Every five years the International Liason Committee On Resuscitation reviews the currently available evidence and updates its recommendations regarding resuscitation. The review board is large and made up of resuscitation experts from all over the world and from several specialty areas, including emergency medicine, prehospital medicine and critical care. The recommendations that they write carry a lot of weight and are in turn taken by the lead resuscitation bodies in the various countries and moulded into tailored region-specific recommendations.

The European Resuscitation Council, the American Heart Association and the Japanese Resuscitation Council have released their 2015 guidelines. The Australian and New Zealand Resuscitation Councils are currently pouring over the latest ILCOR document and developing local recommendations. Hopefully they will be available as planned in December. The same would seem to go for the Resusitation Council of Southern Africa and the Resuscitation Council of Asia, though I can't find any reference to the guidelines on either of these two sites.

So in the meantime we can take a look at what the Europeans have crafted and have a guess at what Australia and New Zealand might go with. More importantly, how much of these recommendations are likely to affect what we do trackside at motorsport events.

First off, the ERC guidelines update mini-site is uber-modern with a slick interface, easy to navigate and rounded off with introductory videos featuring the section lead authors summarizing the key changes. Of itself, this is of little relevance to motorsport medicine, but it does look cool. However, from this one page you can download the executive summary document, the full ERC 2015 guidelines and the full CoSTR document with goes through all of the evidence used to justify the current recommendations. There are also links to posters and ebook versions of the guidelines should you want these.

So what about the recommendations themselves? Well the summary document highlights the key changes, but while there is obviously no specific reference to motorsports, there are some items to pay particular attention to. (I'm going to ignore the paediatric and neonatal guidelines entirely for this post.)

Adult BLS guidelines

No huge surprises here, especially as this section is largely directed at the lay rescuer who just happens to to be in the right place at the right time. There is a statement that:

"Our confidence in the equivalence between chest compression-only and standard CPR is not sufficient to change current practice"

Probably fair enough given the state of current evidence, which you can read about here on the Life In The Fast Lane blog: http://lifeinthefastlane.com/ccc/compression-only-cpr/

Rate and depth of compression haven't changed, though we are given a fairly narrow compression window of "at least 5cm but no greater than 6cm", largely based on low level observational studies. ROSC and survival outcomes seem to improve for every 5mm greater depth of compression and risk of injury climbs sharply with depths greater than 6cm. Not too sure how this narrow window will be guaged in the field.

Adult ALS guidelines

There's a bit more here. A few areas get strong emphasis:
  • Minimal interruptions on high-quality chest compressions is again promoted.
  • The use of self adhesive defib pads is preferred over the older style of paddles. This is worth noting as paddles are still used at many motorsport events, particularly the lower tier events, where equipment is often made up of hospital hand-me-downs. Perhaps these guidelines can be used when arguing for more modern equipment.
  • The use of end-tidal CO2 (EtCO2) monitoring, specifically waveform capnography, is pushed as an ETT placement confirmation tool, a guide to CPR quality and an early indicator of ROSC (sudden jump in the EtCO2 wave and value). This is a good thing, was highlighted in the NAP-4 audit and has become a standard of care in many EDs, ICUs, operating theatres and prehospital services although is by no means universal yet. Motorsport medicine should be no different.
  • There is a greater recognition that there is a fair bit of controversy around which medications make a difference, if any, to the outcomes of a cardiac arrest.
  • The role of ultrasound during a cardiac arrest intervention is formally recognised, though only at the level "may have a role in identifying reversible causes".
Cardiac arrest in special circumstances

This is an interesting section, divided into:
  • Special causes
  • Special environments
  • Special patients
The special causes subsection is notable for its inclusion of a treatment algorithm for traumatic cardiac arrest. This is new and finally catches up with a push that has been going on for some time, led by people like Karim Brohi, to recognise that a true traumatic cardiac arrest is a different beast to a medical cardiac arrest. Check out EM Crit with Podcast 81 - An interview on severe trauma with Karim Brohi.

The ERC TCA algorithm breaks down into three sections, first differentiating a medical from a traumatic cardiac arrest and then separating penetrating from blunt traumatic cardiac arrest. If you have been keeping up with this literature there is little here that will surprise you but it is good to see this area formally laid out by a peak body such as the ERC. Take some time and read through it.

The European Resuscitation Council
2015 Guidelines on Traumatic Cardiac Arrest

Once you have digested this, go to the EM Crit website again and watch this video: Podcast 83 - Crack to cure

The special environments subsection is also interesting as among cardiac arrest in operating theatres and the cath lab and avalanche burial, consideration is given to managing cardiac arrest on the field of play, difficult terrain and at mass casualty incidents.

The field of play environment is largley targeting literal fields of play sports such as soccer, rubgy and athletics where an athlete collapses suddenly without apparent provokation. Sudden cardiac death is a big topic in sports medicine circles and I've been doing a bit of work on this for the CAMS Junior Driver Academy, so I'll go into it more in a separate post. However, it serves as a reminder to consider medical causes of sudden collapse when a single car veers off track with no alternative explanation obvious (no contact with another vehicle, no track debris, good conditions, no pre-existing damage, no evidence of braking or defensive actions).

The recognition of the challenges of difficult terrain and remote locations in getting to a collapsed patient, rendering good quality, minimally interrupted resuscitation and timely disposition is particularly pertinent for rally and off-road events. Helicopter resources are advocated.

One last area that can come up at motorsport events is when a competitor, team member, official or spectator turns up to the medical centre and is clearly having an acute coronary syndrome. Get the 12-lead ECG and send it in to the local accepting ED if you can, especially if it has a cath lab. It will speed up the time to definitive therapy and may improve the overall outcome. Then go ahead and give the antiplatelet therapy if you have it and don't worry about whether it will get in the way of a primary PCI (It won't). And if the transport time is lengthy, be prepared that the ambulance crew that arrives to take the patient to the ED might start getting ready to do pre-hospital fibrinolysis in consultation with the ED.

So looking at the European Resuscitation Council 2015 Guidelines while they are written for the broader civilian population, there are some bits to consider in the specific context of a motorsport event. I imagine the Australian guidelines will run along similar lines when they come out in December.

As usual, please leave your thoughts and comments below.