European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support

CARL – kontrollierte Reperfusion des ganzen Körpers

Hintergrund

Inzidenz und Letalität des akuten Herz-Kreislauf-Stillstands sind seit Jahrzehnten gleichbleibend hoch.

Fragestellung

Wie lassen sich die derzeit unbefriedigenden Ergebnisse nach einer Reanimation mit Blick auf das Überleben und die neurologischen, v. a. mit Blick auf die zerebralen Folgeschäden verbessern?

Material und Methoden

Entwicklung eines therapeutischen Verfahrens zur Eindämmung des Ischämie‑/Reperfusionsschadens im Tiermodell. Entwicklung eines für die Reanimation optimierten Gerätesystems, mit dem sich eine kontrollierte Ganzkörperreperfusion auch außerklinisch umsetzen lässt.

Ergebnisse

Etablierung der CARL-Therapie in der Klinik und in der Behandlung von OHCA-Patienten. Übernahme der Therapie und des CARL-Systems in eine klinische Beobachtungsstudie. Erste Fallberichte, in denen Patienten einen OHCA auch nach Ischämiezeiten bis zu 2 h ohne Schädigung des Gehirns überlebten.

Schlussfolgerungen

Die CARL-Therapie eignet sich potenziell zur Behandlung reanimationspflichtiger Patienten mit einem auch über längere Zeit therapierefraktären Herz-Kreislauf-Stillstand.

Ischemic injury of the upper gastrointestinal tract after out-of-hospital cardiac arrest: a prospective, multicenter study

Background

The consequences of cardiac arrest (CA) on the gastro-intestinal tract are poorly understood. We measured the incidence of ischemic injury in the upper gastro-intestinal tract after Out-of-hospital CA (OHCA) and determined the risk factors for and consequences of gastrointestinal ischemic injury according to its severity.

Methods

Prospective, non-controlled, multicenter study in nine ICUs in France and Belgium conducted from November 1, 2014 to November 30, 2018. Included patients underwent an esophago-gastro-duodenoscopy 2 to 4 d after OHCA if still intubated and the presence of ischemic lesions of the upper gastro-intestinal tract was determined by a gastroenterologist. Lesions were a priori defined as severe if there was ulceration or necrosis and moderate if there was mucosal edema or erythema. We compared clinical and cardiac arrest characteristics of three groups of patients (no, moderate, and severe lesions) and identified variables associated with gastrointestinal ischemic injury using multivariate regression analysis. We also compared the outcomes (organ failure during ICU stay and neurological status at hospital discharge) of the three groups of patients.

Results

Among the 214 patients included in the analysis, 121 (57%, 95% CI 50–63%) had an upper gastrointestinal ischemic lesion, most frequently on the fundus. Ischemic lesions were severe in 55/121 (45%) patients. In multivariate regression, higher adrenaline dose during cardiopulmonary resuscitation (OR 1.25 per mg (1.08–1.46)) was independently associated with increased odds of severe upper gastrointestinal ischemic lesions; previous proton pump inhibitor use (OR 0.40 (0.14–1.00)) and serum bicarbonate on day 1 (OR 0.89 (0.81–0.97)) were associated with lower odds of ischemic lesions. Patients with severe lesions had a higher SOFA score during the ICU stay and worse neurological outcome at hospital discharge.

Conclusions

More than half of the patients successfully resuscitated from OHCA had upper gastrointestinal tract ischemic injury. Presence of ischemic lesions was independently associated with the amount of adrenaline used during resuscitation. Patients with severe lesions had higher organ failure scores during the ICU stay and a worse prognosis.

Clinical Trial RegistrationNCT02349074.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03939-9.

Etiologies of In-hospital cardiac arrest: a systematic review and meta-analysis

BACKGROUND

Etiologies of in-hospital cardiac arrest (IHCA) in general wards may differ from etiologies of out-of-hospital cardiac arrest (OHCA) given the different clinical characteristics of these patient populations. An appreciation for the causes of IHCA may allow the clinician to appropriately target root causes of arrest.

METHODS

MEDLINE/PubMed, EMBASE, and Google Scholar were queried from inception until May 31, 2021. Studies reporting etiologies of IHCA were included. A random effects meta-analysis of extracted data was performed using Review Manager 5.4.

RESULTS

Of 12,451 citations retrieved from the initial literature search, 9 were included in the meta-analysis. The most frequent etiologies of cardiac arrest were hypoxia (26.46%, 95% confidence interval [CI] 14.19% to 38.74%), acute coronary syndrome (ACS) (18.23%, 95% CI 13.91% to 22.55%), arrhythmias (14.95%, 95% CI 0% to 34.92%), hypovolemia (14.81%, 95% CI 6.98% to 22.65%), infection (14.36%, 95% CI 9.46% to 19.25%), and heart failure (12.64%, 95% CI 6.47% to 18.80%). Cardiac tamponade, electrolyte disturbances, pulmonary embolism, neurological causes, toxins, and pneumothorax were less frequent causes of IHCA. Initial rhythm was unshockable (pulseless electrical activity or asystole) in 69.83% of cases and shockable (ventricular tachycardia or ventricular fibrillation) in 21.75%.

CONCLUSION

The most prevalent causes of IHCA among the general wards population are hypoxia, ACS, hypovolemia, arrythmias, infection, heart failure, three of which (arrhythmia, infection, heart failure) are not part of the traditional "H's and T's" of cardiac arrest. Other causes noted in the "H's and T's" of advanced cardiac life support do not appear to be important causes of IHCA.

Efficacy of AutoPulse for Mechanical Chest Compression in Patients with Shock-Resistant Ventricular Fibrillation

INTRODUCTION

Sudden cardiac arrest is one of the most common causes of death. In cases of shock-resistant ventricular fibrillation, immediate transport of patients to the hospital is essential and made possible with use of devices for mechanical chest compression.

OBJECTIVES

The efficacy of AutoPulse in patients with shock-resistant ventricular fibrillation was studied.

METHODS

This is a multicentre observational study on a population of 480,000, with 192 reported cases of out-of-hospital cardiac arrest. The study included patients with shock-resistant ventricular fibrillation defined as cardiac arrest secondary to ventricular fibrillation requiring ≥3 consecutive shocks. Eventually, 18 patients met the study criteria.

RESULTS

The mean duration of resuscitation was 48.4±43 min, 55% of patients were handed over to the laboratory while still in cardiac arrest, 83.3% of them underwent angiography and, in 93.3% of them, infarction was confirmed. Coronary intervention was continued during mechanical resuscitation in 50.0% of patients, 60% of patients survived the procedure, and 27.8% of the patients survived.

CONCLUSIONS

Resistant ventricular fibrillation suggests high likelihood of a coronary component to the cardiac arrest. AutoPulse is helpful in conducting resuscitation, allowing the time to arrival at hospital to be reduced.

Assessment of emergency physicians' performance in identifying shockable rhythm in out-of-hospital cardiac arrest: an observational simulation study

BACKGROUND

Emergency physicians can use a manual or an automated defibrillator to provide defibrillation of patients who had out-of-hospital cardiac arrest (OHCA). Performance of emergency physicians in identifying shockable rhythm with a manual defibrillator has been poorly explored whereas that of automated defibrillators is well known (sensitivity 0.91-1.00, specificity 0.96-0.99). We conducted this study to estimate the sensitivity/specificity and speed of shock/no-shock decision-making by prehospital emergency physicians for shockable or non-shockable rhythm, and their preference for manual versus automated defibrillation.

METHODS

We developed a web application that simulates a manual defibrillator (https://simul-shock.firebaseapp.com/). In 2019, all (262) emergency physicians of six French emergency medical services were invited to participate in a study in which 60 ECG rhythms from real OHCA recordings were successively presented to the physicians for determination of whether they would or would not administer a shock. Time to decision was recorded. Answers were compared with a gold standard (concordant answers of three experts). We report sensitivity for shockable rhythms (decision to shock) and specificity for non-shockable rhythms (decision not to shock). Physicians were also asked whether they preferred manual or automated defibrillation.

RESULTS

Among 215 respondents, we were able to analyse results for 190 physicians. 57% of emergency physicians preferred manual defibrillation. Median (IQR) sensitivity for a shock delivery for shockable rhythm was 0.91 (0.81-1.00); median specificity for no-shock delivery for non-shockable rhythms was 0.91 (0.80-0.96). More precisely, sensitivities for shock delivery for ventricular tachycardia (VT) and coarse ventricular fibrillation (VF) were both 1.0 (1.0-1.0); sensitivity for fine VF was 0.6 (0.2-1). Specificity for not shocking a pulseless electrical activity (PEA) was 0.83 (0.72-0.86), and for asystole, specificity was 0.93 (0.86-1). Median speed of decision-making (in seconds) were: VT 2.0 (1.6-2.7), coarse VF 2.1 (1.7-2.9), asystole 2.4 (1.8-3.5), PEA 2.8 (2.0-4.2) and fine VF 2.8 (2.1-4.3).

CONCLUSIONS

Global sensitivity and specificity were comparable with published automated external defibrillator studies. Shockable rhythms with the best clinical prognoses (VT and coarse VF) were very rapidly recognised with very good sensitivity. The decision-making for fine VF or asystole and PEA was less accurate.

Widening access to the specialised foundation programme

The specialised foundation programme, previously known as the academic foundation programme, is an alternate foundation training pathway for doctors that are interested in research, medical education and leadership. The programme is highly competitive, with competition ratios rising to 1:5 in some units of application. A series of courses is held each year out of goodwill to assist students with the application process, but little has been published with respect to evidence-based approaches to both the application process and interviews. This article provides a series of frameworks to simplify the challenges posed by the application process and the academic, personal and clinical interviews.

Kidney Transplants From Donors on Extracorporeal Membrane Oxygenation Prior to Death Are Associated With Better Long-Term Renal Function Compared to Donors After Circulatory Death

Donation after circulatory death (DCD) allows expansion of the donor pool. We report on 11 years of Italian experience by comparing the outcome of grafts from DCD and extracorporeal membrane oxygenation (ECMO) prior to death donation (EPD), a new donor category. We studied 58 kidney recipients from DCD or EPD and collected donor/recipient clinical characteristics. Primary non function (PNF) and delayed graft function (DGF) rates, dialysis need, hospitalization duration, and patient and graft survival rates were compared. The estimated glomerular filtration rate (eGFR) was measured throughout the follow-up. Better clinical outcomes were achieved with EPD than with DCD despite similar graft and patient survival rates The total warm ischemia time (WIT) was longer in the DCD group than in the EPD group. Pure WIT was the highest in the class II group. The DGF rate was higher in the DCD group than in the EPD group. PNF rate was similar in the groups. Dialysis need was the greatest and hospitalization the longest in the class II DCD group. eGFR was lower in the class II DCD group than in the EPD group. Our results indicate good clinical outcomes of kidney transplants from DCD despite the long “no-touch period” and show that ECMO in the procurement phase improves graft outcome, suggesting EPD as a source for pool expansion.

Effects of targeted temperature management at 33°C vs. 36°C on comatose patients after cardiac arrest stratified by the severity of encephalopathy

OBJECTIVES

To assess neurological outcome after targeted temperature management (TTM) at 33°C vs. 36°C, stratified by the severity of encephalopathy based on EEG-patterns at 12 and 24h.

DESIGN

Post hoc analysis of prospective cohort study.

SETTING

Five Dutch Intensive Care units.

PATIENTS

479 adult comatose post-cardiac arrest patients.

INTERVENTIONS

TTM at 33°C (n=270) or 36°C (n=209) and continuous EEG monitoring.

MEASUREMENTS AND MAIN RESULTS

Outcome according to the cerebral performance category (CPC) score at 6 months post-cardiac arrest was similar after 33°C and 36°C. However, when stratified by the severity of encephalopathy based on EEG-patterns at 12 and 24h after cardiac arrest, the proportion of good outcome (CPC 1-2) in patients with moderate encephalopathy was significantly larger after TTM at 33°C (66% vs. 45%; Odds Ratios 2.38, 95% CI=1.32-4.30; p=0.004). In contrast, with mild encephalopathy, there was no statistically significant difference in the proportion of patients with good outcome between 33°C and 36°C (88% vs. 81%; OR 1.68, 95% CI=0.65-4.38; p=0.282). Ordinal regression analysis showed a shift towards higher CPC scores when treated with TTM 33°C as compared with 36°C in moderate encephalopathy (cOR 2.39; 95% CI=1.40-4.08; p=0.001), but not in mild encephalopathy (cOR 0.81 95% CI=0.41-1.59; p=0.537). Adjustment for initial cardiac rhythm and cause of arrest did not change this relationship.

CONCLUSIONS

Effects of TTM probably depend on the severity of encephalopathy in comatose patients after cardiac arrest. These results support inclusion of predefined subgroup analyses based on EEG measures of the severity of encephalopathy in future clinical trials.

Assessment of a new volumetric capnography-derived parameter to reflect compression quality and to predict return of spontaneous circulation during cardiopulmonary resuscitation in a porcine model

We aimed to evaluate a volumetric capnography (Vcap)-derived parameter, the volume of CO2 eliminated per minute and per kg body weight (VCO2/kg), as an indicator of the quality of chest compression (CC) and to predict the return to spontaneous circulation (ROSC) under stable ventilation status. Twelve male domestic pigs were utilized for the randomized crossover study. After 4 min of untreated ventricular fibrillation (VF), mechanical cardiopulmonary resuscitation and ventilation were administered. Following 5-min washout periods, each animal underwent two sessions of experiments: three types of CC quality for 5 min stages in the first session, followed by advanced life support, consecutively in two sessions. Different CC quality had a significant effect on the partial pressure of end-tidal carbon dioxide (PetCO2), VCO2/kg, aortic pressure (mean), aortic systolic pressure, aortic diastolic pressure, right atrial pressure (mean), and carotid blood flow (P < 0.05). With the improvement in CC quality, the values of PetCO2 and VCO2/kg also increased, and the difference between the groups was statistically significant (P < 0.05). The Spearman rank test revealed a significant correlation between the Vcap-derived parameters and hemodynamics. PetCO2 and VCO2/kg have similar capabilities for discriminating survivors from non-survivors, and the area under the curve for both was 0.97. VCO2/kg had similar performance as PetCO2 in reflecting the quality of CC and prediction of achieving ROSC under stable ventilation status in a porcine model of VF-related cardiac arrest. However, VCO2/kg requires a longer time to achieve a stable state after adjusting for quality of CC than PetCO2.

First-Response ABCDE Management of Status Epilepticus: A Prospective High-Fidelity Simulation Study

Respiratory infections following status epilepticus (SE) are frequent, and associated with higher mortality, prolonged ICU stay, and higher rates of refractory SE. Lack of airway protection may contribute to respiratory infectious complications. This study investigates the order and frequency of physicians treating a simulated SE following a systematic Airways-Breathing-Circulation-Disability-Exposure (ABCDE) approach, identifies risk factors for non-adherence, and analyzes the compliance of an ABCDE guided approach to SE with current guidelines. We conducted a prospective single-blinded high-fidelity trial at a Swiss academic simulator training center. Physicians of different affiliations were confronted with a simulated SE. Physicians (n = 74) recognized SE and performed a median of four of the five ABCDE checks (interquartile range 3–4). Thereof, 5% performed a complete assessment. Airways were checked within the recommended timeframe in 46%, breathing in 66%, circulation in 92%, and disability in 96%. Head-to-toe (exposure) examination was performed in 15%. Airways were protected in a timely manner in 14%, oxygen supplied in 69%, and antiseizure drugs (ASDs) administered in 99%. Participants’ neurologic affiliation was associated with performance of fewer checks (regression coefficient −0.49; p = 0.015). We conclude that adherence to the ABCDE approach in a simulated SE was infrequent, but, if followed, resulted in adherence to treatment steps and more frequent protection of airways.

Implementation of a rapid response system at an isolated radiotherapy facility through simulation training

A rapid response system is required in a radiotherapy department for patients experiencing a critical event when access to an emergency department is poor due to geographic location and the patient is immobilised with a fixation device. We, therefore, rebuilt the response system and tested it through onsite simulations. A multidisciplinary core group was created and onsite simulations were conducted using a Plan-Do-Study-Act cycle. We identified the important characteristics of our facility, including its distance from the emergency department; the presence of many staff with little direct contact with patients; the treatment room environment and patient fixation with radiotherapy equipment. We also examined processes in each phase of the emergency response: detecting an emergency, calling the medical emergency team (MET), MET transportation to the site and on-site response and patient transportation to the emergency department. The protocol was modified, and equipment was updated. On-site simulations were held with and without explanation of the protocol and training scenario in advance. The time for the MET to arrive at the site during a 2017 simulation prior to the present project was 7 min, whereas the time to arrive after the first simulation session was shortened to 5 min and was then shortened further to 4 min in the second session, despite no prior explanation of the situation. A multidisciplinary project for emergency response with on-site simulations was conducted at an isolated radiation facility. A carefully planned emergency response is important not only in heavy ion therapy facilities but also in other departments and facilities that do not have easy access to hospital emergency departments.

Extracorporeal cardiopulmonary resuscitation for refractory in-hospital cardiac arrest: A retrospective cohort study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is a rescue therapy for refractory cardiac arrest, but its high mortality has raised questions about patient selection. No selection criteria have been proposed for patients experiencing in-hospital cardiac arrest. We aimed to identify selection criteria available at the time ECPR was considered for patients with in-hospital cardiac arrest. We analyzed data of in-hospital cardiac arrest patients undergoing ECPR in our extracorporeal membrane oxygenation (ECMO) center (March 2007 to March 2019). Intensive care unit (ICU) and 1-year survival post-hospital discharge were assessed. Factors associated with ICU survival before ECPR were investigated. An external validation cohort from a previous multicenter study was used to validate our results.

RESULTS

Among the 137 patients (67.9% men; median [IQR] age, 54 [43-62] years; low-flow duration, 45 [30-70] min) requiring ECPR, 32.1% were weaned-off ECMO. Their respective ICU- and 1-year survival rates were 21.9% and 19%. Most 1-year survivors had favorable neurological outcomes (cerebral performance category score 1 or 2). ICU survivors compared to nonsurvivors, respectively, were more likely to have a shockable initial rhythm (53.3% versus 24.3%; P < 0.01), a shorter median (IQR) low-flow time (30 (25-53) versus 50 (35-80) min, P < 0.01) and they more frequently underwent a subsequent intervention (63.3% versus 26.2%, P < 0.01). The algorithm obtained by combining age, initial rhythm and low-flow duration discriminated between patient groups with very different survival probabilities in the derivation and validation cohorts.

CONCLUSION

Survival of ECPR-managed in-hospital cardiac arrest patients in this cohort was poor but hospital survivors' 1-year neurological outcomes were favorable. When deciding whether or not to use ECPR, the combination of age, initial rhythm and low-flow duration can improve patient selection.

Subacute Aortic Rupture Due to Mechanical Chest Compression with Indwelling Impella

Mechanical cardiopulmonary resuscitation (CPR) devices like Lund University Cardiopulmonary Assist System (LUCAS) cause more skeletal and visceral injuries than standard CPR. A 62-year-old woman with ST-elevation myocardial infarction was resuscitated with LUCAS and Impella CP for refractory cardiogenic shock during percutaneous coronary intervention. She suffered delayed ascending aortic rupture necessitating supracommissural ascending aortic replacement plus triple bypass grafting. Prolonged mechanical CPR with concomitant Impella may lead to aortic rupture. The combined use of LUCAS and Impella may have disastrous consequences.

Perspectives of Dental Practitioners Regarding Their Readiness for Medical Emergencies: A Study in Saudi Arabia

Background:

Training dental practitioners on emergency preparedness and response is essential for the successful management of medical emergencies.

Objectives:

To assess the perceptions of dental practitioners in Saudi Arabia about their readiness to manage medical emergencies in the dental practices.

Methods:

This cross-sectional survey was conducted among dental practitioners working in 52 dental centers in Saudi Arabia. Questionnaires mainly gathered data on the measures taken by dental practitioners to prevent medical emergencies, BLS certification, availability of essential drugs and equipment, and perceptions of dental practitioners regarding the adequacy of their training for medical emergencies.

Results:

Of the total 270 participants, the majority reported that they take medical history (94%), perform visual inspection (90%), consult with patients’ physician when needed (89%), and modify treatment plan as necessary (94%). However, only 19% of them routinely take baseline vital signs for their patients and 52.6% have valid BLS certification. Only 29.6% and 16.3% of dental practitioners have reported that they have all essential drugs and equipment, respectively.

Conclusion:

The preventive measures for medical emergency appears to be deficient because most dental practitioners are not routinely taking baseline vital signs for their patients. This important issue is combined with shortage of BLS certification among dental practitioners and inadequate availability of all medical emergency drugs and equipment in dental practices.

Effect of Prehospital Epinephrine Use on Survival from Out-of-Hospital Cardiac Arrest and on Emergency Medical Services

This study was to identify the effect of epinephrine on the survival of out-of-hospital cardiac arrest (OHCA) patients and changes in prehospital emergency medical services (EMSs) after the introduction of prehospital epinephrine use by EMS providers. This was a retrospective observational study comparing two groups (epinephrine group and norepinephrine group). We used propensity score matching of the two groups and identified the association between outcome variables regarding survival and epinephrine use, controlling for confounding factors. The epinephrine group was 339 patients of a total 1943 study population. The survival-to-discharge rate and OR (95% CI) of the epinephrine group were 5.0% (p = 0.215) and 0.72 (0.43–1.21) in the total patient population and 4.7% (p = 0.699) and 1.15 (0.55–2.43) in the 1:1 propensity-matched population. The epinephrine group received more mechanical chest compression and had longer EMS response times and scene times than the norepinephrine group. Mechanical chest compression was a negative prognostic factor for survival to discharge and favorable neurological outcomes in the epinephrine group. The introduction of prehospital epinephrine use in OHCA patients yielded no evidence of improvement in survival to discharge and favorable neurological outcomes and adversely affected the practice of EMS providers, exacerbating the factors negatively associated with survival from OHCA.

Anterior-Lateral Versus Anterior-Posterior Electrode Position for Cardioverting Atrial Fibrillation

BACKGROUND

Smaller randomized studies have reported conflicting results regarding the optimal electrode position for cardioverting atrial fibrillation. However, anterior-posterior electrode positioning is widely used as a standard and believed to be superior to anterior-lateral electrode positioning. Therefore, we aimed to compare anterior-lateral and anterior-posterior electrode positioning for cardioverting atrial fibrillation in a multicenter randomized trial.

METHODS

In this multicenter, investigator-initiated, open-label trial, we randomly assigned patients with atrial fibrillation scheduled for elective cardioversion to either anterior-lateral or anterior-posterior electrode positioning. The primary outcome was the proportion of patients in sinus rhythm after the first shock. The secondary outcome was the proportion of patients in sinus rhythm after up to 4 shocks escalating to maximum energy. Safety outcomes were any cases of arrhythmia during or after cardioversion, skin redness, and patient-reported periprocedural pain.

RESULTS

We randomized 468 patients. The primary outcome occurred in 126 patients (54%) assigned to the anterior-lateral electrode position and in 77 patients (33%) assigned to the anterior-posterior electrode position (risk difference, 22 percentage points [95% CI, 13-30]; P<0.001). The number of patients in sinus rhythm after the final cardioversion shock was 216 (93%) assigned to anterior-lateral electrode positioning and 200 (85%) assigned to anterior-posterior electrode positioning (risk difference, 7 percentage points [95% CI, 2-12]). There were no significant differences between groups in any safety outcomes.

CONCLUSIONS

Anterior-lateral electrode positioning was more effective than anterior-posterior electrode positioning for biphasic cardioversion of atrial fibrillation. There were no significant differences in any safety outcome. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03817372.

An evolutionary approach to continuously estimate CPR quality parameters from a wrist-worn inertial sensor

Cardiopulmonary resuscitation (CPR) is one of the most critical emergency interventions for sudden cardiac arrest. In this paper, a robust sinusoidal model-fitting method based on a Evolution Strategy inspired algorithm for CPR quality parameters – naming chest compression frequency and depth – as measured by an inertial measurement unit (IMU) attached to the wrist is presented. The proposed approach will allow bystanders to improve CPR as part of a continuous closed-loop support system once integrated into a smartphone or smartwatch application. By evaluating the model’s precision with data recorded by a training mannequin as reference standard, a variance for the compression frequency of $$\pm 2.22$$ ± 2.22 compressions per minute (cpm) has been found for the IMU attached to the wrist. It was found that this previously unconsidered position and thus, the use of smartwatches is a suitable alternative to the typical placement of phones in hand for CPR training.

Manual Palpation vs. Femoral Arterial Doppler Ultrasound for Comparison of Pulse Check Time During Cardiopulmonary Resuscitation in the Emergency Department: A Pilot Study

BACKGROUND

Manual palpation (MP) is frequently employed for pulse checks, but studies have shown that trained medical personnel have difficulty accurately identifying pulselessness or return of spontaneous circulation (ROSC) using MP. Any delays in identifying pulselessness can lead to significant delays in starting or resuming high-quality chest compressions.

OBJECTIVES

This study explored whether femoral arterial Doppler ultrasound (FADU) decreases pulse check duration during cardiopulmonary resuscitation (CPR) compared with MP among patients in the emergency department (ED) receiving CPR directed by emergency medicine physicians who had received minimal additional didactic ultrasound training.

METHODS

We performed a prospective observational cohort study from October 2018 to May 2019 at an urban community ED. Using convenience sampling, we enrolled patients arriving at our ED or who decompensated during their ED stay and received CPR. For continuous data, median (interquartile range [IQR]) were calculated, and medians were compared using Kruskal-Wallis test.

RESULTS

Fifty-two eligible patients were enrolled and 135 pulse checks via MP and 35 via FADU were recorded. MP observations had a median (IQR) of 11.00 (7.36-15.48) s, whereas FADU had a median (IQR) of 8.98 (5.45-13.85) s. There was a difference between the two medians of 2.02 s (p = 0.05).

CONCLUSIONS

In this study, the use of FADU was superior to MP in achieving shorter pulse check times. Further research is needed to confirm the accuracy of FADU for identifying ROSC as well as to determine whether FADU can improve clinical outcomes.

Dangers of hyperoxia

Oxygen (O2) toxicity remains a concern, particularly to the lung. This is mainly related to excessive production of reactive oxygen species (ROS). Supplemental O2, i.e. inspiratory O2 concentrations (FIO2) > 0.21 may cause hyperoxaemia (i.e. arterial (a) PO2 > 100 mmHg) and, subsequently, hyperoxia (increased tissue O2 concentration), thereby enhancing ROS formation. Here, we review the pathophysiology of O2 toxicity and the potential harms of supplemental O2 in various ICU conditions. The current evidence base suggests that PaO2 > 300 mmHg (40 kPa) should be avoided, but it remains uncertain whether there is an "optimal level" which may vary for given clinical conditions. Since even moderately supra-physiological PaO2 may be associated with deleterious side effects, it seems advisable at present to titrate O2 to maintain PaO2 within the normal range, avoiding both hypoxaemia and excess hyperoxaemia.

Impact of Specific Emergency Measures on Survival in Out-of-Hospital Traumatic Cardiac Arrest

INTRODUCTION

The management of out-of-hospital traumatic cardiac arrest (TCA) for professional rescuers entails Advanced Life Support (ALS) with specific actions to treat the potential reversible causes of the arrest: hypovolemia, hypoxemia, tension pneumothorax (TPx), and tamponade. The aim of this study was to assess the impact of specific rescue measures on short-term outcomes in the context of resuscitating patients with a TCA.

METHODS

This retrospective study concerns all TCA patients treated in two emergency medical units, which are part of the Northern French Alps Emergency Network (RENAU), from January 2004 through December 2017. Utstein variables and specific rescue measures in TCA were compiled: fluid expansion, pelvic stabilization, tourniquet application, bilateral thoracostomy, and thoracotomy procedures. The primary endpoint was survival rate at Day 30 with good neurological status (Cerebral Performance Category [CPC] score CPC 1 and CPC 2).

RESULTS

In total, 287 resuscitation attempts in TCA were included and 279 specific interventions were identified: 262 fluid expansions, 41 pelvic stabilizations, five tourniquets, and 175 bilateral thoracostomies (including 44 with TPx).

CONCLUSION

Among the standard resuscitation measures to treat the reversible causes of cardiac arrest, this study found that bilateral thoracostomy and tourniquet application on a limb hemorrhage improve survival in TCA. A larger sample for pelvic stabilization is needed.

Outcomes and interventions in patients transported to hospital with ongoing CPR after out-of-hospital cardiac arrest - An observational study

Introduction

The main objective was to present characteristics and outcome of patients without sustained field return of spontaneous circulation (ROSC) transported to hospital with ongoing cardiopulmonary resuscitation (CPR). Our secondary objectives were to investigate hospital-based interventions and the performance of the universal Termination of Resuscitation-rule (uTOR).

Methods

In this retrospective observational cohort study, out-of-hospital cardiac arrest (OHCA) patients arriving to the emergency department of a university hospital in Sweden during a six-year period (2010–2015) were identified using a prospectively recorded hospital-based registry. Additional data were retrieved from medical records and from the Swedish cardiopulmonary resuscitation registry.

Results

Among 409 patients transported with ongoing CPR, 7 survived to hospital discharge (1.7%). Hospital-based interventions against a suspected cause of arrest were attempted during ongoing resuscitation in 34 patients (8.3%), of whom 3 survived to hospital discharge. The remaining 4 survivors had spontaneous in-hospital ROSC. Survivors presented with either a shockable rhythm (n = 4) or pulseless electrical activity (n = 3). The uTOR identified non-survivors with a positive predictive value (PPV) of 98.4% and a specificity of 71.4% for termination.

Conclusion

Survival after OHCA where sustained prehospital ROSC is not achieved is rare and available in-hospital interventions are rarely utilised. No patient with asystole as the first recorded rhythm survived. The uTOR identified non-survivors with a PPV of 98.4% but showed poor specificity.

Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial

IMPORTANCE

It is unclear whether administration of calcium has a beneficial effect in patients with cardiac arrest.

OBJECTIVE

To determine whether administration of calcium during out-of-hospital cardiac arrest improves return of spontaneous circulation in adults.

DESIGN, SETTING, AND PARTICIPANTS

This double-blind, placebo-controlled randomized clinical trial included 397 adult patients with out-of-hospital cardiac arrest and was conducted in the Central Denmark Region between January 20, 2020, and April 15, 2021. The last 90-day follow-up was on July 15, 2021.

INTERVENTIONS

The intervention consisted of up to 2 intravenous or intraosseous doses with 5 mmol of calcium chloride (n = 197) or saline (n = 200). The first dose was administered immediately after the first dose of epinephrine.

MAIN OUTCOMES AND MEASURES

The primary outcome was sustained return of spontaneous circulation. The secondary outcomes included survival and a favorable neurological outcome (modified Rankin Scale score of 0-3) at 30 days and 90 days.

RESULTS

Based on a planned interim analysis of 383 patients, the steering committee stopped the trial early due to concerns about harm in the calcium group. Of 397 adult patients randomized, 391 were included in the analyses (193 in the calcium group and 198 in the saline group; mean age, 68 [SD, 14] years; 114 [29%] were female). There was no loss to follow-up. There were 37 patients (19%) in the calcium group who had sustained return of spontaneous circulation compared with 53 patients (27%) in the saline group (risk ratio, 0.72 [95% CI, 0.49 to 1.03]; risk difference, -7.6% [95% CI, -16% to 0.8%]; P = .09). At 30 days, 10 patients (5.2%) in the calcium group and 18 patients (9.1%) in the saline group were alive (risk ratio, 0.57 [95% CI, 0.27 to 1.18]; risk difference, -3.9% [95% CI, -9.4% to 1.3%]; P = .17). A favorable neurological outcome at 30 days was observed in 7 patients (3.6%) in the calcium group and in 15 patients (7.6%) in the saline group (risk ratio, 0.48 [95% CI, 0.20 to 1.12]; risk difference, -4.0% [95% CI, -8.9% to 0.7%]; P = .12). Among the patients with calcium values measured who had return of spontaneous circulation, 26 (74%) in the calcium group and 1 (2%) in the saline group had hypercalcemia.

CONCLUSIONS AND RELEVANCE

Among adults with out-of-hospital cardiac arrest, treatment with intravenous or intraosseous calcium compared with saline did not significantly improve sustained return of spontaneous circulation. These results do not support the administration of calcium during out-of-hospital cardiac arrest in adults.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04153435.

Point-of-care ultrasound in cardiorespiratory arrest (POCUS-CA): narrative review article

The POCUS-CA (Point-of-care ultrasound in cardiac arrest) is a diagnostic tool in the Intensive Care Unit and Emergency Department setting. The literature indicates that in the patient in a cardiorespiratory arrest it can provide information of the etiology of the arrest in patients with non-defibrillable rhythms, assess the quality of compressions during cardiopulmonary resuscitation (CPR), and define prognosis of survival according to specific findings and, thus, assist the clinician in decision-making during resuscitation. This narrative review of the literature aims to expose the usefulness of ultrasound in the setting of cardiorespiratory arrest as a tool that allows making a rapid diagnosis and making decisions about reversible causes of this entity. More studies are needed to support the evidence to make ultrasound part of the resuscitation algorithms. Teamwork during cardiopulmonary resuscitation and the inclusion of ultrasound in a multidisciplinary approach is important to achieve a favorable clinical outcome.

How to Maintain Safety and Maximize the Efficacy of Cardiopulmonary Resuscitation in COVID-19 Patients: Insights from the Recent Guidelines

Since December 2019, the novel coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has remained a challenge for governments and healthcare systems all around the globe. SARS-CoV-2 infection is associated with increased rates of hospital admissions and significant mortality. The pandemic increased the rate of cardiac arrest and the need for cardiopulmonary resuscitation (CPR). COVID-19, with its pathophysiology and detrimental effects on healthcare, influenced the profile of patients suffering from cardiac arrest, as well as the conditions of performing CPR. To ensure both the safety of medical personnel and the CPR efficacy for patients, resuscitation societies have published modified guidelines addressing the specific reality of the COVID-19 pandemic. In this review, we briefly describe the transmission and pathophysiology of COVID-19, present the challenges of CPR in SARS-CoV-2-infected patients, summarize the current recommendations regarding the algorithms of basic life support (BLS), advanced life support (ALS) and pediatric life support, and discuss other aspects of CPR in COVID-19 patients, which potentially affect the risk-to-benefit ratio of medical procedures and therefore should be considered while formulating further recommendations.

Predictors of poor outcome after extra-corporeal membrane oxygenation for refractory cardiac arrest (ECPR): A post hoc analysis of a multicenter database

BACKGROUND

The objective was to assess predictors for unfavorable neurological outcome (UO) in out-of-hospital (OHCA) and in-hospital (IHCA) cardiac arrest patients treated with Extracorporeal cardiopulmonary resuscitation (ECPR).

METHODS

A post hoc analysis of retrospective data from five European ECPR centers (January 2012-December 2016) was performed. The primary composite endpoint was 3-month UO defined as survival with a cerebral performance category (CPC) of 3-4 or death (CPC 5).

RESULTS

A total of 413 patients treated with ECPR were included (median age was 57 [48-65] years, male gender 78%): 61% of patients (n = 250) suffered OHCA. The median time from collapse to ECMO placement was 63 [45-82] minutes. Overall, 81% patients (n = 333) showed unfavorable UO, which was higher in OHCA patients (90% vs 66%), as compared to IHCA. In OHCA, prolonged time from collapse to ECMO initiation (OR 1.02, p < 0.01) and higher ECMO blood flow (OR 1.99, p = 0.01) were associated with UO while initial shockable rhythm (OR 0.04, p < 0.01), previous heart disease (OR 0.20, p < 0.01) and pre-hospital hypothermia (OR 0.08, p < 0.01) had a protective role. In IHCA, prolonged time from arrest to ECMO implantation (OR 1.02, p = 0.03), high lactate level on admission (OR 1.15, p < 0.01) and higher body weight (OR 1.03, p < 0.01) were independently associated with UO.

CONCLUSIONS

IHCA and OHCA patients receiving ECPR have different predictors of UO at presentation, suggesting that selection criteria for ECPR should be decided according to the location of CA. After ECMO initiation, ECMO blood flow management and mean arterial pressure targets might also impact neurological recovery.

Drug-free tracheal intubation by specialist paramedics (critical care) in a United Kingdom ambulance service: a service evaluation

BACKGROUND

Drug-free tracheal intubation has been a common intervention in the context of out-of-hospital cardiac arrest for many years, however its use by paramedics has recently been the subject of much debate. Recent international guidance has recommended that only those achieving high tracheal intubation success should continue to use it.

METHODS

We conducted a retrospective service evaluation of all drug-free tracheal intubation attempts by specialist paramedics (critical care) from South East Coast Ambulance Service NHS Foundation Trust between 1st January and 31st December 2019. Our primary outcome was first-pass success rate, and secondary outcomes were success within two attempts, overall success, Cormack-Lehane grade of view, and use of bougie.

RESULTS

There were 663 drug-free tracheal intubations and following screening, 605 were reviewed. There was a first-pass success rate of 81.5%, success within two attempts of 96.7%, and an overall success rate of 98.35%. There were ten unsuccessful attempts (1.65%). Bougie use was documented in 83.4% on the first attempt, 93.5% on the second attempt and 100% on the third attempt, CONCLUSION: Specialist paramedics (critical care) are able to deliver drug-free tracheal intubation with good first-pass success and high overall success and are therefore both safe and competent at this intervention.

Comparison of VividTrac, King Vision and Macintosh laryngoscopes in normal and difficult airways during simulated cardiopulmonary resuscitation among novices

Introduction

Early endotracheal intubation improves neurological outcomes in cardiopulmonary resuscitation, although cardiopulmonary resuscitation is initially carried out by personnel with limited experience in a significant proportion of cases. Videolaryngoscopes might decrease the number of attempts and time needed, especially among novices. We sought to compare videolaryngoscopes with direct laryngoscopes in simulated cardiopulmonary resuscitation scenarios.

Materials and methods

Forty-four medical students were recruited to serve as novice users. Following brief, standardized training, students executed endotracheal intubation with the King Vision^®, Macintosh and VividTrac^® laryngoscopes, on a cardiopulmonary resuscitation trainer in normal and difficult airway scenarios. We evaluated the time to and proportion of successful intubation, the best view of the glottis, esophageal intubation, dental trauma and user satisfaction.

Results

In the normal airway scenario, significantly shorter intubation times were achieved using the King Vision^® than the Macintosh laryngoscope. In the difficult airway scenario, we found that the VividTrac^® was superior to the King Vision^® and Macintosh laryngoscopes in the laryngoscopy time. In both scenarios, we noted no difference in the first-attempt success rate, but the best view of the glottis and dental trauma, esophageal intubation and bougie use were more frequent with the Macintosh laryngoscope than with the videolaryngoscopes. The shortest tube insertion times were achieved using the King Vision^® in both scenarios.

Conclusion

All providers achieved successful intubation within three attempts, but we found no device superior in any of our scenarios regarding the first-attempt success rate. The King Vision^® was superior to the Macintosh laryngoscope in the intubation time in the normal airway scenario and noninferior in the difficult airway scenario for novice users. We noted significantly less esophageal intubation using the videolaryngoscopes than using the Macintosh laryngoscope in both scenarios. Based on our results, the KingVision^® might be recommended over the VividTrac^® and Macintosh laryngoscopes for further evaluation.

Use of Extracorporeal Membrane Oxygenation in Patients with Refractory Cardiac Arrest due to Severe Persistent Hypothermia: About 2 Case Reports and a Review of the Literature

We report the cases of two patients experiencing persistent severe hypothermia. They were 45 and 30 years old and had a witnessed cardiac arrest managed with mechanized cardiopulmonary resuscitation (CPR) for 4 and 2.5 hours, respectively. Extracorporeal membrane oxygenation was used in both patients who fully recovered without any neurological sequelae. These two cases illustrate the important role of extracorporeal CPR (eCPR) in persistent severe hypothermia leading to cardiac arrest.

Epinephrine before defibrillation in patients with shockable in-hospital cardiac arrest: propensity matched analysis

OBJECTIVE

To determine the use of epinephrine (adrenaline) before defibrillation for treatment of in-hospital cardiac arrest due to a ventricular arrhythmia and examine its association with patient survival.

DESIGN

Propensity matched analysis.

SETTING

2000-18 data from 497 hospitals participating in the American Heart Association’s Get With The Guidelines-Resuscitation registry.

PARTICIPANTS

Adults aged 18 and older with an index in-hospital cardiac arrest due to an initial shockable rhythm treated with defibrillation.

INTERVENTIONS

Administration of epinephrine before first defibrillation.

MAIN OUTCOME MEASURES

Survival to discharge; favorable neurological survival, defined as survival to discharge with none, mild, or moderate neurological disability measured using cerebral performance category scores; and survival after acute resuscitation (that is, return of spontaneous circulation for &gt;20 minutes). A time dependent, propensity matched analysis was performed to adjust for confounding due to indication and evaluate the independent association of epinephrine before defibrillation with study outcomes.

RESULTS

Among 34 820 patients with an initial shockable rhythm, 7054 (20.3%) were treated with epinephrine before defibrillation, contrary to current guidelines. In comparison with participants treated with defibrillation first, participants receiving epinephrine first were less likely to have a history of myocardial infarction or heart failure, but more likely to have renal failure, sepsis, respiratory insufficiency, and receive mechanical ventilation before in-hospital cardiac arrest (standardized differences &gt;10% for all). Treatment with epinephrine before defibrillation was strongly associated with delayed defibrillation (median 4 minutes v 0 minutes). In propensity matched analysis (6569 matched pairs), epinephrine before defibrillation was associated with lower odds of survival to discharge (22.4% v 29.7%; adjusted odds ratio 0.69; 95% confidence interval 0.64 to 0.74; P&lt;0.001), favorable neurological survival (15.8% v 21.6%; 0.68; 0.61 to 0.76; P&lt;0.001) and survival after acute resuscitation (61.7% v 69.5%; 0.73; 0.67 to 0.79; P&lt;0.001). The above findings were consistent in a range of sensitivity analyses, including matching according to defibrillation time.

CONCLUSIONS

Contrary to current guidelines that prioritize immediate defibrillation for in-hospital cardiac arrest due to a shockable rhythm, one in five patients are treated with epinephrine before defibrillation. Use of epinephrine before defibrillation was associated with worse survival outcomes.

[I-Gel® laryngeal mask versus bag-valve-mask in instrumental cardiopulmonary resuscitation under capnographic monitoring: Cluster-randomized pilot clinical trial]

OBJECTIVE

To compare the basic airway and the advanced airway with the supraglottic device I-Gel®, by means of capnography during intermediate CPR.

DESIGN

Randomized experimental pilot study by groups.

SETTING

Out-hospital care basic life support units on the Island of Mallorca.

PARTICIPANTS

Adults attended after cardiorespiratory arrest of non-traumatic origin.

INTERVENTIONS

Advanced airway management during instrumental CPR with I-Gel® or basic CPR with bag-valve-mask, under capnographic monitoring.

MAIN MEASUREMENTS

Capnometric levels obtained according to the device used, number of insertions of the I-Gel®, cases without achieving correct insertion/ventilation by branches, achievement of ROSC in CPR and number of hospital live admissions.

RESULTS

Twenty-three cases were recruited for analysis. The insertion success rate of the I-Gel® was 92.9% at the first attempt, the mean capnometric values were 16.3mmHg in the control group and 27.4% in the intervention group. 34.8% (n=8) of the patients achieved spontaneous circulation recovery at some point and 26.1% (n=6) were admitted to hospital alive. The survival analysis, taking into account the arrival of the unit and the first minute of ventilations recorded together with the variable hospital admission, suggests a certain trend of greater survival in the intervention branch (P=.066).

CONCLUSIONS

The use of I-Gel® raises an improvement in the ventilation of the patients in PCR, evidenced by the mean capnometric values in the intervention group, finding no correlation with CPR outcome variables.

Identification of an optimal CPR chest compression protocol

In this study, we used a high-fidelity integrated computational model of the respiratory and cardiovascular systems to investigate cardiopulmonary resuscitation (CPR) after cardiac arrest in a virtual healthy subject. For the purpose of this work, a newly developed thoracic model has been integrated to the current model, to study the influence of external chest compressions upon the arrested circulation during CPR. We evaluated the chest compression (CC) parameters, namely, end compression force, compression rate, and duty cycle to optimize the coronary perfusion pressure and the systolic blood pressure, using a genetic algorithm. While the sternal displacement associated with the CC force agreed with the ERC guidelines, the CC rate and duty cycle were respectively higher and lower than the ones recommended by the ERC guidelines. The effect of these CC parameters on cardiac output (CO) were also assessed. The end compression force was the parameter with the largest impact on CO, while the compression rate and duty cycle scarcely influence it.Relevance- Our results may aid in understanding the underlying pathophysiology of cardiac arrest and help guide research into the refinement of CPR strategies, without sacrificing animals or conducting clinical trials, which are difficult to undertake in crisis scenarios.

Association Between Converting Asystole From Initial Shockable ECG Rhythm Before Extracorporeal Cardiopulmonary Resuscitation and Outcome

BACKGROUND

Initial electrocardiogram (ECG) rhythm is a predictor of outcomes in out-of-hospital cardiac arrest (OHCA) in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). However, ECG rhythm often changes before ECPR, and the consequence of this change remains unclear. This study aimed to assess the relationship between the conversion of ECG rhythm from initial shockable rhythm before ECPR and mortality.

PATIENTS AND METHODS

This was a retrospective cohort study of OHCA patients with initial shockable rhythm who underwent ECPR between January 2010 and September 2020. Patients were classified into two groups: asystole (patients whose ECG rhythm converted to asystole at any time before initiating ECPR) and non-asystole (patients whose ECG rhythm did not convert to asystole at any time before initiating ECPR) groups. The primary outcome was in-hospital mortality.

RESULTS

A total of 102 patients were included in the study; in-hospital mortality rate was 46.1% (n = 47) and 76 (74.5%) patients had unfavorable neurological outcomes (Cerebral Performance Category: 3-5). There were 33 and 69 patients in the asystole and non-asystole groups, respectively. The mortality rates in the asystole and non-asystole groups were 69.7% and 34.8%, respectively (P = 0.001). On multivariable analysis, the asystole group showed a significant association with mortality (odds ratio, 5.42; 95% confidence interval, 2.11-15.36; P < 0.001).

CONCLUSION

Conversion to asystole before ECPR at any time in patients with OHCA is associated with mortality in patients with an initial shockable ECG rhythm.

Increased 5-year risk of stroke, atrial fibrillation, acute coronary syndrome, and heart failure in out-of-hospital cardiac arrest survivors compared with population controls: A nationwide registry-based study

AIM

Long-term risks of stroke, atrial fibrillation, or flutter (AF), acute coronary syndrome (ACS), and heart failure (HF) among survivors of out-of-hospital cardiac arrest (OHCA) are unknown. We aimed to examine 5-year risks of these outcomes among 30-day survivors of OHCA.

METHODS

Thirty-day survivors of OHCA without a prior (or within 30 days after cardiac arrest) history of stroke, AF, ACS, or HF and population controls without a prior history of these conditions were identified using Danish nationwide registries. Five-year risks of stroke, AF, ACS, and HF standardized to the distributions of age, sex, and comorbidities among OHCA survivors and controls were obtained using multivariable regression.

RESULTS

Of 4,362 30-day OHCA-survivors, 1,051 were stroke-, AF-, ACS-, and HF-naïve and matched with controls using age, sex, and time of OHCA event. Absolute five-year risks for OHCA survivors vs. controls were for stroke: 6.3% [95% confidence interval (CI) 4.1-8.5] vs. 2.0% [1.6-2.5], AF: 7.9% [5.7-10.2] vs. 2.6% [2.1-3.1], ACS: 5.0% [3.2-6.8] vs. 1.5% [1.1-1.9], and HF: 12.7% [10.1-15.4] vs. 1.2% [0.9-1.6], respectively. Corresponding relative risks were 3.18 [95% CI 1.76-4.61] for stroke, 3.03 [1.93-4.14] for AF, 3.23 [1.69-4.77] for ACS, and 10.40 [6.57-14.13] for HF.

CONCLUSION

When compared with population controls, OHCA survivors had significantly increased five-year risks of incident stroke, AF, ACS, and HF.

Effect of implementation of multi-tier response system and prolonged on-scene resuscitation for out-of-hospital cardiac arrest

INTRODUCTION

The purpose of this study was to explain the process and results of implementing a bundle of two cardiopulmonary resuscitation (CPR) programs in Gwang-ju metropolitan city and to determine whether the use of these programs improved the clinical outcomes for out-of-hospital cardiac arrest (OHCA) patients.

METHODS

This was a before- and after-intervention study of the implementation of a bundle of two CPR programs in Gwang-ju. The main intervention was a multi-tier response (MTR) system, with an emphasis on prolonged on-scene resuscitation. The primary outcome was good neurological recovery, and secondary outcomes were survival to discharge and prehospital return of spontaneous circulation (ROSC). A multivariable logistic regression model was used to estimate the association between the study period and outcomes, after adjusting for potential confounders. Interaction analysis was conducted to determine whether the location of arrest and witness status modified the effect of the study period on the study outcomes.

RESULTS

The adjusted odds ratios (AORs) for the intervention were 1.35 (0.96-1.90) for pre-hospital ROSC, 1.19 (0.49-2.86) for survival to discharge, and 3.45 (1.01-11.80) for good CPC. The AORs for good neurological recovery of the after-intervention period were 2.93 (0.73-11.77) for a private place, 4.82 (1.04-22.39) for a public place, 5.88 (1.47-23.57) for a witnessed arrest, and 1.49 (0.28-7.86) for a non-witnessed arrest.

CONCLUSIONS

OHCA patients treated in the after-intervention period with the bundle of CPR programs including MTR and prolonged on-scene resuscitation showed better clinical outcomes, especially pre-hospital ROSC, and neurological recovery at hospital discharge than those treated in the before-intervention period.

Safety of mechanical and manual chest compressions in cardiac arrest patients: A systematic review and meta-analysis

AIM

Summarise the evidence regarding the safety of mechanical and manual chest compressions for cardiac arrest patients.

METHODS

Two investigators separately screened the articles of EMBASE, PubMed, and Cochrane Central databases. Cohort studies and randomized clinical trials (RCTs) that evaluated the safety of mechanical (LUCAS or AutoPulse) and manual chest compressions in cardiac arrest patients were included. A meta-analysis was performed using a random effects model to calculate the pooled odds ratios (ORs) and their 95% confidence intervals (CIs). The primary outcome was the rate of overall compression-induced injuries. The secondary outcomes included the incidence of life-threatening injuries, skeletal fractures, visceral injuries, and other soft tissue injuries.

RESULTS

The meta-analysis included 11 trials involving 2,818 patients. A significantly higher rate of overall compression-induced injuries was found for mechanical compressions than manual compressions (OR, 1.29; 95% CI, 1.19-1.41), while there was no significant difference between the two groups in respect of the rate of life-threatening injuries. Furthermore, both modalities shared similar incidences of sternal fractures, vertebral fractures, lung, spleen, and kidney injuries. However, compared to mechanical compressions, manual compressions were shown to present a reduced risk of posterior rib fractures, and heart and liver lesions.

CONCLUSIONS

The findings suggested that manual compressions could decrease the risk of compression-induced injuries compared to mechanical compressions in cardiac arrest patients. Interestingly, mechanical compressions have not increased the risk of life-threatening injuries, whereas additional high-quality RCTs are needed to further verify the safety of mechanical chest devices.

TRIAL REGISTRY

INPLASY; Registration number: INPLASY2020110111; URL: https://inplasy.com/.

[Use of the intraosseous infusion device in the resuscitation ambulances of the Paris fire brigade]

In the Paris Fire Brigade, in the context of cardiac arrest, the nurses have the greatest reported experience of intraosseous infusion. The adverse events reported are rare, given that the procedure is performed on patients in absolute emergency. All these elements are in favour of discussing a redefinition of the practice of intraosseous infusion by nurses in the specific context of immediate life-saving emergencies.

Efficacy of a Simplified Feedback Trainer for High-Quality Chest Compression Training: A Randomized Controlled Simulation Study

Background: The most recent international guidelines recommended support training of chest compression (CC) using feedback devices. This study aimed to compare the training efficacy of a simplified feedback trainer with the traditional cardiopulmonary resuscitation (CPR) simulator in CPR training. Methods: A total of 60 soldiers were randomly allocated into three groups equally, trained with a simplified external cardiac massage (ECM) trainer named Soul SheathTM (SS) (SS group), a Resusci Anne manikin (RA group), or traditional simulation training with instructor feedback, respectively. After 7 days of training, the CPR skills were tested blindly in a 2-min assessment session. The primary outcome was the proportion of effective CC, and the secondary outcome included CC rate, depth, compression position, and extent of the release. Results: The percentage of effective CC achieved in the SS group was comparable with the RA group (77.0 ± 15.52 vs. 77.5 ± 10.73%, p = 0.922), and significantly higher than that in the control group (77.0 ± 15.52 vs. 66.8 ± 16.87%, p = 0.037). Both the SS and RA groups showed better CC performance than the control group in terms of CC rate (SS group vs. control group, P = 0.032 and RA group vs. control group, P = 0.026), the proportion of shallow CC (SS group vs. control group, P = 0.011 and RA group vs. control group, P = 0.017). No difference between the SS group and RA group was found in all the CC parameters. Conclusions: The simplified ECM trainer (SS) provides a similar efficacy to the traditional manikin simulator with feedback in CC training to improve the quality of CPR skills.

Mildly Reduced Doses of Adrenaline Do Not Affect Key Hemodynamic Parameters during Cardio-Pulmonary Resuscitation in a Pig Model of Cardiac Arrest

Adrenaline is recommended for cardiac arrest resuscitation, but its effectiveness has been questioned recently. Achieving return of spontaneous circulation (ROSC) is essential and is obtained by increasing coronary perfusion pressure (CPP) after adrenaline injection. A threshold as high as 35 mmHg of CPP may be necessary to obtain ROSC, but increasing doses of adrenaline might be harmful to the brain. Our study aimed to compare the increase in CPP with reduced doses of adrenaline to the recommended 1 mg dose in a pig model of cardiac arrest. Fifteen domestic pigs were randomized into three groups according to the adrenaline doses: 1 mg, 0.5 mg, or 0.25 mg administered every 5 min. Cardiac arrest was induced by ventricular fibrillation; after 5 min of no-flow, mechanical chest compression was resumed. The Wilcoxon test and Kruskal-Wallis exact test were used for the comparison of groups. Fisher's exact test was used to compare categorical variables. CPP, EtCO2 level, cerebral, and tissue near-infrared spectroscopy (NIRS) were measured. CPP was significantly lower in the 0.25 mg group 90 s after the first adrenaline injection: 28.9 (21.2; 35.4) vs. 53.8 (37.8; 58.2) in the 1 mg group (p = 0.008), while there was no significant difference with 0.5 mg 39.6 (32.7; 52.5) (p = 0.056). Overall, 0.25 mg did not achieve the threshold of 35 mmHg. EtCO2 levels were higher at T12 and T14 in the 0.5 mg than in the standard group: 32 (23; 35) vs. 19 (16; 26) and 26 (20; 34) vs. 19 (12; 22) (p < 0.05). Cerebral and tissue NIRS did not show a significant difference between the three groups. CPP after 0.5 mg boluses of adrenaline was not significantly different from the recommended 1 mg in our model of cardiac arrest.

Incidence of hyperoxia and factors associated with cerebral oxygenation during cardiopulmonary resuscitation

BACKGROUND

High oxygen levels may worsen cardiac arrest reperfusion injury. We determined the incidence of hyperoxia during and immediately after successful cardiopulmonary resuscitation and identified factors associated with intra-arrest cerebral oxygenation measured with near-infrared spectroscopy (NIRS).

METHODS

A prospective observational study of out-of-hospital cardiac arrest patients treated by a physician-staffed helicopter unit. Collected data included intra-arrest brain regional oxygen saturation (rSO₂) with NIRS, invasive blood pressures, end-tidal CO₂ (etCO₂) and arterial blood gas samples. Moderate and severe hyperoxia were defined as arterial oxygen partial pressure (paO₂) 20.0-39.9 and ≥40 kPa, respectively. Intra-arrest factors correlated with the NIRS value, rSO_2, were assessed with the Spearman's correlation test.

RESULTS

Of 80 recruited patients, 73 (91%) patients had rSO₂ recorded during CPR, and 46 had an intra-arrest paO₂ analysed. ROSC was achieved in 28 patients, of whom 20 had paO₂ analysed. Moderate hyperoxia was seen in one patient during CPR and in four patients (20%, 95% CI 7-42%) after ROSC. None had severe hyperoxia during CPR, and one patient (5%, 95% 0-25%) immediately after ROSC. The rSO₂ during CPR was correlated with intra-arrest systolic (r = 0.28, p < 0.001) and diastolic blood pressure (p = 0.32, p < 0.001) but not with paO₂ (r = 0.13, p = 0.41), paCO₂ (r = 0.18, p = 0.22) or etCO₂ (r = 0.008, p = 0.9).

CONCLUSION

Hyperoxia during or immediately after CPR is rare in patients treated by physician-staffed helicopter units. Cerebral oxygenation during CPR appears more dependent, albeit weakly, on hemodynamics than arterial oxygen concentration.

Reliability of prognostic biomarkers after prehospital extracorporeal cardiopulmonary resuscitation with target temperature management

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) performed at the emergency scene in out-of-hospital cardiac arrest (OHCA) can minimize low-flow time. Target temperature management (TTM) after cardiac arrest can improve neurological outcome. A combination of ECPR and TTM, both implemented as soon as possible on scene, appears to have promising results in OHCA. To date, it is still unknown whether the implementation of TTM and ECPR on scene affects the time course and value of neurological biomarkers.

METHODS

69 ECPR patients were examined in this study. Blood samples were collected between 1 and 72 h after ECPR and analyzed for S100, neuron-specific enolase (NSE), lactate, D-dimers and interleukin 6 (IL6). Cerebral performance category (CPC) scores were used to assess neurological outcome after ECPR upon hospital discharge. Resuscitation data were extracted from the Regensburg extracorporeal membrane oxygenation database and all data were analyzed by a statistician. The data were analyzed using non-parametric methods. Diagnostic accuracy of biomarkers was determined by area under the curve (AUC) analysis. Results were compared to the relevant literature.

RESULTS

Non-hypoxic origin of cardiac arrest, manual chest compression until ECPR, a short low-flow time until ECPR initiation, low body mass index (BMI) and only a minimal need of extra-corporeal membrane oxygenation support were associated with a good neurological outcome after ECPR. Survivors with good neurological outcome had significantly lower lactate, IL6, D-dimer, and NSE values and demonstrated a rapid decrease in the initial S100 value compared to non-survivors.

CONCLUSIONS

A short low-flow time until ECPR initiation is important for a good neurological outcome. Hypoxia-induced cardiac arrest has a high mortality rate even when ECPR and TTM are performed at the emergency scene. ECPR patients with a higher BMI had a worse neurological outcome than patients with a normal BMI. The prognostic biomarkers S100, NSE, lactate, D-dimers and IL6 were reliable indicators of neurological outcome when ECPR and TTM were performed at the emergency scene.

Association between a Multidisciplinary Team Approach and Clinical Outcomes in Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation in the Emergency Department

BACKGROUND AND OBJECTIVES

Despite recent improvements in advanced life support, the overall survival rate after cardiac arrest remains low. We aimed to examine the association of a multidisciplinary team approach with clinical outcomes in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) in the emergency department (ED).

METHODS

This retrospective, single-center, observational study included 125 patients who underwent ECPR in the ED between May 2004-December 2018. In January 2014, our institution implemented a multidisciplinary extracorporeal membrane oxygenation (ECMO) team. Eligible patients were classified into pre-ECMO-team (n=65) and post-ECMO-team (n=60) groups. The primary outcome was in-hospital mortality.

RESULTS

In-hospital mortality (72.3% vs. 58.3%, p=0.102) and poor neurological outcomes (78.5% vs. 68.3%, p=0.283) did not differ significantly between the pre- and post-ECMO-team groups. However, among the 60 patients who experienced in-hospital cardiac arrest, in-hospital mortality (75.8% vs. 40.7%, p=0.006) and poor neurological outcomes (78.8% vs. 48.1%, p=0.015) significantly decreased after the multidisciplinary team formation. Multivariable logistic regression analysis showed that the multidisciplinary team approach (adjusted odds ratio, 0.20; 95% confidence interval, 0.07-0.61; p=0.005) was an independent prognostic factor for in-hospital mortality in in-hospital cardiac arrest patients.

CONCLUSIONS

A multidisciplinary team approach was associated with improved clinical outcomes in in-hospital cardiac arrest patients undergoing ECPR in the ED. These findings may help in improving the selection criteria for ECPR in the ED. Further studies to overcome the study limitations may help improving the outcomes of out-of-hospital cardiac arrest patients.

Initial Outcomes and Survival of Out-of-Hospital Cardiac Arrest: EuReCa Serbia Multicenter Cohort Study

Introduction Although the global survival rate of patients after out-of-hospital cardiac arrest (OHCA) has increased in the previous years, there still remain significant multifactorial public health challenges with many important aspects influencing the overall survival rate of these patients. The objective of this article is to analyze basic epidemiological parameters of OHCA in Serbia and to evaluate the influence of pre-hospitalization factors on the survival of OHCA patients. Methods Data on OHCA within the EuReCa Serbia Registry was collected according to the EuReCa Study protocol during the period October 1, 2014 - December 31, 2019, and included basic demographic data of the patients, data related to OHCA prior to hospital arrival, as well as data regarding subsequent hospitalization. Results The study included 6,266 EuReCa events (54% males), with a median age of 73 years [interquartile range (IQR) 63-82]. Cardiac arrest was witnessed in 3,111 out of 6,266 cases (49.6%), of which 2,725 cases (87.6%) were witnessed by bystanders and 286 cases (12.4%) by the emergency medical service (EMS) team. Resuscitation measures were attempted in 2,097 of 3,111 (67.4%) witnessed OHCA cases. Bystander cardiopulmonary resuscitation (CPR) was initiated in 288 cases within the bystander-witnessed group of 2,725 cases (10.6%). An initial shockable rhythm was detected in 323 out of 3,111 witnessed cases (10.4%). Any return of spontaneous circulation (ROSC) prior to hospital arrival was observed in 441 out of 2,097 cases where CPR was initiated (21.0%). Within the group of 2,097 events where CPR was initiated, in 287 cases the patient was transported to the hospital with ROSC (13.7%). An automated external defibrillator (AED) was used by bystanders in three cases. The collapse in locations other than the place of residence [p < 0.01; odds ratio (OR) 3.928], attempt to initiate CPR by a bystander (p < 0.01; OR 2.169), and presence of initial shockable rhythm (p = 0.01; OR 2.070) were observed as significant predictors of any ROSC in OHCA patients. Out of 287 patients hospitalized with ROSC, 54 (18.8%) were discharged alive. Conclusion Collapse outside of residence place, bystander CPR initiation, and initially detected shockable rhythm are important predictors of ROSC prior to hospital arrival and overall survival. Key factors of CPR-providing performance observed in this study were witnessing OHCA, CPR initiated by a bystander, presence of initial shockable rhythm, and any ROSC prior to hospital arrival.

Reliable and valid assessment of procedural skills in resuscitative endovascular balloon occlusion of the aorta

BACKGROUND

Valid and reliable assessment of skills is essential for improved and evidence-based training concepts. In a recent study, we presented a novel tool to assess procedural skills in resuscitative endovascular balloon occlusion of the aorta (REBOA), REBOA-RATE, based on international expert consensus. Although expert consensus is a strong foundation, the performance of REBOA-RATE has not been explored. The study aimed to examine the reliability and validity of REBOA-RATE.

METHODS

This was an experimental simulation-based study. We enrolled doctors with three levels of expertise to perform two REBOA procedures in a simulated scenario of out-of-hospital cardiac arrest. Procedures were video-recorded, and videos were blinded and randomized. Three clinical experts independently rated all procedures using REBOA-RATE. Data were analyzed using Messick's framework for validity evidence, including generalizability analysis of reliability and determination of a pass/fail standard.

RESULTS

Forty-two doctors were enrolled: 16 novices, 13 anesthesiologists, and 13 endovascular experts. They all performed two procedures, yielding 84 procedures and 252 ratings. The REBOA-RATE assessment tool showed high internal consistency (Cronbach's α = 0.95) and excellent interrater reliability (intraclass correlation coefficient, 0.97). Assessment using one rater and three procedures could ensure overall reliability suitable for high-stakes testing (G-coefficient >0.80). Mean scores (SD) for the three groups in the second procedure were as follows: novices, 32% (24%); anesthesiologists, 55% (29%); endovascular experts, 93% (4%) (p < 0.001). The pass/fail standard was set at 81%, which all experts but no novices passed.

CONCLUSION

Data strongly support the reliability and validity of REBOA-RATE, which successfully discriminated between all experience levels. The REBOA-RATE assessment tool requires minimal instruction, and one rater is sufficient for reliable assessment. Together, these are strong arguments for the use of REBOA-RATE to assess REBOA skills, allowing for competency-based training and certification concepts.

LEVEL OF EVIDENCE

Diagnostic test, no or poor gold standard, level V.

On-Site Medical Management of Avalanche Victims-A Narrative Review

Avalanche accidents are common in mountain regions and approximately 100 fatalities are counted in Europe each year. The average mortality rate is about 25% and survival chances are mainly determined by the degree and duration of avalanche burial, the patency of the airway, the presence of an air pocket, snow characteristics, and the severity of traumatic injuries. The most common cause of death in completely buried avalanche victims is asphyxia followed by trauma. Hypothermia accounts for a minority of deaths; however, hypothermic cardiac arrest has a favorable prognosis and prolonged resuscitation and extracorporeal rewarming are indicated. In this article, we give an overview on the pathophysiology and on-site management of avalanche victims.