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Resuscitation:The Outer limits

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Emcore
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Resuscitation is reaching new limits, with new techniques and technologies giving results that we never thought possible. In Lazarus-like fashion, patients that a few years ago, would have been pronounced deceased, are now leaving hospital to resume their lives, with their families and their work and with very little, if any, deficit.

About 8 years ago I spoke about a new paradigm being needed in Resuscitation. We had to think differently. The resuscitation guidelines emerged in the time of black and white television and apart from some fine tuning, have remained effectively the same.

“The evidence isn’t great, but it’s the best evidence we have”,  is the usual quote. I say:

 “It’s time to push the envelope, to reach the limits of our resuscitation capacities!”

We can’t all have ECMO, but we can push the parameters and dare to do those things that may a difference to our patients’ lives.

This year at EMCORE (Hong Kong, Melbourne and Fiji), I’m talking about: “The Outer Limits of Resuscitation”

Here’s what I mean:

  1. Why aren’t we using apnoeic oxygenation during cardiac arrest?  The theory of a negative pressure gradient oxygenating the apnoeic patient, can surely be applied here. I’m not saying don’t bag valve mask the patient. I’m saying augment that!
  2. The long standing don’t shock systole stance of the guidelines should be revisited.When initially introduced, it was based on poor studies, some of which were paediatric, where DC shocks don’t work, as the cause of arrest is respiratory, rather than cardiac. Of course these studies showed no benefit. This was a different population group! There has always been the fear of cardiac damage caused by shocking the asystole patient. Something that borders on absurdity.”You can’t kill dead!” This becomes very important when we know that a portion of asystole patients actually have coordinated cardiac activity on echo. I’ll go through some cases.
  3. What about PEA?We know that a significant number of these patients have coordinated cardiac motion. What about the use of H’s and T’s? Surely there’s a better way. There is!
  4. Let’s monitor the blood pressure…invasively.What’s measured can be altered. Let’s treat the blood pressure with increments of adrenaline, not buckets of it. I talk about the after-load effects as well as the effects in the stages of arrest. There is both the best dosing and the best timing for adrenaline.

Peter Kas

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