Cardiac arrest in special circumstances

Abstract

Purpose of reviewEuropean Resuscitation Council Guidelines for Cardiopulmonary Resuscitation prioritize treatments like chest compression and defibrillation, known to be highly effective for cardiac arrest from cardiac origin. This review highlights the need to modify this approach in special circumstances. Recent findingsPotentially reversible causes of cardiac arrest are clustered into four Hs and four Ts (Hypoxia, Hypovolaemia, Hyperkalaemia/other electrolyte disorders, Hypothermia, Thrombosis, Tamponade, Tension pneumothorax, Toxic agents). Point-of-care ultrasound has its role in identification of the cause and targeting treatment. Time-critical interventions may even prevent cardiac arrest if applied early. The extracorporeal CPR (eCPR) or mechanical CPR should be considered for bridging the period needed to reverse the precipitating cause(s). There is low quality of evidence available to guide the treatment in the majority of situations. Some topics (pulmonary embolism, eCPR, drowning, pregnancy and opioid toxicity) were included in recent ILCOR reviews and evidence updates but majority of recommendations is based on individual systematic reviews, scoping reviews, evidence updates and expert consensus. SummaryCardiac arrests from reversible causes happen with lower incidence. Return of spontaneous circulation and neurologically intact survival can hardly be achieved without a modified approach focusing on immediate treatment of the underlying cause(s) of cardiac arrest.

Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries

“…The ERC guideline and other guidelines suggest to consider RT when other reversible causes have been addressed and a maximum of 10–15 min has been elapsed since vital signs were lost (Fig. 2 ) [ 15 , 23 , 24 ]. However, the evidence supporting these cut-offs is weak and timings are only general guidance: patients who have exsanguinated and are in cardiac arrest with asystole or a wide complex disorganized rhythm have an extremely poor prognosis, whereas patients who have a low flow state with an organized narrow complex rhythm and/or a (relatively) high ETCO2 may have the potential for a good outcome and warrant ongoing aggressive resuscitation attempts [ 25 – 28 ].…”

“…1 Traumatic cardiac arrest (TCA)

Fig. 2 Options for cardiac resuscitation of patients in traumatic cardiac arrest (TCA) due to non-compressible haemorrhage from non-ballistic penetrating injuries: Addition to the 2021 ERC guidelines [ 15 ] on the treatment of patients in traumatic cardiac arrest (original figure adapted with permission)

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“…The revised traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC) published in 2021 [ 15 ] mentions that interventions such as REBOA and RT can be considered to address potentially reversible causes of a traumatic cardiac arrest (in parallel to other interventions). However, specific guidance on when to deploy these techniques in the pre-hospital setting is currently lacking, leaving pre-hospital clinicians with complex decisions under significant time pressure and high levels of uncertainty: available information is often limited, anatomical injuries are often unknown, and various (non) technical and logistical challenges must be overcome.…”

Letter to the editor in response to “A 6-year case series of resuscitative thoracotomies performed by a helicopter emergency medical service in a mixed urban and rural area with a comparison of blunt versus penetrating trauma”

“…By this time the chances of success of resuscitation efforts would have dropped dramatically, which is reflected by the low ROSC rate in this group (3/17). Therefore, although not absolute, recent guidelines recommend a cut-off of 10–15 min no flow time [ 3 ].…”

Resuscitative thoracotomy in blunt traumatic cardiac arrest

“…European Resuscitation Council (ERC) guidelines [ 3 ] recommend RT for relieving tamponade and aortic control in subdiaphragmatic haemorrhage in the context of appropriate Expertise, Equipment, Environment and Elapsed time (Fig. 1 ).…”