Freiburg 2017 Retrospective

The 2017 ERC Congress in Freiburg (Breisgau) in Germany saw many interesting workshops and speakers. We gladly share the videos and the most important conclusions of each session with you.

BLS Sessions

What Drives Blood Flow During CPR?

Speaker: Marios Georgiou

Messages:

  • Interposed abdominal compression-CPR (IAC-CPR) improves hemodynamics during CPR and improves neurologic outcome
  • Three major mechanisms of blood flow: the thoracic pump, the cardiac pump and the retrograde aortic volume loading (abdominal pump).
  • Could be applied as a primary technique immediately after cardiac arrest, while standard CPR is continued.
  • Limitation of the studies about IAC: small sample size, confounders as body temperature and critical care data during 48h after ROSC

Compression-only CPR: Good or Bad?

Speaker: Gavin Perkins

Messages:

  • All patients should receive chest compressions
  • Ventilations may add value
    • If trained and willing to give rescue breaths to combine with chest compressions
    • Especially in children
    • (non-cardiac, delayed response)
  • Minimise interruptions

Adjuncts to Improve CPR Effectiveness

Speaker: Jasmeet Soar

Messages:

  • Best adjuncts are ‘invisible’ to rescuer
  • Systematic targeted interventions work best
  • Measure & monitor improvement
  • Maker continuous small gains
  • Time savers = life saver

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ALS Sessions

Controversies in ALS

Speaker: Charles Deakin

Messages:

  • Airway: a lot of airway management depends on the skills of the operator
  • Adrenaline: still no changes but remains controversial
  • Defibrillation: stay by a single defibrillator and do not interact with another

Duration of Traditional ALS – When to Stop?

Speaker: Kjetil Sunde

Messages:

  • As a rule, resuscitation should be continued as long as VF persists.
  • Asystole for more than 20 minutes during ALS in the absence of a reversible cause is generally accepted as an indicator to abandon further resuscitation attempts.
  • CPR that has no chance of success in terms of survival or acceptable quality of life is pointless and may violate the right for mercy and dignity in the face of death.
  • Defining this ‘no chance of success’ is however very difficult and, in contrast to other medical interventions, it has been argued that success rates of less than 1% still justify the resuscitation efforts.
  • Institutional guidelines for the Termination of Resuscitation (ToR) in the pre-hospital environment are very much needed to reduce unwanted variability in this decision-making.
  • Universal ToR: No ROSC, no shocks, not EMS witnessed
  • Time to ROSC is a pure quantitative parameter. Quality of care in the whole Chain of Survival is of utmost importance.

Hyperinvasive Approaches to CPR – Are They Worthwile?

Speaker: Lionel Lamhaut

Messages:

  • Good side = it saves life, it gives new hope, it increases the quality of care (and CPR) and it can be a source of organ donation
  • Bad side = cost, time consuming and the possibility to create a vegetative statue.
  • Hyperinvasive approach saves lives at the condition of a good selection of patients and an early implementation (within 20 minutes)

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European Trauma Course

Trauma Network – Improving Patients' Outcome

Speaker: Jonathan Tilsed

Messages:

  • Major trauma networks improve outcome
  • Aim for universal best practice
  • Military have led the way
  • Civilian practice must catch up
  • And meet the challenge of an ageing polytrauma population

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Paediatrics

How to Teach to Perform/Advise on CPR

Speaker: Vinay Nadkani

Messages:

Principles for Success:

  • Just in Time concepts (Teachable Moment)
  • Low-Dose, High Frequency “refreshers”
  • Learning curves (Mastery, not competence)
  • Embed certification into real events and simulation/learning management system
  • Pre-brief and De-brief
  • Develop “Herd Immunity”
  • Develop Clinical “Learning laboratories”
  • Create ”Vectors” for learning

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Neonatals

Newborn Life Support and Simulation – Do We Have The Tools We Need?

Speaker: John Madar

Messages:

  • We have the tools, but …
  • Not perfect but a valuable adjunct.
  • Understand and accommodate limitations.
  • Be prepared to adapt.
  • Expectations must be realistic form both candidate and instructor.
  • Emerging technologies are not everything but may permit interactivity and feedback
  • Need to cater for low and high resource settings.

Advanced Resuscitation of the Newborn Infant Course – Is One Approach Feasible?

Speaker: Joe Fawke

Messages:

Technical skills and non-technical skills:

  • ARNI course background and development from standardised RC(UK) national NLS course.
  • Course components: technical & non-technical skills (communication and human factor skills).
  • Course assessment
  • Feedback to candidates
  • Independent ARNI cours evaluation

Newborn Resuscitation Equipment – State of the Art

Speaker: Charles-Christoph Roehr

Messages:

  • Delaying Cord-Clamping for all stable newborn infants (term and preterm) should be commonly practiced (Grade A evidence). Several new devices (tables/ trolleys) have been designed to help with the physical process of keeping the baby attached to the cord for min. of 60s.
  • During fetal-to-neonatal transition, the clinical assessment for need of resuscitation can be highly subjective
  • Multiple Data Acquisition Systems help guide assessment of the newborn in the DR: SpO2 monitors and ECG display heart rate, respiratory function monitors (RFMs) assess presence of spontaneous breathing and effectively guide manual ventilation efforts, automated temperature control ensures greater stability of core body temperature to reduce morbidity
  • Interosseous needles and laryngeal mask airways are becoming more commonplace tools in the resuscitation of newborn infants during the first days of life.

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ESICM

PCI After Cardiac Arrest

Speaker: Alain Cariou

Messages:

  • Initial management of ACS: Emergent cardiac catheterisation lab evaluation should be performed in selected adult patients with ROSC after OHCA of suspected cardiac origin with ST segment elevation on ECG (Resuscitation 95(2015):264-277)
  • Be selective: early procedure in patients still susceptible to beneftit from PCI
  • Immediate coronary angiogram if STEMI on post-ROSC ECG and to discuss in other patients

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ACS

Networks for STEMI

Speaker: Lionel Lamhaut

Messages:

  • Patients must be evaluated in the ED
  • STEMI patients must bypass hospitals without cathlab facilities
  • DAPT must be implemented ASAP
  • Education of lay people is key to success
  • No good network without involvement of health authorities

Prehospital Treatment of Ischemia in ACS

Speaker: Farzin Beygui

Messages:

  • NON STEMI-ACS
    • Thrombotic and bleeding risk assessment
    • SL or IV nitrates titrated to blood pressure if chest pain
    • The use of prasugrel in the pre-hospital setting is not recommended
    • Direct transfer to cathlab
  • Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin. Eur Heart J: Acute Cardiovasc Care. 2015 (Aug):1-23
  • PCI strategy (table 4)
    • Pain control: opioids in lowest dosis possible
    • Anticoagulants (enoxaparine)
    • Antiplatelet therapy (aspirine 150-300 mg PO or 250-500 mg IV)
    • P2Y12 inhibitor (ticagrelor …)
  • Pre-hospital fibrinolysis strategy (table 5)                                                                 
    <75Y >75Y
Pain control: opioids in lowest dosis possible   yes yes
Aspirin 150–300 mg p.o. or i.v.   yes yes
Clopidogrel ....... mg p.o   300 75
Enoxaparin

30mg i.v. + 1mg/kg s.c.

(max 100mg) 15 min after i.v. bolus
yes  -
  1 mg/kg S.IV (max 75 mg)    yes
Tenecteplase Weight-adjusted dose yes  -
  Half weight-adjusted dose   yes

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Evidence Masterclass

ILCOR - 25 Years Old

Speaker: Gavin Perkins

Messages:

  • CoSTR
    • To be published every year
    • 2017 summary will include 5 BLS and 1 pediatric CoSTR
    • Future summaries likely to involve all Task Forces
    • AHA will update annual guidelines simultaneously
    • ERC will publish 5-yearly guidelines
  • Evidence evaluation
    • A continuous process
    • GRADE used
    • Guidelines to be derived from the Consensus on CPR Science with Treatment Recommendations

 

GRADE

Speaker: Robert Neumar

Messages:

  • GRADE – tool of assessment of outcomes for PICO ST
    • Study design – Risk of bias – inconsistency – indirectness – imprecision – quality of evidence
    • Quality assessment
    • Summary of the findings
  • Sources of information for GRADE:
    • Grade handbook: gdt.gradepro.org/app/handbook/handbook.html
    • Cochrane teaching materials: training.cochrane.org/path/grade-approach-evaluating-quality-evidence-pathway
    • McMaster Grade podcasts (=  best): cebgrade.mcmaster.ca (includes “Cochrane and who” links to GRADE teaching materials)

www.gradeworkinggroup.org

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Kids Save Lives

Kids Save Lives With First Aid

Speaker: Emmy de Buck

Messages:

  • First aid training is comprised in the attainment targets for schools in Belgium.
  • Two-step methodology: an “educational pathway” and educational materials for different age groups.
  • Used by teachers and the Youth Red Cross in Flanders to integrate first aid in the school curriculum. A similar project for Sub-Saharan Africa is now ongoing.

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ESC

Refractory OHCA – CPR from Scene to Hospital

Speaker: Alain Cariou

Messages:

  • To consider if withdrawal criteria are absent and if EMS witnessed, ROSC at any moment, VF/VT present and reversible cause (Resuscitation 95(2015):302-311)
  • Selection to make, best candidates to be better identified
  • Decision should be prompted
  • More evidence is needed

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First Aid

Gaps in Evidence Concerning First Aid and How to Fill the Gaps

Speaker: Eunice Singletary

Messages:

  • Gaps in First Aid science are numerous and slow to be addressed, yet over 15 million people worldwide are taught firs aid annually.
  • When gaps is knowledge are identified in first aid science, don’t just wait for someone to do the research
  • Develop a core of interested first aid instructors, evidence evaluators and academicians to form a first aid research group
  • Encourage attendance at first aid/first aid educator conferences to network and design new studies
  • Explore creation n of research funds and an application process
  • One study leads to another. Group potential studies can share supplies and equipment.

Guideline Development – More than Evidence Alone

Speaker: Emmy de Buck

Messages:

  • Occurrence of some reasons for first aid can differ from one country to another
  • Use the best available scientific evidence
  • Include also the practical experience and expertise of experts in the world
  • Take into account the preferences and available resources of the target group

The Best Implementation Strategies for Society

Speaker: Pascal Cassan

Messages:

  • With all possible partners
  • Take into account the 2015 Guidelines
  • Set objectives
  • Deciding who needs immediate attention
  • Training improvement (short course?)
  • Repeat/refresh

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Education

Teaching the Community to Talk with a Dispatcher in CA Situations

Speaker: Tonje Birkenes Soraas

Messages:

  • Train the community
    • to call earlier for help
    • in using the speaker function to talk with the dispatcher and helping the patient simultaneously
    • about abnormal breathing
    • that CPR is doing CPR with dispatcher assistance
    • to do CPR for prolonged period, closer to ambulance response time. This is feasible buy using continuous coaching from the dispatcher.
  • Use public awareness campaigns, audio logs (for abnormal breathing) or video from real incidents
  • Use simulation in training to enhance learning (experience dispatcher and rescuer role)

Non-Technical Skills in Cardiac Arrest training

Speaker: Carsten Lott

Messages:

  • Leadership, team training and implementation has a positive effect on mortality
  • Training can improve ALS provider knowledge, skills and attitudes in NTS
  • The briefing/feedback should be an integral part of every NTS training in advanced training formats

How to Best Teach Children CPR 

Speaker: Andrew Lockey

Message:

  • Ideally, as mandatory part of school curriculum
  • Preferably through schools even if not mandatory
  • Don’t ignore out-of-school initiative though
  • Lots of innovation happening organically
  • National strategic alliances are very productive

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Ethical Challenges

Patient Autonomy in Europe: the Law and the Practice

Speaker: Spiros Mentzelopoulos

Messages:

  • Despite common principles, there is still substantial variability in ethical practices across Europe, reflecting differences in the perception of respect for autonomy.
  • To work toward a harmonized legal framework allowing for Advance Care Planning.
  • Potentially successful effort to harmonise research, but differences in ethical practices could still result in variability of characteristics of patients enrolled in different countries.

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Special Circumstances

Resuscitating Children

Speaker: Richard Aickin

Messages:

  • Quality of CPR more important than differences in technique between children and adults
  • Survival is better with fill CPR (= chest compressions + rescue breaths)
  • It seems safe and effective to use unmodified AEDs in children, but AEDs with energy step down are preferred
  • Drugs should not take priority over CPR/ventilation/circulatory support
  • Ongoing debate regarding best approach to fluid resuscitation in shock

Cardiac Arrest in the Air

Speaker: Tony Handley

Messages:

  • No more likely than on land
  • Outcomes relatively good for shockable rhythms
  • Standard basic life support (with oxygen)
  • Aircraft diversion appropriate if ROSC
  • Legal consequences of assistance are minimal
  • AEDs are cost-effective for most commercial aircrafts

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