In-Hospital Resuscitation: A Statement for Healthcare Professionals From the American Heart Association Emergency Cardiac Care Committee and the Advanced Cardiac Life Support, Basic Life Support, Pediatric Resuscitation, and Program Administration Subcommittees.
Richard O. Cummins, MD; Arthur Sanders, MD; Elizabeth Mancini, RN; Mary Fran Hazinski, MSN, RN. Circulation 1997; 95: 2211-2212.

The first AHA statement specifically about in-hospital resuscitation. It appropriately emphasizes the central importance of early defibrillation.

Recommended Guidelines for Reviewing, Reporting, and Conducting Research on In-Hospital Resuscitation: The In-Hospital 'Utstein Style.'
Richard O. Cummins, MD, Cochair; Douglas Chamberlain, MD, Cochair; Mary Fran Hazinski, MSN, RN; Vinay Nadkarni, MD; Walter Kloeck, MD; Efraim Kramer, MD; Lance Becker, MD; Colin Robertson, MD; Rudi Koster, MD; Arno Zaritsky, MD; Leo Bossaert, MD; Joseph P. Ornato, MD; Victor Callanan, MD; Mervyn Allen, MD; Petter Steen, MD; Brian Connolly, MD; Arthur Sanders, MD; Ahamed Idris, MD; Stuart Cobbe, MD. Circulation 1997; 95: 2213-2239.

A very important and much-needed document which should both encourage and vastly improve research in the field of in-hospital resuscitation. My only gripe (again) is that one brief statement leaves the impression that early in-hospital defibrillation has been made possible by AED technology, and that it is only feasible with AEDs: "The widespread availability of automated external defibrillators, with their documented ease of training, provides the technological capacity to support such early defibrillation programs."  (To be fair, the authors do acknowledge elsewhere that using "conventional" defibrillators is an option.)  I maintain that the big obstacle over the years has been (and remains) failure to recognize and fully acknowledge the problem--not a technological inadequacy but a problem with "the vision thing." 

Sudden Cardiac Arrest: A Treatable Public Health Crisis

A "white  paper" written under an educational grant from Heartstream, Inc., an AED maker, by Communicore, an "independent medical communications organization." This is part of Heartstream's commercial site. It's a good overview of the problem of delayed defibrillation in the pre-hospital setting. Of particular interest is a graph (on page 5, integrating results from several studies) which illustrates that decline in survival from VF is not linear over time. A "rule of thumb" is often quoted in the literature, which states that survival decreases 10% for each minute that defibrillation is delayed. Actually, there is fairly good evidence that the decline is much more rapid in the first few minutes after arrest, and that small decreases in that time interval (which are potentially achievable with many in-hospital arrests) can bring about large increases in the probability of survival. However, a good study elucidating the survival curve accurately for a given population of cardiac arrest victims has yet to be done.

Improving outcome from cardiac arrest in the hospital with a reorganized and strengthened chain of survival: an American view. Kaye W, Mancini ME. Resuscitation 1996; 31: 181-186.

A good overview of various factors that impinge upon in-hospital survival, with strategies outlined for addressing each of them. Early defibrillation is stressed (of course), but the article assumes that early in-hospital defibrillation is synonymous with use of AEDs and does not mention other alternatives.

Automatic External Defibrillators for Public Access Defibrillation: Recommendations for Specifying and Reporting Arrhythmia Analysis Algorithm Performance, Incorporating New Waveforms, and Enhancing Safety  Circulation. 1997;95:1677-1682.

A detailed set of recommendations for devices intended for use by the lay public. 

A logical extension of the AED concept is "public access defibrillation" or widespread distribution and use of AEDs by nonmedical, minimally trained personnel .... Public access defibrillation poses unique challenges. AEDs must be simple to operate.... The device must accurately diagnose lethal arrhythmias under unfavorable conditions .... It could be misused, either inadvertently (e.g., the patient is conscious and breathing) or deliberately.

The reason given in this document for classification of asystole as a "nonshockable" rhythm is quite interesting: "To maximize safety in the event of misapplication of the device/electrodes, asystole is included in this group." In other words, asystole should not be shocked because a flat line might indicate the electrodes are not properly attached. This fits with what the research director for a major AED manufacturer told me once: that the real reason for the AHA Guidelines' prohibition on shocking apparent asystole was to prevent intentional misuse of AEDs. For example, attaching electrodes to the head, where there would be no detection of cardiac electrical activity, could permit delivery of shocks if there was no lockout for flatline. The clinical rationale for not shocking apparent asystole has always been weak at best in my opinion (see "Questions remain about shocking asystole"); perhaps it resulted from an attempt to provide further justification for a decision made by AED designers for another reason entirely. I'll probably have more to say about this on my blog.

Mouth-to-Mouth Ventilation During CPR: A Reappraisal of Mouth-to-Mouth Ventilation During Bystander-Initiated Cardiopulmonary Resuscitation

A Statement for Healthcare Professionals From the Ventilation Working Group of the Basic Life Support and Pediatric Life Support Subcommittees, American Heart Association: Lance B. Becker, MD, Chair; Robert A. Berg, MD; Paul E. Pepe, MD, MPH; Ahamed H. Idris, MD; Thomas P. Aufderheide, MD; Thomas A. Barnes, EdD, RRT; Samuel J. Stratton, MD; Nisha C. Chandra, MD.

A bit off the main subject, but of interest to anyone involved in resuscitation. What we thought we knew for many years may be wrong. Since this review came out, numerous studies have called into question the need for MTM ventilation during the first few minutes of cardiac arrest and have even produced some pretty strong evidence that it's harmful The AHA is inching away from MTM with the new guidelines' 30:2 compression:ventilation ratio. I'll try to provide some more links on this important topic in coming weeks.

 Time accuracy of a barcode system for recording resuscitation events: laboratory trials. Stewart JA, Short FA. . Resuscitation 1999; 42(3): 235-40.

This is the first report of results from the system Dr. Short and I have been developing. Our current Palm-based system also seems to work well in recording actual resuscitation events, but we're still accumulating the numbers. We will be demonstrating the system in presentations at the European Resuscitation Council Congress (Florence, Italy, October 2002), and the American Heart Association Scientific Sessions (Chicago, November 2002).

 Family presence during invasive procedures and resuscitation. Meyers TA, Eichhorn DJ, Guzzetta CE, Clark AP, Klein JD, Taliaferro E, Calvin A. American Journal of Nursing 2000 Feb;100(2):32-42.

A descriptive study of the effects of family presence during CPR and invasive procedures on the family members and health care providers. This study had the noteworthy direct effect of changing a major medical center's practice guidelines.

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