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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses the best practices for treating cardiac arrest in the emergency department (ED), emphasizing the need to optimize procedures based on the literature to give patients the best chance for survival. Specific topics include prehospital intubation, intraosseous access, cardiopulmonary resuscitation, and termination of resuscitation, among other topics.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EFirst Aid\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ETransportation Myocardial Infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECritical Care\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EFirst Aid\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ETransportation\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EEmergency Medicine\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECritical Care\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EMatthew Strehlow, MD, Stanford University, Stanford, California, USA, presented what he considers the best practices for treating cardiac arrest in the emergency department (ED), underscoring the need to optimize procedures based on the literature to give patients the best chance for survival.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EDr Strehlow began with a discussion of prehospital intubation, which remains a controversial topic in part because esophageal intubations are common. There are 2 key steps to check for missed intubations. The first is to monitor end-tidal carbon dioxide (ETCO\u003Csub\u003E2\u003C\/sub\u003E). It is also important to ensure that the endotracheal tube (ETT) is not placed too high, which will not be detected with ETCO\u003Csub\u003E2\u003C\/sub\u003E in a patient with spontaneous breathing. Dr Strehlow recommended that every prehospital ETT placement be confirmed either by direct visualization or via video laryngoscopy.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003ESpontaneous and assisted ventilation has the opposite effects on cardiac output. When a patient is breathing spontaneously, negative pressure draws in air and blood, which increases venous return and cardiac output. In contrast, during assisted ventilation, hyperventilation decreases cardiac output, cerebral perfusion, and coronary perfusion. Dr Strehlow emphasized the importance of not hyperventilating the patient, by having the team leader call out the ventilatory rate and monitor for adherence, with a target of 8 to 10 bag compressions per minute [Neumar RW et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2010]. He also recommended decreasing the bag size to a 500-mL pediatric Ambu bag in an average-sized adult to further reduce the risk of hyperventilation [Sherren PB et al. \u003Cem\u003EAnaesthesia\u003C\/em\u003E. 2011].\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EWhen intravenous (IV) access is difficult, Dr Strehlow endorsed using intraosseous (IO) access in cardiac arrest. Modern IO devices work well, with a first-pass success rate ranging from 85% to 95% [Nagler J et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2011; Voight J et al. \u003Cem\u003EPediatr Emer Care\u003C\/em\u003E. 2012]. The proximal tibia is the site typically used in pediatric patients. While this site can also be used in adults, the flow rate will be limited to approximately 1 L\/hr. Therefore, for adult patients in cardiac arrest, it is preferable to use the proximal humerus as the IO site. This is a painful procedure for conscious patients, so the proper protocol should be followed to ensure adequate pain control (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). The rapid flush cleans out the marrow and allows for a faster rate. Any drug may be given via IO, but it is best to switch to IV when possible.\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/46\/24\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Pain Management Protocol of Intraosseous Device Placement\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-733860110\u0022 data-figure-caption=\u0022Pain Management Protocol of Intraosseous Device Placement\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/46\/24\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/46\/24\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/46\/24\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15536\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003EPain Management Protocol of Intraosseous Device Placement\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EI V, intravenous.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003ESource: Miller L et al. \u003Cem\u003EAnn Emerg Med.\u003C\/em\u003E 2010.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-7\u0022\u003EDespite guideline recommendations by both the American Heart Association and the International Liaison Committee on Resuscitation regarding the management of cardiac arrest [\u003Cem\u003ECirculation\u003C\/em\u003E. 2005], the IO technique remains underutilized. It is possible that clinicians are concerned about complications; however, the complication rate is similar to that of IV access. The infection rate is \u0026lt; 3%, and the rate of osteomyelitis is \u0026lt; 0.6% [Nagler J et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2011]. Rates of serious complications, such as infection, compartment syndrome, and bone necrosis, are very rare, and regular checks of the IO site can reduce this risk.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EEfforts should also be made to improve cardiopulmonary resuscitation (CPR) techniques. Pauses during CPR should be avoided when possible. If chest compressions stop even for 5 seconds, the coronary perfusion pressure starts to decrease. Compressions should be continued during intubation and defibrillator charging, but Dr Strehlow does not recommend hands-on defibrillation, because the safety is not well established. The 5 essential elements of CPR are presented in \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E. CPR must be monitored to determine if it is successful. The goal is to achieve diastolic blood pressure \u0026gt; 25 mm Hg. If it falls below 15 mm Hg, the heart will not come back.\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15537\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15537\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15537\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003EFive Essential Elements of Cardiopulmonary Resuscitation\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-11\u0022\u003EAutomated CPR has been promoted as an advance in the management of cardiac arrest. However, the large randomized LINC study [Rubertsson S et al. \u003Cem\u003EJAMA\u003C\/em\u003E. 2014] found no difference in outcome when automated CPR was compared with manual CPR in patients with out-of-hospital cardiac arrest.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EDespite research demonstrating that hospitals with longer resuscitation efforts brought more patients back with good neurologic outcomes, according to Dr Strehlow, this does not mean that resuscitation should go on indefinitely [Goldberger ZD et al. \u003Cem\u003ELancet\u003C\/em\u003E. 2012]. As a measure of perfusion and cardiac output, ETCO\u003Csub\u003E2\u003C\/sub\u003E is a useful tool for determining prognosis. The goal for high-quality CPR is ETCO\u003Csub\u003E2\u003C\/sub\u003E \u0026gt; 20 mm Hg during CPR; with return of spontaneous circulation (ROSC), it will rise to \u0026gt; 30 mm Hg. If ETCO\u003Csub\u003E2\u003C\/sub\u003E is \u0026lt; 10 mm Hg when the patient arrives in the ED, the patient is most likely not going to come back. If after 20 minutes of advanced cardiac life support, the ETCO\u003Csub\u003E2\u003C\/sub\u003E is \u0026lt; 10 mm Hg, the patient is not coming back, and the resuscitation efforts can be stopped [Levine RL et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 1997; Kolar M \u003Cem\u003ECritical Care\u003C\/em\u003E. 2008].\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EThe prehospital basic life support (BLS) rule for termination of resuscitation (TOR) states that if the arrest was not witnessed by emergency medical services (EMS) personnel, if no shock was delivered before transport, and if no ROSC occurred before transport, there is a 99.8% chance that the patient will not survive [Verbeek PR et al. \u003Cem\u003EAcad Emerg Med.\u003C\/em\u003E 2002]. The advanced life support rule for TOR\u2014which is similar to the BLS rule but with the addition of arrest not witnessed by bystander or EMS, and no bystander CPR\u2014predicts 100% mortality [Morrison LJ et al. \u003Cem\u003EResuscitation\u003C\/em\u003E. 2007].\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EDr Strehlow stated that prehospital adoption of these TOR rules should be encouraged and that physicians can be confident in stopping resuscitation efforts if a patient arrives in the ED without having ROSC or meeting either TOR rule.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EDr Strehlow concluded that for a patient in cardiac arrest, the ABCs should be followed: airway, breathing, and circulation. For airway and breathing, confirmation of ETT placement and avoidance of hyperventilation are key. For circulation, IO use should be encouraged and chest compressions optimized.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/46\/24.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzohmp\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzohmp\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzohmp\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}