Cardiac arrest: a public health perspective

Bag-Valve-Mask Ventilation and Survival From Out-of-Hospital Cardiac Arrest: A Multicenter Study

BACKGROUND

Few studies have measured ventilation during early cardiopulmonary resuscitation (CPR) before advanced airway placement. Resuscitation guidelines recommend pauses after every 30 chest compressions to deliver ventilations. The effectiveness of bag-valve-mask ventilation delivered during the pause in chest compressions is unknown. We sought to determine: (1) the incidence of lung inflation with bag-valve-mask ventilation during 30:2 CPR; and (2) the association of ventilation with outcomes after out-of-hospital cardiac arrest.

METHODS

We studied patients with out-of-hospital cardiac arrest from 6 sites of the Resuscitation Outcomes Consortium CCC study (Trial of Continuous Compressions versus Standard CPR in Patients with Out-of-Hospital Cardiac Arrest). We analyzed patients assigned to the 30:2 CPR arm with ≥2 minutes of thoracic bioimpedance signal recorded with a cardiac defibrillator/monitor. Detectable ventilation waveforms were defined as having a bioimpedance amplitude ≥0.5 Ω (corresponding to ≥250 mL VT) and a duration ≥1 s. We defined a chest compression pause as a 3- to 15-s break in chest compressions. We compared the incidence of ventilation and outcomes in 2 groups: patients with ventilation waveforms in <50% of pauses (group 1) versus those with waveforms in ≥50% of pauses (group 2).

RESULTS

Among 1976 patients, the mean age was 65 years; 66% were male. From the start of chest compressions until advanced airway placement, mean±SD duration of 30:2 CPR was 9.8±4.9 minutes. During this period, we identified 26 861 pauses in chest compressions; 60% of patients had ventilation waveforms in <50% of pauses (group 1, n=1177), and 40% had waveforms in ≥50% of pauses (group 2, n=799). Group 1 had a median of 12 pauses and 2 ventilations per patient versus group 2, which had 12 pauses and 12 ventilations per patient. Group 2 had higher rates of prehospital return of spontaneous circulation (40.7% versus 25.2%; P<0.0001), survival to hospital discharge (13.5% versus 4.1%; P<0.0001), and survival with favorable neurological outcome (10.6% versus 2.4%; P<0.0001). These associations persisted after adjustment for confounders.

CONCLUSIONS

In this study, lung inflation occurred infrequently with bag-valve-mask ventilation during 30:2 CPR. Lung inflation in ≥50% of pauses was associated with improved return of spontaneous circulation, survival, and survival with favorable neurological outcome.

Cardiac Arrest as a Public Health Issue

Sudden cardiac arrest has a large public health impact, especially, because its incidence continues to increase across the globe. Data for low-to-middle income countries is incomplete. CPR training and automatic external defibrillator availability are important points for focusing future efforts.

Assessing the weak links - Necessity and impact of regional cardiac arrest awareness campaigns for laypersons

Introduction

Public knowledge of out-of-hospital cardiac arrest (OHCA), and initiation of basic life support (BLS) is crucial to increase survival in OHCA.

Methods

The study analysed the knowledge and willingness to perform BLS of laypersons passing an AED at a public train station. Interviewees were recruited at two time points before and after a four year-long structured regional awareness campaign, which focused on call, compress, shock in a mid-size European city (270,000 inhabitants). Complete BLS was defined as multiple responses for call for help; initiation of chest compressions; and usage of an AED, without mentioning recovery position. Minimal BLS was defined as call for help and initiation of chest compressions.

Results

A total of 784 persons were interviewed, 257 at baseline and 527 post-campaign. Confronted with a fictional OHCA, at baseline 8.5% of the interviewees spontaneously mentioned actions for complete BLS and 17.9% post-campaign (p = 0.009). An even larger increase in knowledge was seen in minimal BLS (34.6% vs 60.6%, p < 0.001).

Conclusion

After a regional cardiac arrest awareness campaign, we found an increase in knowledge of BLS actions in the lay public. However, our investigation revealed severe gaps in BLS knowledge, possibly resulting in weak first links of the chain of survival.

Estimating the impact of the COVID‐19 pandemic on out‐of‐hospital cardiac arrest burden of disease in the United States

Background

The impact of the COVID‐19 pandemic on out‐of‐hospital cardiac arrest (OHCA) burden of disease in the United States is unknown. We sought to estimate and compare disability‐adjusted life years (DALYs) lost because of OHCA during the COVID‐19 pandemic to prepandemic values.

Methods

DALY were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD). Adult non‐traumatic emergency medical services‐treated OHCA from the Cardiac Arrest Registry to Enhance Survival database for 2016 to 2020 were used to estimate YLL. Cerebral performance category score disability weights were used to estimate YLD. The calculated DALY for the study population was extrapolated to a national level to estimate total US DALY. Data were reported as DALY total and rate. Data for 2020 (pandemic) were compared prepandemic years (2016–2019) via the chi‐square test or t‐test, as appropriate.

Results

A total of 440,438 OHCA met study inclusion criteria. Total OHCA DALY in the United States increased from 4,468,155 (YLL = 4,463,988; YLD = 4167) in 2019 to 5,379,660 (YLL = 5,375,464; YLD = 4197) in 2020. The DALY rate increased from 1357 per 100,000 individuals in 2019 to 1630 per 100,000 individuals in 2020. Bystander cardiopulmonary resuscitation (CPR) rates did not significantly change (47.96% in 2016–2019 vs. 47.89% in 2020; p = 0.157).

Conclusion

The overall burden of disease because of adult OHCA increased significantly during the COVID‐19 pandemic. We observed no change in the willingness of layperson bystanders to perform CPR on a national level in the United States.

ECPR2: Expert Consensus on PeRcutaneous Cannulation for Extracorporeal CardioPulmonary Resuscitation

AIM

Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a promising resuscitation strategy for select patients suffering from refractory out-of-hospital cardiac arrest (OHCA), though limited data exist regarding the best practices for ECPR initiation after OHCA.

METHODS

We utilized a modified Delphi process consisting of two survey rounds and a virtual consensus meeting to systematically identify detailed best practices for ECPR initiation following adult non-traumatic OHCA. A modified Delphi process builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires. Consensus was achieved when items reached a high level of agreement, defined as greater than 80% responses for a particular item rated a 4 or 5 on a 5-point Likert scale.

RESULTS

Snowball sampling generated a panel of 14 content experts, composed of physicians from four continents and five primary specialties. Seven existing institutional protocols for ECPR cannulation following OHCA were identified and merged into a single comprehensive list of 207 items. The panel reached consensus on 101 items meeting final criteria for inclusion: Prior to Patient Arrival (13 items), Inclusion Criteria (8), Exclusion Criteria (7), Patient Arrival (8), ECPR Cannulation (21), Go On Pump (18), and Post-Cannulation (26).

CONCLUSION

We present a list of items for ECPR initiation following adult nontraumatic OHCA, generated using a modified Delphi process from an international panel of content experts. These findings may benefit centers currently performing ECPR in quality assurance and serve as a template for new ECPR programs.

Comparison of Tele-Education and Conventional Cardiopulmonary Resuscitation Training During COVID-19 Pandemic

Background

Cardiopulmonary resuscitation (CPR) performed by lay rescuers can increase a person's chance of survival. The COVID-19 pandemic enforced prevention policies that encouraged social distancing, which disrupted conventional modes of health care education. Tele-education may benefit CPR training during the pandemic.

Objective

Our aim was to compare CPR knowledge and skills using tele-education vs. conventional classroom teaching methods.

Methods

A noninferiority trial was conducted as a Basic Life Support workshop. Participants were randomly assigned to a tele-education or conventional group. Primary outcomes assessed were CPR knowledge and skills and secondary outcomes assessed were individual skills, ventilation, and chest compression characteristics.

Results

Pretraining knowledge scores (mean ± standard deviation [SD] 3.50 ± 2.18 vs. 4.35 ± 1.70; p = 0.151) and post-training knowledge scores (7.91 ± 2.14 vs. 8.52 ± 0.90; p = 0.502) of the tele-education and conventional groups, respectively, had no statistically significant difference. Both groups’ training resulted in a significant and comparable gain in knowledge scores (p < 0.001). The tele-education and conventional groups skill scores (mean ± SD 78.30 ± 6.77 vs. 79.65 ± 9.93; p = 0.579) had no statistical difference. Skillset scores did not differ statistically except for the compression rate and ventilation ratio; the conventional group performed better (p = 0.042 vs. p = 0.017). The tele-education and conventional groups’ number of participants passed the skill test (95.5% and 91.3%, respectively; p = 1.000).

Conclusions

Tele-education offers a pragmatic and reasonably effective alternative to conventional CPR training during the COVID-19 pandemic.

Elevated prehospital point-of-care glucose is associated with worse neurologic outcome after out-of-hospital cardiac arrest

Objectives

Hyperglycemia is associated with poor outcomes in critically-ill patients. This has implications for prognostication of patients with out-of-hospital cardiac arrest (OHCA) and for post-resuscitation care. We assessed the association of hyperglycemia, on field point-of-care (POC) testing, with survival and neurologic outcome in patients with return of spontaneous circulation (ROSC) after OHCA.

Methods

This was a retrospective analysis of data in a regional cardiac care system from April 2011 through December 2017 of adult patients with OHCA and ROSC who had a field POC glucose. Patients were excluded if they were hypoglycemic (glucose <60 mg/dl) or received empiric dextrose. We compared hyperglycemic (glucose >250 mg/dL) with euglycemic (glucose 60–250 mg/dL) patients. Primary outcome was survival to hospital discharge (SHD). Secondary outcome was survival with good neurologic outcome (cerebral performance category 1 or 2 at discharge). We determined the adjusted odds ratios (AORs) for SHD and survival with good neurologic outcome.

Results

Of 9008 patients with OHCA and ROSC, 6995 patients were included; 1941 (28%) were hyperglycemic and 5054 (72%) were euglycemic. Hyperglycemic patients were more likely to be female, of non-White race, and have an initial non-shockable rhythm compared to euglycemic patients (p < 0.0001 for all). Hyperglycemic patients were less likely to have SHD compared to euglycemic survivors, 24.4% vs 32.9%, risk difference (RD) −8.5% (95 %CI −10.8%, −6.2%), p < 0.0001. Hyperglycemic survivors were also less likely to have good neurologic outcome compared to euglycemic survivors, 57.0% vs 64.6%, RD −7.6% (95 %CI −12.9%, −2.4%), p = 0.004. The AOR for SHD was 0.72 (95 %CI 0.62, 0.85), p < 0.0001 and for good neurologic outcome, 0.70 (95 %CI 0.57, 0.86), p = 0.0005.

Conclusion

In patients with OHCA, hyperglycemia on field POC glucose was associated with lower survival and worse neurologic outcome.

Low serum cholesterol level as a risk factor for out-of-hospital cardiac arrest: a case-control study

OBJECTIVE

We aimed to identify the association between low serum total cholesterol levels and the risk of out-of-hospital cardiac arrest (OHCA).

METHODS

This case-control study was performed using datasets from the Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance (CAPTURES) project and the Korea National Health and Nutrition Examination Survey (KNHANES). Cases were defined as emergency medical service-treated adult patients who experienced OHCA with a presumed cardiac etiology from the CAPTURES project dataset. Four controls from the KNHANES dataset were matched to each case based on age, sex, and county. Multivariable conditional logistic regression analysis was conducted to evaluate the effect of total cholesterol levels on OHCA.

RESULTS

A total of 607 matched case-control pairs were analyzed. We classified total cholesterol levels into six categories (<148, 148-166.9, 167-189.9, 190-215.9, 216-237.9, and ≥238 mg/dL) according to the distribution of total cholesterol levels in the KNHANES dataset. Subjects with a total cholesterol level of 167-189.9 mg/dL (25th-49th percentile of the KNHANES dataset) were used as the reference group. In both the adjusted models and sensitivity analysis, a total cholesterol level of <148 mg/dL was significantly associated with OHCA (adjusted odds ratio [95% confidence interval], 6.53 [4.47-9.56]).

CONCLUSION

We identified an association between very-low total cholesterol levels and an increased risk of OHCA in a large, community-based population. Future prospective studies are needed to better understand how a low lipid profile is associated with OHCA.

A simulation study of drone delivery of Automated External Defibrillator (AED) in Out of Hospital Cardiac Arrest (OHCA) in the UK

Background

Drones are increasingly used in healthcare, and feasibility studies of deployment of Automated External Defibrillators (AED) in Out-of-hospital cardiac arrest (OHCA) have been conducted. Despite the potential contribution of drones to healthcare, regulatory barriers exist, including limits on flights beyond visual line-of-sight (BVLOS). The aim of this project was to deliver an AED BVLOS in Wales.

Methods

We developed of a Concept of Operations (CONOPS) to identify requirements, constraints, organisation and roles and responsibilities associated with deploying a drone to deliver an AED BVLOS. We equipped a Penguin B drone with satellite-enabled technology to enhance situational awareness and safety for the remote pilot. A BVLOS Operating Safety Case and three-week flight test programme was conducted with an AED attached directly to parachute for deployment to simulated OHCA.

Results

We completed six flights totalling 92km, 1:02.5 hours of flight time and four successful parachute payload drops. We conducted a successful end-to-end flight demonstration of an AED delivered via BVLOS by drone to a simulated OHCA and resuscitation by lay responder’s in a remote location; the final delivery of 4.5km was completed in 2:50 minutes.

Conclusion

We have delivered an AED by parachute, from fixed wing drone BVLOS in the UK in simulated OHCA. This project adds to the body of knowledge required for regulatory assurance on drone use BVLOS. Further research is needed before routine use of this technology.

The effect of content knowledge and repeated teaching on teaching and learning basic life support: a cluster randomised controlled trial

BACKGROUND

Experimental research on the training of BLS instructors and how their performance evolves is scarce. This study investigated the role of content knowledge and repeated teaching trials for improving teaching and learning Basic Life Support (BLS).

METHODS

A cluster randomised controlled trial. Six secondary school teachers were assigned to either a common content knowledge (CCK) or specialised content knowledge (SCK) training. In the CCK group, teachers were taught to perform BLS technically correct. In the SCK group, teachers were additionally taught to detect and correct common errors students would make. Following the training, teachers taught two BLS lessons to two different classes of secondary school students (n = 216, age 12-14). Teachers' lesson organisation in terms of cognitive (e.g. task presentations), motor (e.g. practice time), and general (e.g. getting organised) activities was assessed. Students' BLS and CPR performance was assessed as the primary outcomes.

RESULTS

BLS performance was significantly higher in the second lesson for students taught by SCK versus CCK teachers (73% vs 63%). No significant difference was detected between lesson one and two across conditions and teachers. For cardiopulmonary resuscitation (CPR) variables, significant differences in favour of the SCK condition were found for chest compression depth after lesson one, and the amount and volume of ventilations after lesson two.

CONCLUSION

Students' BLS and CPR performance was positively impacted by the SCK training. BLS performance varied greatly by teachers with averages ranging from 53% to 83% across conditions. Results suggest teaching experience alone is not sufficient to improve teaching effectiveness.

Annual and lifetime economic productivity loss due to adult out-of-hospital cardiac arrest in the United States: A study for the CARES Surveillance Group

OBJECTIVE

To estimate the annual and lifetime economic productivity loss due to adult out-of-hospital cardiac arrest (OHCA) in the United States (U.S.).

METHODS

All adult (age ≥ 18 years) non-traumatic EMS-treated OHCA with complete data for age, sex, race, and survival outcomes from the CARES database for 2013-2018 were included. Annual and lifetime labor productivity values, based on age and gender, were obtained from previously published national economic data. Productivity losses for OHCA events were calculated by year in U.S. dollars. Productivity losses for survivors were assigned by cerebral performance category score (CPC): CPC 1 and 2 = 0% productivity loss; CPC 3-5 = 100% productivity loss. Sensitivity analyses were performed assigning CPC 2 varying productivity losses (0-100%) based on CPC score and discharge location. Lifetime productivity values assumed 1% annual growth and 3% discount rate and were adjusted for inflation based on 2016 values. Results were extrapolated to annual U.S. population estimates for the study period.

RESULTS

A total of 338,492 (96.5%) cases met inclusion criteria. The mean annual and lifetime productivity losses per OHCA in 2018 were $48,224 and $638,947 respectively. The total annual economic productivity loss due to OHCA in the U.S. increased from $7.4B in 2013 to $11.3B in 2018. Lifetime economic productivity loss increased from $95.2B in 2013 to $150.2B in 2018. Sensitivity analyses yielded similar findings. Per annual death, OHCA ranked third ($10.2B) in annual economic productivity loss in the U.S. behind cancer ($22.9B) and heart disease ($20.3B) in 2018.

CONCLUSION

Adult non-traumatic OHCA events are associated with significant annual and lifetime economic productivity losses and should be the focus of public health resources to improve preventative measures and survival outcomes.

The use of virtual reality and augmented reality to enhance cardio-pulmonary resuscitation: a scoping review

BACKGROUND AND OBJECTIVE

Virtual reality (VR) and augmented reality (AR) have been proposed as novel methods to enhance cardio-pulmonary resuscitation (CPR) performance and increase engagement with CPR training. A scoping review was conducted to map the global evolution of these new approaches to CPR training, to assess their efficacy and determine future directions to meet gaps in current knowledge.

METHODS

A standardised five-stage scoping methodology was used to (1) identify the research question, (2) identify relevant studies, (3) select the studies, (4) chart the data and (5) summarise the findings. The Kirkpatrick model levels of evidence were used to chart and assess the efficacy of each intervention reported. A multi-pronged search term strategy was used to search the Web of Science, PubMed, CINAHL and EMBASE databases up to June 2020.

RESULTS

A total of 42 articles were included in this review. The first relevant paper identified was published in 2009 and based on VR, from 2014 onwards there was a large increase in the volume of work being published regarding VR and AR uses in CPR training. This review reports Kirkpatrick level one to three evidence for the use of VR/AR-CPR. Inconsistencies in the specific language, keywords used and methodologies are highlighted.

CONCLUSION

VR and AR technologies have shown great potential in the area of CPR, and there is continuing evidence of new novel applications and concepts. As VR/AR research into CPR reaches an inflection point, it is key to bring collaboration and consistency to the wider research community, to enable the growth of the area and ease of access to the wider medical community.

Trend analysis of disability-adjusted life years following adult out-of-hospital cardiac arrest in the United States: A study from the CARES Surveillance Group

AIM

To estimate and trend disability-adjusted life years (DALY) following adult out-of-hospital cardiac arrest (OHCA) over time, and to compare OHCA DALY to other leading causes of death and disability in the U.S.

METHODS

DALY were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD). Adult non-traumatic emergency medical services-treated OHCA from the Cardiac Arrest Registry to Enhance Survival (CARES) database for 2013-2018 were used to estimate YLL. Cerebral performance category score disability weights were used to estimate YLD. The calculated DALY for the study population was extrapolated to a national level to estimate total U.S. DALY. Data were reported as DALY total and rate. Data were compared to the top 10 causes of DALY in the U.S.

RESULTS

337,991 OHCA met study inclusion criteria. Total U.S. OHCA DALY increased from 3,005,308 in 2013 to 4,326,745 in 2018. The DALY rate increased from 950.9 per 100,000 individuals to 1322.4 per 100,000 individuals. OHCA DALY ranked fifth in the U.S. behind ischemic heart disease (2470), drug use disorders (1703), chronic obstructive pulmonary disease (1449), and back pain (1336). OHCA represented the largest percent increase in DALY rate (40.3%) over the study period.

CONCLUSION

Adult non-traumatic OHCA is a leading cause of DALY in the U.S. and the burden of disease due to OHCA has increased rapidly over time. These findings are likely due to more precise national OHCA surveillance, and suggest that the public health impact of OHCA is larger than previously described.

[Can we train the chain of survival while playing? Validation of the tool «Rescube»]

PURPOSE

To validate the content and adequacy of the «Rescube» training material that includes adapted information from the chain of survival.

MATERIAL AND METHODS

The study included three steps: (i)material development by 7 experts, following Delphi method; (ii)assessment of training material by 11 experts by means of a Likert score and calculation of content validity; and (iii)pilot study in two groups of 5 to 8years-old: Rescube group (GR; n=60) and Traditional group (GT; n=60). GR was trained with Rescube and a Teddy bear, while GT was traditionally trained with a pediatric manikin. Participants were individually assessed at baseline, and one week and one month after training.

RESULTS

All content validity indexes calculated are above the recommended cut-off for analysis with more than 9 experts (≥0,80). Children's learning results were positive, with percentages equal or higher than 80% in all registered variables at the first (one week) evaluation and equal or higher than 67% when evaluated one month after training. No significant differences were detected between groups.

CONCLUSION

The Rescube training tool based on infantile pictures is valid and useful to train young schoolchildren in the chain of survival.

Up to 206 Million People Reached and Over 5.4 Million Trained in Cardiopulmonary Resuscitation Worldwide: The 2019 International Liaison Committee on Resuscitation World Restart a Heart Initiative

Sudden out‐of‐hospital cardiac arrest is the third leading cause of death in industrialized nations. Many of these lives could be saved if bystander cardiopulmonary resuscitation rates were better. “All citizens of the world can save a life—CHECK—CALL—COMPRESS.” With these words, the International Liaison Committee on Resuscitation launched the 2019 global “World Restart a Heart” initiative to increase public awareness and improve the rates of bystander cardiopulmonary resuscitation and overall survival for millions of victims of cardiac arrest globally. All participating organizations were asked to train and to report the numbers of people trained and reached. Overall, social media impact and awareness reached up to 206 million people, and >5.4 million people were trained in cardiopulmonary resuscitation worldwide in 2019. Tool kits and information packs were circulated to 194 countries worldwide. Our simple and unified global message, “CHECK—CALL—COMPRESS,” will save hundreds of thousands of lives worldwide and will further enable many policy makers around the world to take immediate and sustainable action in this most important healthcare issue and initiative.

The Effect of Basic CPR Training on Adults' Knowledge and Performance in Rural Areas of Iran: A Quasi-Experimental Study

Introduction

Cardiac arrest happening outside the hospital, specifically in rural regions that are more distant from health centers, is a crucial issue in the health of individuals in those regions. Therefore, the ability of residents in those regions to do cardiopulmonary resuscitation (CPR) is very important in preventing death among people. This study aimed at determining the effect of basic CPR training on the adults’ knowledge and performance in rural areas.

Methodology

This quasi-experimental study was conducted on 92 adults from rural areas of Shouraab Kohmareh-Sorkhi in Fars province, Iran, in September and October 2018. The samples were selected and divided into two groups using the simple random method. The data were collected using a demographic information form, knowledge questionnaire, and an observational checklist of CPR performance devised by the researcher. Basic teaching of CPR for the intervention group included two hours of oral teaching using lecture and question and answer as well as two hours of practical teaching using demonstration, practice on a manikin, provision of feedback, and correction of errors. The data were entered into the SPSS statistical software, version 21 and were analyzed using descriptive statistical tests, Kolmogorov–Smirnov test, independent t-test, chi-square test, Wilcoxon signed-rank test, and Mann–Whitney test.

Findings

The study results revealed that the intervention group’s mean score of knowledge was significantly greater after the intervention (6.78±1.23) compared to that at baseline (2.78±1.74) and compared to the control group (3.24±1.84) (p<0.001). Additionally, the intervention group’s mean score of performance was significantly greater after the intervention (8.22±1.65) than that before the intervention (0.8±0.77) and compared to the control group (1.17±0.71) (p<0.001).

Conclusion

According to the study findings, the villagers’ performance and knowledge could be enhanced by teaching basic CPR techniques.

Trial Registration Number

IRCT20150714023199N3; date registered: 2018-05-06.

'The (second) year of first aid': a 15-month follow-up after a 3-day first aid programme

AIM

First aid education in early childhood can be an effective method to increase the number of trained bystanders. Our aim was to evaluate the long-term effects of a 3-day first aid programme for all primary school-age groups (7-14 years old).

METHODS

This study was a 15-month follow-up of our previous investigation. Five-hundred and twenty-four primary school children were involved in this study. Measurements were made on the following topics: adult basic life support, using an automated external defibrillator (AED), handling an unconscious patient, managing bleeding and calling the ambulance. Data collection was made with a self-made questionnaire and skill test.

RESULTS

Knowledge and skills were significantly higher after 15 months than before training (p<0.01). However, these results were significantly worse than immediately and 4 months after training (p<0.01). Based on the questionnaire, more than three-quarters knew the emergency phone number 15 months after training. Approximately two-thirds of the children could use the correct hand position in cardiopulmonary resuscitation, the correct compression-ventilation ratio and an AED, and half of them could perform correct recovery position at 15 months. Correct assessment of breathing was similar in a situation game than before training. Self-efficacy improved significantly after training (p<0.01) and remained improved after 4 and 15 months when compared with before training (p<0.01).

CONCLUSION

Participants could remember some aspects of first aid long term. However, knowledge and skills had declined after 15 months, so refresher training would be recommended. Self-efficacy towards first aid improved after training and remained high after 15 months.

Effect of estimated glomerular filtration rate (eGFR) on incidence of out-of-hospital cardiac arrests: A case-control study

OBJECTIVES

Serum creatinine levels in the post-resuscitative state have been associated with poor prognosis for out-of-hospital cardiac arrest (OHCA). Several studies have focused on kidney dysfunction in the general population, and the results suggested that serum creatinine level elevation or reduction of the estimated glomerular filtration rate (eGFR) are associated with increased risk of death and cardiovascular events. However, it is uncertain whether the serum creatinine levels or eGFR of OHCA patients are related to the incidence of OHCA. The aim of this study was to determine the association between eGFR and the incidence of OHCA.

METHODS

This study was a case-control study performed using the Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance (CAPTURES) project dataset and the Korea National Health and Nutrition Examination Survey (KNHANES) dataset. Cases were defined as emergency medical service-treated adult OHCA patients with presumed cardiac etiology collected from the CAPTURES dataset. Four controls from the KNHANES dataset were matched to one case based on age, gender, and county. Multivariable conditional logistic regression analysis was conducted to evaluate the effect of eGFR on the incidence of OHCA.

RESULTS

A total of 1211 matched case-control pairs were included in the study analysis. We classified eGFR into 6 categories (≥90, 60-89, 45-59, 30-44, 15-29, and <15 mL/min/1.73 m²) according to the chronic kidney disease stage. Subjects with an eGFR ≥90 mL/min/1.73 m² were used as the reference group. In both the unadjusted and adjusted models, lower eGFR was significantly associated with OHCA incidence. The odds ratio (OR) for OHCA incidence increased sharply as the eGFR declined; the adjusted OR (95% CI) for OHCA incidence was 4.09 (2.81-5.95) with an eGFR of 60-89 mL/min/1.73 m², 36.59 (22.24-60.21) with an eGFR of 45-59 mL/min/1.73 m², 55.26(29.66-102.94) with an eGFR of 30-44 mL/min/1.73 m², 89.65 (37.25-215.79) with an eGFR of 15-29 mL/min/1.73 m², and 241.87 (73.49-796.01) with an eGFR of less than 15 mL/min/1.73 m².

CONCLUSION

In this study, we observed an association between reduced eGFR and the risk of OHCA incidence in a large, community-based population. Future prospective studies are needed to better understand how reduced renal function is associated with OHCA occurrence as well as the impact of intensive risk management and intervention of renal function on OHCA incidence.

Association of ventilation with outcomes from out-of-hospital cardiac arrest

AIM OF STUDY

To determine the association between bioimpedence-detected ventilation and out-of-hospital cardiac arrest (OHCA) outcomes.

METHODS

This is a retrospective, observational study of 560 OHCA patients from the Dallas-Fort Worth site enrolled in the Resuscitation Outcomes Consortium Trial of Continuous or Interrupted Chest Compressions During CPR from 4/2012 to 7/2015. We measured bioimpedance ventilation (lung inflation) waveforms in the pause between chest compression segments (Physio-Control LIFEPAK 12 and 15, Redmond, WA) recorded through defibrillation pads. We included cases ≥18 years with presumed cardiac cause of arrest assigned to interrupted 30:2 chest compressions with bag-valve-mask ventilation and ≥2 min of recorded cardiopulmonary resuscitation. We compared outcomes in two a priori pre-specified groups: patients with ventilation waveforms in <50% of pauses (Group 1) versus those with waveforms in ≥50% of pauses (Group 2).

RESULTS

Mean duration of 30:2 CPR was 13 ± 7 min with a total of 7762 pauses in chest compressions. Group 1 (N = 424) had a median 11 pauses and 3 ventilations per patient vs. Group 2 (N = 136) with a median 12 pauses and 8 ventilations per patient, which was associated with improved return of spontaneous circulation (ROSC) at any time (35% vs. 23%, p < 0.005), prehospital ROSC (19.8% vs. 8.7%, p < 0.0009), emergency department ROSC (33% vs. 21%, p < 0.005), and survival to hospital discharge (10.3% vs. 4.0%, p = 0.008).

CONCLUSIONS

This novel study shows that ventilation with lung inflation occurs infrequently during 30:2 CPR. Ventilation in ≥50% of pauses was associated with significantly improved rates of ROSC and survival.

Survival After Exercise-Related Sudden Cardiac Arrest in Young Athletes: Can We Do Better?

BACKGROUND:

Sudden cardiac arrest (SCA) is the leading cause of death in young athletes during sports.

HYPOTHESIS:

Survival after SCA in young athletes is variable.

STUDY DESIGN:

Prospective, active surveillance study.

LEVEL OF EVIDENCE:

Level 3.

METHODS:

From July 1, 2014, to June 30, 2016, exercise-related SCA in competitive young athletes was identified through a systematic search of traditional and social media sources, direct reporting to the National Center for Catastrophic Sports Injury Research, searching of the National Collegiate Athletic Association Resolutions List, regular communication with national and state high school athletic associations, and review of cases in the Parent Heart Watch database.

RESULTS:

A total of 132 cases were identified during the 2-year study period (mean patient age, 16 years; age range, 11-27 years; 84% male; 51% white non-Hispanic/Latino, 30% black/African American, and 11% white Hispanic/Latino). High school athletes accounted for 78 (59%) cases, with 28 (21%) in middle school and 15 (11%) in college athletes. Overall survival was 48% (95% CI, 40%-57%; 64 survivors, 68 deaths). Survival was similar in male versus female athletes but higher in white non-Hispanic/Latino (40/67; 60%) versus black/African American (13/39; 33%) athletes (difference, 27%; 95% CI, 7%-45%; P = 0.008) and white non-Hispanic/Latino versus all minority (18/59; 31%) athletes (difference, 29%; 95% CI, 13%-46%; P = 0.001). Basketball accounted for 30% of cases, followed by football (25%), track/cross-country (12%), and soccer (11%). The majority (93%) of cases were witnessed. If a certified athletic trainer was on-site and involved in the resuscitation, 83% of athletes survived. If an on-site automated external defibrillator was used in the resuscitation, 89% of athletes survived.

CONCLUSION:

Exercise-related SCA in young, competitive athletes is typically witnessed, providing an opportunity for rapid resuscitation. Additional research is needed to identify factors that affect survival in different athlete populations.

CLINICAL RELEVANCE:

Public access defibrillator programs should be universal in schools and youth sporting venues and have the potential to increase survival after SCA in young athletes.

The impact of cardiopulmonary resuscitation (CPR) manikin chest stiffness on motivation and CPR performance measures in children undergoing CPR training-A prospective, randomized, single-blind, controlled trial

BACKGROUND

Cardio-pulmonary-resuscitation (CPR) training starting at the age of 12 years is recommended internationally. Training younger children is not recommended because young children lack the physical ability to perform adequate CPR and discouragement to perform CPR later is apprehended. The aim of this study was to answer the following questions: Are younger children discouraged after CPR training? Is discouragement caused by their lack in physical ability to perform adequate chest compressions on a standard manikin and would the use of manikins with a reduced resistance affect their motivation or performance?

METHODS

We investigated the motivation and CPR performance of children aged 8-13 years after CPR training on manikins of different chest stiffness in a prospective, randomized, single-blind, controlled trial. 322 children underwent randomization and received 30 minutes CPR training in small groups at school. We used two optically identical resuscitation manikins with different compression resistances of 45kg and 30kg. Motivation was assessed with a self-administered questionnaire. Performance was measured with the Resusci®Anne SkillReporter™.

FINDINGS

Motivation after the training was generally high and there was no difference between the two groups in any of the questionnaire items on motivation: Children had fun (98 vs. 99%; P = 0.32), were interested in the training (99 vs. 98%; P = 0.65), and were glad to train resuscitation again in the future (89 vs. 91%; P = 0.89). CPR performance was generally poor (median compression score (8, IQR 1-45 and 29, IQR 11-54; P<0.001) and the mean compression depth was lower in the 45kg-resistance than in the 30kg-resistance group (33±10mm vs. 41±9; P<0.001).

CONCLUSIONS

Compression resistances of manikins, though influencing CPR performance, did not discourage 8 to 13 year old children after CPR training. The findings refute the view that young children are discouraged when receiving CPR training even though they are physically not able to perform adequate CPR.

The past, present, and future of ventilation during cardiopulmonary resuscitation

PURPOSE OF REVIEW

To evaluate the past and present literature on ventilation during out of hospital cardiac arrest, highlighting research that has informed current guidelines.

RECENT FINDINGS

Previous studies have studied what are optimal compression-to-ventilation ratios, ventilation rates, and methods of ventilation. Continuous chest compression cardiopulmonary resuscitation (CPR) has not shown to provide a significant survival benefit over the traditional 30 : 2 CPR. The optimal ventilation rate is recommended at 8 to 10 breaths per minute. Methods such as capnography and thoracic impedance are being used to evaluate ventilation in research studies.

SUMMARY

Future out of hospital cardiac arrest studies are still exploring how to optimize the delivery of ventilation during the initial stages of resuscitation. More prospective studies focusing on ventilation are needed to inform guidelines.

School Children Save Lives

Sudden cardiac death is one of the most common causes of preventable death in the industrialized world. In countries with organized emergency health services, it is possible to increase the rate of resuscitation performed by the public and save more lives. Increasing the rate of correct intervention by those witnessing sudden cardiac death requires an increase in the number of adults with training in CPR in society. Resuscitation training should begin in the school years to reach the whole of society within time. As school children with training in CPR increase, the proportion of individuals in society with training and the desire to help others increases, which causes a general increase in resuscitation rates. To teach children "Basic Life Support" the training models should be applied in theory, with training kits, and accompanied by educators, with a variety of figures based on video or computer based training. One of the most important steps in increasing the resuscitation rates performed by the public globally and enhancing survival is through training school children.

Dysfunction of Membrane Trafficking Leads to Ischemia-Reperfusion Injury After Transient Cerebral Ischemia

Neurons require an extraordinarily high level of membrane trafficking activities because of enriched axonal terminals and dendritic branches. For that reason, defects in the membrane trafficking pathway are a hallmark of most, and may be all, neurodegenerative disorders. A major cellular membrane trafficking pathway is the Golgi apparatus (Golgi hereafter)-late endosome-lysosome axis for supplying lysosomal enzymes. This pathway is regulated by N-ethylmaleimide-sensitive factor (NSF) ATPase. This review article is to discuss a novel hypothesis that brain ischemia inactivates NSF ATPase, resulting in a cascade of events of disruption of the Golgi-endosome-lysosome pathway, release of cathepsin B (CTSB), and induction of mitochondrial outer membrane permeabilization (MOMP) during the postischemic phase. This hypothesis is supported by recent studies demonstrating that NSF is trapped into inactive protein aggregates in neurons destined to die after brain ischemia. Consequently, Golgi, transport vesicles (TVs), and late endosomes (LEs) are accumulated and damaged, which is followed by CTSB release from these damaged structures. Moderate release of CTSB cleaves Bax-like BH3 protein (Bid) to become active truncated Bid (tBid). Active tBid is then translocated to the mitochondrial outer membrane, resulting in oligomerization of BCL2-associated X protein (Bax) forming the mitochondrial outer membrane pores, and releasing mitochondrial intramembranous proteins. Extensive CTSB release, however, can digest cellular proteins indiscriminately to induce cell death. Based on these new observations, we propose a novel hypothesis, i.e., brain ischemia leads to NSF inactivation, resulting in a massive buildup of damaged Golgi, TVs and LEs, fatal release of CTSB, induction of MOMP, and eventually brain ischemia-reperfusion injury.

Impact of training in Advanced Cardiac Life Support (ACLS) in the professional career and work environment

We sought to evaluate the impact of Advanced Cardiac Life Support (ACLS) training in the professional career and work environment of physicians who took the course in a single center certified by the American Heart Association (AHA). Of the 4631 students (since 1999 to 2009), 2776 were located, 657 letters were returned, with 388 excluded from the analysis for being returned lacking addressees. The final study population was composed of 269 participants allocated in 3 groups (< 3 years, 3-5 and > 5years). Longer training was associated with older age, male gender, having undergone residency training, private office, greater earnings and longer time since graduation and a lower chance to participate in providing care for a cardiac arrest. Regarding personal change, no modification was detected according to time since taking the course. The only change in the work environment was the purchase of an automated external defibrillator (AED) by those who had taken the course more than 5 years ago. In multivariable analysis, however, the implementation of an AED was not independently associated with this group, which showed a lower chance to take a new ACLS course. ACLS courses should emphasize also how physicians could reinforce the survival chain through environmental changes.

National Institutes of Health-Funded Cardiac Arrest Research: A 10-Year Trend Analysis

BACKGROUND

Cardiac arrest (CA) is a leading cause of death in the United States, claiming over 450 000 lives annually. Improving survival depends on the ability to conduct CA research and on the translation and implementation of research findings into practice. Our objective was to provide a descriptive analysis of annual National Institutes of Health (NIH) funding for CA research over the past decade.

METHOD AND RESULTS

A search within NIH RePORTER for the years 2007 to 2016 was performed using the terms: "cardiac arrest" or "cardiopulmonary resuscitation" or "heart arrest" or "circulatory arrest" or "pulseless electrical activity" or "ventricular fibrillation" or "resuscitation." Grants were reviewed and categorized as CA research (yes/no) using predefined criteria. The annual NIH funding for CA research, number of individual grants, and principal investigators were tabulated. The total NIH investment in CA research for 2015 was calculated and compared to those for other leading causes of death within the United States. Interrater reliability among 3 independent reviewers for fiscal year 2015 was assessed using Fleiss κ. The search yielded 2763 NIH-funded grants, of which 745 (27.0%) were classified as CA research (κ=0.86 [95%CI 0.80-0.93]). Total inflation-adjusted NIH funding for CA research was $35.4 million in 2007, peaked at $76.7 million in 2010, and has decreased to $28.5 million in 2016. Per annual death, NIH invests ≈$2200 for stroke, ≈$2100 for heart disease, and ≈$91 for CA.

CONCLUSIONS

This analysis demonstrates that the annual NIH investment in CA research is low relative to other leading causes of death in the United States and has declined over the past decade.

Kids save lives: a six-year longitudinal study of schoolchildren learning cardiopulmonary resuscitation: Who should do the teaching and will the effects last?

AIMS

This prospective longitudinal study over 6 years compared schoolteachers and emergency physicians as resuscitation trainers for schoolchildren. It also investigated whether pupils who were trained annually for 3 years retain their resuscitation skills after the end of this study.

METHODS

A total of 261 pupils (fifth grade) at two German grammar schools received resuscitation training by trained teachers or by emergency physicians. The annual training events stopped after 3 years in one group and continued for 6 years in a second group. We measured knowledge about resuscitation (questionnaire), chest compression rate (min(-1)), chest compression depth (mm), ventilation rate (min(-1)), ventilation volume (mL), self-efficacy (questionnaire). Their performance was evaluated after 1, 3 and 6 years.

RESULTS

The training events increased the pupils' knowledge and practical skills. When trained by teachers, the pupils achieved better results for knowledge (92.86% ± 8.38 vs. 90.10% ± 8.63, P=0.04) and ventilation rate (4.84/min ± 4.05 vs. 3.76/min ± 2.37, P=0.04) than when they were trained by emergency physicians. There were no differences with regard to chest compression rate, depth, ventilation volume, or self-efficacy at the end of the study. Knowledge and skills after 6 years were equivalent in the group with 6 years training compared with 3 years training.

CONCLUSIONS

Trained teachers can provide adequate resuscitation training in schools. Health-care professionals are not mandatory for CPR training (easier for schools to implement resuscitation training). The final evaluation after 6 years showed that resuscitation skills are retained even when training is interrupted for 3 years.

Comparative effectiveness of standard CPR vs active compression-decompression CPR with CardioPump for treatment of cardiac arrest

BACKGROUND

Despite all of the studies conducted on cardiopulmonary resuscitation (CPR), the mortality rate of cardiac arrest patients is still high. This has led to a search for alternative methods. One of these methods is active compression-decompression CPR (ACD-CPR) performed with the CardioPump.

OBJECTIVE

The differences in the restoration of spontaneous circulation; the 1-, 7-, and 30-day survival rates; and hospital discharge rates between conventional CPR and ACD-CPR performed with CardioPump were investigated. In addition, the differences between the 2 methods with respect to complications were also investigated.

METHODS

Our study was a prospective, randomized medical device study with a case-control group. Cardiac arrest cases brought to our emergency medicine clinic by the 112 emergency ambulances from out of hospital and patients who had developed cardiac arrest inhospital clinics between April 2015 and September 2015 were included in our study. For randomization, standard CPR was performed on odd days of each month, and CPR using CardioPump was performed on the even days of each month.

RESULTS

A total of 181 patients were included in our study. The number of patients who received conventional CPR was determined as 86 (47.5%), and the number of patients who received CPR using the CardioPump was determined as 95 (52.5%). We did not identify any difference between conventional CPR and CardioPump ACD-CPR with respect to restoration of spontaneous circulation, discharge rates, and the 1-, 7-, and 30-day survival rates. (P=.384, P=.601, P=.997, P=.483, and P=.803, respectively) The complication rate was higher in the patient group that received conventional CPR (P<.001).

CONCLUSION

As a result of our study, we did not obtain any evidence supporting the replacement of conventional CPR with ACD-CPR performed using CardioPump.

Treatment and outcome of out-of-hospital cardiac arrest in outpatient health care facilities

AIM

We evaluated the frequency and effectiveness of basic and advanced life support (ALS) interventions by medical professionals when out-of-hospital cardiac arrest (OHCA) occurred in ambulatory healthcare clinics before emergency medical services (EMS) arrival.

METHODS

Non-traumatic OHCAs in adults were systematically characterized over a 15 year period by their occurrence in clinics, at home, or in non-medical public locations, and outcomes compared between matched cohorts from each group.

RESULTS

Among 7784 patients, 6098 OHCA occurred at home, 1612 in non-medical public locations and 74 in clinics. Compared to non-medical public locations, clinic patients with OHCA were older, more often women and more frequently shocked; clinic arrests were more often witnessed, less likely to be of cardiac cause and to occur before EMS arrival. Compared to home, more clinic arrests were witnessed, occurred after EMS arrival, had bystander CPR, shockable rhythms and were defibrillated. When OHCA occurred before EMS arrival, 51 of 56 clinic patients (91%) received CPR, a defibrillator applied to 23 (41%), 17 (30%) were shocked, 4 (7%) intubated, and 7 (13%) received intravenous medications from facility personnel. Of these, only pre-EMS defibrillator use was associated with improved outcome. Among matched patients, OHCA survival was higher in clinics than at home (42% vs 26%, p=0.029), but comparable to other public locations.

CONCLUSIONS

Survival from OHCA in clinics was comparable to non-medical public locations, and higher than at home. Alongside CPR, use of defibrillators was associated with improved survival and worth prioritizing over other interventions before EMS arrival regardless of OHCA location.

Basic life support knowledge of first-year university students from Brazil

We aimed to evaluate knowledge of first aid among new undergraduates and whether it is affected by their chosen course. A questionnaire was developed to assess knowledge of how to activate the Mobile Emergency Attendance Service - MEAS (Serviço de Atendimento Móvel de Urgência; SAMU), recognize a pre-hospital emergency situation and the first aid required for cardiac arrest. The students were also asked about enrolling in a first aid course. Responses were received from 1038 of 1365 (76.04%) new undergraduates. The questionnaires were completed in a 2-week period 1 month after the beginning of classes. Of the 1038 respondents (59.5% studying biological sciences, 11.6% physical sciences, and 28.6% humanities), 58.5% knew how to activate the MEAS/SAMU (54.3% non-biological vs 61.4% biological, P=0.02), with an odds ratio (OR)=1.39 (95%CI=1.07-1.81) regardless of age, sex, origin, having a previous degree or having a relative with cardiac disease. The majority could distinguish emergency from non-emergency situations. When faced with a possible cardiac arrest, 17.7% of the students would perform chest compressions (15.5% non-biological vs 19.1% biological first-year university students, P=0.16) and 65.2% would enroll in a first aid course (51.1% non-biological vs 74.7% biological, P<0.01), with an OR=2.61 (95%CI=1.98-3.44) adjusted for the same confounders. Even though a high percentage of the students recognized emergency situations, a significant proportion did not know the MEAS/SAMU number and only a minority had sufficient basic life support skills to help with cardiac arrest. A significant proportion would not enroll in a first aid course. Biological first-year university students were more prone to enroll in a basic life support course.