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Since the introduction of modern cardiopulmonary resuscitation [1,2,3,4] and defibrillation [5,6] into clinical practice it has been commonplace for hospitals to provide cardiac arrest teams to respond immediately to any site on the campus
where a cardiac or respiratory arrest occurs. The team is alerted using a dedicated emergency phone number and radiopagers or loudspeaker address system. Often the team consists of an anesthesiologist, a physician, and a nurse or technician. The necessary equipment is either located at or near the site or is carried by the team. Hospitals have become vast complexes and
may take the team some considerable time to arrive -and
when they do the members may be breathless and temporarily exhausted and unable to perform tricky manual skills for a minute or two until they recover.
Until recently all that the majority
of first responders could do was to try
to buy time by providing basic life support
until the team arrived. Often the members
of the team were unrehearsed, and confusion
as to who should be team leader existed,
resulting in a less than perfect performance.
It is now clear that the majority of
survivors come from amongst those who
have ventricular fibrillation (VF) or pulseless
ventricular tachycardia (VT) and receive
early defibrillation 7,8]. The advice
and guidelines issued by the International
Liason Committee on Resuscitation (ILCOR)
[9], the European Resuscitation Council
[10], and the recent International Consensus
on Science promulgating the 2000 Guidelines
for cardiopulmonary Resuscitation [11]
have all emphasized the teed for first
responder defibrillation as well as basic
life support. Gwinnutt et al, in a survey
of 49 United Kingdom hospitals reported
survival to discharge rates of 42% in
patients with a shockable rhythm, compared
with 6% with non VF/VT [8]. )Others have
reported their positive experience with
first responder nurse defibrillation [12-17].
Soar and McKay [18] reported their experience
of survival rates from in-hospital cardiac
arrest. All survivors to hospital
discharge achieved a return of spontaneous
circulation (ROSC) by the first responders.
No patient, who was still in arrest by
the time the cardiac arrest team arrived,
survived to discharge.
The advent of automatic external defibrillators (AED) has brought defibrillation into the hands of nurses and others [12- 17, 19-23]. Simple airway adjuncts can also be used by nurses on the wards [24]. Good basic life support, early defibrillation, airway control and ventilation with oxygen will produce the vast majority of survivors.
Outcome from non VF/VT is notoriously poor but the majority of patients in this group have premonitory signs [25, 26]. To wait until the arrest has occurred is too late and some proactive management is required [27]. A lead in this field has been given by the Australians, who have introduced the concept of the Medical Emergency Team (MET) [28]. The initiative has been followed up by others in the United Kingdom [29, 30, 31]. The experience in Sydney and environs has shown that patients at risk can be identified using simple
criteria 'relating to deteriorating airway control, respiratory rate, pulse rate, blood pressure and level of consciousness [28]. Using this practical approach nurses called the MET , which was usually composed of a physician and nurse from the Intensive Care Unit (ICU). As a result a substantial number of patients were admitted to the ICU for treatment that probably prevented cardiac arrest. Furthermore, the MET were able to identify patients for whom resuscitation was deemed to be futile and, after consultation with the clinician in charge, and the patient and relatives as appropriate, a "Do Not Attempt Resuscitation" instruction was made, thus preventing the indignity of an unwarranted resuscitation intervention. Naturally some unexpected cardiac arrests did occur but the number fell dramatically.
So what is the future for management of the in-hospital cardiac arrest?
I believe that we should follow the
example of the MET to prevent as many
cardiac arrests as possible, especially
in the non VFNT group, and to identify
in advance those in whom resuscitation
is inappropriate [34]. For those who do
arrest on the wards we should concentrate
on achieving the optimal survival rates
by training nurses as effective first
responders able to provide basic life
support, automated defibrillation, and
management of the airway with simple adjuncts.
They should be supported (in reasonable
time -not at a sprint) by a team who are
expert in advanced life support. The members
of this team can make the decision to
abandon the ongoing resuscitation attempt
if appropriate, or provide sophisticated
life support such as the management of
periarrest arrhythmias, advanced airway!
management techniques, and specialist
definitive care including thrombolysis,
angioplasty, surgery and intensive care.
The members of the MET could well undertake this function.
References:
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