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European resuscitation council newsletter 1992 — A year of international collaboration for CPR
93
Resuscitation, 24 (1992) 93-96 Elsevier Scientific Publishers Ireland Ltd.
European Resuscitation
Council
Newsletter 1992 -
A Year of International Collaboration for CPR
1992 has been a very eventful year in the field of CPR. During 1991/92 the American Heart Association (AHA) prepared new standards and guidelines for cardiopulmonary resuscitation (CPR). Similarly to previous versions of the guidelines, they will be published early in 1993 in the JAMA (Journal ofthe American Medical Association) [ 11.The AHA is an organisation which concerns for, and largely comprises lay people. For about 20 years now it has produced the “Standards and guidelines for CPR”, publications which have become the international gold standard in this field. During the interval since the publication of the 1986 guidelines, CPR-related activities have increased considerably in Europe. Important technical advances such as semiautomatic defibrillators have been introduced into clinical practice, while in the USA the increasingly litigious environment has created a situation where the medical profession looks upon guidelines such as these as a medicolegal protective device. Ethical and legal considerations have become increasingly important in the AHA guidelines. In Europe, however, the requirements of CPR guidelines are mainly concerned with excellence in teaching and clinical practice. The AHA has an impressive tradition of generous international collaboration, but it is primarily an American national organisation and as such it has no intention of adjusting its policies or publications to the local needs of other nations. This was one of the reasons for creating the European Resuscitation Council (ERC), a multidisciplinary international professional organisation (Secretariat: European Resuscitation Council, c/o Professor Leo Bossaert, Universitetsplein 1, B-26 10, Antwerpen, Belgium). The ERC does not intend to compete with the AHA, but to be a complementary organisation. The ERC plans to publish guidelines for CPR adjusted for European needs. It also plans to review the leading scientific edge in CPR and if it seems appropriate to aid in the coordination of international research projects. Since the medicolegal situation is less threatening in Europe than in the USA, it may be possible for the ERC to update practices more rapidly than is possible for the AHA. One result of the collaboration between the AHA and the ERC is the Utstein document [2]. It concerns a unified form for reporting out-of-hospital resuscitation and follow-up. A number of professional publications have accepted the Utstein style of reporting CPR. Therefore it would be a matter of great clinical and scientific advantage if this became universally accepted among European ambulance and hospital organisations. Such an acceptance would permit local and international comparisons of the outcome of CPR efforts. This document is available in several professional publications (Resuscitation, Circulation, Annals of Emergency Medicine, British Heart Journal, Notfallmedizin, Intensivmedizin und Notfallmedizin) 0300-9572/92/$05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
94
Simultaneously with the 1992 AHA guidelines, the ERC plans to publish its first guidelines for CPR in the winter 1992-1993. The preparation of these have been coordinated with those of the AHA. The international (English language) publication Resuscitation will be the main line of communication for the ERC. The first international ERC conference will be held on November 20-21 1992 in the English town of Brighton. The continued ERC activities will be presented and debated. This author participated in the 1991-1992 AHA preparatory conferences for guidelines, as a representative of the ERC (AHA preliminary fact finding exercises September 29-30 1991, Fourth National AHA Conference on Cardiopulmonary Resuscitation and Emergency Cardiac Care. Feb 22-25 1992). The 1992 guidelines for CPR will probably not propose major policy changes compared with the 1986 version, but the process of preparing them has been considerably revised. Being a predominantly lay organisation the AHA has previously utilized a kind of democratic consensus procedure as foundation for their ‘Standards and Guidelines’. A number of preparatory committees presented their suggestions to a general assembly meeting. This procedure makes it possible for charismatic and overwhelming personalities to obtain consensus for less well thought out propositions, whilst other suggestions might risk obscurity regardless of intrinsic merit if they were put forward by a less impressive personality. The AHA has recognized this risk, and for the current guidelines a very strict scientific review process was instituted. Panels of international experts were invited to discuss pros and cons of relevant issues. There still remains the problem of whether it is possible for an expert panel to reach appropriate conclusions by democratic procedure. To overcome this obstacle the arguments and propositions were reviewed and graded according to a predetermined template as follows: Class Z, usually indicated, always acceptable and considered useful and effective; Class ZZ,acceptable treatments of uncertain efficacy and maybe controversial (class two is split in two subgroups: group II A - the weight of evidence is in favour of their usefulness and efficacy; and group II B - these are not well established by evidence, can be helpful but are probably not harmful); Class ZZZ,not indicated, may be harmful. This template made it possible to come to a group consensus, where the strength of each proposition was clearly spelled out. During the AHA discussion sessions it became evident that certain well established therapies were built on surprisingly weak clinical studies. One case in point was the use and dosage of epinephrine. Several important clinical studies of epinephrine dosage are currently being prepared for publication. Despite the agreement that only peer reviewed publications should be regarded as evidence, data were presented from a couple of these studies. Nothing was presented to indicate that the 1992 recommendations for epinephrine use should be significantly changed compared to the 1986 guidelines. The Heimlich manouvre is based on a few case descriptions and will probably be less strongly recommended than previously. The use of various buffer solutions was discussed in a lively session. Many animal experimental studies were cited, but conclusive clinical studies of buffering during CPR have not been published. Even less research is available on the significance of the optimal technique for ventilation during CPR. A multitude of (partially contradictory) animal studies concerning thoracic compressions - ‘cardiac massage’ during CPR were reviewed, but clear cut results from clinical studies are unavailable. Open cardiac compressions
95
have been well documented. It is a method that may have been deleted from the standard of clinical practice without good reason. It still remains, however, to clearly define the indications for open versus closed cardiac massage. A new device, a pneumatic ‘machine’ for open cardiac compressions was recently presented with persuasive animal data and a short series of clinical case histories [3,4]. It seems promising but not ready for general clinical use. On the other hand we have seen the documentation of defibrillation impressively increased with the introduction and trials of semi-automatic defibrillators. It has been persuasively proven that these computer-aided devices are highly efficacious. The possibilities for prevention of recurrent cardiac arrests were reviewed - implantable automatic defibrillators using the computer technology referred to above, have been tested in humans with encouraging results. Human studies indicating that chronic antiarythmic medications were associated with increased mortality rates were presented. Several ‘brain resuscitation’-studies were reviewed. No break-through was identified, but the importance of diligent post-arrest intensive care seemed persuasive. The AHA does not consider guidelines for post-resuscitation intensive care to be within it’s field of interest. The 1992 ERC standards and guidelines, however, will include principles of intensive care for patients following resuscitation from cardiac arrest. At the boundary between technical and ethical question a debate took place concerning the fear of infectious diseases (AIDS related) among lay people and professionals. This has had a significant impact on attitudes to CPR, particularly in the major cities of the USA. The question was raised whether this should be primarily regarded as an ethical/psychological problem, or an attempt should be made to improve the situation by technical means, providing massive numbers of breathing masks with barrier devices. No determination was made concerning this. A very comprehensive discussion concerning ethical issues occurred at the AHA meetings. This subject was given more time than any other single issue. The AHA seems to feel that this is an area that has previously been overlooked. It is possible that this is one reason why in the USA, medicolegal problems have become particularly prominent in CPR during recent years [5]. One local US issue deserves comment because it may be confusing to an outsider. There was a long, very animated, even agitated debate concerning a suggestion from the pedagogic committee to change the format of the examinations and the documents that are awarded by the AHA. The proposition was put forth to alter the nature of the document from being a licence to becoming a certificate of satisfactory course participation. In many areas of the USA these AHA documents are mandatory for certain types of medical practitioners like MDs, nurses, emergency technicians, plus firemen and police. I came to understand that the controversy was based on the fact that many American organisations in the USA, such as the Red Cross, but also a large number of private entrepreneurs and schools, turn over colossal amounts of money providing CPR-certification courses of various types. A group within the AHA seemed to fear that the quality of these courses varied unacceptably. The AHA, however, does not see its role in providing a strict quality control program. The quality and standards of schools and universities are generally checked by state authorities in the USA. Some AHA members desire that such quality con-
96
trol should be extended to the AHA certification courses. The new format of the certificates would encourage the development of state licencing procedures for CPR. Naturally some diligent educators felt slighted by this proposal and some entrepreneurs felt that a profitable business might be threatened by such regulation. The above is a brief review of the backstage work that provided the expert review necessary for the production of the AHA and ERC standards and guidelines for CPR. Hopefully these publications will be helpful for those colleagues and educators who wish to provide rational and up-to-date clinical care. They may also provide an incentive for those who wish to develop medical science further by performing clinical research. I strongly recommend every interested party to watch for the forthcoming CPR issues of JAM,4 and Resuscitation during the winter of 1992/93. Erik Edgren Department of Anesthesiology and Intensive Care, University Hospital, S 75185 Vppsala. Sweakrt.
REFERENCES 1
2
3
4 5
Rinke CM. Standards and guidelines for cardiopulmonary resuscitation (CPR). J Am Med Assoc 1987; 255: 2905-2992. Task force of representatives from European Resuscitation Council, American Heart Association, Heart and Stroke Foundation of Canada, Australian Resuscitation Council. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the ‘Utstein style’. Resuscitation 1991; 22: l-26. Anstadt MP, Griffith RF, Hoekstra J, Anstadt GL and Brown CG. Acute myocardial reperfusion using direct mechanical ventricular actuation vs. hand cardiac massage [abstract]. Crit Care Med 1992; 20 Suppl.: S25. Anstadt MP, Tedder M, Hendry PJ and Lowe JE. Myocardial function following successful cardiac resuscitation with mechanical circulatory support [abstract]. Crit Care Med 1992; 20 Suppl.: S86. Edgren E. The ethics of resuscitation; differences between Europe and the USA - Europe should not adopt American guidelines without debate (Invited Editorial). Resuscitation 1992; 23: 85-90.
Resuscitation, 24 (1992) 93-96 Elsevier Scientific Publishers Ireland Ltd.
European Resuscitation
Council
Newsletter 1992 -
A Year of International Collaboration for CPR
1992 has been a very eventful year in the field of CPR. During 1991/92 the American Heart Association (AHA) prepared new standards and guidelines for cardiopulmonary resuscitation (CPR). Similarly to previous versions of the guidelines, they will be published early in 1993 in the JAMA (Journal ofthe American Medical Association) [ 11.The AHA is an organisation which concerns for, and largely comprises lay people. For about 20 years now it has produced the “Standards and guidelines for CPR”, publications which have become the international gold standard in this field. During the interval since the publication of the 1986 guidelines, CPR-related activities have increased considerably in Europe. Important technical advances such as semiautomatic defibrillators have been introduced into clinical practice, while in the USA the increasingly litigious environment has created a situation where the medical profession looks upon guidelines such as these as a medicolegal protective device. Ethical and legal considerations have become increasingly important in the AHA guidelines. In Europe, however, the requirements of CPR guidelines are mainly concerned with excellence in teaching and clinical practice. The AHA has an impressive tradition of generous international collaboration, but it is primarily an American national organisation and as such it has no intention of adjusting its policies or publications to the local needs of other nations. This was one of the reasons for creating the European Resuscitation Council (ERC), a multidisciplinary international professional organisation (Secretariat: European Resuscitation Council, c/o Professor Leo Bossaert, Universitetsplein 1, B-26 10, Antwerpen, Belgium). The ERC does not intend to compete with the AHA, but to be a complementary organisation. The ERC plans to publish guidelines for CPR adjusted for European needs. It also plans to review the leading scientific edge in CPR and if it seems appropriate to aid in the coordination of international research projects. Since the medicolegal situation is less threatening in Europe than in the USA, it may be possible for the ERC to update practices more rapidly than is possible for the AHA. One result of the collaboration between the AHA and the ERC is the Utstein document [2]. It concerns a unified form for reporting out-of-hospital resuscitation and follow-up. A number of professional publications have accepted the Utstein style of reporting CPR. Therefore it would be a matter of great clinical and scientific advantage if this became universally accepted among European ambulance and hospital organisations. Such an acceptance would permit local and international comparisons of the outcome of CPR efforts. This document is available in several professional publications (Resuscitation, Circulation, Annals of Emergency Medicine, British Heart Journal, Notfallmedizin, Intensivmedizin und Notfallmedizin) 0300-9572/92/$05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
94
Simultaneously with the 1992 AHA guidelines, the ERC plans to publish its first guidelines for CPR in the winter 1992-1993. The preparation of these have been coordinated with those of the AHA. The international (English language) publication Resuscitation will be the main line of communication for the ERC. The first international ERC conference will be held on November 20-21 1992 in the English town of Brighton. The continued ERC activities will be presented and debated. This author participated in the 1991-1992 AHA preparatory conferences for guidelines, as a representative of the ERC (AHA preliminary fact finding exercises September 29-30 1991, Fourth National AHA Conference on Cardiopulmonary Resuscitation and Emergency Cardiac Care. Feb 22-25 1992). The 1992 guidelines for CPR will probably not propose major policy changes compared with the 1986 version, but the process of preparing them has been considerably revised. Being a predominantly lay organisation the AHA has previously utilized a kind of democratic consensus procedure as foundation for their ‘Standards and Guidelines’. A number of preparatory committees presented their suggestions to a general assembly meeting. This procedure makes it possible for charismatic and overwhelming personalities to obtain consensus for less well thought out propositions, whilst other suggestions might risk obscurity regardless of intrinsic merit if they were put forward by a less impressive personality. The AHA has recognized this risk, and for the current guidelines a very strict scientific review process was instituted. Panels of international experts were invited to discuss pros and cons of relevant issues. There still remains the problem of whether it is possible for an expert panel to reach appropriate conclusions by democratic procedure. To overcome this obstacle the arguments and propositions were reviewed and graded according to a predetermined template as follows: Class Z, usually indicated, always acceptable and considered useful and effective; Class ZZ,acceptable treatments of uncertain efficacy and maybe controversial (class two is split in two subgroups: group II A - the weight of evidence is in favour of their usefulness and efficacy; and group II B - these are not well established by evidence, can be helpful but are probably not harmful); Class ZZZ,not indicated, may be harmful. This template made it possible to come to a group consensus, where the strength of each proposition was clearly spelled out. During the AHA discussion sessions it became evident that certain well established therapies were built on surprisingly weak clinical studies. One case in point was the use and dosage of epinephrine. Several important clinical studies of epinephrine dosage are currently being prepared for publication. Despite the agreement that only peer reviewed publications should be regarded as evidence, data were presented from a couple of these studies. Nothing was presented to indicate that the 1992 recommendations for epinephrine use should be significantly changed compared to the 1986 guidelines. The Heimlich manouvre is based on a few case descriptions and will probably be less strongly recommended than previously. The use of various buffer solutions was discussed in a lively session. Many animal experimental studies were cited, but conclusive clinical studies of buffering during CPR have not been published. Even less research is available on the significance of the optimal technique for ventilation during CPR. A multitude of (partially contradictory) animal studies concerning thoracic compressions - ‘cardiac massage’ during CPR were reviewed, but clear cut results from clinical studies are unavailable. Open cardiac compressions
95
have been well documented. It is a method that may have been deleted from the standard of clinical practice without good reason. It still remains, however, to clearly define the indications for open versus closed cardiac massage. A new device, a pneumatic ‘machine’ for open cardiac compressions was recently presented with persuasive animal data and a short series of clinical case histories [3,4]. It seems promising but not ready for general clinical use. On the other hand we have seen the documentation of defibrillation impressively increased with the introduction and trials of semi-automatic defibrillators. It has been persuasively proven that these computer-aided devices are highly efficacious. The possibilities for prevention of recurrent cardiac arrests were reviewed - implantable automatic defibrillators using the computer technology referred to above, have been tested in humans with encouraging results. Human studies indicating that chronic antiarythmic medications were associated with increased mortality rates were presented. Several ‘brain resuscitation’-studies were reviewed. No break-through was identified, but the importance of diligent post-arrest intensive care seemed persuasive. The AHA does not consider guidelines for post-resuscitation intensive care to be within it’s field of interest. The 1992 ERC standards and guidelines, however, will include principles of intensive care for patients following resuscitation from cardiac arrest. At the boundary between technical and ethical question a debate took place concerning the fear of infectious diseases (AIDS related) among lay people and professionals. This has had a significant impact on attitudes to CPR, particularly in the major cities of the USA. The question was raised whether this should be primarily regarded as an ethical/psychological problem, or an attempt should be made to improve the situation by technical means, providing massive numbers of breathing masks with barrier devices. No determination was made concerning this. A very comprehensive discussion concerning ethical issues occurred at the AHA meetings. This subject was given more time than any other single issue. The AHA seems to feel that this is an area that has previously been overlooked. It is possible that this is one reason why in the USA, medicolegal problems have become particularly prominent in CPR during recent years [5]. One local US issue deserves comment because it may be confusing to an outsider. There was a long, very animated, even agitated debate concerning a suggestion from the pedagogic committee to change the format of the examinations and the documents that are awarded by the AHA. The proposition was put forth to alter the nature of the document from being a licence to becoming a certificate of satisfactory course participation. In many areas of the USA these AHA documents are mandatory for certain types of medical practitioners like MDs, nurses, emergency technicians, plus firemen and police. I came to understand that the controversy was based on the fact that many American organisations in the USA, such as the Red Cross, but also a large number of private entrepreneurs and schools, turn over colossal amounts of money providing CPR-certification courses of various types. A group within the AHA seemed to fear that the quality of these courses varied unacceptably. The AHA, however, does not see its role in providing a strict quality control program. The quality and standards of schools and universities are generally checked by state authorities in the USA. Some AHA members desire that such quality con-
96
trol should be extended to the AHA certification courses. The new format of the certificates would encourage the development of state licencing procedures for CPR. Naturally some diligent educators felt slighted by this proposal and some entrepreneurs felt that a profitable business might be threatened by such regulation. The above is a brief review of the backstage work that provided the expert review necessary for the production of the AHA and ERC standards and guidelines for CPR. Hopefully these publications will be helpful for those colleagues and educators who wish to provide rational and up-to-date clinical care. They may also provide an incentive for those who wish to develop medical science further by performing clinical research. I strongly recommend every interested party to watch for the forthcoming CPR issues of JAM,4 and Resuscitation during the winter of 1992/93. Erik Edgren Department of Anesthesiology and Intensive Care, University Hospital, S 75185 Vppsala. Sweakrt.
REFERENCES 1
2
3
4 5
Rinke CM. Standards and guidelines for cardiopulmonary resuscitation (CPR). J Am Med Assoc 1987; 255: 2905-2992. Task force of representatives from European Resuscitation Council, American Heart Association, Heart and Stroke Foundation of Canada, Australian Resuscitation Council. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the ‘Utstein style’. Resuscitation 1991; 22: l-26. Anstadt MP, Griffith RF, Hoekstra J, Anstadt GL and Brown CG. Acute myocardial reperfusion using direct mechanical ventricular actuation vs. hand cardiac massage [abstract]. Crit Care Med 1992; 20 Suppl.: S25. Anstadt MP, Tedder M, Hendry PJ and Lowe JE. Myocardial function following successful cardiac resuscitation with mechanical circulatory support [abstract]. Crit Care Med 1992; 20 Suppl.: S86. Edgren E. The ethics of resuscitation; differences between Europe and the USA - Europe should not adopt American guidelines without debate (Invited Editorial). Resuscitation 1992; 23: 85-90.