Cardiopulmonary resuscitation in special circumstances.

Cardiopulmonary resuscitation prioritises treatment for cardiac arrests from a primary cardiac cause, which make up the majority of treated cardiac arrests. Early chest compressions and, when indicated, a defibrillation shock from a bystander give the best chance of survival with a good neurological status. Cardiac arrest can also be caused by special circumstances, such as asphyxia, trauma, pulmonary embolism, accidental hypothermia, anaphylaxis, or COVID-19, and during pregnancy or perioperatively. Cardiac arrests in these circumstances represent an increasing proportion of all treated cardiac arrests, often have a preventable cause, and require additional interventions to correct a reversible cause during resuscitation. The evidence for treating these conditions is mostly of low or very low certainty and further studies are needed. Irrespective of the cause, treatments for cardiac arrest are time sensitive and most effective when given early-every minute counts.

Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

Conservation resource allocation, small population resiliency, and the fallacy of conservation triage.

Some conservation prioritization methods are based on the assumption that conservation needs overwhelm current resources and not all species can be conserved; therefore, a conservation triage scheme (i.e., when the system is overwhelmed, species should be divided into three groups based on likelihood of survival, and efforts should be focused on those species in the group with the best survival prospects and reduced or denied to those in the group with no survival prospects and to those in the group not needing special efforts for their conservation) is necessary to guide resource allocation. We argue that this decision-making strategy is not appropriate because resources are not as limited as often assumed, and it is not evident that there are species that cannot be conserved. Small population size alone, for example, does not doom a species to extinction; plants, reptiles, birds, and mammals offer examples. Although resources dedicated to conserving all threatened species are insufficient at present, the world's economic resources are vast, and greater resources could be dedicated toward species conservation. The political framework for species conservation has improved, with initiatives such as the UN Sustainable Development Goals and other international agreements, funding mechanisms such as The Global Environment Facility, and the rise of many nongovernmental organizations with nimble, rapid-response small grants programs. For a prioritization system to allow no extinctions, zero extinctions must be an explicit goal of the system. Extinction is not inevitable, and should not be acceptable. A goal of no human-induced extinctions is imperative given the irreversibility of species loss.

Asignación de Recursos para la Conservación, Resiliencia de Poblaciones Pequeñas y la Falacia del Triaje de Conservación Resumen Algunos métodos de priorización de la conservación están basados en el supuesto de que las necesidades de la conservación superan a los actuales recursos y que no todas las especies pueden ser conservadas; por lo tanto, se necesita un esquema de triaje (esto es, cuando el sistema está abrumado, las especies deben dividirse en tres grupos con base en su probabilidad de supervivencia y los esfuerzos deben enfocarse en aquellas especies dentro del grupo con las mejores probabilidades de supervivencia y a aquellas en el grupo sin probabilidades de supervivencia o aquellas en el grupo que no necesita esfuerzos especializados para su conservación se les deben reducir o negar los esfuerzos de conservación) para dirigir la asignación de recursos. Discutimos que esta estrategia para la toma de decisiones no es apropiada porque los recursos no están tan limitados como se asume con frecuencia y tampoco es evidente que existan especies que no puedan ser conservadas. Por ejemplo, tan sólo un tamaño poblacional pequeño no es suficiente para condenar a una especie a la extinción; contamos con ejemplos en plantas, reptiles, aves y mamíferos. Aunque actualmente todos los recursos dedicados a la conservación de todas las especies amenazadas son insuficientes, los recursos económicos mundiales son vastos y se podrían dedicar mayores recursos a la conservación de especies. El marco de trabajo político para la conservación de especies ha mejorado, con iniciativas como los Objetivos de Desarrollo Sustentable de la ONU y otros acuerdos internacionales, el financiamiento de mecanismos como el Fondo para el Medio Ambiente Mundial, y el surgimiento de muchas organizaciones no gubernamentales mediante programas de subsidios pequeños hábiles y de respuesta rápida. Para que un sistema de priorización no permita las extinciones, las cero extinciones deben ser un objetivo explícito del sistema. La extinción no es inevitable y no debería ser aceptable. El objetivo de cero extinciones inducidas por humanos es imperativo dada la irreversibilidad de la pérdida de especies.

Frailty, delirium and hospital mortality of older adults admitted to intensive care: the Delirium (Deli) in ICU study.

BACKGROUND: Clinical frailty among older adults admitted to intensive care has been proposed as an important determinant of patient outcomes. Among this group of patients, an acute episode of delirium is also common, but its relationship to frailty and increased risk of mortality has not been extensively explored. Therefore, the aim of this study was to explore the relationship between clinical frailty, delirium and hospital mortality of older adults admitted to intensive care. METHODS: This study is part of a Delirium in Intensive Care (Deli) Study. During the initial 6-month baseline period, clinical frailty status on admission to intensive care, among adults aged 50 years or more; acute episodes of delirium; and the outcomes of intensive care and hospital stay were explored. RESULTS: During the 6-month baseline period, 997 patients, aged 50 years or more, were included in this study. The average age was 71 years (IQR, 63-79); 55% were male (n = 537). Among these patients, 39.2% (95% CI 36.1-42.3%, n = 396) had a Clinical Frailty Score (CFS) of 5 or more, and 13.0% (n = 127) had at least one acute episode of delirium. Frail patients were at greater risk of an episode of delirium (17% versus 10%, adjusted rate ratio (adjRR) = 1.71, 95% confidence interval (CI) 1.20-2.43, p = 0.003), had a longer hospital stay (2.6 days, 95% CI 1-7 days, p = 0.009) and had a higher risk of hospital mortality (19% versus 7%, adjRR = 2.54, 95% CI 1.72-3.75, p < 0.001), when compared to non-frail patients. Patients who were frail and experienced an acute episode of delirium in the intensive care had a 35% rate of hospital mortality versus 10% among non-frail patients who also experienced delirium in the ICU. CONCLUSION: Frailty and delirium significantly increase the risk of hospital mortality. Therefore, it is important to identify patients who are frail and institute measures to reduce the risk of adverse events in the ICU such as delirium and, importantly, to discuss these issues in an open and empathetic way with the patient and their families.

2018 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the second annual summary of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations that includes the most recent cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation. This summary addresses the role of antiarrhythmic drugs in adults and children and includes the Advanced Life Support Task Force and Pediatric Task Force consensus statements, which summarize the most recent published evidence and an assessment of the quality of the evidence based on Grading of Recommendations, Assessment, Development, and Evaluation criteria. The statements include consensus treatment recommendations approved by members of the relevant task forces. Insights into the deliberations of each task force are provided in the Values and Preferences and Task Force Insights sections. Finally, the task force members have listed the top knowledge gaps for further research.

Characteristics and outcomes of patients admitted to ICU following activation of the medical emergency team: impact of introducing a two-tier response system.

OBJECTIVE: To determine the impact of introducing a two-tier system for responding to deteriorating ward patients on ICU admissions after medical emergency team review. DESIGN: Retrospective database review before (2006-2009) and after (2011-2013) the introduction of a two-tier system. SETTING: Tertiary, university-affiliated hospital. PATIENTS: A total of 1,564 ICU admissions. INTERVENTIONS: Two-tier rapid response system. MEASUREMENTS AND MAIN RESULTS: The median number of medical emergency team activations/1,000 hospitalizations increased from 22 to 31 (difference [95% CI], 9 [5-10]; p<0.0001) with a decreased rate of medical emergency team activations leading to ICU admission (from median 11 to 8; difference [95% CI], 3 [3-4]; p=0.03). The median proportion of medical emergency team reviews leading to ICU admission increased for those triggered by tachypnoea (from 11% to 15%; difference [95% CI], 4 [3-5]; p<0.0001) and by hypotension (from 27% to 43%; difference [95% CI], 15 [12-19]; p<0.0001) and decreased for those triggered by reduced level of consciousness (from 20% to 17%; difference [95% CI], 3 [2-4]; p<0.0001) and by clinical concern (from 18% to 9%; difference [95% CI], 10 [9-13]; p<0.0001). The proportions of ICU admissions following medical emergency team review did not change significantly for tachycardia, seizure, or cardiorespiratory arrest. The overall ICU mortality for admissions following medical emergency team review for tachypnoea, tachycardia, and clinical concern decreased (from 29% to 9%: difference [95% CI], 20 [11-29]; p<0.0001) but did not change for the other triggers. The Acute Physiology and Chronic Health Evaluation predicted and observed ICU mortality and the proportion of patients dying with a not-for-resuscitation order decreased. CONCLUSIONS: The introduction of a two-tier response to clinical deterioration increased ICU admissions triggered by cardiorespiratory criteria, whereas admissions triggered by more subjective criteria decreased. The overall ICU mortality for patients admitted following medical emergency team review decreased, suggesting that the two-tier system led to earlier recognition of reversible pathology or a decision not to escalate the level of care.

The role of the medical emergency team in end-of-life care: a multicenter, prospective, observational study.

OBJECTIVE: To investigate the role of medical emergency teams in end-of-life care planning. DESIGN: One month prospective audit of medical emergency team calls. SETTING: Seven university-affiliated hospitals in Australia, Canada, and Sweden. PATIENTS: Five hundred eighteen patients who received a medical emergency team call over 1 month. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 652 medical emergency team calls in 518 patients, with multiple calls in 99 (19.1%) patients. There were 161 (31.1%) patients with limitations of medical therapy during the study period. The limitation of medical therapy was instituted in 105 (20.3%) and 56 (10.8%) patients before and after the medical emergency team call, respectively. In 78 patients who died with a limitation of medical therapy in place, the last medical emergency team review was on the day of death in 29.5% of patients, and within 2 days in another 28.2%.Compared with patients who did not have a limitation of medical therapy, those with a limitation of medical therapy were older (80 vs. 66 yrs; p < .001), less likely to be male (44.1% vs. 55.7%; p = .014), more likely to be medical admissions (70.8% vs. 51.3%; p < .001), and less likely to be admitted from home (74.5% vs. 92.2%, p < .001). In addition, those with a limitation of medical therapy were less likely to be discharged home (22.4% vs. 63.6%; p < .001) and more likely to die in hospital (48.4% vs. 12.3%; p < .001). There was a trend for increased likelihood of calls associated with limitations of medical therapy to occur out of hours (51.0% vs. 43.8%, p = .089). CONCLUSIONS: Issues around end-of-life care and limitations of medical therapy arose in approximately one-third of calls, suggesting a mismatch between patient needs for end-of-life care and resources at participating hospitals. These calls frequently occur in elderly medical patients and out of hours. Many such patients do not return home, and half die in hospital. There is a need for improved advanced care planning in our hospitals, and to confirm our findings in other organizations.

A multicentre evaluation of two intensive care unit triage protocols for use in an influenza pandemic.

OBJECTIVE: To determine the increase in intensive care unit (ICU) bed availability that would result from the use of the New South Wales and Ontario Health Plan for an Influenza Pandemic (OHPIP) triage protocols. DESIGN, SETTING AND PATIENTS: Prospective evaluation study conducted in eight Australian, adult, general ICUs, between September 2009 and May 2010. All patients who were admitted to the ICU, excluding those who had elective surgery, were prospectively evaluated using the two triage protocols, simulating a pandemic situation. Both protocols were originally developed to determine which patients should be excluded from accessing ICU resources during an influenza pandemic. MAIN OUTCOME MEASURE: Increase in ICU bed availability. RESULTS: At admission, the increases in ICU bed availability using Tiers 1, 2 and 3 of the NSW triage protocol were 3.5%, 14.7% and 22.7%, respectively, and 52.8% using the OHPIP triage protocol (P < 0.001). Re-evaluation of patients at 12 hours after admission using Tiers 1, 2 and 3 of the NSW triage protocol incrementally increased ICU bed availability by 19.2%, 16.1% and 14.1%, respectively (P < 0.001). The maximal cumulative increases in ICU bed availability using Tiers 1, 2 and 3 of the NSW triage protocol were 23.7%, 31.6% and 37.5%, respectively, at 72 hours (P < 0.001), and 65.0% using the OHPIP triage protocol, at 120 hours (P < 0.001). CONCLUSION: Both triage protocols resulted in increases in ICU bed availability, but the OHPIP protocol provided the greatest increase overall. With the NSW triage protocol, ICU bed availability increased as the protocol was escalated.

Educational initiative on critical bleeding in trauma: Chicago, July 11-13, 2008.

The Educational Initiative on Critical Bleeding in Trauma was formed to assess current data and to guide future research and practice in the management of coagulopathy after severe trauma. The Educational Initiative on Critical Bleeding in Trauma recently published structured literature reviews on animal models and mechanisms of trauma-associated coagulopathy and the results of a survey of international clinical practice. The authors convened a symposium in July 2008 and invited researchers and opinion leaders in trauma care, transfusion medicine, and coagulation research to discuss current understanding and management and to identify future areas of exploration. This document reviews the content and conclusions of the meeting. The association between trauma and bleeding from patient registries, basic science, and clinical studies was confirmed, as was the association between the coagulopathy that presents early after major injury and excess mortality. Meeting participants identified the need for consensus definitions and common terminology to describe coagulopathy after trauma, including the term acute coagulopathy of trauma shock to describe the early coagulopathy induced by tissue injury/shock and the global term trauma-induced coagulopathy to describe coagulopathy after injury and its sequelae (loss, consumption, acidemia, acute coagulopathy, and dilution). Other conclusions included the need for increased clinical awareness, new methods and tools for early diagnosis, consistent early preventative strategies, and evidence-based therapies for these conditions.