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Semin Neurol 2006; 26(4): 380-386
DOI: 10.1055/s-2006-948318
Copyright © 2006 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Prehospital Interventions to Improve Neurological Outcome Following Cardiac Arrest

Charles M. Little1 , Norman A. Paradis1 , Kennon Heard1
  • 1Division of Emergency Medicine, Department of Surgery, University of Colorado School of Medicine, Colorado Emergency Medicine Research Center, Denver, Colorado
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Publication History

Publication Date:
10 August 2006 (online)

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ABSTRACT

As many cases of cardiac arrest occur outside of the health care setting, prehospital treatment may dramatically affect patient outcomes. The three major interventions that have been studied are chest compressions and ventilation, electrical defibrillation, and medications. Recent studies show that increasing the rate of cardiopulmonary resuscitation (CPR), decreasing the rate of ventilation, and initiation of CPR prior to defibrillation may result in improved survival. Biphasic defibrillators can restore perfusing rhythms while minimizing myocardial injury. Public access to automatic defibrillators has been shown to increase the survival of cardiac arrest patients. Medications such as amiodarone, vasopressin, and thrombolytics also may have a role in the prehospital treatment of cardiac arrest. Recent advances in these areas will be reviewed with a discussion of the effect of each intervention on the restoration of circulation and neurological outcomes.

KEYWORDS

Cardiac arrest - prehospital treatments - neuroprotection

REFERENCES

  • 1 Eisenberg M S, Mengert T J. Cardiac resuscitation.  N Engl J Med. 2001;  344 1304-1313
    CrossrefPubMedGoogle Scholar
  • 2 Weisfeldt M L, Becker L B. Resuscitation after cardiac arrest: a 3-phase time-sensitive model.  JAMA. 2002;  288 3035-3038
    CrossrefPubMedGoogle Scholar
  • 3 Paradis N A, Martin G B, Rivers E P et al.. Coronary perfusion pressure and the return of spontaneous circulation in human cardiopulmonary resuscitation.  JAMA. 1990;  263 1106-1113
    CrossrefPubMedGoogle Scholar
  • 4 Gazmuri R J, von Planta M, Weil M H et al.. Arterial PCO2 as an indicator of systemic perfusion during cardiopulmonary resuscitation.  Crit Care Med. 1989;  17 237-240
    PubMedGoogle Scholar
  • 5 Michael J R, Guerci A D, Koehler R C et al.. Mechanisms by which epinephrine augments cerebral and myocardial perfusion during cardiopulmonary resuscitation in dogs.  Circulation. 1984;  69 822-835
    PubMedGoogle Scholar
  • 6 Lee S K, Vaagenes P, Safar P et al.. Effect of cardiac arrest time on cortical cerebral blood flow during subsequent standard external cardiopulmonary resuscitation in rabbits.  Resuscitation. 1989;  17 105-117
    CrossrefPubMedGoogle Scholar
  • 7 Berkowitz I D, Gervais H, Schleien C L et al.. Epinephrine dosage effects on cerebral and myocardial blood flow in an infant swine model of cardiopulmonary resuscitation.  Anesthesiology. 1991;  75 1041-1050
    PubMedGoogle Scholar
  • 8 Paradis N A, Martin G B, Goetting M G et al.. Simultaneous aortic, jugular bulb, and right atrial pressures during cardiopulmonary resuscitation in humans: insights into mechanisms.  Circulation. 1989;  80 361-368
    CrossrefPubMedGoogle Scholar
  • 9 Chen Y S, Chao A, Yu H Y et al.. Analysis and results of prolonged resuscitation in cardiac arrest patients rescued by extracorporeal membrane oxygenation.  J Am Coll Cardiol. 2003;  41 197-203
    PubMedGoogle Scholar
  • 10 American Heart Association in collaboration with International Liaison Committee on Resuscitation . Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science, Part 6: Advanced Cardiovascular Life Support: 7B: Understanding the Algorithm Approach to ACLS.  Circulation. 2000;  102(suppl I) I140-I141
    PubMedGoogle Scholar
  • 11 Kern K B, Hilwig R W, Berg R A et al.. Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario.  Circulation. 2002;  105 645-649
    Google Scholar
  • 12 Berg R A, Kern K B, Hilwig R W et al.. Assisted ventilation does not improve outcome in a porcine model of single-rescuer bystander cardiopulmonary resuscitation.  Circulation. 1997;  95 1635-1641
    CrossrefPubMedGoogle Scholar
  • 13 Aufderheide T P, Lurie K G. Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation.  Crit Care Med. 2004;  32 S345-S351
    CrossrefPubMedGoogle Scholar
  • 14 Adams C P, Martin G B, Rivers E P et al.. Hemodynamics of interposed abdominal compression during human cardiopulmonary resuscitation.  Acad Emerg Med. 1994;  1 498-502
    PubMedGoogle Scholar
  • 15 Lindner K H, Pfenninger E G, Lurie K G et al.. Effects of active compression-decompression resuscitation on myocardial and cerebral blood flow in pigs.  Circulation. 1993;  88 1254-1263
    PubMedGoogle Scholar
  • 16 Halperin H R, Tsitlik J E, Gelfand M et al.. A preliminary study of cardiopulmonary resuscitation by circumferential compression of the chest with use of a pneumatic vest.  N Engl J Med. 1993;  329 762-768
    CrossrefPubMedGoogle Scholar
  • 17 Aufderheide T P, Pirrallo R G, Yannopoulos D et al.. Incomplete chest wall decompression: a clinical evaluation of CPR performance by EMS personnel and assessment of alternative manual chest compression-decompression techniques.  Resuscitation. 2005;  64 353-362
    CrossrefPubMedGoogle Scholar
  • 18 Plaisance P, Lurie K G, Payen D. Inspiratory impedance during active compression-decompression cardiopulmonary resuscitation: a randomized evaluation in patients in cardiac arrest.  Circulation. 2000;  101 989-994
    PubMedGoogle Scholar
  • 19 Adgey A A, Spence M S, Walsh S J. Theory and practice of defibrillation: (2) defibrillation for ventricular fibrillation.  Heart. 2005;  91 118-125
    CrossrefPubMedGoogle Scholar
  • 20 Cobb L A, Fahrenbruch C E, Walsh T R et al.. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation.  JAMA. 1999;  281 1182-1188
    CrossrefPubMedGoogle Scholar
  • 21 Wik L, Hansen T B, Fylling F et al.. Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial.  JAMA. 2003;  289 1389-1395
    Google Scholar
  • 22 Jacobs I G, Finn J C, Oxer H F et al.. CPR before defibrillation in out-of-hospital cardiac arrest: a randomized trial.  Emerg Med Australas. 2005;  17 39-45
    CrossrefPubMedGoogle Scholar
  • 23 Weisfeldt M L, Becker L B. Resuscitation after cardiac arrest: a 3-phase time-sensitive model.  JAMA. 2002;  288 3035-3038
    CrossrefPubMedGoogle Scholar
  • 24 Eisenberg M S, Copass M K, Hallstrom A P et al.. Treatment of out-of-hospital cardiac arrests with rapid defibrillation by emergency medical technicians.  N Engl J Med. 1980;  302 1379-1383
    PubMedGoogle Scholar
  • 25 Stiell I G, Wells G A, Field B J et al.. Improved out-of-hospital cardiac arrest survival through the inexpensive optimization of an existing defibrillation program: OPALS study phase II. Ontario Prehospital Advanced Life Support.  JAMA. 1999;  281 1175-1181
    CrossrefPubMedGoogle Scholar
  • 26 Stiell I G, Wells G A, Field B et al.. Advanced cardiac life support in out-of-hospital cardiac arrest.  N Engl J Med. 2004;  351 647-656
    CrossrefPubMedGoogle Scholar
  • 27 White R D, Hankins D G, Bugliosi T F. Seven years' experience with early defibrillation by police and paramedics in an emergency medical services system.  Resuscitation. 1998;  39 145-151
    CrossrefPubMedGoogle Scholar
  • 28 Page R L, Joglar J A, Kowal R C et al.. Use of automated external defibrillators by a U.S. airline.  N Engl J Med. 2000;  343 1210-1216
    CrossrefPubMedGoogle Scholar
  • 29 Valenzuela T D, Roe D J, Nichol G et al.. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos.  N Engl J Med. 2000;  343 1206-1209
    Google Scholar
  • 30 Hallstrom A P, Ornato J P, Weisfeldt M et al.. Public-access defibrillation and survival after out-of-hospital cardiac arrest.  N Engl J Med. 2004;  351 637-646
    Google Scholar
  • 31 Culley L L, Rea T D, Murray J A et al.. Public access defibrillation in out-of-hospital cardiac arrest: a community-based study.  Circulation. 2004;  109 1859-1863
    CrossrefPubMedGoogle Scholar
  • 32 Vandycke C, Martens P. High dose versus standard dose epinephrine in cardiac arrest: a meta-analysis.  Resuscitation. 2000;  45 161-166
    CrossrefPubMedGoogle Scholar
  • 33 Jaffe R, Rubinshtein R, Feigenberg Z et al.. Evaluation of isoproterenol in patients undergoing resuscitation for out-of-hospital asystolic cardiac arrest (the Israel Resuscitation with Isoproterenol Study Prospective Randomized Clinical Trial).  Am J Cardiol. 2004;  93 1407-1409
    CrossrefPubMedGoogle Scholar
  • 34 Patrick W D, Freedman J, McEwen T et al.. A randomized, double-blind comparison of methoxamine and epinephrine in human cardiopulmonary arrest.  Am J Respir Crit Care Med. 1995;  152 519-523
    PubMedGoogle Scholar
  • 35 Lindner K H, Dirks B, Strohmenger H U et al.. Randomised comparison of epinephrine and vasopressin in patients with out-of-hospital ventricular fibrillation.  Lancet. 1997;  349 535-537
    CrossrefPubMedGoogle Scholar
  • 36 Dorian P, Cass D, Schwartz B et al.. Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation.  N Engl J Med. 2002;  346 884-890
    Google Scholar
  • 37 Kudenchuk P J, Cobb L A, Copass M et al.. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation.  N Engl J Med. 1999;  341 871-878
    Google Scholar
  • 38 Miller B, Craddock L, Hoffenberg S et al.. Pilot study of intravenous magnesium sulfate in refractory cardiac arrest: safety data and recommendations for future studies.  Resuscitation. 1995;  30 3-14
    CrossrefPubMedGoogle Scholar
  • 39 Fatovich D M, Prentice D A, Dobb G J. Magnesium in cardiac arrest (the magic trial).  Resuscitation. 1997;  35 237-241
    CrossrefPubMedGoogle Scholar
  • 40 Hassan T B, Jagger C, Barnett D B. A randomised trial to investigate the efficacy of magnesium sulphate for refractory ventricular fibrillation.  Emerg Med J. 2002;  19 57-62
    CrossrefPubMedGoogle Scholar
  • 41 Allegra J, Lavery R, Cody R et al.. Magnesium sulfate in the treatment of refractory ventricular fibrillation in the prehospital setting.  Resuscitation. 2001;  49 245-249
    CrossrefPubMedGoogle Scholar
  • 42 Thel M C, Armstrong A L, McNulty S E et al.. Randomised trial of magnesium in in-hospital cardiac arrest. Duke Internal Medicine Housestaff.  Lancet. 1997;  350 1272-1276
    CrossrefPubMedGoogle Scholar
  • 43 Mader T J, Gibson P. Adenosine receptor antagonism in refractory asystolic cardiac arrest: results of a human pilot study.  Resuscitation. 1997;  35 3-7
    CrossrefPubMedGoogle Scholar
  • 44 Mader T J, Smithline H A, Durkin L et al.. A randomized controlled trial of intravenous aminophylline for atropine-resistant out-of-hospital asystolic cardiac arrest.  Acad Emerg Med. 2003;  10 192-197
    CrossrefPubMedGoogle Scholar
  • 45 Lederer W, Lichtenberger C, Pechlaner C et al.. Recombinant tissue plasminogen activator during cardiopulmonary resuscitation in 108 patients with out-of-hospital cardiac arrest.  Resuscitation. 2001;  50 71-76
    CrossrefPubMedGoogle Scholar
  • 46 Bottiger B W, Bode C, Kern S et al.. Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation: a prospective clinical trial.  Lancet. 2001;  357 1583-1585
    CrossrefPubMedGoogle Scholar
  • 47 Abu-Laban R B, Christenson J M, Innes G D et al.. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity.  N Engl J Med. 2002;  346 1522-1528
    CrossrefPubMedGoogle Scholar
  • 48 Fatovich D M, Dobb G J, Clugston R A. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial).  Resuscitation. 2004;  61 309-313
    CrossrefPubMedGoogle Scholar
  • 49 Longstreth Jr W T, Fahrenbruch C E, Olsufka M et al.. Randomized clinical trial of magnesium, diazepam, or both after out-of-hospital cardiac arrest.  Neurology. 2002;  59 506-514
    PubMedGoogle Scholar
  • 50 Roine R O, Kaste M, Kinnunen A et al.. Nimodipine after resuscitation from out-of-hospital ventricular fibrillation: a placebo-controlled, double-blind, randomized trial.  JAMA. 1990;  264 3171-3177
    CrossrefPubMedGoogle Scholar
  • 51 Longstreth Jr W T, Copass M K, Dennis L K et al.. Intravenous glucose after out-of-hospital cardiopulmonary arrest: a community-based randomized trial.  Neurology. 1993;  43 2534-2541
    PubMedGoogle Scholar
  • 52 Lederer W, Lichtenberger C, Pechlaner C et al.. Long-term survival and neurological outcome of patients who received recombinant tissue plasminogen activator during out-of-hospital cardiac arrest.  Resuscitation. 2004;  61 123-129
    CrossrefPubMedGoogle Scholar
  • 53 Newman D H, Greenwald I, Callaway C W. Cardiac arrest and the role of thrombolytic agents.  Ann Emerg Med. 2000;  35 472-480
    PubMedGoogle Scholar

Kennon HeardM.D. 

UCHSC Division of Emergency Medicine

4200 E. 9th Avenue, B215, Denver, CO 80262

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