BACKGROUND:The Adult Deterioration Detection System for Medical Emergency Team (MET) activation is widely used and includes single parameter (SP-MET) and multiple parameter (MP-MET) disturbances. Whether the patient characteristics, interventions and outcomes differ for SP-MET compared with MP-MET is uncertain.AIMS:To describe MET interventions and outcomes of SP versus MP MET in the Acute Medical Unit (AMU) of a tertiary care hospital.METHODS:Retrospective audit over 6 months comparing SP-MET and MP-MET groups.RESULTS:SP-MET constituted 64.1% (168) of 262 AMU MET calls, most commonly for hypotension (35.5%) and tachycardia (14.1%). There were no significant differences in demographic and disease characteristics between the two groups. Common interventions included fluid/electrolyte replacement in 139 (52%), oxygen therapy in 46 (17%) and non-invasive ventilation in 33 (13%) patients. After MET intervention, 82.4% patients stayed on the ward, 8.4% died/were palliated, 6.5% were transferred to the Intensive Care Unit (ICU) and 2.7% patients required urgent transfer to the theatre for intervention. SP-MET patients were more likely to remain on the ward (88.7% vs 71.3%; P = 0.001), receive ward-based interventions (85.1% vs 61.7%; P < 0.001) and less likely to experience death/palliation (4.2% vs 16%, P = 0.001) compared with the MP-MET group. MP-MET were independently associated with negative outcomes (OR 3.10; 95% CI 1.60-6.00).CONCLUSION:SP-MET identify a cohort of patients at lower risk of requiring escalation of care and ICU admission. Given the resource intensity of MET activation, further research is warranted to determine whether alternative response strategies are appropriate for selected SP disturbances.

INTRODUCTION:The global pandemic of coronavirus disease 2019 (COVID-19) has caused significant worldwide disruption. Although Australia and New Zealand have not been affected as much as some other countries, resuscitation may still pose a risk to health care workers and necessitates a change to our traditional approach. This consensus statement for adult cardiac arrest in the setting of COVID-19 has been produced by the Australasian College for Emergency Medicine (ACEM) and aligns with national and international recommendations. MAIN RECOMMENDATIONS:In a setting of low community transmission, most cardiac arrests are not due to COVID-19. Early defibrillation saves lives and is not considered an aerosol generating procedure. Compression-only cardiopulmonary resuscitation is thought to be a low risk procedure and can be safely initiated with the patient's mouth and nose covered. All other resuscitative procedures are considered aerosol generating and require the use of airborne personal protective equipment (PPE). It is important to balance the appropriateness of resuscitation against the risk of infection. Methods to reduce nosocomial transmission of COVID-19 include a physical barrier such as a towel or mask over the patient's mouth and nose, appropriate use of PPE, minimising the staff involved in resuscitation, and use of mechanical chest compression devices when available. If COVID-19 significantly affects hospital resource availability, the ethics of resource allocation must be considered. CHANGES IN MANAGEMENT:The changes outlined in this document require a significant adaptation for many doctors, nurses and paramedics. It is critically important that all health care workers have regular PPE and advanced life support training, are able to access in situ simulation sessions, and receive extensive debriefing after actual resuscitations. This will ensure safe, timely and effective management of the patients with cardiac arrest in the COVID-19 era.

This review paper summarises the key changes made to the resuscitation guidelines used in Australia and New Zealand. They were released by the Australian and New Zealand Committee on Resuscitation in January 2016. These are local adaptations of the evidence previously published in October 2015 by the International Liaison Committee on Resuscitation (ILCOR). They are presented across the main working groups in ILCOR: ALS, BLS, paediatrics, neonates, acute coronary syndromes, first aid and 'Education, Implementation and Teams'.

The International Liaison Committee on Resuscitation (ILCOR) encompasses a large number of national resuscitation councils and other key stakeholders. These include the Australian and New Zealand Committee on Resuscitation (ANZCOR), as well as the European Resuscitation Council (ERC) and the American Heart Association (AHA). In developing their 2010 guidelines, ILCOR set out to identify and review international science and knowledge relevant to CPR and emergency cardiovascular care and, where consensus existed, to offer treatment recommendations.1 The first ILCOR conference was originally hosted by the AHA in 1999, and led to the publication of the International Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.2 The evaluation of the science was planned to occur in 5 year cycles, thus ILCOR updated the guideline in 2005, and most recently in 2010. The current process of evidence evaluation started with the formation of six task forces: BLS, ALS, acute coronary syndromes, paediatric life support, neonatal life support, and education, implementation and teams. These task forces identified topics requiring evaluation of the evidence, and standardized evidence evaluation worksheets were created that detailed the search strategy, evidence evaluation and the level of evidence, and development of treatment recommendations. A total of 313 experts from over 30 countries evaluated 277 resuscitation questions, each using a standard PICO (Population, Intervention, Comparison, Outcome) format. These worksheets were presented and discussed at regular web conferences and other meetings, and were also posted online (http://www.ilcor.org) for public comment. For example, the Australasian College for Emergency Medicine (ACEM) was invited to comment through e-bulletins issued by the College. The agreed 2010 guidelines were published simultaneously in Resuscitation and Circulation in October 2010, and the final worksheets are available on the ILCOR website (http://www.ilcor.org). The Australian Resuscitation Council (ARC) and the New Zealand Resuscitation Council (NZRC) worked collaboratively through the ANZCOR partnership to co-publish, for the first time, joint resuscitation guidelines in December 2010.3 Previously, clinical staff working or transferring between New Zealand and Australia would need to follow separate guidelines. Also, as many Australian and New Zealand professional health-care training bodies, such as the medical colleges, have an Australasian organizational structure, they had to teach and examine on different guidelines. This will no longer be necessary. A brief summary of some of the most important updates to the Australasian guidelines for 2010 follows. This is not intended as a review of the evidence underpinning the changes, as this can be found in the published International Consensus on CPR Science with Treatment Recommendation (CoSTR) documents. It aims to highlight the areas of change that will most affect BLS and ALS trainers and providers in Australasia. The term ‘signs of life’ has been removed from the guidelines, as it was deemed confusing. The focus should be on the patient who is unresponsive and not breathing normally. If the victim is not responsive, the airway should be cleared and breathing assessed. If the victim is not breathing normally, then CPR should be commenced with 30 compressions followed by two breaths. ‘Compression-only’ CPR is recommended where rescuers are unable or unwilling to perform mouth-to-mouth rescue breaths (i.e. ‘standard’ CPR). The technique is also recommended when providing telephone advice to an untrained rescuer. Those with a duty to respond (e.g. health-care workers) should still use ventilations with compressions. The ratio for compressions to ventilations remains unchanged at 30 compressions followed by two breaths. Of note, the two initial rescue breaths have been removed from the initial BLS algorithm. However, it is recognized that in some settings (e.g. drowning) two initial rescue breaths have a greater role and should continue to be provided. The algorithm's acronym has also changed to DRSABCD. An ‘S’ has been inserted, which stands for Send for help. Local modification of the algorithm could allow the insertion here of relevant emergency phone numbers for in-hospital use, or national emergency numbers. The D has been emphasized to attach an automated external defibrillator as soon as it becomes available. The flow chart also includes reference to compression-only CPR. There is a new focus on maintenance of CPR quality, and so it is recommended that rescuers change every 2 min. Other training issues that have been addressed include the recommendation that training in automated external defibrillator use should be part of BLS training, that prompt or feedback devices can improve quality of CPR in training and that CPR skills should be refreshed at least annually. The new guidelines deal specifically with CPR for ALS providers recognizing the increased training and skills within this group. The guidelines recommend that the rate of compression should be a least 100 per minute, with rates over 120 per minute offering no advantage. The depth is recommended to be at least 5 cm or 1/3 of the chest depth, even though no evidence exists to support a defined upper limit of compression depth. The use of waveform capnography (rather than colour change CO2 detector devices) is recommended, as this not only allows detection of ETT placement, but also can monitor the quality of CPR and identify early return of spontaneous circulation (ROSC). Pulse checks are noted to be unreliable in the detection of ROSC. Additional issues addressed were the need to avoid simultaneous ventilations and compressions, and the potential to use a 15:1 ratio rather than 30:2 if an advanced airway was used; also, awareness that if using a CPR feedback device, an overestimate of compression depth might occur if compressions are being performed on a soft surface such as a mattress. A new co-badged universal algorithm for ALS has been developed. The design has been changed to make it easier to follow, and to increase awareness of the importance of post-resuscitation care. The main change to the performance of ALS is to charge the defibrillator during CPR, which is charging while a rescuer continues to perform compressions. This will allow earlier, more rapid defibrillation (when appropriate) immediately after cessation of the 2 min of compressions, and minimize interruption to compressions. The implementation of this change will have a significant impact upon ALS and resuscitation team training, as regards minimizing inadvertent shock risk to rescuers. Single shocks are still recommended, with an initial stack of three shocks only indicated in certain special circumstances, such as a monitored witnessed arrest when a defibrillator is immediately available and able to deliver a shock within 10 s (e.g. in most ED resuscitation areas). Energy settings remain at 200 J for biphasic machines (unless the manufacturer recommends an alternative amount) and 360 J if using a monophasic device. There has been no significant change in the drugs used in ALS, other than with atropine (see later). Adrenaline 1 mg is still recommended, and should be given immediately for non-shockable rhythms, and after the second shock at the time of recommencement of CPR for shockable rhythms. This is a change from the previous recommendation of giving adrenaline just before the third shock, which was always a timing challenge. Adrenaline should be repeated every alternate loop of CPR, that is, every 3–5 min. Amiodarone 300 mg is given for shockable rhythms and is administered after the third shock. There is an important distinction between the ANZCOR recommendations, which separate the first doses of adrenaline and amiodarone, to those of the ERC, which recommends giving these drugs together after the third shock.4 There is no evidence to support one recommendation over the other, but separating the drug timings was felt to be easier and safer by ANZCOR. Atropine is no longer recommended for routine use in PEA/asystole. The ETT route of drug administration is de-emphasized, with the preferred alternative to failed or impossible intravenous access being the intra-osseous route. The precordial thump is no longer recommended for VF, but may be used in monitored ventricular tachycardia if a defibrillator is not immediately available. The routine use of a comprehensive post-resuscitation treatment protocol for the management of patients post cardiac arrest is recommended. This includes avoiding hyperoxia by keeping SaO2 to 94–98%; that primary percutaneous coronary intervention is appropriate in sustained ROSC following sudden primary cardiac arrest (as opposed to drowning), even if the ECG does not show classic ST changes; the avoidance of hypo- or hyperglycaemia (>10 mmol/L); managing the underlying cause of the arrest; and awareness of the limitations of prognostic tools in survivors. Therapeutic hypothermia (32–34°C for 12–24 h) remains a strong recommendation in survivors from out-of-hospital cardiac arrest. This recommendation has been broadened to include survivors from non-shockable rhythms, and in-hospital cardiac arrest. There have been no substantial developments in the evidence base for resuscitation that have a major impact on the 2010 iteration of the guidelines. The emphasis for advanced CPR providers is still in providing highest quality and minimally interrupted CPR, with a real focus on minimizing pauses between compressions and defibrillations. Effective overall team leadership and team training will continue to improve the safety and efficacy of resuscitation attempts. A well-structured post-resuscitation care pathway is essential in maximizing outcome in survivors of sudden cardiac arrest.

Evidence so far shows no improvement in clinical outcomes

“Acute physicians” herald the new specialty of acute medicine

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Objective:  To compare the novel Boussignac valve continuous positive airways pressure (CPAP) delivery mask and a standard closed‐circuit Drager CF800 CPAP system in the management of acute pulmonary oedema (APO) patients.

The application of pharmacogenetics in preventing adverse drug reactions as illustrated by Konstantopoulou et al1 is not new. In 510 bc Pythagoras observed that only some individuals—those with a deficiency of glucose-6-phosphate dehydrogenase (G6PD)—developed a potentially fatal reaction after ingesting fava beans. For nearly 50 years anaesthetists have been identifying patients who may have a deficiency of normal plasma cholinesterase (leading to prolonged suxamethonium neuromuscular blockade or “scoline apnoea”) by taking a simple patient history.2 Although the development of modern pharmacogenetic assays designed to reduce the incidence of adverse drug reactions is still its infancy, the case presented by Konstantopoulou et al …