Intensive care medicine in 2050: managing cardiac arrest
Survival rates after out-of-hospital cardiac arrest (OHCA) vary considerably worldwide and are highly dependent on the organization of emergency medical services (EMS), rates of bystander performing cardiopulmonary resuscitation (CPR), time to first defibrillation, quality of advanced life support (ALS) and post-resuscitation care, i.e. the quality of the local chain of survival (LOS) . Health care systems that have implemented rigorous training and monitoring systems to strengthen weak links in the local LOS have arguably had the greatest impact on survival from cardiac arrest .
Chain of survival in 2050
Early recognition and alert
Wireless biosensors in high-risk patients
Widespread education of public
Use of GPS systems
Widespread deployment of AEDs
AEDs delivery by drones
Waveform analysis-guided defibrillation
Advanced life support
Fast ECPR in refractory cases
Better early diagnostic tools
ALS providers should focus on good quality CPR, defibrillation, airway management, drug therapy and use of more advanced adjuncts that might further improve haemodynamics . However, ALS will evolve beyond routine use of standardised drugs with a ‘one size fits all’ philosophy. Instead of using a standardised algorithm, injection of vasopressors is likely to be guided by the haemodynamic response, such as the diastolic aortic pressure . Furthermore, the timing of drug delivery as well as the drugs used (e.g. vasopressors, antiarrhythmics) will be individualised. Use of technologies such as capnography, near infrared spectrophotometry (NIRS), waveform analysis for optimizing shock delivery,  carotid Doppler blood flow measurements  and ultrasound examination  will enable haemodynamics during CPR to be optimised and individualised taking into account the cause of cardiac arrest. Use of more sophisticated mechanical chest compression devices is likely to become more widespread, either as a bridge to coronary angiography/percutaneous coronary intervention or to extracorporeal CPR (ECPR). By 2050, it is likely to be much easier to undertake ECPR for the treatment of refractory cardiac arrest, and therefore extending its existing availability from tertiary centres to most acute hospitals .
Most patients who have an in-hospital cardiac arrest (IHCA) will show signs of deterioration in the hours preceding the event. The most effective way of reducing mortality from IHCA is to recognise those at risk of cardiac arrest and either treat to prevent the cardiac arrest or make a do not attempt CPR (DNACPR) decision. By 2050, electronic medical records will be implemented widely, enabling automatic capture of vital sign data from wireless monitors and derivation of automated early-warning scores. Such systems will enable efficient automatic alerting of the rapid response team that can then intervene and potentially prevent cardiac arrest. By 2050, the wide adoption of emergency care and treatment plans will mean that most in-patients will have discussed with hospital staff and agreed their emergency treatment, including CPR, in advance. This will reduce or, ideally, eliminate futile resuscitation attempts in hospital.
When return of spontaneous circulation (ROSC) is obtained, finding and treating the cause of the cardiac arrest can prevent relapse and subsequent clinical deterioration. In this way, recent guidelines recommend that resuscitated patients of presumed coronary cause should undergo immediate coronary angiography with subsequent revascularisation if indicated . Although it presents some organisational challenges, a 24/7 coronary angiography should be made available in all our future cardiac arrest centres. The principal challenge is to identify those cardiac arrest patients with a presumed coronary cause and to avoid taking patients without acute culprit lesions to coronary angiography. We hope that the future will give us better diagnostic tools (transportable CT, handheld echocardiography, early biomarkers), because an early ECG, performed at the scene of resuscitation immediately after ROSC, is insufficiently precise to detect or exclude acute culprit lesions responsible for the arrest . Furthermore, it will become much easier to perform a coronary CT scan at the time of hospital admission. This non-invasive strategy could be used in ‘low-risk patients’ (i.e. those without evidence of a coronary cause), since it will be possible to avoid further invasive procedures in those with a normal coronary CT scan .
Post-resuscitation brain injury is the commonest cause of death following OHCA. Today, the only way to maximise neurological recovery is to lower the body temperature after hospital admission, even if the optimal target is still debated (between 32 and 36 °C). The severity of the reperfusion injury, which is dependent on the cause of arrest, pre-arrest condition, anoxia time, time to ROSC and quality of CPR/ALS, should probably prompt different treatment options and not the ‘one size fits all’ strategy that we follow today. Novel cooling techniques will be able to provide ultrafast cooling, which has proven highly efficient in animal experiments, even intra-arrest, and this will perhaps provide us with more answers. In 2050, it will also be possible to combine targeted temperature management (TTM) with pharmacological neuroprotection, and, the use of inhaled noble gases (particularly xenon) is probably one of the most exciting ongoing research programs . Finally, early neuroprognostication will be facilitated by using a well-established algorithm combining clinical data, biomarkers, electrophysiology (continuous EEG and evoked potentials) and brain magnetic resonance imaging. Importantly, both timing and methods are crucial to avoid self-fulfilling prophecy .
Efficacy (explanatory) trials examine interventions under ideal and controlled circumstances and by using narrow inclusion criteria tend to involve relatively homogeneous populations. Effectiveness (pragmatic) trials evaluate interventions in real-life settings. The high mortality and the heterogeneity of cardiac arrest patients can make it challenging to demonstrate significant differences between control and intervention groups in effectiveness trials. This might be partly because most included patients already have irreversible neurological injury before randomisation and treatment allocation. In the future, new approaches to the design of clinical trials in resuscitation (e.g. adaptive trial design) may improve efficiency and produce more meaningful results.
Compliance with ethical standards
Conflicts of interest
- 12.Nolan JP, Soar J, Cariou A, European Resuscitation Council, European Society of Intensive Care Medicine et al (2015) European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care. Intensive Care Med 41:2039–2056CrossRefPubMedGoogle Scholar