Friday, July 02, 2010

Lessons Learned From ICEM 2010 (Part C)

Lessons learned from:
Resuscitation in Asia by Prof Hwang-Sung Oh

This talk is relevant to those working within the Asian setting, and it is certainly a wake-up call to me that there is much to be done to improve the outcome of resuscitation, particularly for out-of-hospital cardiac arrest cases.

As highlighted in Prof Oh from the Republic of Korea, only few Asian countries have their own national resuscitation guideline, and national data registry.

In terms of ambulance response time, for example, in Malaysia it is about 17 minutes, and we are only slightly better than Vietnam, which records a 30 minutes response time. Even China which is such a big, populous country, is better than us, at 13 minutes and Singapore records a 11 minutes’ response time.

Public access AEDs are almost non-existent and Prof Oh reported that the number of AEDs available in Malaysia is 0 until I told him in a smaller scientific track later that we have at least public access AEDs in KLIA and LCCT Sepang. The challenge for us is to play our different parts, abeit small roles, and together, we hope we can develop and construct a registry system as well as strengthening our chain of survival.

Lessons learned from:
Evolution and Hybridization of Emergency Medicine by Prof Gunnar Ohlen

Re-iterating what Prof Anatharaman has said, emergency medicine department cannot continue to become the safety net forever. There is a need for a paradigm shift. In some countries, for example, in China, traditional medicine or complementary medicine has been incorporated into Western medicine. As the speaker shared, one of the problems of modern medicine that has evolved over the years is the fragmentation of medicine – specialties within the specialty (subspecialties). There may come a time where there is need to tear down the ivory towers of clinical departments in order to offer a more wholistic, intergrated medicine to the patients. We must also arrest waste and over-production – for example, ordering tests that do not change the patient management. Ultimately, at the end of the day, the speaker shared that in the beginning, we shape the buildings we want to build, but afterwards, our buildings shape us. Therefore, it is better not to build when the building is going to be is sub-optimal; it is better to build on something small but optimal.

“We must not look back in hopes of recreating what once was. We must look forward and create what has never been.”

Lessons learned from:
The Three Things That Improve Outcome in Hospital Arrest by Dr. Michael Parr

The speaker shared these three interventions:
A. Treating the underlying causes of the arrest.
For cases of ACS, for example, he shared of performing emergency PCI even while CPR is being carried out (e.g. using mechanical device)

B. Therapeutic hypothermia
Therapeutic hypothermia seems to be the “in-thing” for the new resuscitation guidelines. More and more papers have been published regarding the use of mild therapeutic hypothermia, among which:

1. Bernard SA et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002 Feb 21; 346:557-63.

2. The Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002 Feb 21; 346:549-56.

3. Cheung KW et al. Systematic review of randomized controlled trials of therapeutic hypothermia as a neuroprotectant in post cardiac arrest patients. Can J Emerg Med 2006 Sep; 8:329-37.

In fact, the International Liaison Committee on Resuscitation (ILCOR) has issued two rather very specific recommendations for use of hypothermia in selected cardiac-arrest patients:
1. Unconscious adults with spontaneous out-of-hospital cardiac arrest and an initial rhythm of ventricular fibrillation (VF) should be cooled to 32°-34°C for 12 to 24 hours

2. Such cooling also may be beneficial for other rhythms or for in-hospital cardiac arrest.

According to ILCOR advisory statement, therapeutic hypothermia should not be used for patients with severe cardiogenic shock or life-threatening arrhythmias, pregnant patients, or patients with primary coagulopathy.

Various cooling methods are discussed in that advisory statement too.
Reference: Nolan JP et al. Therapeutic hypothermia after cardiac arrest: An advisory statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation. Circulation 2003 Jul 8; 108:118-21.

C. Bundle of ICU interventions (much similar to those bundles of care in Surviving Sepsis Campaign)

Here, the speaker shared on the bundle of ICU interventions, known as “FAST HUG”. FAST HUG is a mnemonic proposed five years ago by Jean-Louis Vincent as a way of assisting healthcare workers looking after critically ill patients.

The mnemonic stands for:
➢ F = Feeding
➢ A = Analgesia
➢ S = Sedation
➢ T = Thromboembolic prophylaxis
➢ H = Head-of-bed elevation
➢ U = stress Ulcer prophylaxis, and
➢ G = Glucose/glycemic control.

All the components are evidence-based and have been used in many parts of the world.
Reference: Vincent JL. Give your patient a fast hug (at least) once a day. Crit Care Med. 2005 Jun;33(6):1225-9.

See my blog entry on FAST HUG here.

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