It is important that the medical profession plays a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced and tested in the detection, management, or prevention of disease states. Rigorous and expert analysis of the available data documenting absolute and relative benefits and risks of those procedures and therapies can produce helpful guidelines that improve the effectiveness of care, optimize patient outcomes, and favorably affect the overall cost of care by focusing resources on the most effective strategies.

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly engaged in the production of such guidelines in the area of cardiovascular disease since 1980. The ACC/AHA Task Force on Practice Guidelines, whose charge is to develop, update, or revise practice guidelines for important cardiovascular diseases and procedures, directs this effort. The Task Force is pleased to have this guideline developed in conjunction with the European Society of Cardiology (ESC). Writing committees are charged with the task of performing an assessment of the evidence and acting as an independent group of authors to develop or update written recommendations for clinical practice.

Experts in the subject under consideration have been selected from all 3 organizations to examine subject-specific data and write guidelines. The process includes additional representatives from other medical practitioner and specialty groups when appropriate. Writing committees are specifically charged to perform a formal literature review, weigh the strength of evidence for or against a particular treatment or procedure, and include estimates of expected health outcomes where data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that might influence the choice of particular tests or therapies are considered as well as frequency of follow-up and cost effectiveness. When available, information from studies on cost will be considered; however, review …

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ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death

The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.

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Part 8: Adult Advanced Cardiovascular Life Support 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

https://www.urgences-serveur.fr/IMG/pdf/TDRV_ESC.pdf

ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death)

The International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support (ALS) Task Force performed detailed systematic reviews based on the recommendations of the Institute of Medicine of the National Academies1 and using the methodological approach proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group.2 Questions to be addressed (using the PICO [population, intervention, comparator, outcome] format)3 were prioritized by ALS Task Force members (by voting). Prioritization criteria included awareness of significant new data and new controversies or questions about practice. Questions about topics no longer relevant to contemporary practice or where little new research has occurred were given lower priority. The ALS Task Force prioritized 42 PICO questions for review. With the assistance of information specialists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library).

By using detailed inclusion and exclusion criteria, articles were screened for further evaluation. The reviewers for each question created a reconciled risk of bias assessment for each of the included studies, using state-of-the-art tools: Cochrane for randomized controlled trials (RCTs),4 Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 for studies of diagnostic accuracy,5 and GRADE for observational studies that inform both therapy and prognosis questions.6

GRADE evidence profile tables7 were then created to facilitate an evaluation of the evidence in support of each of the critical and important outcomes. The quality of the evidence (or confidence in the estimate of the effect) was categorized as high, moderate, low, or very low,8 based on the study methodologies and the 5 core GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and other considerations (including publication bias).9

These evidence profile tables were then used to create a …

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Part 4: Advanced life support: 2015 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations

https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000549

2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society

Background Clinical trials have not shown a benefit of high doses of epinephrine in the management of cardiac arrest. We conducted a prospective, multicenter, randomized study comparing repeated high doses of epinephrine with repeated standard doses in cases of out-of-hospital cardiac arrest. Methods Adult patients who had cardiac arrest outside the hospital were enrolled if the cardiac rhythm continued to be ventricular fibrillation despite the administration of external electrical shocks, or if they had asystole or pulseless electrical activity at the time epinephrine was administered. We randomly assigned 3327 patients to receive up to 15 high doses (5 mg each) or standard doses (1 mg each) of epinephrine according to the current protocol for advanced cardiac life support. Results In the high-dose group, 40.4 percent of 1677 patients had a return of spontaneous circulation, as compared with 36.4 percent of 1650 patients in the standard-dose group (P=0.02); 26.5 percent of the patients in the high-dose ...

A Comparison of Repeated High Doses and Repeated Standard Doses of Epinephrine for Cardiac Arrest Outside the Hospital

Standard doses versus repeated high doses of epinephrine in cardiac arrest outside the hospital.

OBJECTIVE: It is proposed to not resuscitate trauma patients who have a cardiac arrest outside the hospital because they are assumed to have a dismal prognosis. Our aim was to compare the outcome of patients with traumatic or nontraumatic ("medical") out-of-hospital cardiac arrest.

DESIGN: Cohort analysis of patients with out-of-hospital cardiac arrest included in the European Epinephrine Study Group's trial comparing high vs. standard doses of epinephrine.

SETTING: Nine French university hospitals.

PATIENTS: A total of 2,910 patients.

INTERVENTIONS: Patients were successively and randomly assigned to receive repeated high doses (5 mg each) or standard doses (1 mg each) of epinephrine at 3-min intervals.

MEASUREMENTS AND MAIN RESULTS: Return of spontaneous circulation, survival to hospital admission and discharge, and secondary outcome measures of 1-yr survival and neurologic outcome were recorded. In the trauma group, patients were younger (42 +/- 17 vs. 62 +/- 17 yrs, p <.001), presented with fewer witnessed out-of-hospital cardiac arrests (62.3% vs. 79.7%), and had fewer instances of ventricular fibrillation as the first documented pulseless rhythm (3.4% [95% confidence interval, 1.2-5.5%] vs. 17.3% [15.8-18.7%]). A return of spontaneous circulation was observed in 91 of 268 trauma patients (34.0% [28.3-39.6%]) compared with 797 of 2,642 medical patients (30.2% [28.4-31.9%]), and more trauma patients survived to be admitted to the hospital (29.9% [24.4-35.3%] vs. 23.5% [22.0-25.2%]). However, there was no significant difference between trauma and medical groups at hospital discharge (2.2% [0.5-4.0%] vs. 2.8% [2.1-3.4%]) and 1-yr survival (1.9% [0.3-3.5%] vs. 2.5% [1.9-3.1%]). Among patients who were discharged, a good neurologic status was observed in two trauma patients (33.3% [4.3-77.7%]) and 37 medical patients (50% [38.1-61.9%]).

CONCLUSIONS: The survival and neurologic outcome of out-of-hospital cardiac arrest were not different between trauma and medical patients. This result suggests that, under the supervision of senior physicians, active resuscitation after out-of-hospital cardiac arrest is as important in trauma as in medical patients.

Does the prognosis of cardiac arrest differ in trauma patients

Resume Objectif Analyser les variations des profils hemodynamiques et oxymetriques mesures par catheterisme cardiaque droit et rechercher une relation avec les modifications des concentrations plasmatiques de cytokines au cours de la phase initiale de la reanimation des brules graves. Type d'etude Etude prospective ouverte realisee sur une periode de 18 mois. Patients Treize patients âges de plus de 12 ans, sans antecedents, victimes d'une brulure thermique depassant 50% de superficie cutanee et hospitalises moins de 6 heures apres la brulure. Methodes Une surveillance hemodynamique grâce a un catheter de Swan-Ganz a fibre optique a ete mise en place a l'admission. La reanimation a suivi le protocole therapeutique prealablement etabli dans le service. Des dosages plasmatiques de cytokines ont ete programmes a l'entree, toutes les 12 heures apres la brulure jusqu'au 2 e jour, puis au 3 e et 5 e jours (methode Elisa). Des mesures hemodynamiques et oxymetriques ont ete realisees simultanement aux dosages biologiques pendant les 5 premiers jours postbrulure. Les valeurs de ces derniers parametres ont ete analysees au moyen d'une Anova monofactorielle avec mesures repetees completee par un test de Duncan pour determiner les temps differents des donnees initiales. Resultats (x ± ESM): Les patients avaient un âge de 32 ± 3 ans et une superficie brulee de 72 ± 4%. Apres une courte periode de choc hypovolemique ne depassant pas 12 heures est apparu un profil hyperkinetique se majorant jusqu'au 5 e jour, avec augmentation de l'index cardiaque (6,9 ± 0,4 a la 120 e h vs 2,9 ± 0,3 L·min −1 m −2 a la 6 e h, P e h vs 543 ± 58mL·min −1 · m −2 a la 12 e h, P e h vs 129 ± 25 mL·min −1 · m −2 a la 6 e h, Recu le 31 mars 1995; accepte apres revision le 6 septembre 1995 P e h vs 2 330 ± 328 dyn·s·cm −5 m 2 a la 6 e e h, P e h et 15 406 6 509 pg·mL −1 a la 36 e h), simultanement a l'effondrement des resistances arterielles systemiques. Conclusions Au cours de la premiere semaine de reanimation, les brules graves ont un etat circulatoire hyperdynamique particulier, suggerant la place specifique de l'interleukine-6 a cette phase precoce postbrulure dans l'apparition de la vasoplegie.

Emmanuel Pham

Papers

A Comparison of Repeated High Doses and Repeated Standard Doses of Epinephrine for Cardiac Arrest Outside the Hospital

A Comparison of Repeated High Doses and Repeated Standard Doses of Epinephrine for Cardiac Arrest Outside the Hospital

Standard doses versus repeated high doses of epinephrine in cardiac arrest outside the hospital.

Does the prognosis of cardiac arrest differ in trauma patients

Brûlés graves: état hémodynamique, transport et consommation d'oxygène, cytokines plasmatiques