New Lease of Life for Return of Spontaneous Circulation

Paramedic Matt Green PG Dip BSc (Hons) Cert HE MCPara

M.L.Green@Live.co.uk @MLG1611

February 2016

The United Kingdom’s ambulance services are successfully restoring a pulse in more cardiac arrest

victims than ever before1,2 and it’s a huge cause for celebration3. The root cause appears to be

improvements in the quality of cardiopulmonary resuscitation using non-technical skills such as

pit-crew resuscitation tactics4 and increasingly appropriate use of advanced techniques including

airway management and clinically effective doses of evidence-based drugs. Studies are collecting

currently data about some of these technical issues to enhance the literature5,6.

Today, it is argued that most patients are receiving similarly skilled resuscitation inside and outside

of the hospital environment and that’s a great credit to a paramedic profession barely two decades

old7.

Moreover, patients who are successfully resuscitated are going on to benefit from extremely

effective alternative care pathways which bypass traditional delays associated with emergency

department admission to reach definitive care sooner. Patients with acute myocardial infarction may

directly access primary percutaneous coronary intervention (PPCI), for example8.

2013’s Joint Royal College Ambulance Liaison Committee (JRCALC) Clinical Practice Guidelines9 for

return of spontaneous circulation (ROSC) encourage clinicians to:

assess the victim using an Airway, Breathing, Circulation, Disability and Expose/Examine

approach

Provide controlled oxygenation and ventilation

Acquire a 12-lead electrocardiogram

Undertake investigations

Treat the precipitating cause

Provide temperature control

Provide therapeutic hypothermia only with appropriate equipment

Whilst patients displaying ROSC in a hospital setting have traditionally benefitted from sedation and

inotropes where indicated10, this has been outside of the traditional scope of practice for ambulance

staff in the United Kingdom. It is uncertain whether this paucity of skills has precipitated further

cardiac arrests and resulted in poorer outcomes in the recently resuscitated population.

Things are set to change as a result of the 2015 Resuscitation Council (UK) (RCUK) Prehospital

resuscitation guidelines11, which have more detailed and specific advice on pre-hospital return of

spontaneous circulation.

Key recommendations:

Continuous capnography

Saline boluses in the hypotensive patient

Cardioversion of pulsed ventricular tachycardia causing instability

Intravenous adrenaline boluses for profound hypotension, titrated to effect (in the context

of governance where telephone medical support is available)

Transport to a primary percutaneous coronary intervention-capable hospital, regardless of

consciousness level, where ST segment elevation is detected

Mechanical ventilation targeted to normal oxygen saturations and capnography values

Intravenous diazepam or midazolam for those cerebrally irritated or combative (with

appropriate telephone medical support if advanced medical care is not available on scene)

Transporting the patient supine with their head at a 300 tilt

It is yet to be seen how closely the latest edition of the JRCALC Clinical Practice Guidelines, due in

March 2016, will reflect the RCUK’s position. Hopefully it is accepted in full and used as a

springboard to support a significant shift forward in paramedic ROSC care. Any unwelcome

hesitation by JRCALC should be unlikely against a context of excellent quality and specific pre-

hospital recommendations released as recently as 2015 from a seminal organisation such as RCUK.

References:

1. Cardiac Arrest Annual Report 2010/11 (2011), London Ambulance Service NHS Trust,

http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=6&cad=rja&uact=8&

ved=0ahUKEwjao_r1jIHLAhVBWSwKHbpFBLMQFghFMAU&url=http%3A%2F%2Fwww.londo

nambulance.nhs.uk%2Fabout_us%2Fidoc.ashx%3Fdocid%3Db77b0219-5446-4136-ac0a-

f936af6e1989%26version%3D-1&usg=AFQjCNFYUUaIcqou6xMGfqEGwLhRxv9esQ

2. Cardiac Arrest Annual Report 2014/15, (2015), London Ambulance Service NHS Trust,

http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=5&cad=rja&uact=8&

ved=0ahUKEwjao_r1jIHLAhVBWSwKHbpFBLMQFghAMAQ&url=http%3A%2F%2Fwww.londo

nambulance.nhs.uk%2Fabout_us%2Fidoc.ashx%3Fdocid%3D2d51ac9a-bd44-4cc4-9443-

946533911275%26version%3D-1&usg=AFQjCNFFjbebJmwJWu26nB1nqNnSALiNHw

3. Survivors 2015, South East Coast Ambulance Service NHS Foundation Trust,

http://www.secamb.nhs.uk/about_us/our_successes-1.aspx

4. Team approach to resuscitation (2015), Resuscitation Today,

http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=9&cad=rja&uact=8&

ved=0ahUKEwjb1q2fj4HLAhVLhSwKHXQXBWoQFghVMAg&url=http%3A%2F%2Fwww.resust

oday.com%2Fwp-

content%2Fuploads%2F2015%2F07%2F34519_Resus_Today_Summer_2015_V3_WEB.pdf&u

sg=AFQjCNGTZHJOlZ02FRWuWYLTTArHFYBGmw&bvm=bv.114733917,d.bGg

5. Airways-2 trial (2015), University of Bristol, http://www.airways-2.bristol.ac.uk/

6. PARAMEDIC2 trial (2016), Warwick Medical School,

http://www2.warwick.ac.uk/fac/med/research/hscience/ctu/trials/critical/paramedic2/

7. Treat cardiac arrest patients at the scene, says top doctor (2014), Independent,

http://www.independent.co.uk/life-style/health-and-families/health-news/treat-heart-

attack-patients-at-the-scene-says-top-doctor-9751659.html

8. Resuscitation Policy (2014), South Central Ambulance Service NHS Foundation Trust,

http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=5&cad=rja&uact=8&

ved=0ahUKEwjtz5b6lIHLAhXCuBQKHY7eDbwQFgg7MAQ&url=http%3A%2F%2Fwww.southce

ntralambulance.nhs.uk%2F_assets%2Fdocuments%2Fpolicies%2Fclinical%2Fcspp%25203%2

520resuscitation%2520policy%2520v4%2520july%25202014.pdf&usg=AFQjCNFg_oaz1vEzB5

B4Zpt7f4GBnH_ReA

9. Clinical Practice Guidelines (2013), Joint Royal Colleges Ambulance Liaison Committee,

http://www.jrcalc.org.uk/guidelines/

10. Post-resuscitation care (2015), Resuscitation Council (UK),

https://www.resus.org.uk/resuscitation-guidelines/post-resuscitation-care/

11. Prehosital resuscitation (2015), Resuscitation Council (UK),

https://www.resus.org.uk/resuscitation-guidelines/prehospital-resuscitation/