Are we (EPs) the weakest link in cardiac arrest?

A recent publication in Intensive Care summarises the strategies involved in improving cardiac arrest outcomes, as can be seen in this infographic:

We have many of the elements in place to improve cardiac arrest outcomes. There is an agency with lots of funding looking into increasing pre-hospital cardiac arrest care; this includes - improving bystander CPR, a lot of this involves teaching CPR skills in the schools. CPR instructions over phone are also given to the public who reports a cardiac arrest. There are more and more AEDs available in public places, and instructions to their use are increased as well.

Our pre-hospital services provide reasonably good ACLS, with mechanical CPR available, intravenous and intra-osseous access when needed, and ability to administer adrenaline. Most of our hospitals have incorporated therapeutic hypothermia for post-cardiac arrest victims, and cardiologists nowadays are more willing to bring more of these patients to the cath lab. We have a Pan-Asian cardiac arrest registry, and there is fairly robust cardiac arrest research ongoing in Singapore.

That leaves the final piece of the puzzle - that of monitoring - and this happens in the ED when the cardiac arrest victims arrive. Therein lies the weakest link - ourselves. How often, when we receive cardiac arrest victims, do actually think about, monitor, or make subtle changes to improve the quality of CPR? Do we check that the mechanical CPR on the patient is actually providing adequate flow? Or when manual CPR is performed, do we check on its quality? Do we aggressively check compression timing, depth, adequate recoil and minimal hands-off time? Do we routinely use end-tidal CO2 monitoring to guide CPR and assess cardiac output?

The answer is no - we are not consistent in any of the above. It is telling, if one observes the current resuscitation process in our ED, there is a lot of room for improvement. Therefore, if we seek to improve cardiac arrest outcomes, one simple thing might be, to look inward, and see if we are actually performing good quality CPR.

Cariou et al. Ten strategies to increase survival of cardiac arrest patients. Intensive Care Med (2015) 41:1820–1823