Clinical Review
Team-focused Cardiopulmonary Resuscitation: Prehospital Principles Adapted for Emergency Department Cardiac Arrest Resuscitation

https://doi.org/10.1016/j.jemermed.2017.08.065Get rights and content

Abstract

Background

Out-of-hospital cardiac arrest has high rates of morbidity and mortality, and a growing body of evidence is redefining our approach to the resuscitation of these high-risk patients.

Objectives

Team-focused cardiopulmonary resuscitation (TFCPR), most commonly deployed and described by prehospital care providers, is a focused approach to cardiac arrest care that emphasizes early defibrillation and high-quality, minimally interrupted chest compressions while de-emphasizing endotracheal intubation and intravenous drug administration. TFCPR is associated with statistically significant increases in survival to hospital admission, survival to hospital discharge, and survival with good neurologic outcome; however, the adoption of similar streamlined resuscitation approaches by emergency physicians has not been widely reported. In the absence of a deliberately streamlined approach, such as TFCPR, other advanced therapies and procedures that have not shown similar survival benefit may be prioritized at the expense of simpler evidence-based interventions.

Discussion

This review examines the current literature on cardiac arrest resuscitation. The recent prehospital success of TFCPR is highlighted, including the associated improvements in multiple patient-centered outcomes. The adaptability of TFCPR to the emergency department (ED) setting is also discussed in detail. Finally, we discuss advanced interventions frequently performed during ED cardiac arrest resuscitation that may interfere with early defibrillation and effective high-quality chest compressions.

Conclusion

TFCPR has been associated with improved patient outcomes in the prehospital setting. The data are less compelling for other commonly used advanced resuscitation tools and procedures. Emergency physicians should consider incorporating the TFCPR approach into ED cardiac arrest resuscitation to optimize delivery of those interventions most associated with improved outcomes.

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

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