051-1055. Abstract
Rivers EP, Wortsman J, Rady MY, et al. The effect of total cumulative epinephrine dose administered during human CPR on hemodynamic, oxygen transport, and utilization variables in the postresuscitation period. Chest. 1994 ;106:1499-1507. Abstract
Behringer W, Kittler H, Sterz F, et al. Cumulative epinephrine dose during cardiopulmonary resuscitation and neurologic outcome. Ann Intern Med. 1998 ;129:450-456. Abstract
Guegniaud PY, Mols P, Goldstein P, et al. A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. N Engl J Med. 1998 ;339:1595-1601. Abstract
Hagihara A, Hasegawa M, Abe T, et al. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012 ;307:1161-1168. Abstract
Dumas F, Bougouin W, Geri G, et al. Is epinephrine during cardiac arrest associated with worse outcomes in resuscitated patients ? J Am Coll Cardiol. 2014 ;64:2360-2367. Abstract
Warren SA, Huszti E, Bradley SM, et al. Adrenaline (epinephrine) dosing period and survival after in-hospital cardiac arrest : a retrospective review of prospectively collected data. Resuscitation. 2014 ;85:350-358. Abstract
Jacobs IG, Finn JC, Jelinek GA, et al. Effect of adrenaline on survival in out-of-hospital cardiac arrest : a randomized double-blind placebo-controlled trial. Resuscitation. 2011 ;82:1138-1143. Abstract
Ewy GA. The time-sensitive role of vasopressors during resuscitation of ventricular fibrillation. J Am Coll Cardiol. 2014 ;64:2368-2370. Abstract
Adrénaline et arrêt cardiaque : enfin des chiffres !
L’adrénaline est toujours considérée comme l’agent vasopresseur numéro un dans l’arrêt cardiaque et ceci en dépit de l’absence totale d’essai clinique ayant à ce jour prouvé une réelle efficacité dans cette indication. aberdeaux C’est dans ce contexte que Jacobs et al (Perth, Australie) ont présenté samedi les résultats de l’essai PACA (Placebo Controlled Trial of Adenaline) dans lequel 535 patients ayant eu un arrêt cardiaque en dehors de l’hôpital ont reçu dans un ordre aléatoire et en double-insu, soit un placebo (n=262) soit des bolus d’adrénaline (1 mg IV) toutes les 3 à 5 min (n=273) jusqu’à retour à une circulation spontanée (ROSC).
Le critère primaire de l’essai était la survie des patients et secondairement les succès du ROSC et le score neurologique à la sortie de l’hôpital. Le recours à l’adrénaline s’est traduit par une augmentation significative (en intension de traiter) des patients ayant eu un retour à une circulation spontanée (ROSC) par rapport à ceux qui ont reçu le placebo (83/273 (30.4%) vs 29/262 (11.1%), odds ratio : 3.51 [95%IC2.21 à 5.58]). Par contre, la survie à la sortie de l’hôpital n’était pas significativement différente entre les groupes (11 patients dans le groupe traité par adrénaline (4.1%) vs 5 (1.9%) dans le groupe placebo (odds ratio : 2.16 [IC : 0.74-6.30]).
Les orateurs ont conclu que si l’adrénaline avait donc montré qu’elle améliorait le pourcentage de patients bénéficiant d’un retour à une circulation spontanée, l’administration de cet agent vasopresseur de référence n’améliorait pas la survie de ces patients au sortir de l’hôpital, sachant que les limites de cet essai sont avant tout la faiblesse des effectifs en présence (mais qu’il faudrait des milliers de patients pour prouver ou non une telle efficacité).
Alain Berdeaux source : sfcardio.fr
J Am Coll Cardiol. 2014 Dec 9 ;64(22):2360-7. doi : 10.1016/j.jacc.2014.09.036. Epub 2014 Dec 1.
Is epinephrine during cardiac arrest associated with worse outcomes in resuscitated patients ?
Dumas F1, Bougouin W2, Geri G2, Lamhaut L3, Bougle A4, Daviaud F4, Morichau-Beauchant T4, Rosencher J5, Marijon E6, Carli P7, Jouven X6, Rea TD8, Cariou A2. Author information Abstract BACKGROUND :
Although epinephrine is essential for successful return of spontaneous circulation (ROSC), the influence of this drug on recovery during the post-cardiac arrest phase is debatable.
This study sought to investigate the relationship between pre-hospital use of epinephrine and functional survival among patients with out-of-hospital cardiac arrest (OHCA) who achieved successful ROSC.
We included all patients with OHCA who achieved successful ROSC admitted to a cardiac arrest center from January 2000 to August 2012. Use of epinephrine was coded as yes/no and by dose (none, 1 mg, 2 to 5 mg, >5 mg). A favorable discharge outcome was coded using a Cerebral Performance Category 1 or 2. Analyses incorporated multivariable logistic regression, propensity scoring, and matching methods.
Of the 1,556 eligible patients, 1,134 (73%) received epinephrine ; 194 (17%) of these patients had a good outcome versus 255 of 422 patients (63%) in the nontreated group (p < 0.001). This adverse association of epinephrine was observed regardless of length of resuscitation or in-hospital interventions performed. Compared with patients who did not receive epinephrine, the adjusted odds ratio of intact survival was 0.48 (95% confidence interval [CI] : 0.27 to 0.84) for 1 mg of epinephrine, 0.30 (95% CI : 0.20 to 0.47) for 2 to 5 mg of epinephrine, and 0.23 (95% CI : 0.14 to 0.37) for >5 mg of epinephrine. Delayed administration of epinephrine was associated with worse outcome.
In this large cohort of patients who achieved ROSC, pre-hospital use of epinephrine was consistently associated with a lower chance of survival, an association that showed a dose effect and persisted despite post-resuscitation interventions. These findings suggest that additional studies to determine if and how epinephrine may provide long-term functional survival benefit are needed.
Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved. KEYWORDS :
cardiac arrest ; hypothermia ; percutaneous coronary intervention Comment in
Prehospital use of adrenaline reduces survival in cardiac arrest, study finds. [BMJ. 2014] The time-sensitive role of vasopressors during resuscitation of ventricular fibrillation. [J Am Coll Cardiol. 2014]
PMID : 25465423 DOI : 10.1016/j.jacc.2014.09.036
Rev Lat Am Enfermagem. 2016 Dec 8 ;24:e2821. doi : 10.1590/1518-8345.1317.2821.
Epinephrine in cardiac arrest : systematic review and meta-analysis.
[Article in English, Portuguese, Spanish] Morales-Cané I1, Valverde-León MD2, Rodríguez-Borrego MA3. Author information Abstract Objective ::
systematic review of scientific literature with meta-analysis, using a random effects model. The following databases were used to research clinical trials and observational studies : Medline, Embase and Cochrane, from 2005 to 2015.
when the Return of Spontaneous Circulation (ROSC) with administration of epinephrine was compared with ROSC without administration, increased rates were found with administration (OR 2.02. 95% CI 1.49 to 2.75 ; I2 = 95%). Meta-analysis showed an increase in survival to discharge or 30 days after administration of epinephrine (OR 1.23 ; 95% IC 1.05-1.44 ; I2=83%). Stratification by shockable and non-shockable rhythms showed an increase in survival for non-shockable rhythm (OR 1.52 ; 95% IC 1.29-1.78 ; I2=42%). When compared with delayed administration, the administration of epinephrine within 10 minutes showed an increased survival rate (OR 2.03 ; 95% IC 1.77-2.32 ; I2=0%).
Circulation. 2016 Dec 20 ;134(25):2105-2114. Epub 2016 Dec 1.
Khera R1, Chan PS2, Donnino M2, Girotra S2 ; American Heart Association’s Get With The Guidelines-Resuscitation Investigators. Author information Abstract
For patients with in-hospital cardiac arrests attributable to nonshockable rhythms, delays in epinephrine administration beyond 5 minutes is associated with worse survival. However, the extent of hospital variation in delayed epinephrine administration and its effect on hospital-level outcomes is unknown.
Within Get With The Guidelines-Resuscitation, we identified 103 932 adult patients (≥18 years) at 548 hospitals with an in-hospital cardiac arrest attributable to a nonshockable rhythm who received at least 1 dose of epinephrine between 2000 and 2014. We constructed 2-level hierarchical regression models to quantify hospital variation in rates of delayed epinephrine administration (>5 minutes) and its association with hospital rates of survival to discharge and survival with functional recovery.
Overall, 13 213 (12.7%) patients had delays to epinephrine, and this rate varied markedly across hospitals (range, 0%-53.8%). The odds of delay in epinephrine administration were 58% higher at 1 randomly selected hospital in comparison with a similar patient at another randomly selected hospital (median odds ratio, 1.58 ; 95% confidence interval, 1.51-1.64). The median risk-standardized survival rate was 12.0% (range, 5.4%-31.9%), and the risk-standardized survival with functional recovery was 7.4% (range, 0.9%-30.8%). There was an inverse correlation between a hospital’s rate of delayed epinephrine administration and its risk-standardized rate of survival to discharge (ρ=-0.22, P<0.0001) and survival with functional recovery (ρ=-0.14, P=0.001). In comparison with a median survival rate of 12.9% (interquartile range, 11.1%-15.4%) at hospitals in the lowest quartile of epinephrine delay, risk-standardized survival was 16% lower at hospitals in the quartile with the highest rate of epinephrine delays (10.8% ; interquartile range, 9.7%-12.7%).
Delays in epinephrine administration following in-hospital cardiac arrest are common and variy across hospitals. Hospitals with high rates of delayed epinephrine administration had lower rates of overall survival for in-hospital cardiac arrest attributable to nonshockable rhythm. Further studies are needed to determine whether improving hospital performance on time to epinephrine administration, especially at hospitals with poor performance on this metric, will lead to improved outcomes.
Le drone volant transportant un défibrillateur automatisé externe (DAE) n’est pas une utopie. Il a été mis au point en 2014 par un jeune élève ingénieur de l’université de Delft (Pays-Bas). Le prototype permettait d’amener le matériel dans un territoire de 12 km2 en une minute, à la vitesse de 100 km/heure, ce qui en théorie doit augmenter considérablement les chances de survie (+ 80 % à + 90 %) pour les plus optimistes), chez les victimes d’un arrêt cardiorespiratoire (ACR) survenu hors du milieu hospitalier. En effet, les DAE de plus en plus implantés dans l’espace public ne sauraient couvrir l’ensemble d’un territoire national, de sorte que le témoin de l’ACR n’a le plus souvent que le massage cardiaque externe à sa disposition pour tenter de sauver son prochain.
Combien de drones pour gagner quelques (précieuses) minutes ?
Quand on sait la fréquence de cette situation, le drone défibrillateur est à l’évidence prometteur, d’autant que les performances de la réanimation peuvent être améliorées par l’utilisation conjointe d’une caméra pour faciliter la communication avec un médecin. Alors, la mise en place d’un réseau de drones défibrillateurs est-elle une bonne solution ? C’est là le point de départ d’une modélisation mathématique réalisée par une équipe canadienne et publiée dans Circulation. Le modèle a combiné des équations d’optimisation sous contrainte appliquées à une série d’opérations, l’objectif étant de raccourcir au maximum le délai entre l’ACR et l’arrivée du drone sauveur. Son application a concerné 53 702 ACR survenus dans les huit régions autour de Toronto formant le réseau RescuNET, entre le 1er janvier 2006 et le 31 décembre 2014, avec deux objectifs : (1) déterminer la taille du réseau nécessaire pour amener l’engin sur les lieux dans un délai plus court que celui permis par l’arrivée des secours en temps normal (estimé à partir de 911 interventions), le gain de temps pouvant être en moyenne de 1, 2 ou 3 minutes, toutes zones confondues, rurales et urbaines ; (2) en second, quantifier la réduction des ressources en drones, si RescuNET était organisé en une seule et même région.
Pour couvrir les besoins de la région précédemment définie sous sa forme actuelle, il faudrait créer 81 bases, chacune équipée de 100 drones, si l’objectif est de gagner en moyenne 3 minutes par rapport au délai disons conventionnel. Si l’analyse se focalise sur les zones urbanisées et si l’on raisonne en 90e percentile de ce délai, l’arrivée du DAE pourrait être raccourcie de 6 minutes et 43 secondes. Dans les régions rurales, le gain serait de 10 minutes et 34 secondes. La réorganisation de RescuNET en coordonnant les régions et en simplifiant le réseau permettrait de diminuer le nombre de bases de près de 40 % et le celui des drones de 30 %, en gardant les mêmes objectifs que ceux précédemment définis.
Bénéfice surtout évident dans les zones rurales
Le modèle mathématique élaboré par cette équipe canadienne donne une idée des moyens à déployer pour optimiser un réseau de drones défibrillateurs visant à lutter contre le fléau que représentent les ACR survenant hors du milieu hospitalier. C’est dans les régions rurales que le bénéfice au moins mathématique serait le plus évident, en sachant que le rapport coût-efficacité de ces mesures devrait être évalué. Au passage, il faut rappeler que la faisabilité d’un tel projet est loin d’être établie, compte tenu du coût unitaire d’un drone spécifiquement conçu à cette fin et de toute la logistique afférente, des imprécisions sur la géolocalisation et de l’effet des conditions météo sur les déplacements du défibrillateur volant. La limitation aux zones rurales pourrait être une alternative à un projet national ou régional de grande envergure, sauf à disposer de moyens à hauteur des ambitions affichées. Dans la famille drones à tout faire, on n’en retiendra pas moins qu’elle compte désormais un membre de plus : le drone défibrillateur.
RÉFÉRENCES Boutillier JJ et coll. Optimizing a Drone Network to Deliver Automated External Defibrillators. Circulation 2017 : publication avancée enligne le 2 mars. doi : 10.1161/CIRCULATIONAHA.116.026318. Copyright © http://www.jim.fr
L’incidence de survenue des arrêts cardiaques pré-hospitaliers (ACPH) est de 55 à 113/100 000 personnes et par an. Le nombre de personnes en arrêt cardiaque avec un rythme cardiaque initial choquable et donc récupérable par un défibrillateur précocement appliqué, décroît avec le temps d’intervention. La défibrillation au cours des toutes premières minutes d’un arrêt cardiaque peut sauver plusieurs années de vie pondérées par la qualité (QALY). Mais en dépit d’investissements énormes, dont les défibrillateurs installés dans les lieux publics, les services d’urgence ne sont, le plus souvent, pas en mesure d’être auprès de ces patients en ACPH dans les 5 à 10 minutes. Il n’est guère possible de multiplier à l’envi le nombre d’ambulances spécialisées dont le coût annuel de chacune d’entre elles a été estimé dans le plat pays à 150 000 euros.
Des drones équipés de défibrillateurs pourraient-ils suppléer à cette carence en raison de leur rapidité d’intervention, de leur faible coût d’exploitation, de la possibilité d’assistance de l’intervenant sur site par télémédecine visuelle ? Quelles sont les barrières technologiques et légales à résoudre avant de passer du rêve à la réalité, s’interrogent, une fois, des auteurs belges ?
Une alternative à la multiplication des défibrillateurs
La première alternative consiste à multiplier considérablement le nombre de défibrillateurs, ainsi que des volontaires entrainés à leur utilisation et aux manœuvres de réanimation, puis à les relier par des applications capables de lancer des SMS sur leurs téléphones portables 24 heures sur 24 leur indiquant où trouver un défibrillateur dont la maintenance aurait été correctement assurée. Les premiers retours d’expériences du genre conduites aux Pays-Bas montrent un délai encore trop long de 8 minutes entre l’appel et le premier choc délivré.
Et quid des zones rurales ?
La deuxième alternative est le recours à des drones équipés de défibrillateurs (unmanned aerial system UAS) dont le vol serait tout ou partie automatisé, stratégiquement positionnés selon une cartographie des probabilités d’arrêts cardiaques et du temps d’intervention, avec un « pilote » à distance qui les superviserait dans chaque région. Sur le terrain, des volontaires formés et prévenus par SMS ou des bien des badauds, pourraient alors intervenir immédiatement. Le pilote guiderait à distance, sous contrôle de la vue les manœuvres de réanimation (bouche-à-bouche et utilisation du défibrillateur) avec une bien meilleure incitation à les faire accomplir et correctement, par les badauds.
Le coût actuel d’un prototype équipé du défibrillateur est de 15 000 euro, mais baisserait rapidement avec la production de masse. Le coût du pilote 24 heures sur 24 est certes important, mais le pilote pourrait couvrir une région entière avec 10 à 20 drones, avec un œil direct sur les manœuvres de réanimation et être déjà un membre des équipes de secours.
Gaulois, faut-il toujours craindre que le ciel nous tombe sur la tête ?
Le marché civil des drones est estimé à 750 millions de dollars avec un taux de croissance annuel de 19 % entre 2015 et 2020. Mais la plupart des pays ont émis des limitations à leur utilisation pour des raisons de sécurité (vol de jour uniquement à vue, qualification du pilote, vols bannis au-dessus des villes, hauteur maximale du vol). Resterait également à définir des procédures d’atterrissage sûres, à s’assurer que le drone se trouve auprès du patient en moins de 5 minutes, alors que les drones à hélices capables de se poser verticalement ne volent qu’à 50 km/heure, que le poids minimum des défibrillateurs actuels est de 490 grammes et qu’il faut un positionnement très précis par système d’information géographique (SIG). Les expériences de simulation conduites en Suède, avec des drones volant à 70 km/heure avec un rayon d’action de 10 km, montrent qu’en milieu urbain, le drone arrive avant les secours dans 32 % des cas avec un gain de temps moyen de 1,5 minutes ; et qu’en milieu rural, il devance les secours dans 93 % des cas avec un gain de temps moyen de 19 minutes.
Référence Van de Voorde P et coll. : The drone ambulance [A-UAS] : golden bullet or just a blank ? Resuscitation. 2017 ; 116 : 46-48. doi : 10.1016/j.resuscitation.2017.04.037.
Références : Andersen L W et coll. : Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA, 2017 ; 317:494-506. doi : 10.1001/jama.2016.20165.
L’intubation n’est pas synonyme de coma !
Aux Etats-Unis, chaque année, plus de 200 000 patients font un arrêt cardiaque intra-hospitalier (ACIH) avec une mortalité de 75 %. Le maintien d’une certaine température est considéré comme favorable pour le devenir des patients bien que les études prospectives n’aient porté que sur des arrêts cardiaques pré-hospitaliers. Il n’existe aucune étude prospective portant sur l’intérêt du contrôle de la température au décours des ACIH. Fait troublant, des travaux récents ont retrouvé un moins bon pronostic chez les patients maintenus en hypothermie lors des ACIH, alors que les auteurs avaient retenu le critère intubation comme condition nécessaire au déclenchement et au maintien de l’hypothermie et donc comme critère de coma. La validité de cette approche demande donc confirmation.
Des auteurs américains ont pris pour hypothèses le fait qu’un certain nombre de patients intubés pendant l’ACIH n’étaient pas tous comateux après avoir été réanimés avec succès et que le coma post ACIH associé à la mortalité intra hospitalière pourrait être un facteur confondant lors d’une analyse portant sur l’intérêt de l’hypothermie pour ces patients.
Pour ce faire, ils ont donc mené une étude rétrospective monocentrique chez des adultes victimes d’un ACIH en service de réanimation, intubés avant ou pendant l’ACIH ou immédiatement après avoir été réanimés avec succès. Les patients dont les score de Glasgow (GCS) était inférieur à 8 ont été définis comme étant comateux. Leur taux de survie a ensuite été comparé avec celui des patients dont le GCS était > à 8. Réserver l’hypothermie aux patients vraiment dans le coma
Parmi les 102 patients intubés, ventilés et réanimés avec succès après au moins 20 minutes de manœuvres, 29 (28 %) ont eu un GCS ≥ 8, et 22 (22 %) pouvaient répondre aux ordres simples. La survie des patients avec GCS ≥ 8 vs. <8 a été de 62 % (18/29) vs. 37 % (27/73) (p = 0,02). L’odds ratio ajusté de survie à la sortie de l’hôpital a été de 3,81 (intervalle de confiance à 95 % : 1,37–10,61, p = 0,01).
Bien que monocentrique, rétrospective et portant sur un petit effectif, il ressort de cette étude que l’intubation avant ou pendant l’ACIH n’est pas un bon marqueur de coma et est encore moins prédictive du coma consécutif au succès de la réanimation. Sans surprise, ceux dont le CGS était le plus élevé ont eu un meilleur taux de survie post hospitalière. L’hypothermie « protectrice » devrait uniquement être appliquée aux patients vraiment comateux après réanimation et non systématiquement parce que intubation serait synonyme de coma.
Berg KM et coll. : Intubation is not a marker for coma after in-hospital cardiac arrest : A retrospective study. Resuscitation. 2017 ; 119 : 18-20. doi : 10.1016/j.resuscitation.2017.07.024
Nichol. NEJM 2015 ; published online first (accessed 19th November 2015). doi:10.1056/NEJMoa1509139
In adult patients that are in cardiac arrest, do uninterrupted chest compressions compared to chest compressions interrupted for manual ventilation improve survival, neurological recovery or the rate of adverse events ?
Cluster randomised, controlled, cross-over trial Emergency Medical Services (EMS) grouped into clusters Randomised to intervention or control as a cluster Run-in phase to demonstrate adherence and performance Cross-over to alternative trial arm twice a year Unblinded EMS providers ; outcome assessment blinding not specified Huber-White sandwich adjustment used to statistically account for cluster design (reduces risk of false positive conclusion) Adjustment made for interim analyses to reduce false positive risk Designed to have 90% power to detect survival rates of 8.1% in the control group versus 9.4% in the intervention group with a two-sided alpha level of 0.05
8 Resuscitation Outcome Consortium sites with 114 participating EMS agencies All based in USA or Canada June 2011 to May 2015
Inclusion : adults with non-traumatic out-of-hospital cardiac arrest
Continuous chest compressions Chest compressions at a rate of 100/min Asynchronous positive pressure ventilation at 10/min commenced within 2 minutes of chest compressions starting Ventilation maintained via “oral airway” for first 3 cycles of 2 minutes each If no ROSC or termination of CPR, then an endotracheal or supraglottic airway was inserted as soon after 3rd cycle as possible Continuous chest compressions and asynchronous ventilation continued once advanced airway device inserted
Interrupted chest compressions Chest compressions at a rate of 100/min Interrupted for ventilation at a ratio of 30:2 Positive pressure ventilation delivered during 5 second pause in compressions Ventilation maintained via “oral airway” for 3 cycles of 2 minutes each If no ROSC or termination of CPR, then an endotracheal or supraglottic airway was inserted as soon after 3rd cycle as possible Continuous chest compressions and asynchronous ventilation continued once advanced airway device inserted
Once an advanced airway was inserted, or ROSC was achieved, CPR was standardised to existing guidelines in both groups (continuous compressions with asynchronous ventilation) Hospital care such as temperature management or coronary intervention was monitored but not standardised
Primary outcome : no statistically significant difference in survival to hospital discharge between the groups was demonstrated Continuous chest compressions : 9.7% Interrupted chest compressions : 9.0% Adjusted difference : -0.7 (95% CI -1.5 to 0.1 ; p-value 0.07) Secondary outcome : Per-protocol analysis of survival to hospital discharge A statistically significant difference was demonstrated favouring interrupted chest compressions Continuous group 7.6% vs Interrupted group 9.6% Adjusted difference : -1.3 (95% CI -2.5 to -0.1 ; p-value 0.04) Neurological outcome at discharge There was no statistically significant difference in the proportion of survivors with a modified Rankin Scale score of 3 or less (favourable outcome) Continuous group 7.0% vs Interrupted group 7.7% Adjusted difference : -0.6% (95% CI -1.4 to 0.1 ; p-value 0.09) Hospital-free survival at 30-days Patients in the continuous group had less hospital-free survival with statistical significance, but the difference is of questionable clinical significance Continuous group 1.3 days vs Interrupted group 1.5 days Adjusted difference : -0.2 days (95% CI -0.3 to -0.1 ; p-value 0.004) Tertiary observational data The rate of transfer to hospital was lower in the continuous group Continuous group 52.8% vs Interrupted group 54.9% Adjusted difference : -2.0% (95% CI -3.6 to -0.5 ; p-value 0.01)
Pragmatic design – given the difficulty of performing a trial in community emergencies, the authors did well to perform this trial ; the cluster and cross-over design is well suited to this area of research and the run-in phase design allowed for appropriate training to occur Statistical corrections – to the best of my understanding, the Huber-White sandwich correction is an appropriate statistical method to correct for non-independent events that occur in cluster randomised trials Internal validity – Screening over 35,000 patients to achieve a 90 power is impressive and strengthens the validity of the conclusion
Credibility – the difference in management between the groups was only maintained until a advanced airway device was inserted ( 6 minutes) ; considering the bigger picture of the pathophysiology and patient journey, is it even feasible that a different CPR strategy for the first 6 minutes can modify long term outcomes ? Internal validity – some non-study differences existed between the groups ; the rate of transfer and subsequent admission to hospital was lower in the continuous group ; it is unclear if this was due to early death and cessation of CPR related to the intervention (an important outcome) or if it was a choice made by an un-blinded EMS provider (an important bias) ; this difference biases toward a negative conclusion although it is unclear if it is ‘false’ or ‘true’ External validity – the chest compression fractions (the proportion of each minute during the first 6 minutes during which chest compressions were occurring) only differed slightly between the groups and both were greater than other observational studies have previously described ; this represents high quality CPR in both groups that may not be representative of real-world resuscitation ; this may produce a bias toward a false negative conclusion
[article] Trial of Continuous or Interrupted Chest Compressions during CPR [further reading] Resuscitation Council (UK) 2015 Guidelines on Adult Advanced Life Support
Summary author : @DuncanChambler Summary date : 25 November 2015 Peer-review editor : @DavidSlessor
ERC Summary of the main changes in the resuscitation guidelines 2015 [(PDF – 2.4 Mo)]