Читать книгу Emergency Medical Services - Группа авторов - Страница 309

There is growing awareness of the importance of post‐resuscitation care, which formally constitutes the final link in the chain of survival [114]. Care initiated in the field may prove fruitless if not continued in the hospital. The medical director should work closely with receiving hospitals to ensure continuity in cardiac arrest care, and targeted interventions and care algorithms initiated in the field should be continued in the hospital. For example, when determining the receiving hospital facility, EMS agencies that induce hypothermia after cardiac arrest in unconscious survivors should consider whether the receiving facility will continue this therapy [115–119].

Studies are currently being performed that use a system‐based approach in an attempt to integrate therapies that may have synergistic effects, and that are likely to show co‐dependence in outcome. These are typified by the CHEER study, designed to treat cardiac arrest patients with mechanical chest compressions and cool them to 33 degrees C in the prehospital setting, place them on an extracorporeal membrane oxygenator at the hospital, transport them to the interventional cardiac catheter laboratory for angioplasty, then maintain hypothermia for 24 hours [120].

Davis et al. demonstrated that diverting patients post‐arrest past the closest available hospital and to a tertiary care center did not worsen outcomes [121]. Future work should consider if regionalization of care and transfer of these patients to specialty facilities improves outcomes as it does for victims of major trauma [122–125]. Regional systems of care have improved both clinician experience and patient outcomes for those with ST‐elevation myocardial infarction and with life‐threatening traumatic injury. A Japanese cardiac arrest registry of 10,000 patients with OHCA transported to critical cardiac care hospitals showed improved 1‐month survival compared with those patients transported to hospitals without specialized cardiac facilities [126]. Compared with historical controls, survival to hospital discharge in the Take Heart America Program, a regionalized system of cardiac arrest care in Minnesota, improved from 8.5% to 19%. The difference was a dramatic improvement in survival after admission to intensive care from 24% to 51% [127]. This program seeks to optimize prehospital care, including EMS and community training, while establishing transport and treatment protocols with three dedicated cardiac arrest centers providing therapeutic hypothermia, interventional coronary artery evaluation and treatment, and electrophysiological evaluation. However, analysis of CARES data has not revealed a similar relationship between survival or neurological outcome and the presence of a coronary catheterization laboratory or the volume of patients received [128].