Cardiac Arrest

Therapeutic Hypothermia after Cardiac Arrest

Therapeutic Hypothermia after Cardiac Arrest

Introduction

The frequency and quality of emergency resuscitation training in the UK have improved during the past 20 years (Colquhoun et al 2004). During this period resuscitation guidelines have been reviewed and updated, most recently in 2005 (Deakin et al 2005, Soar and Spearpoint 2005). However, despite perceived progress, discharge outcomes from in-hospital resuscitation remain poor at 17% (Tunstall-Pedoe et al 1992, p. 1347-1351, Gwinnutt et al 2000, p. 125-135, Peberdy et al 2003, p. 297-308). Poor resuscitation skills were evident among nurses in 1987 (Wynne et al 1987, p. 1198-1199) and there was little evidence of improvement 20 years later (Kramer-Johansen et al 2007a, p. 406-417).

This paper considers the management of a cardiac patient in emergency department and how the current resuscitation guidelines (Deakin et al 2005, Soar and Spearpoint 2005) inform and direct resuscitation practice, concentrating on those resuscitation skills that are most likely to be provided by nurses. It also considers important policy and guidance developments on preventing cardiac arrest and the emerging clinical interventions aimed at improving quality of survival at the immediate post-resuscitation phase of care. The paper ends with an overview of current policy and guidance on end-of-life decisions.

Prevention of cardiac arrest

Cardiac arrest is considered preventable for many in-hospital patients. Of those patients who experience in-hospital cardiac arrest, 79%display basic signs of physiological deterioration before collapse (Kause et al 2004, p. 275-282). Consequently early identification of a patient at risk of cardiac arrest is important. Prevention of cardiac arrest features prominently in the most recent in-hospital resuscitation guidelines (Smith 2005, Soar and Spearpoint 2005) and has become an important component of the Resuscitation Council (UK) (RC(UK)) advanced life support (ALS) provider course (Nolan et al 2008) and the RC(UK) immediate life support (ILS) course (Soar et al 2003, p. 21-26). After the development of critical care outreach services (Department of Health (DH) 2000a) and early warning/patient-at-risk systems, prediction and prevention of in-hospital cardiac arrest have become widely adopted strategies (Rowan 2007).

Recent evidence indicates that there are variations in how acute NHS trusts have set up track and trigger systems and RRTs (Rowan and arrison 2007, p. 1165-1166). While improvements in patient outcomes have been predicted (Kenward et al2004, p. 257-263 Smith et al 2006), limited success in reducing cardiac arrest rates has been reported (Gold hill et al 1999, p. 853-860, Ball et al 2003, p. 1014-1017 Priestley et al2004, Buist et al 2007, p. 1210-1212). Buist et al (2007) suggested that the formation and placement of medical emergency teams is only part of the story. Success took six years and required the provision of a committed educational strategy, accompanied by a supportive team to ensure acceptance of the concept, including removal of the fear (particularly among nurses) of calling the RRT to patients not yet in cardiac arrest.

The importance of reflective audit and the influence on staff behaviour following the introduction of a new approach to detecting and preventing cardiac arrest were additional and significant ...