Articles at the Top

Articles at the Top. Take home messages from 2017 (part 2).

Advanced Life Support

Here are the best 2017 articles:

  • Cardiocerebral and cardiopulmonary resuscitation – 2017 update
  • Ventilation rate in adults with a tracheal tube during cardiopulmonary resuscitation: a systematic review
  • Favorable neurocognitive outcome with low tidal volume ventilation after cardiac arrest
  • Improving CPR Performance
  • Association of Mechanical Cardiopulmonary Resuscitation Device Use With Cardiac Arrest Outcomes
  • Safety of mechanical chest compression devices AutoPulse and LUCAS in cardiac arrest: a randomized clinical trial for non-inferiority
  • Conventional versus chest-compression-only cardiopulmonary resuscitation by bystanders for children with out-of-hospital cardiac arrest
  • Post-admission outcomes of participants in the PARAMEDIC trial: a cluster randomised trial of mechanical or manual chest compressions
  • Pre-hospital Supraglottic Airway was Associated with Good Neurological Outcome in Cardiac Arrest Victims Especially Who Received Prolonged Cardiopulmonary Resuscitation.
  • Cardiac Arrest and Mortality Related to Intubation Procedure in Critically Ill Adult Patients: A Multicenter Cohort Study
  • Out-of-hospital airway management during manual compression or automated chest compression devices
  • Paramedic Intubation Experience Is Associated With Successful Tube Placement but Not Cardiac Arrest Survival
  • Cardiac Arrest and Mortality Related to Intubation Procedure in Critically Ill Adult
    Patients: A Multicenter Cohort Study
  • Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival
  • Whether to Intubate During Cardiopulmonary Resuscitation
  • A multicenter prospective randomized study comparing the efficacy of escalating higher biphasic versus low biphasic energy defibrillations in patients presenting with cardiac arrest in the in-hospital environment
  • Double sequential defibrillation for refractory ventricular fibrillation
  • Comparative effectiveness of antiarrhythmics for out-of-hospital cardiac arrest: A systematic review and network meta-analysis
  • Antiarrhythmics in Cardiac Arrest: A Systematic Review and Meta-Analysis
  • Antiarrhythmic drugs for out-of-hospital cardiac arrest with refractory ventricular
  • A retrospective study of Pulseless Electrical Activity, Bedside ultrasound identifies
    interventions during resuscitation associated with improved survival to hospital admission. A REASON Study.
  • Rebellions of the Heart: The End of Amiodarone
  • Emergent coronary angiography post arrest–Do observational studies provide enough evidence for strong recommendations?
  • Distance to invasive heart centre, performance of acute coronary angiography, and angioplasty and associated outcome in out-of-hospital cardiac arrest: a nationwide study
  • Post-resuscitation arterial oxygen and carbon dioxide and outcomes after out-of-hospital cardiac arrest.
  • The effect of 50% compared to 100% inspired oxygen fraction on brain oxygenation and post cardiac arrest mitochondrial function in experimental cardiac arrest
  • Prehospital cooling to improve successful targeted temperature management after cardiac arrest: A randomized controlled trial
  • Targeted Temperature Management After Cardiac Arrest: Systematic Review and Meta-analyses
  • Targeted Temperature Management for 48 vs 24 Hours and Neurologic Outcome After Out-of-Hospital Cardiac Arrest A Randomized Clinical Trial


My take home messages:


Pathophysiological bases in experimental swine models

  • In a swine model following primary cardiac arrest the respiration continues at least for 1 minute, and after that Gasping starts lasting for another minute.
  • In a swine model following primary cardiac arrest the blood shifts from high pressure compartment (arteries) to low pressure compartment (veins). 
  • In a swine model the PaO2 following primary cardiac untreated VF arrests PaO2 results 70 mmHg after 9 min with a saturation of 93% and decrease at 44 mmHg with a saturation of 61% after 14 min of CPR. In this period airway management with possible interruption of chest compressions and starting positive pressure ventilation (with decreased return to the thorax end depression of cardiac output) is not mandatory due to the low cost/beneficial ratio and the potential detrimental effect. 


Chest compressions

  • Chest compressione only CPR is associated with worst outcome in children under 8 yers. Always perform chest compression/ventilation (ratio 15:2) in children <8 years of age (only exception if the cardiac arrest is due to primitive cardiac causes). 
  • Chest compressione only CPR can be a valuable option in adult witnessed VF/pulseless VT primary cardiac arrest (delayed airway management and passive O2 administration is reasonable).
  • Mechanical chest compression (MCC) is the future of CPR. They still do not demonstrated evident superiority in terms of outcome respect to manual chest compressions, but are evidently not inferior with a similar rate of life treating lesions. For sure MCC avoid variability in quality and allows good quality CC during transport. 



  • Lower Tidal volumes following OHCA is independently associated with favourableneurocognitive outcome
  • Weak evidences demonstrate that the ideal rate for ventilation of intubated patients  during CPR is 10/min


Airway management

  • There is not beneficial effect on outcome with early intubation in Cardiac Arrest (CA). 
  • Privilege High Quality CPR and Defibrillation (if needed).
  • Use Supraglottic Airway Devices (SAD) in first part (15 min) of resuscitation 
  • If Mechanical Chest Compressions is used, to optimise ventilation with SAD, use 30:2 ratio (because the intrathoracic pressure generated during MCC overrules that generated from SAD and impaires ventilation).
  • In prolonged Cardiac Arrest management converting SAD to Endotracheal Tube can be considered.
  • Experience provider only can perform endotracheal intubation in CA. They have a better chance of first passage rate, without interruption in chest compressions. First pass success rate is positively associated to survival and good neurological outcome.



  • Escalating bilevel energy (150-200-360 Joule) is associated with more efficacy in termination of shock resistant VF/pulseless VT cardiac arrest
  • Dual Sequential Defibrillation is feasible and safe. Although the evidences on its beneficial effect on outcome are still lacking it has to be considered in case of CA with refractory shockable rhythm. 


Antiarrhythmics drugs

  • There has been no conclusive evidence that any antiarrhythmic agents improve rates of ROSC, survival to admission, survival to discharge or neurological outcomes.



  • Ultrasound in PEA is a key tool to detect CA causes improving survivival.


Post Resuscitation Care

  • In post resuscitation phase avoid any arterial oxygen and carbon dioxide abnormality because are associated to increased mortality.
  • Centralisation of resuscitated patients toward an acute PCI/CABG capable Center  is associated to better outcome.


Targeted Temperature Management

  • Prehospital cooling does not improve faster in-hospital target temperature achieving and due to its costs is not recommended.


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