Clinical ReviewTeam-focused Cardiopulmonary Resuscitation: Prehospital Principles Adapted for Emergency Department Cardiac Arrest Resuscitation
Introduction
More than 356,000 out-of-hospital cardiac arrests (OHCA) occur each year while overall risk-adjusted survival remains at a dismal 8.3% 1, 2, 3. Over the past decade, many clinical research reports have redefined our approach to cardiac arrest resuscitation, and over this time we have seen a slow trend toward improved outcomes (2). Prehospital medicine has led the charge for this revolution by emphasizing a standardized and simplified approach to cardiopulmonary resuscitation (CPR), focusing only on the most important interventions shown to improve patient-centered outcomes, including return of spontaneous circulation (ROSC), survival to hospital admission, survival to hospital discharge and, most importantly, survival with intact neurologic function.
Team-focused CPR (TFCPR) is one such cardiac arrest protocol used by prehospital providers in North Carolina. TFCPR is associated with statistically significant improvements in each of these patient-centered outcomes, yet its incorporation into emergency department (ED) resuscitation has not been widely reported 4, 5. This review examines the evidence base for many commonly used cardiac arrest interventions, including those that may directly or indirectly interfere with early defibrillation or high-quality chest compressions. It also introduces the logistics of TFCPR and discusses the incorporation of TFCPR principles into an organized approach to cardiac arrest resuscitation in the ED.
Section snippets
Current CPR Guidelines
In the 2015 guidelines update for CPR and Emergency Cardiovascular Care, the American Heart Association (AHA) reaffirmed the two cornerstones of early cardiac arrest resuscitation as: 1) quality chest compressions, and 2) early defibrillation for shockable cardiac rhythms 6, 7. Despite all we have historically done, these two intra-arrest interventions have been proven in clinical trials to have the most consistent and significant impact on improving patient-centered outcomes.
Recent trials from
Blending Prehospital Success with ED Expertise
As emergency physicians, our training and instincts allow us to quickly and effectively resuscitate sick and dying patients every day. For this same reason, it is often difficult to employ cognitive and procedural restraint when the clinical scenario dictates. Cardiac arrest is a unique entity. These patients are effectively dead, and we are attempting to bring them back to life. Emergency physicians should prioritize interventions proven to save lives while at the same time avoiding actions
References (72)
- et al.
CARES: Cardiac Arrest Registry to Enhance Survival
Ann Emerg Med
(2009) - et al.
Comparison of team-focused CPR vs. standard CPR in resuscitation from out-of-hospital cardiac arrest: results from a statewide quality improvement initiative
Resuscitation
(2016) - et al.
Chest compression depth and survival in out-of-hospital cardiac arrest
Resuscitation
(2014) - et al.
The impact of increased chest compression fraction on return of spontaneous circulation for out-of-hospital cardiac arrest patients not in ventricular fibrillation
Resuscitation
(2011) - et al.
Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation
Ann Emerg Med
(2009) - et al.
Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: a randomized controlled trial
Ann Emerg Med
(2011) - et al.
Efficacy and safety of the EZ-IO™ intraosseous device: out-of-hospital implementation of a management algorithm for difficult vascular access
Resuscitation
(2011) - et al.
King LT-D use by urban basic life support first responders as the primary airway device for out-of-hospital cardiac arrest
Resuscitation
(2011) - et al.
The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation Outcomes Consortium PRIMED trial
Resuscitation
(2014) - et al.
Safety and efficacy of defibrillator charging during ongoing chest compressions: a multi-center study
Resuscitation
(2010)
Is external defibrillation an electric threat for bystanders?
Resuscitation
Will medical examination gloves protect rescuers from defibrillation voltages during hands-on defibrillation?
Resuscitation
Do clinical examination gloves provide adequate electrical insulation for safe hands-on defibrillation? I: Resistive properties of nitrile gloves
Resuscitation
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
Airway management and out-of-hospital cardiac arrest outcome in the CARES registry
Resuscitation
Endotracheal intubation versus supraglottic airway placement in out-of-hospital cardiac arrest: a meta-analysis
Resuscitation
Randomised comparison of the effectiveness of the laryngeal mask airway supreme, i-gel and current practice in the initial airway management of out of hospital cardiac arrest: a feasibility study
Br J Anaesth
Design and implementation of the Resuscitation Outcomes Consortium Pragmatic Airway Resuscitation Trial (PART)
Resuscitation
Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins
Resuscitation
Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians
J Am Soc Echocardiogr
Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients
Am J Emerg Med
Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest
Resuscitation
C.A.U.S.E.: cardiac arrest ultra-sound exam—a better approach to managing patients in primary non-arrhythmogenic cardiac arrest
Resuscitation
Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial
Resuscitation
Transesophageal echocardiography during cardiopulmonary arrest in the emergency department
Resuscitation
Diagnostic accuracy and therapeutic impact of transthoracic and transesophageal echocardiography in mechanically ventilated patients in the ICU
Chest
Hemodynamic-directed cardiopulmonary resuscitation during in-hospital cardiac arrest
Resuscitation
Audiovisual feedback device use by health care professionals during CPR: a systematic review and meta-analysis of randomised and non-randomised trials
Resuscitation
A sudden increase in partial pressure end-tidal carbon dioxide (PETCO2) at the moment of return of spontaneous circulation
J Emerg Med
Effect of adrenaline on survival in out-of-hospital cardiac arrest: a randomised double-blind placebo-controlled trial
Resuscitation
Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study
Resuscitation
Comparing extracorporeal cardiopulmonary resuscitation with conventional cardiopulmonary resuscitation: a meta-analysis
Resuscitation
Heart disease and stroke statistics - 2013 update: a report from the American Heart Association
Circulation
Recent trends in survival from out-of-hospital cardiac arrest in the United States
Circulation
Impact of a “team-focused CPR” protocol on out-of-hospital cardiac arrest survival in a rural EMS system
Crit Pathw Cardiol
2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care
Circulation
Cited by (8)
Goldilocks in cardiac arrest: A scoping review of invasive hemodynamic monitoring in the pre-hospital setting for getting adrenaline dosing just right
2021, Australasian Journal of ParamedicineCoordinating clinical teams: Using robots to empower nurses to stop the line
2019, Proceedings of the ACM on Human-Computer InteractionRecommendations for extracorporeal cardiopulmonary resuscitation (eCPR): Consensus statement of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC
2019, Zeitschrift fur Herz-, Thorax- und GefasschirurgieRecommendations for extracorporeal cardiopulmonary resuscitation (eCPR): Consensus statement of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC
2018, Medizinische Klinik - Intensivmedizin und Notfallmedizin
Reprints are not available from the authors.