Precordial thump efficacy in termination of induced ventricular arrhythmias

Advanced life support interventions during intra-operative cardiac arrest among adults as reported to the 7th National Audit Project of the Royal College of Anaesthetists

BACKGROUND

Few existing resuscitation guidelines include specific reference to intra-operative cardiac arrest, but its optimal treatment is likely to require some adaptation of standard protocols.

METHODS

We analysed data from the 7th National Audit Project of the Royal College of Anaesthetists to determine the incidence and outcome from intra-operative cardiac arrest and to summarise the advanced life support interventions reported as being used by anaesthetists.

RESULTS

In the baseline survey, > 50% of anaesthetists responded that they would start chest compressions when the non-invasive systolic pressure was < 40-50 mmHg. Of the 881 registry patients, 548 were adult patients (aged > 18 years) having non-obstetric procedures under the care of an anaesthetist, and who had arrested during anaesthesia (from induction to emergence). Sustained return of spontaneous circulation was achieved in 425 (78%) patients and 338 (62%) were alive at the time of reporting. In the 365 patients with pulseless electrical activity or bradycardia, adrenaline was given as a 1 mg bolus in 237 (65%). A precordial thump was used in 14 (3%) patients, and although this was associated with return of spontaneous circulation at the next rhythm check in almost three-quarters of patients, in only one of these was the initial rhythm shockable. Calcium (gluconate or chloride) and 8.4% sodium bicarbonate were given to 51 (9%) and 25 (5%) patients, but there were specific indications for these treatments in less than half of the patients. A thrombolytic drug was given to 5 (1%) patients, and extracorporeal cardiopulmonary resuscitation was used in 9 (2%) of which eight occurred during cardiac procedures.

CONCLUSIONS

The specific characteristics of intra-operative cardiac arrest imply that its optimal treatment requires modifications to standard advanced life support guidelines.

The effect of alternative methods of cardiopulmonary resuscitation - Cough CPR, percussion pacing or precordial thump - on outcomes following cardiac arrest. A systematic review

BACKGROUND

Cardiopulmonary resuscitation (CPR) improves cardiac arrest survival. Cough CPR, percussion pacing and precordial thump have been reported as alternative CPR techniques. We aimed to summarise in a systematic review the effectiveness of these alternative CPR techniques.

METHODS

We searched Ovid MEDLINE, EMBASE and the Cochrane Library on 24/08/2020. We included randomised controlled trials, observational studies and case series with five or more patients. Two reviewers independently reviewed title and abstracts to identify studies for full-text review, and reviewed bibliographies and 'related articles' (using PubMed) of full-texts for further eligible studies. We extracted data and performed risk-of-bias assessments on studies included in the systematic review. We summarised data in a narrative synthesis, and used GRADE to assess evidence certainty.

RESULTS

We included 23 studies (cough CPR n = 4, percussion pacing n = 4, precordial thump n = 16; one study studied two interventions). Only two (both precordial thump) had a comparator group ('standard' CPR). For all techniques evidence certainty was very low. Available evidence suggests that precordial thump does not improve survival to hospital discharge in out-of-hospital cardiac arrest. The review did not find evidence that cough CPR or percussion pacing improve clinical outcomes following cardiac arrest.

CONCLUSION

Cough CPR, percussion pacing and precordial thump should not be routinely used in established cardiac arrest. In specific inpatient, monitored settings cough CPR (in conscious patients) or percussion pacing may be attempted at the onset of a potential lethal arrhythmia. These must not delay standard CPR efforts in those who lose cardiac output.

PROSPERO REGISTRATION NUMBER

CRD42019152925.

Adult Basic Life Support: International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care Science With Treatment Recommendations on basic life support summarizes evidence evaluations performed for 20 topics that were prioritized by the Basic Life Support Task Force of the International Liaison Committee on Resuscitation. The evidence reviews include 16 systematic reviews, 3 scoping reviews, and 1 evidence update. Per agreement within the International Liaison Committee on Resuscitation, new or revised treatment recommendations were only made after a systematic review.

Systematic reviews were performed for the following topics: dispatch diagnosis of cardiac arrest, use of a firm surface for CPR, sequence for starting CPR (compressions-airway-breaths versus airway-breaths-compressions), CPR before calling for help, duration of CPR cycles, hand position during compressions, rhythm check timing, feedback for CPR quality, alternative techniques, public access automated external defibrillator programs, analysis of rhythm during chest compressions, CPR before defibrillation, removal of foreign-body airway obstruction, resuscitation care for suspected opioid-associated emergencies, drowning, and harm from CPR to victims not in cardiac arrest.

The topics that resulted in the most extensive task force discussions included CPR during transport, CPR before calling for help, resuscitation care for suspected opioid-associated emergencies, feedback for CPR quality, and analysis of rhythm during chest compressions. After discussion of the scoping reviews and the evidence update, the task force prioritized several topics for new systematic reviews.

Adult Basic Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This2020 International Consensus on Cardiopulmonary Resuscitation(CPR)and Emergency Cardiovascular Care Science With Treatment Recommendationson basic life support summarizes evidence evaluations performed for 22 topics that were prioritized by the Basic Life Support Task Force of the International Liaison Committee on Resuscitation. The evidence reviews include 16 systematic reviews, 5 scoping reviews, and 1 evidence update. Per agreement within the International Liaison Committee on Resuscitation, new or revised treatment recommendations were only made after a systematic review.

Systematic reviews were performed for the following topics: dispatch diagnosis of cardiac arrest, use of a firm surface for CPR, sequence for starting CPR (compressions-airway-breaths versus airway-breaths-compressions), CPR before calling for help, duration of CPR cycles, hand position during compressions, rhythm check timing, feedback for CPR quality, alternative techniques, public access automated external defibrillator programs, analysis of rhythm during chest compressions, CPR before defibrillation, removal of foreign-body airway obstruction, resuscitation care for suspected opioid-associated emergencies, drowning, and harm from CPR to victims not in cardiac arrest.

The topics that resulted in the most extensive task force discussions included CPR during transport, CPR before calling for help, resuscitation care for suspected opioid-associated emergencies, feedback for CPR quality, and analysis of rhythm during chest compressions. After discussion of the scoping reviews and the evidence update, the task force prioritized several topics for new systematic reviews.

Spontaneous Pothole Cardioversion of a Wide Complex Tachycardia

External mechanical forces, if properly timed and of sufficient energy, have rarely been reported to convert tachyarrhythmias to sinus rhythm. We report a case of a patient with a wide-complex tachycardia that spontaneously converted to sinus rhythm after an ambulance ran over a pothole during emergency transport to the hospital. (Level of Difficulty: Beginner.).

Cardiac Mechano-Electric Coupling: Acute Effects of Mechanical Stimulation on Heart Rate and Rhythm

The heart is vital for biological function in almost all chordates, including humans. It beats continually throughout our life, supplying the body with oxygen and nutrients while removing waste products. If it stops, so does life. The heartbeat involves precise coordination of the activity of billions of individual cells, as well as their swift and well-coordinated adaption to changes in physiological demand. Much of the vital control of cardiac function occurs at the level of individual cardiac muscle cells, including acute beat-by-beat feedback from the local mechanical environment to electrical activity (as opposed to longer term changes in gene expression and functional or structural remodeling). This process is known as mechano-electric coupling (MEC). In the current review, we present evidence for, and implications of, MEC in health and disease in human; summarize our understanding of MEC effects gained from whole animal, organ, tissue, and cell studies; identify potential molecular mediators of MEC responses; and demonstrate the power of computational modeling in developing a more comprehensive understanding of ‟what makes the heart tick.ˮ.

[Implementation of regularly performed resuscitation training at a hyperbaric treatment center]

BACKGROUND

Medical emergency situations and even cardiac arrest can occur during treatment of patients in therapeutic hyperbaric chambers just as in other clinical departments; therefore, high quality structured management should be implemented for dealing with emergencies in this special working area. To ensure this the emergency medical treatment should not only be performed according to the current state of medical knowledge but needs to take the special features of the hyperbaric environment including safety aspects into account.

METHOD

This article presents a description of the implementation and effects of routine emergency and resuscitation training at a center for hyperbaric medicine.

RESULTS

By simulation of emergencies in a hyperbaric chamber it rapidly became clear that the treatment of medical emergencies and cardiac arrest under hyperbaric conditions has some special features and due to safety aspects cannot always be performed according to current medical guidelines. At the time of this simulation in a real life working environment, previously unknown structural and logistic problems became obvious whereby the solutions contributed to a significant improvement of structural and process quality and could potentially also improve the outcome quality. Furthermore, a positive and lasting learning effect in the fields of quality of resuscitation measures, organization of the workplace, communication skills, logistics and safety aspects was detectable by analyzing participant performance over a period of 4 years. On the part of the participating staff a positive feedback and high acceptance of emergency simulator training was confirmed.

CONCLUSION

Through annual compulsory emergency training of the complete staff of the hyperbaric unit at the actual workplace, a structural and confident approach to dealing with emergencies and resuscitation situations was observed. By the use of on-site simulator training even in specialized hospital units, deficits and tentativeness regarding logistics, course of action, organization and communication in emergency situations can be minimized to provide optimum patient care in a real life emergency situation by focusing on the medical measures.

Cardiac Mechano-Gated Ion Channels and Arrhythmias

Mechanical forces will have been omnipresent since the origin of life, and living organisms have evolved mechanisms to sense, interpret, and respond to mechanical stimuli. The cardiovascular system in general, and the heart in particular, is exposed to constantly changing mechanical signals, including stretch, compression, bending, and shear. The heart adjusts its performance to the mechanical environment, modifying electrical, mechanical, metabolic, and structural properties over a range of time scales. Many of the underlying regulatory processes are encoded intracardially and are, thus, maintained even in heart transplant recipients. Although mechanosensitivity of heart rhythm has been described in the medical literature for over a century, its molecular mechanisms are incompletely understood. Thanks to modern biophysical and molecular technologies, the roles of mechanical forces in cardiac biology are being explored in more detail, and detailed mechanisms of mechanotransduction have started to emerge. Mechano-gated ion channels are cardiac mechanoreceptors. They give rise to mechano-electric feedback, thought to contribute to normal function, disease development, and, potentially, therapeutic interventions. In this review, we focus on acute mechanical effects on cardiac electrophysiology, explore molecular candidates underlying observed responses, and discuss their pharmaceutical regulation. From this, we identify open research questions and highlight emerging technologies that may help in addressing them.

RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 7: Clinical guidelines

OBJECTIVE

To present a series of evidence-based, consensus guidelines for veterinary CPR in dogs and cats.

DESIGN

Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality, and development of consensus on conclusions for application of the concepts to clinical practice. Questions in five domains were examined: Preparedness and Prevention, Basic Life Support, Advanced Life Support, Monitoring, and Post-Cardiac Arrest Care. Standardized worksheet templates were used for each question, and the results reviewed by the domain members, by the RECOVER committee, and opened for comments by veterinary professionals for 4 weeks. Clinical guidelines were devised from these findings and again reviewed and commented on by the different entities within RECOVER as well as by veterinary professionals.

SETTING

Academia, referral practice and general practice.

RESULTS

A total of 74 worksheets were prepared to evaluate questions across the five domains. A series of 101 individual clinical guidelines were generated. In addition, a CPR algorithm, resuscitation drug-dosing scheme, and postcardiac arrest care algorithm were developed.

CONCLUSIONS

Although many knowledge gaps were identified, specific clinical guidelines for small animal veterinary CPR were generated from this evidence-based process. Future work is needed to objectively evaluate the effects of these new clinical guidelines on CPR outcome, and to address the knowledge gaps identified through this process.

Commotio cordis - under-recognized in Europe?: a case report and review

This case and the review illustrate the induction of a sudden collapse of a football player secondary to a blow to his chest (commotio cordis) [CC]. The article argues that CC probably is under recognized in Europe and cautions that the mounting intensity and speed inherent in modern sports possibly increase the likeliness of CC in the future. If CC occurs, immediate cardiopulmonary resuscitation and automatic external defibrillator should be used.

Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.

Part 7: CPR techniques and devices: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

A variety of CPR techniques and devices may improve hemodynamics or short-term survival when used by well-trained providers in selected patients. All of these techniques and devices have the potential to delay chest compressions and defibrillation. In order to prevent delays and maximize efficiency, initial training, ongoing monitoring, and retraining programs should be offered to providers on a frequent and ongoing basis. To date, no adjunct has consistently been shown to be superior to standard conventional (manual) CPR for out-of-hospital basic life support, and no device other than a defibrillator has consistently improved long-term survival from out-of-hospital cardiac arrest.

Precordial thump for cardiac arrest is effective for asystole but not for ventricular fibrillation

BACKGROUND

Precordial thump for cardiac arrest remains controversial. Although precordial blows can trigger ventricular fibrillation (VF) (i.e., commotio cordis), they paradoxically have been regarded as potential therapy for cardiac arrest. In commotio cordis, impact energy and resultant peak left ventricular (LV) pressure are important variables in VF initiation.

OBJECTIVE

The purpose of this study was to assess the relationship between LV pressures generated by thumps and their effectiveness in defibrillation of VF or resuscitation of asystole after defibrillation.

METHODS

After induction of VF, 10 swine each received 18 chest thumps; two sets of three thumps each with a clenched fist, a 30-mph lacrosse ball, and a 40-mph lacrosse ball. If asystole followed defibrillation, manual thumps were given to induce ventricular depolarizations until resumption of spontaneous rhythm.

RESULTS

During VF, generated LV pressure (mmHg) was 263 +/- 52 with manual thumps, 392 +/- 179 with 30-mph ball thumps, and 616 +/- 182 with 40-mph ball thumps (P <.001). None of the 180 thumps terminated VF. All episodes required electrical defibrillation. During asystole, generated LV pressures were greater for thumps that induced ventricular depolarizations than for those that did not (111 +/- 27 mmHg vs 73 +/- 23 mmHg, P <.001). A significant association was observed between induction of ventricular depolarizations and thump-generated LV pressures (odds ratio 2.0 per 10 mmHg rise in LV pressure, 95% confidence interval 1.8-2.1).

CONCLUSION

Despite generating high LV pressures, precordial thumps were not effective in terminating VF. Based on these data, precordial thump for VF in cardiac arrest victims cannot be recommended but for asystolic victims might be beneficial.