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Education for cardiac arrest – Prevention AND treatment

2015; Elsevier BV; Volume: 96; Linguagem: Inglês

10.1016/j.resuscitation.2015.06.011

1873-1570

David Pitcher, Carl Gwinnutt, Andrew Lockey,

Trauma and Emergency Care Studies

We read with interest the paper by Smith et al.1Smith G.B. Welch J. DeVita M.A. Hillman K.M. Jones D. Education for cardiac arrest – treatment or prevention?.Resuscitation. 2015; 92: 59-62Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar in which they recommend reducing training in advanced life support (ALS) and substituting training in Immediate Life Support and in the recognition and response to clinical deterioration. We agree that the latter is very important and for this reason the ALS course includes teaching on recognition and management of the deteriorating patient, prevention of cardiac arrest and the fundamental importance of non-technical skills in delivering resuscitation effectively. It also raises awareness of the importance of good post-resuscitation care in achieving optimal outcomes. The original concept of using cardiopulmonary resuscitation (CPR) to rescue 'hearts too GOOD to die'2Beck C.S. Hearts too good to die.JAMA. 1961; 176: 141-142Crossref Scopus (4) Google Scholar referred to the treatment of ventricular fibrillation occurring in the acute phase of myocardial infarction. Prompt delivery of CPR by trained staff in coronary care units was shown to achieve better outcomes than occurred when similar patients received attempted CPR on general wards.3Killip T. Kimball J.T. Treatment of myocardial infarction in a coronary care unit: a two-year experience with 250 patients.Am J Cardiol. 1967; 20: 457-464Abstract Full Text PDF PubMed Scopus (1771) Google Scholar Absence of evidence of benefit of ALS training on outcome from cardiac arrest is not evidence of absence. Indeed, when an event is infrequent and its causes are multifactorial, obtaining statistically significant evidence of benefit from an intervention may be very difficult. We believe that it is wrong to presume that if an event is infrequent, it is acceptable not to be fully trained and prepared for it. Airline pilots train rigorously to deal with very infrequent emergency events: how many of us would willingly board an aircraft if we thought that they did not? Junior doctors find cardiac arrest and delivery of CPR stressful.4Menezes B.F. Morgan R. Attitudes of doctors in training to cardiopulmonary resuscitation.Clin Med. 2008; 8: 149-151Crossref PubMed Scopus (11) Google Scholar In feedback following ALS training they report improved confidence, and that is more likely to be sustained if they receive debriefing after cardiac arrests and regular training updates.4Menezes B.F. Morgan R. Attitudes of doctors in training to cardiopulmonary resuscitation.Clin Med. 2008; 8: 149-151Crossref PubMed Scopus (11) Google Scholar The proposed alternative, having 'permanent' cardiac arrest teams on constant standby in every hospital, would have huge staffing and cost implications and is probably unachievable in the UK. Delivery of CPR is all the more stressful for staff when inappropriate resuscitation attempts result from failure of others to make anticipatory decisions about CPR.4Menezes B.F. Morgan R. Attitudes of doctors in training to cardiopulmonary resuscitation.Clin Med. 2008; 8: 149-151Crossref PubMed Scopus (11) Google Scholar Smith and colleagues make scant reference to the importance of a DNACPR policy and training in decisions about CPR as a means of preventing inappropriate CPR attempts.5Mockford C. Fritz Z. George R. et al.Do not attempt cardiopulmonary resuscitation (DNACPR) orders: a systematic review of the barriers and facilitators of decision-making and implementation.Resuscitation. 2015; 88: 99-113Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar The Resuscitation Council (UK) ALS course is kept under close review and is updated whenever necessary to ensure that its content and training methods are relevant and educationally effective. The implication by Smith et al. that the course is designed only to teach the management of cardiac arrest is incorrect. In conclusion, we agree with Smith et al. that healthcare professionals should receive training in the recognition and response to clinical deterioration; the ALS course appropriately devotes time to this. Whilst some individual healthcare professionals may encounter a cardiac arrest infrequently, when they do, the public will expect them to have been trained to deal with it in a complete and systematic way. All three authors wish to draw the attention of the Editor to the fact that each of us is an Officer of the Resuscitation Council (UK) and a member of both its Executive Committee and ALS Subcommittee, which may be considered potential conflicts of interest. We have no personal financial conflicts of interest.