Cardiopulmonary resuscitation by trained responders versus lay persons and outcomes of out-of-hospital cardiac arrest: A community observational study

Ventricular fibrillation waveform properties influenced by thoracic impedance guided chest compressions in a porcine model

BACKGROUND AND OBJECTIVE

Quantitative measures extracted from ventricular fibrillation (VF) waveform reflect the metabolic state of the myocardium and are associated with survival outcome. The quality of delivered chest compressions during cardiopulmonary resuscitation are also linked with survival. The aim of this research is to explore the viability and effectiveness of a thoracic impedance (TI) based chest compression (CC) guidance system to control CC depth within individual subjects and influence VF waveform properties.

METHODS

This porcine investigation includes an analysis of two protocols. CC were delivered in 2 min episodes at a constant rate of 110 CC min-1. Subject-specific CC depth was controlled using a TI-thresholding system where CC were performed according to the amplitude (ZRMS, 0.125 to 1.250 Ω) of a band-passed TI signal (ZCC). Protocol A was a retrospective analysis of a 12-porcine study to characterise the response of two VF waveform metrics: amplitude spectrum area (AMSA) and mean slope (MS), to varying CC quality. Protocol B was a prospective 12-porcine study to determine if changes in VF waveform metrics, due to CC quality, were associated with defibrillation outcome.

RESULTS

Protocol A: A directly proportional relationship was observed between ZRMS and CC depth applied within each subject (r = 0.90; p <0.001). A positive relationship was observed between ZRMS and both AMSA (p <0.001) and MS (p <0.001), where greater TI thresholds were associated with greater waveform metrics.

PROTOCOL B

MS was associated with return of circulation following defibrillation (odds ratio = 2.657; p = 0.043).

CONCLUSION

TI-thresholding was an effective way to control CC depth within-subjects. Compressions applied according to higher TI thresholds evoked an increase in AMSA and MS. The response in MS due to deeper CC resulted in a greater incidence of ROSC compared to shallow chest compressions.

The Association Between the Duration of Chest Compression and Thoracic Injuries in Patients With Non-Traumatic Out-of-Hospital Cardiac Arrest

BACKGROUND

Current guidelines emphasize the indispensability of high-quality chest compression for improving survival in patients who experience out-of-hospital cardiac arrest (OHCA). However, chest compression can cause thoracic injuries that may contribute to poor prognosis; therefore, the purpose of this study is to identify the predictors of thoracic injuries and evaluate the association between thoracic injuries and prognosis.

METHODS AND RESULTS

Between June 2017 to July 2019, Utstein-style data on 384 consecutive adult patients who experienced non-traumatic OHCA and who were transferred to our hospital (Aso Iizuka Hospital) were collected. Each patient underwent a full-body computed tomography scan. Two-hundred and thirty-four patients (76%) had thoracic injuries (Group-T). The duration of chest compression was significantly longer in Group-T than in patients without thoracic injuries (Group-N; 43 vs. 32 min, respectively, P<0.001). Multivariate analysis revealed that older age and longer chest compression duration were predictors of thoracic injuries (odds ratios 1.03 and 1.07, respectively, P≤0.005). Among patients who achieved return of spontaneous circulation, Kaplan-Meier curves showed a significantly higher cumulative survival rate in Group-N than in Group-T at the 30-day follow up (log-rank test P=0.009).

CONCLUSIONS

Older age and longer chest compression duration were independent predictors of thoracic injuries due to chest compression in patients who experienced non-traumatic OHCA. Moreover, the presence of thoracic injuries was associated with worse short-term prognosis.

Out of hospital cardiac arrest: experience of a bystander CPR training program in Karachi, Pakistan

Background

Nearly 90% of out-of-hospital cardiac arrest (OHCA) patients are witnessed, yet only 2.3% received bystander cardiopulmonary resuscitation (CPR) in Pakistan. This study aimed to determine retention of knowledge and skills of Hands-Only CPR among community participants in early recognition of OHCA and initiation of CPR in Karachi, Pakistan.

Methods

Pre and post-tests were conducted among CPR training participants from diverse non-health-related backgrounds from July 2018 to October 2019. Participants were tested for knowledge and skills of CPR before training (pre-test), immediately after training (post-test), and 6 months after training (re-test). All the participants received CPR training through video and scenario-based demonstration using manikins. Post-training CPR skills of the participants were assessed using a pre-defined performance checklist. The facilitator read out numerous case scenarios to the participants, such as drowning, poisoning, and road traffic injuries, etc., and then asked them to perform the critical steps of CPR identified in the scenario on manikins. The primary outcome was the mean difference in the knowledge score and skills of the participants related to the recognition of OHCA and initiation of CPR.

Results

The pre and post-tests were completed by 652 participants, whereas the retention test after 6 months was completed by 322 participants. The mean knowledge score related to the recognition of OHCA, and initiation of CPR improved significantly (p < 0.001) from pre-test [47.8/100, Standard Deviation (SD) ±13.4] to post-test (70.2/100, SD ±12.1). Mean CPR knowledge after 6 months (retention) reduced slightly from (70.2/100, ±12.1) to (66.5/100, ±10.8). CPR skill retention for various components (check for scene safety, check for response, check for breathing and correct placement of the heel of hands) deteriorated significantly (p < 0.001) from 77.9% in the post-test to 72.8% in re-test. Participants performed slightly better on achieving an adequate rate of chest compressions from 73.1% in post-test to 76.7% in re-test (p 0.27).

Conclusion

Community members with non-health backgrounds can learn and retain CPR skills, allowing them to be effective bystander CPR providers in OHCA situations. We recommend mass population training in Pakistan for CPR to increase survival from OHCA.

Effect of topography and weather on delivery of automatic electrical defibrillator by drone for out-of-hospital cardiac arrest

Delivery of automatic electrical defibrillator (AED) by unmanned aerial vehicle (UAV) was suggested for out-of-hospital cardiac arrest (OHCA). The goal of this study is to assess the effect of topographic and weather conditions on call to AED attach time by UAV-AED. We included OHCA patients from 2013 to 2016 in Seoul, South Korea. We developed a UAV-AED flight simulator using topographic information of Seoul for Euclidean and topographic flight pathway including vertical flight to overcome high-rise structures. We used 4 kinds of UAV flight scenarios according to weather conditions or visibility. Primary outcome was emergency medical service (EMS) call to AED attach time. Secondary outcome was pre-arrival rate of UAV-AED before current EMS based AED delivery. Call to AED attach time in topographic pathway was 7.0 min in flight and control advanced UAV and 8.0 min in basic UAV model. Pre-arrival rate in Euclidean pathway was 38.0% and 16.3% for flight and control advanced UAV and basic UAV. Pre-arrival rate in the topographic pathway was 27.0% and 11.7%, respectively. UAV-AED topographic flight took longer call to AED attach time than Euclidean pathway. Pre-arrival rate of flight and control advanced UAV was decreased in topographic flight pathway compared to Euclidean pathway.

[Ethics of resuscitation and end of life decisions]

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

Type of bystander and rate of cardiopulmonary resuscitation in nursing home patients suffering out-of-hospital cardiac arrest

AIM

We investigated bystander cardiopulmonary resuscitation (CPR) provision rate and survival outcomes of out-of-hospital cardiac arrest (OHCA) patients in nursing homes by bystander type.

METHODS

A population-based observational study was conducted for nursing home OHCAs during 2013-2018. The exposure was the bystander type: medical staff, non-medical staff, or family. The primary outcome was bystander CPR provision rate; the secondary outcomes were prehospital return of spontaneous circulation (ROSC) and survival to discharge. Multivariable logistic regression analysis which corrected for various demographic and clinical characteristics evaluated bystander type impact on study outcomes. Bystander CPR rate trend was investigated by bystander type.

RESULTS

Of 8281 eligible OHCA patients, 26.0%, 70.8%, and 3.2% cases were detected by medical staff, non-medical staff, and family, respectively. Provision rate of bystander CPR was 69.9% and rate of bystander defibrillation was 0.4% in total. Bystander CPR was provided by medical staff, non-medical staff, and families in 74.8%, 68.9%, and 52.1% respectively. Total survival rate was 2.2%, out of which, 3.3% was for medical staff, 3.2% for non-medical staff, and 0.6% for family. Compared to the results of detection by medical staff, the adjusted odds ratios (95% CIs) for provision of bystander CPR were 0.56 (0.49-0.63) for detection by non-medical staff and 0.33 (0.25-0.44) for detection by family. The bystander CPR rates of all three groups increased over time, and among them, the medical staff group increased the most. For prehospital ROSC and survival to discharge, no significant differences were observed according to bystander type.

CONCLUSION

Although OHCA was detected more often by non-medical staff, they provided bystander CPR less frequently than the medical staff did. To improve survival outcome of nursing home OHCA, bundle interventions including increasing the usage of automated external defibrillators and expanding CPR training for non-medical staff in nursing home are needed.

Place-provider-matrix of bystander cardiopulmonary resuscitation and outcomes of out-of-hospital cardiac arrest: A nationwide observational cross-sectional analysis

AIMS

This study aims to test the association between the place-provider-matrix (PPM) of bystander cardiopulmonary resuscitation (CPR) and outcomes of out-of-hospital cardiac arrest (OHCA).

METHODS

Adult patients with OHCA with a cardiac etiology from 2012 to 2017 in Korea were analyzed, excluding patients who had unknown information on place, type of bystander, or outcome. The PPM was categorized into six groups by two types of places (public versus home) and three types of providers (trained responder (TR), family bystander, and layperson bystander). Outcomes were survival to discharge and good cerebral performance category (CPC) of 1 or 2. Multivariable logistic regression analysis was performed to test the association between PPM group and outcomes with adjustment for potential confounders to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs) (reference = Public-TR).

RESULTS

A total of 73,057 patients were analyzed and were categorized into Public-TR (0.6%), Home-TR (0.3%), Public-Family (1.8%), Home-Family (79.8%), Public-Layperson (9.9%), and Home-Layperson (7.6%) groups. Compared with the Public-TR group, the AORs (95% CIs) for survival to discharge were 0.61 (0.35-1.05) in the Home-TR group, 0.85 (0.62-1.17) in the Public-Family group, 0.38 (0.29-0.50) in the Home-Family group, 1.12 (0.85-1.49) in the Public-Layperson group, and 0.42 (0.31-0.57) in the Home-Layperson group. The AORs (95% CIs) for good CPC were 0.58 (0.27-1.25) in the Home-TR group, 0.88 (0.61-1.27) in the Public-Family group, 0.38 (0.28-0.52) in the Home-Family group, 1.20 (0.87-1.65) in the Public-Layperson group, and 0.42 (0.30-0.59) in the Home-Layperson group.

CONCLUSION

The OHCA outcomes of the Home-Family and Home-Layperson groups were worse than those of the Public-TR group. This finding suggests that OHCA occurring in private places with family or layperson bystanders requires a new strategy, such as dispatching trained responders to the scene to improve CPR outcomes.

The impact of bystander relation and medical training on out-of-hospital cardiac arrest outcomes

AIM

In this study, we investigate the impact of bystander relation and medical training on survival to hospital discharge in out-of-hospital cardiac arrest (OHCA) patients receiving bystander cardiopulmonary resuscitation (CPR).

METHODS

A retrospective analysis was performed on non-traumatic OHCA patients receiving bystander CPR and Emergency Medical Service (EMS) attempted resuscitation from 2015 through 2017. Adjusted logistic regression was used to assess the association between related versus unrelated and layperson versus medically trained bystander CPR providers and survival to hospital discharge.

RESULTS

A total of 4464 OHCA were eligible for inclusion, of which 2385 (53.4%) received CPR from a relative, 468 (10.5%) from a work colleague or friend and 1611 (36.1%) from a stranger. Layperson's provided CPR in 3703 (83.0%) OHCA and medically trained professionals in 761 (17.0%). After adjustment for arrest characteristics, there was no difference in survival to hospital discharge between related versus unrelated CPR (adjusted odds ratio [AOR] 0.92, 95% confidence interval [CI]: 0.68-1.23, p = 0.555). However, bystander CPR by a medically trained provider rather than a layperson, was associated with an increase in the odds of survival by 47% (AOR 1.47, 95% CI: 1.09-2.00, p = 0.012) in the overall population and 73% (AOR 1.73, 95% CI: 1.21-2.49; p = 0.003) in patients with an initial shockable arrest. Adjusting for public access defibrillation significantly attenuated the effect of medically trained bystander CPR in initial shockable arrests (AOR 1.42, 95% CI: 0.97-2.07; p = 0.073).

CONCLUSION

This study supports ongoing efforts to crowdsource a larger number of first responders with medical training to OHCA patients to assist with the provision of CPR and early defibrillation.

Cardiopulmonary resuscitation performed by off-duty medical professionals versus laypersons and survival from out-of-hospital cardiac arrest among adult patients

BACKGROUND

Cardiopulmonary resuscitation (CPR) performed by bystanders is a key factor for out-of-hospital cardiac arrest (OHCA) survival. This study aimed to evaluate the relationship between CPR performed by off-duty medical professionals vs. laypersons and one-month survival with favorable neurological outcome after OHCA.

METHODS

Using a population-based database of OHCA patients in Osaka City, Japan, from 2013 through 2015, we enrolled adult OHCA patients with resuscitation attempts performed by bystanders before the arrival of emergency-medical-service personnel. Multivariable logistic regression analysis was performed to assess the association between CPR performed by off-duty medical professionals vs. laypersons and the OHCA outcome after adjusting for potential confounding factors. The primary outcome measure was one-month survival with favorable neurological outcome, defined as cerebral performance category of 1 or 2.

RESULTS

A total of 2326 subjects were eligible for our study. Among these, 365 (15.7%) patients received CPR by off-duty medical professionals and 1,961 (84.3%) received CPR by laypersons. In the multivariable analysis, there was no difference in favorable neurological outcome between off-duty medical professionals (6.3% [23/365]) and laypersons (5.1% [100/1,961]) among eligible patients (adjusted odds ratio 0.83, 95% confidence interval [0.37-2.06]). This finding was also confirmed in propensity score-matched patients.

CONCLUSIONS

In Japan where the CPR training or bystander CPR has been widely disseminating, CPR by laypersons had similar effects compared to that by off-duty medical professionals. As this study could not assess the quality of bystander CPR, further studies are essential to verify the effects of the bystander CPR type on OHCA patients.

Effect of a first responder on survival outcomes after out-of-hospital cardiac arrest occurs during a period of exercise in a public place

INTRODUCTION

The deployment of first responders in a public place is one of the interventions that is used for increasing bystander cardiopulmonary resuscitation (CPR) of out-of-hospital cardiac arrests (OHCA). We studied the association between the presence of a first responder and the survival of OHCA that occurred during a period of exercise in a public place.

METHODS

All of the adult OHCAs of a presumed cardiac etiology that occurred during a period of exercise in a public place and that were witnessed by a bystander between 2013 and 2015 were analyzed. The main exposure of interest was the characteristics of the bystander (first responder vs. layperson). The endpoints were the provision of bystander CPR and good neurological recovery. Multivariable logistic regression analysis, adjusting for patient-environment and prehospital factors, was performed.

RESULTS

A total of 870 patients had a cardiac arrest during a period of exercise in a public place, and 58 (6.7%) patients were witnessed by the first responder. The OHCAs witnessed by first responders were more likely to result in bystander CPR than those witnessed by laypersons (89.7% vs. 75.4%, p = 0.01, adjusted OR (95% CI): 3.51 (1.44-8.55)). In terms of good neurological recovery, the OHCAs witnessed by first responders had a higher likelihood than the patients witnessed by laypersons (37.9% vs, 24.0%, p = 0.02, adjusted OR (95% CI): 2.92 (1.33-6.40)).

CONCLUSION

The OHCAs occurred during a period of exercise in a public place and whom first responders witnessed were more likely to receive bystander CPR and to have a neurologically intact survival.