|Year : 2017 | Volume
| Issue : 11 | Page : 883-894
Comprehensive cardiopulmonary life support (CCLS) for cardiopulmonary resuscitation by trained paramedics and medics inside the hospital
Rakesh Garg1, Syed Moied Ahmed2, Mukul Chandra Kapoor3, SSC Chakra Rao4, Bibhuti Bhusan Mishra5, M Venkatagiri Kalandoor6, Baljit Singh7, Jigeeshu Vasishtha Divatia8
1 Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
2 Department of Anaesthesiology and Critical Care, J N Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
3 Department of Anesthesia, Max Smart Super Specialty Hospital, New Delhi, India
4 Department of Anaesthesiology, Care Emergency Hospital, Kakinada, Andhra Pradesh, India
5 Department of Anaesthesiology, Indian College of Anaesthesiologists, Bhubaneswar, Odisha, India
6 Department of Anaesthesiology, Government General Hospital, Kasaragod, Kerala, India
7 Department of Anaesthesiology and Intensive Care, GB Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
8 Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
|Date of Web Publication||13-Nov-2017|
Syed Moied Ahmed
Department of Anaesthesiology and Critical Care, J N Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
The cardiopulmonary resuscitation (CPR) guideline of comprehensive cardiopulmonary life support (CCLS) for management of the patient with cardiopulmonary arrest in adults provides an algorithmic step-wise approach for optimal outcome of the patient inside the hospital by trained medics and paramedics. This guideline has been developed considering the infrastructure of healthcare delivery system in India. This is based on evidence in the international and national literature. In the absence of data from the Indian population, the extrapolation has been made from international data, discussed with Indian experts and modified accordingly to ensure their applicability in India. The CCLS guideline emphasise the need to recognise patients at risk for cardiac arrest and their timely management before a cardiac arrest occurs. The basic components of CPR include chest compressions for blood circulation; airway maintenance to ensure airway patency; lung ventilation to enable oxygenation and defibrillation to convert a pathologic 'shockable' cardiac rhythm to one capable to maintaining effective blood circulation. CCLS emphasises incorporation of airway management, drugs, and identification of the cause of arrest and its correction, while chest compression and ventilation are ongoing. It also emphasises the value of organised team approach and optimal post-resuscitation care.
Keywords: Cardiopulmonary resuscitation, inside the hospital, chest compression, defibrillation, airway management, drugs in cardiopulmonary resuscitation
|How to cite this article:|
Garg R, Ahmed SM, Kapoor MC, Rao SC, Mishra BB, Kalandoor M V, Singh B, Divatia JV. Comprehensive cardiopulmonary life support (CCLS) for cardiopulmonary resuscitation by trained paramedics and medics inside the hospital. Indian J Anaesth 2017;61:883-94
|How to cite this URL:|
Garg R, Ahmed SM, Kapoor MC, Rao SC, Mishra BB, Kalandoor M V, Singh B, Divatia JV. Comprehensive cardiopulmonary life support (CCLS) for cardiopulmonary resuscitation by trained paramedics and medics inside the hospital. Indian J Anaesth [serial online] 2017 [cited 2017 Nov 23];61:883-94. Available from: http://www.ijaweb.org/text.asp?2017/61/11/883/218102
| Disclaimer|| |
This guideline has been made to improve the outcome of the patient with cardiopulmonary arrest. The guideline presents a streamlined algorithmic approach using evidence-based recommendations. Consensus opinions from experts are used, wherein robust Indian data were not available. However, these consensus statements remain based on inputs from international data and suitability modified to overcome the infrastructural and economic restrictions in India. It is emphasised that these guidelines do not represent the minimum standard of practice, nor are they a substitution for the good clinical judgment.
| Preamble|| |
The optimal outcome of a patient after cardiac arrest inside the hospital depends on not only the basic resuscitation steps but also the incorporation of advanced steps including administration of drugs, airway management, correction of underlying aetiologies, advanced monitoring and post-resuscitation care.,,,,,, In the absence of a robust pre-hospital medical transfer system in India, many patients are brought by the family members and may not have received optimal medical care. Cardiopulmonary arrest can occur in any part of the hospital ranging from a well-equipped critical care unit to lesser-equipped peripheral wards and outpatient clinics. Such patients require comprehensive management of the cardiac arrest starting from basic steps and thereafter incorporating advanced care at the earliest. The comprehensive cardiopulmonary life support (CCLS) emphasises five core links for an optimal outcome in a patient with cardiac arrest. Early comprehensive life support has been incorporated as the fifth link in core links in adult CCLS. Hence, considering this, a comprehensive approach is required, which incorporates all steps of cardiopulmonary resuscitation (CPR) in a single algorithm. Time is of the essence during resuscitation! The resuscitation trolley such as crash cart, with all essential equipment, may take time to shift even in hospitals, especially to peripheral wards. Therefore, it becomes essential that medical personnel available immediately initiate basic resuscitation to start the process. Patients also require post-resuscitation care to manage underlying aetiologies, neurological injuries and refractory cardiac arrest, and prevent complications of resuscitation attempts., This CCLS guideline encompasses all the steps of resuscitation, after cardiac arrest inside the hospital, with an aim to integrate the basic and advanced components of CPR.
| Methods|| |
The detailed methodology has been discussed earlier in section on basic cardiopulmonary life support (BCLS).
A list of resuscitation-related search terms was identified. A literature search for studies published in English language between June 2005 and June 2017 using PubMed, Embase, Medline, Ovid, Google Scholar Databases and other search engines using the following search items and key words: CPR; inside the hospital cardiac arrest; defibrillation; automated external defibrillation; early defibrillation; high-quality CPR; chest compression; early transfer; pulse check for cardiac arrest; airway management; drugs; reversible causes; antiarrhythmics; trained personnel in different combinations. Additional articles were retrieved by cross-referencing and manual search of the desired manuscripts. The main focus was on randomised clinical trials, but observational cohort studies and case reports/series were also identified. A total of 3985 abstracts were reviewed for relevance, and this list was narrowed down to 79 articles for detailed study. In addition, CPR guidelines of various societies were reviewed. Articles specifically related to the individual guideline were circulated to the experts. Each article was reviewed by at least two members of the resuscitation Group.
| Comprehensive Cardiopulmonary Life Support (CCLS) Links and Algorithm Description|| |
Core links in adult comprehensive cardiopulmonary life support (CCLS)
The five essential core links for optimal outcome in patient with cardiopulmonary arrest during CCLS are [Figure 1]:
|Figure 1: Core links in adult comprehensive cardiopulmonary life support (CCLS)|
Click here to view
- Early recognition and management of pre-arrest conditions
- Early recognition of arrest and activation of Code blue
- Early high-quality CPR
- Early defibrillation
- Early comprehensive life support and post-resuscitation care.
These links remain the focus for improved outcome in CCLS. The early identification of pre-arrest conditions and appropriate management are essential to prevent cardiac arrest in the controlled environment of a hospital. The early recognition and delivery of high-quality CPR by a dedicated team are the most important aspects of the links in CCLS. The role of early defibrillation is paramount in a patient with sudden collapse due to a cardiac cause. After basic resuscitation, the patient requires further assessment and management, to correct the underlying aetiology, to prevent re-arrest and minimise the damage that would have occurred during the arrest period and resuscitation.
Adult comprehensive cardiopulmonary life support (CCLS) steps
The management of a patient with cardiopulmonary arrest inside the hospital requires a systematic approach for an optimal outcome. A sequential series of predefined steps, for the assessment and management of the arrest patient, must be followed to ensure return of spontaneous circulation (ROSC). The CCLS is a simplified algorithm-based approach to be followed to resuscitate a patient with cardiopulmonary arrest [Figure 2]. Although the algorithm of CCLS is sequential, these steps may be done simultaneously as more than one trained person are usually available in a hospital. However, the ethos of the algorithm needs to be followed. The division of work needs to be done in such a way that the patient gets care at the earliest while all steps are being followed. The steps of CCLS are:
Safe place for resuscitation
The place usually remains safe inside the hospital. However, in certain situations, patient may have collapsed while not in bed or in emergency or may be in outpatient department. The patient should be shifted immediately to safe place, wherein CPR could be performed optimally. However, delay in shifting or starting CPR should always be avoided. All places inside the hospital are suitable for CCLS and no specific area is being suggested in this guideline. Once the patient has been shifted to suitable place, the assessment and resuscitation of the patient should be initiated at the earliest.
Patient's response check
The patient's response check needs to be done immediately. The rescuer should come from front facing the patients face, tap on the shoulder, speak loudly (e.g., Hello-Are You Alright?) in a language patient could understand to elicit the response from the patient. The patient should not be shaken and neck movements done (such as tapping on face) should not be done as they could cause further harm in cases of injury to cervical spine, if present. Two situations arise:
- Responsive: If the patient responds either verbally and/or by purposeful movement, then there is less likelihood of cardiopulmonary arrest. Such a patient needs to be monitored frequently. He may be shifted to high dependency unit or a monitored area and further evaluation needs to be done
- Not Responsive: If no response is elicited, then patient may be in cardiac arrest. Additional help is required, and hence, Code blue team or local team (as in Intensive care unit or other dedicated area) needs to be activated.
Activate Code blue team or local team
The person observing the patient collapsing should immediately activate the Code blue or inform the local team as per institutional protocol. All hospitals should assign a Code blue speed dial number in their internal telephone exchange, and the Code blue number must be prominently displayed in all areas of the hospital. In case help is available, he may be instructed to activate the Code blue or local team and inform them to bring defibrillator and emergency crash cart (emergency drugs and equipment including venous access, airway management equipment, etc.). The resuscitation team must be defined, based on the duty roster, and their contact details must be prominently displayed for immediate contact in case of Code blue.
Check pulse and breath simultaneously
After activation of Code blue, the pulse and breathing should be assessed simultaneously. The carotid pulse should be identified and checked for its definite presence. The pulse needs to be checked for 5–10 s. During this pulse check, the chest should also be scanned for breathing movements. The absence of breathing or abnormal breathing such as gasping or agonal breaths and absence of definite carotid pulse are suggestive of cardiopulmonary arrest. In case of doubtful presence of pulse and breath, the patient should be assumed to have cardiopulmonary arrest. The check for pulse and breath should not take >10 s. The timing for 10 s may be done by chanting loudly 1001, 1002, 1003,….1010 to avoid delay for an initiation of 'early CPR'. During the check of pulse and breath, three situations may be arise:
- Normal breathing with definite carotid pulse: the patient needs to be assessed every 2 min or more frequently for some change in vital parameters. Patient may be shifted to high dependency unit or intensive care set-up for continuous monitoring, and further evaluation for cause of collapse and its management
- Abnormal or no breathing with a definite carotid pulse: the patient is in respiratory arrest. After opening of the airway by head tilt and chin lift (only jaw thrust or chin lift in victim of suspected cervical spine trauma), a normal tidal volume breath should be provided (end point is visible chest rise) every 5 s (12 breaths every minute) using bag-mask device. The use of oropharyngeal or nasopharyngeal airway devices may be used in case ventilation using bag-mask device is not optimal. In case expertise is available, then the airway may be secured using endotracheal tube and ventilation continued using bag-mask device. Each breath should be delivered over 1 s. Reassess the patient for pulse every 2 min or earlier for change in the vital parameters. Evaluate the patient for the cause of respiratory arrest and manage accordingly
- Abnormal or no breathing without a definite carotid pulse: the patient is in cardiopulmonary arrest and requires high-quality CPR at the earliest.
Early high-quality cardiopulmonary resuscitation
Once the cardiopulmonary arrest is recognised, the cycles of 30 chest compressions and 2 breaths should be initiated. To ensure optimised chest compressions, patients should be placed supine on a hard bed, on the ground or a hard board may be slipped behind the back of the patient to prevent backward movement of the vertebral column during the compressions.
Chest Compressions: The 30 chest compressions should be started at the speed of 120 compressions/min and compression depth of 5 cm–6 cm. The rescuer should chant loudly 1, 2, 3, 4,....30 to optimise the speed and number of chest compressions. The rescuer should allow complete chest recoil between compressions without lifting the hand from the chest but without leaning on the patient's chest. To ensure optimal chest compression, the rescuers should position himself higher than the patient; interlock his hands; place the palmar surface of his hand on the centre of chest by identifying the xiphoid process and keeping heel of the hand 2 fingers above it for chest compressions, and ensure that the elbows are locked in extension so that his body weight rather arm movements facilitate the compression. There should be minimum interruptions between chest compressions
Breaths: Once chest compressions have been initiated, rescue breaths need to be delivered using a self-inflating bag-mask device. Bag-mask ventilation (BMV) involves keeping a triangular, cushioned, well-fitting mask covering the mouth and the nose, with the apex of the triangular mask resting on the bridge of the nose. The mask is connected to a compressible, self-inflating bag (with unidirectional valve) that is connected to a source of high flow oxygen. Selection of the correct size mask and achieving a proper mask seal is important to ensure adequate ventilation. BMV ventilation may be facilitated by performing a triple airway manoeuvre and/or insertion of basic airway adjuncts such as nasal or oral airways, in case adequate chest rise is not achieved. Each tidal volume breath should be delivered over 1 s with end point of visible chest rise. After allowing 1 s for exhalation, another breath over 1 s is provided and thereafter chest compression should be immediately restarted to minimise interruption in chest compressions.
The rescuer providing chest compressions and the one providing breath should interchange their role after every 5 cycles of CPR to prevent rescuer exhaustion and to maintain effective CCLS, especially chest compression. After 5 cycles of 30 chest compressions and 2 breaths*, the patient should be reassessed with carotid pulse check #. During the pulse check, the possible situations are:
Pulse present: Check for the presence of breath. If absent, provide breath every 5 s and reassess every 2 min. In case of the presence of breath, reassess every 2 min and shift the patient to a monitored area and correct the underlying aetiology
Pulse absent: Continue with another 5 cycles of 30 chest compressions and 2 breaths and reassess the carotid pulse.
*In case the patient's airway is already secured with an endotracheal tube, then chest compressions should be given continuously at a rate of 120 compressions/min without interruption, and 1 breath should be delivered every 6 s (10 breaths/min), rather than cycles of 30 chest compressions and 2 breaths. The rescuer performing compressions must rotate, approximately every 2 min, to ensure high-quality CPR.
# In case cardiac monitor or defibrillator pads/paddles are attached to the patient, then cardiac rhythm should be checked on the monitor instead of pulse. Based on rhythm assessment, need for defibrillation should be decided. However, pulse check may still be required in certain situations such as confirmation of an organised rhythm without a pulse (pulseless electrical activity [PEA]) and to differentiate ventricular tachycardia (VT) with/without pulse.
Defibrillation should be done at the earliest, especially in patient with witnessed sudden cardiac arrest. Defibrillation can be provided using a manual defibrillator. Till the arrival of the defibrillator and its attachment, high-quality CPR should be ensured. The first shock should be administered at the earliest, irrespective of the stage of the ongoing CPR cycle. Thereafter, the defibrillation should be done after 5 cycles of 30 compressions and 2 breaths. Once the defibrillation or cardiac monitor is attached, the pulse check should be replaced by rhythm check on the monitor.
Defibrillator: Follow the steps to prepare for defibrillation:
- Switch on the defibrillator
- Attach electrocardiogram (ECG) leads of the defibrillator or keep paddles on the chest (one at apex of heart at left side of the chest and other below the clavicle on the right side in midclavicular line). Continue CPR during lead attachments
- Analyse the rhythm. No rescuer should touch the patient during rhythm analysis
- If the rhythm is shockable (ventricular fibrillation [VF] and pulseless VT), charge the defibrillator at 120 J (biphasic). Continue chest compression during charging. Deliver the shock after ensuring that no rescuer is touching the patient or his bed. After delivery of the shock, resume CPR, starting with chest compression. Subsequent shock may be same or escalated to higher dose with maximum of 200 J (biphasic). In case of monophasic defibrillator, the initial and subsequent energy for defibrillation should be 360 J
- If rhythm is non-shockable (asystole and PEA), then immediately resume CPR cycles starting with chest compressions.
While the cycles of CPR are in process, other advanced aspects such as venous access, airway management, and drug administration should be integrated with cycles of CPR as early as possible. Simultaneously, identify the possible cause of cardiac arrest, send suitable investigations based on possible aetiology and treat accordingly. It needs to be emphasised during all these advanced management, the cycles of CPR should continue with minimal interruption in chest compression.
Venous access should be secured during ongoing chest compression and ventilation. The peripheral venous access is the most preferred. In case the venous access is not secured in initial 3 attempts, then the second choice remains intraosseous (IO) cannulation. All drugs and fluids may be administered through the IO route similar to intravenous access. However, it should be replaced with intravenous access at the earliest. In the absence of both of these accesses, the drugs may also be administered through endotracheal route (if already intubated). These drugs include naloxone, adrenaline, atropine and lidocaine. The intratracheal dose should be 2–2½ times that of intravenous dose and diluted to 10 mL.
The definitive airway may be secured with an endotracheal tube in case expertise is available. The use of supraglottic devices is also advocated if rescuer is appropriately trained and endotracheal tube placement is not feasible or successful. The correct placement of these devices must be verified after their placement. The use of end-tidal capnography is recommended to verify their correct placement. However, if the BMV is optimal, then securing definitive airway can be deferred to prevent unnecessary interruption of chest compression. In such cases, BMV should be continued till expert help arrives.
Drugs including antiarrhythmics
Once the vascular access is secured, adrenaline (epinephrine) 1 mg diluted in 10 mL should be administered as bolus, irrespective of the type of heart rhythm. This bolus needs to be repeated every 3–5 min. All drugs administered through peripheral venous access must be flushed with 20 mL of normal saline. Whenever feasible, the limb should also be elevated for 10–20 s after administration of the drug to facilitate its passage to the central circulation. Drugs should be administered during chest compression, so as to ensure their systemic distribution. If arrhythmias persist even after initial 2–3 cycles of CPR, then antiarrhythmics drugs are warranted. Amiodarone 300 mg should be administered intravenous as a slow bolus. A second intravenous dose of amiodarone 150 mg may be administered if arrhythmia persists. Lignocaine may be considered as an alternate drug in patients with persistent arrhythmia.
Assess and manage the reversible causes
The underlying aetiology of the cardiorespiratory arrest needs to be assessed. The history and physical examination needs to be reviewed for possible underlying aetiologies. The medical record and history from patient attendants needs to be reviewed. Based on the findings, the appropriate investigations should to be performed. However, it needs to be emphasised that during this process, the chest compressions and other aspects of resuscitation must not be interrupted. The patient should not be transported to another location for imaging or any special investigation while chest compression is ongoing.
The common causes for a cardiorespiratory arrest include hypovolaemia, hypoxia, acidosis, electrolyte imbalance, pneumothorax, cardiac tamponade, drug toxicity, pulmonary embolism and myocardial infarction. They need to be primarily addressed on clinical examination and blood investigations.
After successful resuscitation, the patient needs definitive medical care and management for underlying aetiology of the cardiopulmonary arrest. Patient should be shifted to a high dependency unit or critical care unit. If the cause of cardiac arrest is underlying neurological or cardiac disease, the patients may be shifted to speciality setting of the hospital for an appropriate early intervention and optimal recovery. The patient should receive appropriate post-resuscitation care.
Once there is ROSC, patient requires specific care in a dedicated unit. During this period, not only are maintenance of perfusion and oxygenation paramount but also the correction of precipitating cause of cardiac arrest needs to be addressed. Ventilatory support may be continued as per patient assessment to maintain normocarbia (end-tidal CO2 35–40 mmHg). During resuscitation, highest oxygen concentration is recommended but after return of circulation, the inspired fraction of oxygen (Fio2) should be titrated to maintain oxygen saturation at 95% or more. These ventilatory parameters and targets may be tailored as per patient need. Specialist consultation is essential for assessment for the need of coronary or neurological interventions. The haemodynamic monitoring should be initiated with a target of mean arterial pressure of >65 mmHg. The optimal blood pressure should be ensured for optimal perfusion of vital organs. In case, if patient remains comatose after resuscitation, active warming must be avoided. Temperature may be kept not >36°C and not necessarily in the range of 32°C–36°C, in the absence of controlled hypothermic equipment. Prophylactic antiepileptic drugs are not recommended but, if seizures occur, then drug therapy should be initiated.
Quality assurance of comprehensive cardiopulmonary life support (CCLS) conduct
High-quality CCLS, and not just following the steps of CCLS, is paramount for an optimal outcome after a cardio-respiratory arrest. Emphasis on continued real-time quality check for CPR is essential. The various aspects that enhance the outcome include:
- Chest compressions speed, rate and recoil: Ensure a chest compression speed of 120 compressions/min to a depth of 5–6 cm
- Allow complete chest recoil between compression without lifting hands from the chest (do not lean on the patient's chest)
- Do not stop chest compressions unnecessarily.
Ventilation and Airway
- Do not unnecessarily interrupt chest compression for securing the airway
- Do not hyperventilate
- End point for ventilation is visible chest rise after a normal tidal volume breath.
- Monitor end-tidal capnography, if available. If it is <10 mmHg, then the CPR quality is inadequate and needs improvement.
If intra-arterial pressure monitoring is available or feasible, then relaxation phase pressure (diastolic) <20 mmHg indicates inadequate chest compression and needs improvement.
| Discussion|| |
Good quality CPR, with early defibrillation, early correction of underlying aetiology and effective post-resuscitation care are essential to improve the neurological recovery after cardiac arrest.,,,, The management of cardiopulmonary arrest inside the hospital is different as compared to that outside the hospital as expert workforce, with better infrastructure and other support, is available., The aetiology in an admitted patient is varied as compared to a victim outside the hospital, who has sudden loss of consciousness and cardiac arrest. Thus, a stand-alone management plan is needed for patients having cardiopulmonary arrest inside the hospital. The CCLS is a step-wise algorithmic approach to manage a patient with cardiopulmonary arrest inside the hospital. It is designed for trained personnel (medics and paramedics) with adequate skill and knowledge, who have basic infrastructure support available. The proposed CCLS algorithm is recommended to be followed for patients with cardiac arrest inside the hospital. The use of automated mechanical CPR devices is not being elaborated, as the same are not available in most parts of India.
The prevention of cardiac arrest should be a priority in admitted patients.,, This could be encouraged by appropriate surveillance system and identification of at-risk patients.,, The first core link of CCLS is early recognition and management of pre-arrest conditions.
Hence, admitted patients having risk factors for cardiac arrest should be identified and corrective measures taken before the cardiac arrest occurs. The cardiac arrest is usually preceded by deterioration in physiological instability including abnormal vital signs such as tachypnoea, tachycardia and hypotension. These pre-arrest conditions should be identified and timely corrective measures should be initiated. Patient being managed in general wards usually have less direct observations and intense monitoring and thus remains at risk of cardiac arrest. Strategies need to be developed for early recognition of high-risk patients and the management of underlying aetiology.
The initial steps for the management of CCLS remain similar as described in section on BCLS. The basic components include effective chest compressions to maintain perfusion of vital organs, airway maintenance to achieve the patent airway, ventilation of the lungs for optimal cellular oxygenation and defibrillation to convert a shockable rhythm to perfusing rhythm. A system should be in place for prompt activation of the resuscitation team along with the crash cart (including drugs, airway equipment and defibrillator) to be brought to the site of cardiac arrest at the earliest. The call for help is sought from hospital teams which may be named as code blue or local team in an intensive care set-up or other similar dedicated places. The response check, checking of pulse and breathing in a time-bound manner is similar to BCLS. The chest compression depth, rate, breaths and other related quality check of CPR remains the same as discussed in BCLS. In hospitals, manual defibrillator is usually used for reverting the abnormal cardiac rhythm. The assessment, delivery of shock remains the same as described for manual defibrillator in BCLS.
The pulse check should be done at the beginning to ascertain cardiac arrest and thereafter following every 5 sets of CPR. Once the defibrillator is available, the pulse check should be replaced with rhythm analysis after every 5 sets of CPR. In patients on ECG monitoring, rhythm must be assessed on monitor rather than by pulse check. Interruption to chest compression during rhythm analysis or pulse check should be <10 s. Pulse check is warranted in addition to rhythm analysis in clinical conditions such as VT or organised rhythm to ascertain the presence and absence of pulse. In case a flat line is seen on the monitor, a quick check within 10 s should be performed for lead connections, mode of monitor (paddle vs. lead mode), gain or amplitude to verify true asystole or fine VF. It is warranted not to stop chest compression, to assess rhythm during the 5 sets of CPR, even if the patient is not on continuous rhythm monitoring.
Airway management during resuscitation
The goal for the airway management during CPR is to ensure a patent airway and oxygenation. A decade back, the priority sequence of Airway ⇒ Breathing ⇒ Circulation (ABC) was replaced by Circulation ⇒ Airway ⇒ Breathing (CAB)., The regular use of cricoid pressure is not suggested in these guidelines. There are differing views on the need, type and equipment for airway management during CPR.,, Airway management is a highly skilled and operator-dependent arm of resuscitation. It is essential that the chest compressions should either not be interrupted at all or interrupted <10 s during airway management. The healthcare professionals should be well versed with basic airway management as it is crucial for maintaining airway patency and providing breaths. Basic airway management consists of manual relief of upper airway obstruction ('Triple airway manoeuvre'), BMV or the insertion of oropharyngeal or nasopharyngeal airway.,
It is suggested that maximal inspired oxygen concentration, at high flows, be provided to all patients. In a retrospective resuscitation study, Bobrow et al. found significantly higher survival without neurological deficit with passive oxygen insufflation as compared to positive pressure BMV. Better survival and neurological outcomes have also been reported with BMV ventilation as compared to use of advanced airway insertion (endotracheal tube and laryngeal mask airway [LMA]) in studies from Korea and Japan.,
The two goals of advanced airway management are control of oxygenation/ventilation and airway protection from aspiration of vomitus, secretions, blood or gastric contents. Advanced airway are indicated for airway protection as apnoeic patients lack protective reflexes. BMV is recommended in a cardiac arrest patient, not tracheally intubated, until trained help arrives. Alternative airway adjuncts were incorporated in cardiac arrest resuscitation to reduce 'hands-off' times during CPR. They include insertion of a supraglottic airway device (SAD), endotracheal tube, Combitube or cricothyroidotomy.
The chest compression fraction (CCF) (proportion of CPR time spent providing chest compressions) greatly influences the survival after cardiac arrest and CPR. CCF should be above 0.6 to ensure the probability of a successful CPR. Gaszynska et al. reported better mean CCF with LMA Supreme and Combitube use compared to endotracheal tube. Although endotracheal intubation provides both oxygenation/ventilation control and airway protection, it is associated with several complications in cardiac arrest situations. The rescuer should ask for momentary interruption of chest compressions to facilitate tracheal intubation only if absolutely required. Such interruptions should not exceed 10 s. Videolaryngoscope, if available, may be used for better success rate and reduction in complications.
Difficult airway (DA) can arise during intubation, SAD placement or BMV ventilation. Chest compressions should never be stopped for the DA assessment or management. If direct laryngoscopy and intubation is difficult, a SAD should be promptly inserted to maintain oxygenation and ventilation. It is best to continue with BMV combined with chest compressions till expert help arrives. 'Cannot ventilate, cannot intubate' situations are difficult to manage and it is best to administer high flow oxygen through a face mask and continue with 'compression-only life support' (COLS) till experienced rescuers arrive. More randomised, controlled trials are needed to recommend management of DA with cardiac arrest. Surgical cricothyroidotomy is a life-saving procedure for DA management.
The correct placement of endotracheal tube should be ascertained using clinical signs (such as bilateral chest expansion and five-point auscultation starting from epigastrium) and waveform capnography. The other alternatives could be oesophageal detector devices, carbon dioxide detectors or ultrasound by an experienced person.,,, Subsequently, endotracheal tube placement must be rechecked on X-ray. ROSC is indicated during CPR as a sudden increase in the end-tidal carbon dioxide.,,,, Further trials are required to assess the value and role of capnography in cardiac arrest situations using BMV or SAD.
There is some evidence of providing breaths at equal interval rather than in sets of 30 compressions and two breaths during resuscitation., Till there is concrete evidence on synchronisation of compressions and breaths, we suggest continuing sets of 30 compressions and 2 breaths till the advanced airway is placed. Thereafter, synchronisation is not required and the chest compression is continued at 120 compressions/min and 1 breath every 6 s.
Vascular access and drugs
Most of the admitted patients in the hospital have venous access which should be used. In case it is not available, it should be secured once CPR has been started. Peripheral large calibre veins are suggested for venous access. Alternate access could be through the IO routes at sites such as humerus, proximal/distal tibia and sternum. The proximal tibia appears to be the most suitable site. At times central venous access may be present, then it should be preferably be used to shorten transit of drugs to the central circulation.,, However, central venous access should not be attempted, if not already present, as it may interrupt chest compression and also because it requires expertise. The endotracheal route use is discouraged but it can be used as desperate measure.
The comprehensive management during CPR requires use of drugs.,,,, Robust evidence to use various drugs during CPR is lacking. Adrenaline remains the drug of choice in all arrested cardiac rhythms.,,, One mg of it should be administered and repeated every 3–5 min, whereas ongoing chest compression for its distribution to central circulation. In case of refractory VF and pulseless VT (not responding or recurs after 2–3 defibrillation shock), antiarrhythmic agents such as amiodarone (300 mg as first bolus and repeat 150 mg if required) needs to be administered.,, Alternate to amiodarone could be lidocaine (1–1.5 mg/kg slow bolus). Routine use of drugs such as sodium bicarbonate, calcium or glucose is not recommended but they may be used if indicated, based on the assessment and underlying aetiology.
Identifying the underlying aetiology and its correction is important for an optimal outcome after CPR., The more common causes requiring assessment and management can be remembered with the mnemonic 'HIT THE TARGET' (H – Hypoxia, I – Increased H Ions [Acidosis], T – Tension Pneumothorax, T – Toxins/Poisons, H – Hypovolaemia, E – Electrolyte Imbalance [Hypo-/Hyperkalaemia], T – Tamponade Cardiac, A – Acute Coronary Syndrome, R – Raised Intracranial Pressure [Subarachnoid Haemorrhage], G – Glucose [Hypo-/hyperglycaemia], E – Embolism (Pulmonary Thrombosis), T – Temperature [Hypothermia]). In a hospital setting, many other cardiac and non-cardiac causes could also lead to cardiac arrest and should also be sought based on pre-existing clinical diagnosis, history, clinical signs and appropriate investigations. Blood sample should be sought during the venous cannulation itself. Ultrasound has been used as bedside tool for the assessment of the cause of arrest, but it requires expertise and its routine use is not recommended in the present guidelines.
During CPR, it is not only essential to monitor the quality of rescuers performance (like chest compression quality) but also patient physiological parameters to ascertain overall optimisation of CPR., Monitoring like end-tidal CO2(EtCO2), central venous pressure, central venous oxygen saturation and arterial blood pressure are important to ascertain the CPR quality and its outcome.,,, The abrupt increase in their values is suggestive of ROSC.,,, Urine output is an important monitor for ascertaining perfusion after ROSC. Ultrasound has also been reported a bedside repeatable monitoring tool., Blood gas values are difficult to interpret during CPR.
Duration of cardiopulmonary resuscitation
CPR discontinuation should be based on clinical condition of the patient.,,, Once the reversible causes have been ruled out and/or corrected, based on clinical judgment and a careful assessment, a decision may be taken to discontinue CPR. The presence of rhythm such as VF/pulseless VT should prompt to continue the resuscitation attempts. EtCO2 has been suggested a good sign of perfusion and thus can be used for prognostication in intubated patients. It may be suggested that with high-quality CPR and rhythm as asystole for >20 min, EtCO2 <10 mmHg may be considered a sign to forgo further attempts. In patients without such monitoring, a definite time frame is not suggested and duration should be based on clinical decision. The final decision to start and stop resuscitation would also be based on the overall clinical assessment. Patient receiving palliative care or end-of-life care should be carefully chosen for initiation of resuscitation.,
The patient should receive post-resuscitation care once there is ROSC. Patients should be shifted to a monitored area and further definitive management of the underlying aetiology should be started. Since cardiac cause is one of the important contributors, consultation for coronary intervention should be sought at the earliest. CPR may lead to hypoxic insult to various organ systems including brain. Oxygen supplementation and ventilation support should be provided based on the post-resuscitation assessment. The haemodynamic monitoring is essential, and the mean arterial pressure should be maintained >65 mmHg., At present, controlled hypothermic equipment are not easily available in India. The need of hypothermia should be assessed if the necessary equipment is present. However, active warming should not be started.
| Conclusion|| |
The management of patient of cardiopulmonary arrest inside hospital requires early recognition along with early high-quality resuscitation, including defibrillation. Following the core links of CCLS in adult resuscitation would improve the overall outcome. CCLS emphasises providing high-quality resuscitation, simultaneously looking for the cause of cardiac arrest and correcting the reversible cause, while continuing resuscitation.
Financial support and sponsorship
All expenses related to the development of the guidelines were funded by ISA.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ching CK, Leong SH, Chua SJ, Lim SH, Heng K, Pothiawala S, et al.
Advanced cardiac life support: 2016 Singapore guidelines. Singapore Med J 2017;58:360-72.
Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ, et al.
Part 5: Adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015;132:S414-35.
Lim SH, Wee FC, Chee TS. Basic cardiac life support: 2016 Singapore guidelines. Singapore Med J 2017;58:347-53.
Perkins GD, Handley AJ, Koster RW, Castrén M, Smyth MA, Olasveengen T, et al.
European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation. Resuscitation 2015;95:81-99.
Neumar RW, Shuster M, Callaway CW, Gent LM, Atkins DL, Bhanji F, et al.
Part 1: Executive summary: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015;132:S315-67.
Callaway CW, Soar J, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, et al.
Part 4: Advanced life support: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2015;132:S84-145.
Lee CY, Anantharaman V, Lim SH, Ng YY, Chee TS, Seet CM, et al.
Singapore defibrillation guidelines 2016. Singapore Med J 2017;58:354-9.
Garg R, Ahmed SM, Kapoor MC, Mishra BB, Chakra Rao SS, Venkatagiri Kalandoor M, et al
. Basic Cardiopulmonary Life Support (BCLS) for cardiopulmonary resuscitation by trained paramedics and medics outside the hospital. Indian J Anaesth 2017;61:874-82. [Full text]
Sandroni C, Nolan J, Cavallaro F, Antonelli M. In-hospital cardiac arrest: Incidence, prognosis and possible measures to improve survival. Intensive Care Med 2007;33:237-45.
Nolan JP, Soar J, Smith GB, Gwinnutt C, Parrott F, Power S, et al.
Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit. Resuscitation 2014;85:987-92.
Cha KC, Kim HJ, Shin HJ, Kim H, Lee KH, Hwang SO, et al.
Hemodynamic effect of external chest compressions at the lower end of the sternum in cardiac arrest patients. J Emerg Med 2013;44:691-7.
Niles DE, Sutton RM, Nadkarni VM, Glatz A, Zuercher M, Maltese MR, et al.
Prevalence and hemodynamic effects of leaning during CPR. Resuscitation 2011;82 Suppl 2:S23-6.
Nichol G, Leroux B, Wang H, Callaway CW, Sopko G, Weisfeldt M, et al.
Trial of continuous or interrupted chest compressions during CPR. N
Engl J Med 2015;373:2203-14.
Smith GB. In-hospital cardiac arrest: Is it time for an in-hospital 'chain of prevention'? Resuscitation 2010;81:1209-11.
Asadollahi K, Hastings IM, Beeching NJ, Gill GV. Laboratory risk factors for hospital mortality in acutely admitted patients. QJM 2007;100:501-7.
Hodgetts TJ, Kenward G, Vlachonikolis IG, Payne S, Castle N. The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team. Resuscitation 2002;54:125-31.
Paterson R, MacLeod DC, Thetford D, Beattie A, Graham C, Lam S, et al.
Prediction of in-hospital mortality and length of stay using an early warning scoring system: Clinical audit. Clin Med (Lond) 2006;6:281-4.
Gardner-Thorpe J, Love N, Wrightson J, Walsh S, Keeling N. The value of modified early warning score (MEWS) in surgical in-patients: A prospective observational study. Ann R Coll Surg Engl 2006;88:571-5.
Smith GB, Prytherch DR, Schmidt P, Featherstone PI, Knight D, Clements G, et al.
Hospital-wide physiological surveillance-a new approach to the early identification and management of the sick patient. Resuscitation 2006;71:19-28.
Tanabe S, Ogawa T, Akahane M, Koike S, Horiguchi H, Yasunaga H, et al.
Comparison of neurological outcome between tracheal intubation and supraglottic airway device insertion of out-of-hospital cardiac arrest patients: A nationwide, population-based, observational study. J Emerg Med 2013;44:389-97.
Khalid U, Juma AA. Paradigm shift: 'ABC' to 'CAB' for cardiac arrests. Scand J Trauma Resusc Emerg Med 2010;18:59.
Marsch S, Tschan F, Semmer NK, Zobrist R, Hunziker PR, Hunziker S. ABC versus CAB for cardiopulmonary resuscitation: A prospective, randomized simulator-based trial. Swiss Med Wkly 2013;143:w13856.
Ho AM, Wong W, Ling E, Chung DC, Tay BA. Airway difficulties caused by improperly applied cricoid pressure. J Emerg Med 2001;20:29-31.
Wang HE. Emergency airway management: The need to refine – And redefine – The “state of the art”. Resuscitation 2012;83:405-6.
Myatra SN, Shah A, Kundra P, Patwa A, Ramkumar V, Divatia JV, et al.
All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults. Indian J Anaesth 2016;60:885-98.
] [Full text]
Soar J, Nolan JP. Airway management in cardiopulmonary resuscitation. Curr Opin Crit Care 2013;19:181-7.
Bernhard M, Mohr S, Weigand MA, Martin E, Walther A. Developing the skill of endotracheal intubation: Implication for emergency medicine. Acta Anaesthesiol Scand 2012;56:164-71.
Cho YC, Cho SW, Chung SP, Yu K, Kwon OY, Kim SW, et al.
How can a single rescuer adequately deliver tidal volume with a manual resuscitator? An improved device for delivering regular tidal volume. Emerg Med J 2011;28:40-3.
Spindelboeck W, Schindler O, Moser A, Hausler F, Wallner S, Strasser C, et al.
Increasing arterial oxygen partial pressure during cardiopulmonary resuscitation is associated with improved rates of hospital admission. Resuscitation 2013;84:770-5.
Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, et al.
Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA 2008;299:1158-65.
Shin SD, Ahn KO, Song KJ, Park CB, Lee EJ. Out-of-hospital airway management and cardiac arrest outcomes: A propensity score matched analysis. Resuscitation 2012;83:313-9.
Hasegawa K, Hiraide A, Chang Y, Brown DF. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA 2013;309:257-66.
Kurz MC, Prince DK, Christenson J, Carlson J, Stub D, Cheskes S, et al.
Association of advanced airway device with chest compression fraction during out-of-hospital cardiopulmonary arrest. Resuscitation 2016;98:35-40.
Gaszynska E, Gsazynski T. The influence of different airway management strategies on chest compression fraction in simulated cardiopulmonary resuscitation, provided by paramedics: LMA Supreme versus Endotracheal Intubation and Combitube. Signa Vitae 2014;9:22-6.
Benoit JL, Gerecht RB, Steuerwald MT, McMullan JT. Endotracheal intubation versus supraglottic airway placement in out-of-hospital cardiac arrest: A meta-analysis. Resuscitation 2015;93:20-6.
Wong ML, Carey S, Mader TJ, Wang HE, American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. Time to invasive airway placement and resuscitation outcomes after inhospital cardiopulmonary arrest. Resuscitation 2010;81:182-6.
Patel SA, Meyer TK. Surgical airway. Int J Crit Illn Inj Sci 2014;4:71-6.
] [Full text]
Grmec S. Comparison of three different methods to confirm tracheal tube placement in emergency intubation. Intensive Care Med 2002;28:701-4.
Chou HC, Tseng WP, Wang CH, Ma MH, Wang HP, Huang PC, et al.
Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube placement during emergency intubation. Resuscitation 2011;82:1279-84.
Zadel S, Strnad M, Prosen G, Mekiš D. Point of care ultrasound for orotracheal tube placement assessment in out-of hospital setting. Resuscitation 2015;87:1-6.
Levine RL, Wayne MA, Miller CC. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. N
Engl J Med 1997;337:301-6.
Wayne MA, Levine RL, Miller CC. Use of end-tidal carbon dioxide to predict outcome in prehospital cardiac arrest. Ann Emerg Med 1995;25:762-7.
Callaham M, Barton C. Prediction of outcome of cardiopulmonary resuscitation from end-tidal carbon dioxide concentration. Crit Care Med 1990;18:358-62.
Lin S, Scales DC. Cardiopulmonary resuscitation quality and beyond: The need to improve real-time feedback and physiologic monitoring. Crit Care 2016;20:182.
Grmec S, Klemen P. Does the end-tidal carbon dioxide (EtCO2) concentration have prognostic value during out-of-hospital cardiac arrest? Eur J Emerg Med 2001;8:263-9.
Pokorná M, Necas E, Kratochvíl J, Skripský R, Andrlík M, Franek O. Asudden increase in partial pressure end-tidal carbon dioxide (P(ET)CO(2)) at the moment of return of spontaneous circulation. J Emerg Med 2010;38:614-21.
Heradstveit BE, Sunde K, Sunde GA, Wentzel-Larsen T, Heltne JK. Factors complicating interpretation of capnography during advanced life support in cardiac arrest – A clinical retrospective study in 575 patients. Resuscitation 2012;83:813-8.
Weiser G, Hoffmann Y, Galbraith R, Shavit I. Current advances in intraosseous infusion – A systematic review. Resuscitation 2012;83:20-6.
Emerman CL, Pinchak AC, Hancock D, Hagen JF. Effect of injection site on circulation times during cardiac arrest. Crit Care Med 1988;16:1138-41.
Leidel BA, Kirchhoff C, Bogner V, Braunstein V, Biberthaler P, Kanz KG. Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. Resuscitation 2012;83:40-5.
Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A. Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation. N
Engl J Med 2002;346:884-90.
Herlitz J, Ekström L, Wennerblom B, Axelsson A, Bång A, Lindkvist J, et al.
Lidocaine in out-of-hospital ventricular fibrillation. Does it improve survival? Resuscitation 1997;33:199-205.
Donnino MW, Salciccioli JD, Howell MD, Cocchi MN, Giberson B, Berg K, et al.
Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: Retrospective analysis of large in-hospital data registry. BMJ 2014;348:g3028.
Koscik C, Pinawin A, McGovern H, Allen D, Media DE, Ferguson T, et al.
Rapid epinephrine administration improves early outcomes in out-of-hospital cardiac arrest. Resuscitation 2013;84:915-20.
Dumas F, Rea TD, Fahrenbruch C, Rosenqvist M, Faxén J, Svensson L, et al.
Chest compression alone cardiopulmonary resuscitation is associated with better long-term survival compared with standard cardiopulmonary resuscitation. Circulation 2013;127:435-41.
van Walraven C, Stiell IG, Wells GA, Hébert PC, Vandemheen K. Do advanced cardiac life support drugs increase resuscitation rates from in-hospital cardiac arrest? The OTAC Study Group. Ann Emerg Med 1998;32:544-53.
Perkins GD, Nolan JP. Early adrenaline for cardiac arrest. BMJ 2014;348:g3245.
Dumas F, Bougouin W, Geri G, Lamhaut L, Bougle A, Daviaud F, et al.
Is epinephrine during cardiac arrest associated with worse outcomes in resuscitated patients? J Am Coll Cardiol 2014;64:2360-7.
Patanwala AE, Slack MK, Martin JR, Basken RL, Nolan PE. Effect of epinephrine on survival after cardiac arrest: A systematic review and meta-analysis. Minerva Anestesiol 2014;80:831-43.
Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, et al.
Amiodarone, lidocaine, or placebo in out-of-hospital cardiac arrest. N
Engl J Med 2016;374:1711-22.
Hodgetts TJ, Kenward G, Vlackonikolis I, Payne S, Castle N, Crouch R, et al.
Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital. Resuscitation 2002;54:115-23.
Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: Preliminary study. BMJ 2002;324:387-90.
Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, et al.
Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: A consensus statement from the American Heart Association. Circulation 2013;128:417-35.
Abella BS, Alvarado JP, Myklebust H, Edelson DP, Barry A, O'Hearn N, et al.
Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA 2005;293:305-10.
Ahrens T, Schallom L, Bettorf K, Ellner S, Hurt G, O'Mara V, et al.
End-tidal carbon dioxide measurements as a prognostic indicator of outcome in cardiac arrest. Am J Crit Care 2001;10:391-8.
Wang AY, Huang CH, Chang WT, Tsai MS, Wang CH, Chen WJ. Initial end-tidal CO3 partial pressure predicts outcomes of in-hospital cardiac arrest. Am J Emerg Med 2016;34:2367-71.
Sheak KR, Wiebe DJ, Leary M, Babaeizadeh S, Yuen TC, Zive D, et al.
Quantitative relationship between end-tidal carbon dioxide and CPR quality during both in-hospital and out-of-hospital cardiac arrest. Resuscitation 2015;89:149-54.
Paradis NA, Martin GB, Rivers EP, Goetting MG, Appleton TJ, Feingold M, et al.
Coronary perfusion pressure and the return of spontaneous circulation in human cardiopulmonary resuscitation. JAMA 1990;263:1106-13.
Breitkreutz R, Walcher F, Seeger FH. Focused echocardiographic evaluation in resuscitation management: Concept of an advanced life support-conformed algorithm. Crit Care Med 2007;35:S150-61.
Chardoli M, Heidari F, Rabiee H, Sharif-Alhoseini M, Shokoohi H, Rahimi-Movaghar V. Echocardiography integrated ACLS protocol versus conventional cardiopulmonary resuscitation in patients with pulseless electrical activity cardiac arrest. Chin J Traumatol 2012;15:284-7.
Chiang WC, Ko PC, Chang AM, Liu SS, Wang HC, Yang CW, et al.
Predictive performance of universal termination of resuscitation rules in an Asian community: Are they accurate enough? Emerg Med J 2015;32:318-23.
van Walraven C, Forster AJ, Stiell IG. Derivation of a clinical decision rule for the discontinuation of in-hospital cardiac arrest resuscitations. Arch Intern Med 1999;159:129-34.
Goldberger ZD, Chan PS, Berg RA, Kronick SL, Cooke CR, Lu M, et al.
Duration of resuscitation efforts and survival after in-hospital cardiac arrest: An observational study. Lancet 2012;380:1473-81.
Nolan JP, Soar J. Duration of in-hospital resuscitation: When to call time? Lancet 2012;380:1451-3.
Downar J, Rodin D, Barua R, Lejnieks B, Gudimella R, McCredie V, et al.
Rapid response teams, do not resuscitate orders, and potential opportunities to improve end-of-life care: A multicentre retrospective study. J Crit Care 2013;28:498-503.
Myatra SN, Salins N, Iyer S, Macaden SC, Divatia JV, Muckaden M, et al.
End-of-life care policy: An integrated care plan for the dying: A Joint position statement of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Association of Palliative Care (IAPC). Indian J Crit Care Med 2014;18:615-35.
] [Full text]
Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VR, Deakin CD, et al.
European Resuscitation Council and European Society of intensive care medicine guidelines for post-resuscitation care 2015: Section 5 of the European Resuscitation Council guidelines for resuscitation 2015. Resuscitation 2015;95:202-22.
[Figure 1], [Figure 2]