Current opinion in critical care
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Curr Opin Crit Care · Jun 2021
ReviewTransportation during and after cardiac arrest: who, when, how and where?
Out-of-hospital cardiac arrest (OHCA) is the most devastating and time-critical medical emergency. Survival after OHCA requires an integrated system of care, of which transport by emergency medical services is an integral component. The transport system serves to commence and ensure uninterrupted high-quality resuscitation in suitable patients who would benefit, terminate resuscitation in those that do not, provide critical interventions, as well as convey patients to the next appropriate venue of care. We review recent evidence surrounding contemporary issues in the transport of OHCA, relating to who, where, when and how to transport these patients. ⋯ There remains limited evidence to guide some decisions in transporting the OHCA patient. Evidence is urgently needed to elucidate the roles of cardiac arrest centers and ECPR in OHCA.
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Current cardiac arrest guidelines are based on a fixed, time-based defibrillation strategy. Rhythm analysis and shock delivery (if indicated) are repeated every 2 min requiring cyclical interruptions of chest compressions. This approach has several downsides, such as the need to temporarily stop cardiopulmonary resuscitation (CPR) for a variable amount of time, thus reducing myocardial perfusion and decreasing the chance of successful defibrillation. A tailored defibrillation strategy should identify treatment priority for each patient, that is chest compressions (CCS) or defibrillation, minimize CCs interruptions, speed up the delivery of early effective defibrillation and reduce the number of ineffective shocks. ⋯ Real-time ECG analysis and AMSA have the potential to predict ventricular fibrillation termination, return of spontaneous circulation and even survival, with discretely high confidence. Prospective studies are now necessary to validate these new approaches in the clinical scenario.
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Obesity prevalence is increasing in most countries in the world. In the United States, 42% of the population is obese (body mass index (BMI) > 30) and 9.2% is obese class III (BMI > 40). One of the greatest challenges in critically ill patients with obesity is the optimization of mechanical ventilation. The goal of this review is to describe respiratory physiologic changes in patients with obesity and discuss possible mechanical ventilation strategies to improve respiratory function. ⋯ Obesity greatly alters the respiratory system mechanics causing atelectasis and prolonged duration of mechanical ventilation. At present, novel strategies to ventilate patients with obesity based on individual respiratory physiology showed to be superior to those based on standard universal tables of mechanical ventilation. Esophageal manometry and EIT are essential tools to systematically assess respiratory system mechanics, safely adjust relatively high levels of PEEP, and improve chances for successful weaning.
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Curr Opin Crit Care · Jun 2021
ReviewImpact of the COVID-19 pandemic on cardiac arrest systems of care.
The emergence of severe acute respiratory syndrome coronavirus 2 virus, which causes coronavirus disease 2019 (COVID-19), led to the declaration of a global pandemic by the World Health Organization on March 11, 2020. As of February 6, 2021, over 105 million persons have been infected in 223 countries and there have been 2,290,488 deaths. As a result, emergency medical services and hospital systems have undergone unprecedented healthcare delivery reconfigurations. Here, we review the effects of the COVID-19 pandemic on out-of-hospital cardiac arrest (OHCA) epidemiology and systems of care. ⋯ The COVID-19 pandemic has had direct, indirect, psychosocial, and ethical impacts on the cardiac arrest chain of survival.
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Curr Opin Crit Care · Jun 2021
ReviewImmediate postcardiac arrest treatment: coronary catherization or not?
Early coronary angiogram (CAG) remains a cornerstone in postcardiac arrest management as coronary disease (CAD)-related cardiac arrest is the leading cause of sudden death in adults. The opportunity to treat the cause early on with immediate CAG may improve outcome in cardiac arrest patients with AMI. Identifying the patients who will benefit from such an early invasive strategy is an unanswered question. Recent and ongoing trials may improve the level of evidence on this problematic, especially for some subgroup; however, current guidelines remain founded upon a very heterogeneous level of evidence. ⋯ This review aims to provide an overview of these different discussion points. The indication for early CAG should rely on multiple factors and an individual approach.