Resuscitation for patients with out-of-hospital cardiac arrest: Singapore

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.

A Six-Year Prospective Study of Out-of-Hospital Cardiac Arrest Managed by a Voluntary Ambulance Organisation

Objective

To obtain a database on the epidemiology of prehospital cardiac arrest and its management by a voluntary ambulance service, with the view for developing future strategies and service improvement.

Design

A 6-year prospective study from December 1998 to November 2004, using the Utstein-style template.

Setting

A voluntary ambulance service in Hong Kong.

Subjects and methods

Ambulance members had to complete and submit a specially designed data form after managing a cardiac arrest case, together with the ambulance run record and the automated external defibrillator (AED) computer printout, if appropriate.

Main outcome measures

Survival to hospital discharge and return of spontaneous circulation after resuscitation.

Results

A total of 72 cardiac arrests occurred during the period, with patients' age ranging from 29 to 106 years (mean 73.4). Most cardiac arrests occurred at home (46 or 63.9%). There were 58 witnessed cardiac arrests (80.5%), but bystander cardiopulmonary resuscitation (CPR) was started in only nine cases (15.5%) before the arrival of the ambulance crew. Six patients had evidence of rigor mortis or dependent lividity on ambulance arrival. For the 61 patients with electrocardiogram strips, the initial presenting rhythm on the AED was asystole in 45 (73.8%), pulseless electrical activity in 5 (8.2%), and ventricular fibrillation (VF) in 11 (18.0%). The median call-to-arrival time for VF cases (4.0 minutes) was significantly shorter than that of non-VF rhythms (8.5 minutes) [Mann-Whitney U test p=0.008]. Five patients had return of spontaneous circulation after resuscitation, but only one survived to hospital discharge.

Conclusions

Bystander CPR and ambulance response time are two areas requiring urgent improvement in our locality. As the majority of cardiac arrests occurred at home, the cost-effectiveness of public access defibrillation for Hong Kong is unclear. However, strategic placement of AED at high incidence' locations should be seriously considered.

Neuropsychological Outcome following Resuscitation after Out-of-Hospital Cardiac Arrest: A One-Year Follow-Up

A 61-year-old woman survived resuscitation after out-of-hospital cardiac arrest. The heterogeneity of the resulting cognitive impairments and the recovery over a one-year period are presented, highlighting the need for standardized neuropsychological testing even after short cardiac arrests and for effective treatment both out of hospital and in hospital.

[Epidemiological characteristics of out-of-hospital cardiorespiratory arrest recorded by the 061 emergencies system (SAMU) in the Balearic Islands (Spain), 2009-2012]

OBJECTIVE

To describe the epidemiology of out-of-hospital cardiorespiratory arrest (OHCA) and identify factors associated with recovery of spontaneous circulation (ROSC).

DESIGN

Observational study of OHCA registered on a continuous basis in the Emergency Medical Services (EMS) database during 2009-2012.

SETTING

The islands of Mallorca, Ibiza, Menorca and Formentera (Balearic Islands, Spain).

PATIENTS

OHCA in patients ≥ 18 years of age. The main variables were: Patient sex, age, probable cause, place of arrest, bystander, witnessed, basic life support (BLS), shockable rhythm, intervention time, semi-automatic defibrillator (AED), duration of cardiopulmonary arrest (CA), and ROSC. Independent variables were defined according to the Utstein protocol, and the dependent variable was defined as ROSC.

RESULTS

The EMS treated 1170 OHCAs (28/100,000 persons-year). We included 1130 CA. The mean age was 61.4 years (73.4% males). Most CA (72.3%) were of cardiac etiology, and 84.7% were witnessed. A total of 840 (74.3%) received BLS and 400 (47.6%) did so before arrival of the EMS (45 by bystander relatives). AED was available in 330 cases CA (29.2%) (96 with shockable rhythm). The interval between emergency call and BLS and between emergency call and advanced life support was 8.4 and 15.8min, respectively. Shockable rhythm was monitored in 257 CAs (22.7%). ROSC occurred in 261 (23.1%). Factors associated with ROSC were age, shockable rhythm, BLS before EMS arrival, and CA duration less than 30min.

CONCLUSION

The incidence rate of the OHCA is low. The proportion of patients receiving BLS from relatives was low. Age, shockable rhythm and BSL before EMS arrival were associated with ROSC.

Cardiopulmonary resuscitation training in high school using avatars in virtual worlds: an international feasibility study

Background

Approximately 300,000 people suffer sudden cardiac arrest (SCA) annually in the United States. Less than 30% of out-of-hospital victims receive cardiopulmonary resuscitation (CPR) despite the American Heart Association training over 12 million laypersons annually to conduct CPR. New engaging learning methods are needed for CPR education, especially in schools. Massively multiplayer virtual worlds (MMVW) offer platforms for serious games that are promising learning methods that take advantage of the computer capabilities of today’s youth (ie, the digital native generation).

Objective

Our main aim was to assess the feasibility of cardiopulmonary resuscitation training in high school students by using avatars in MMVM. We also analyzed experiences, self-efficacy, and concentration in response to training.

Methods

In this prospective international collaborative study, an e-learning method was used with high school students in Sweden and the United States. A software game platform was modified for use as a serious game to train in emergency medical situations. Using MMVW technology, participants in teams of 3 were engaged in virtual-world scenarios to learn how to treat victims suffering cardiac arrest. Short debriefings were carried out after each scenario. A total of 36 high school students (Sweden, n=12; United States, n=24) participated. Their self-efficacy and concentration (task motivation) were assessed. An exit questionnaire was used to solicit experiences and attitudes toward this type of training. Among the Swedish students, a follow-up was carried out after 6 months. Depending on the distributions, t tests or Mann-Whitney tests were used. Correlation between variables was assessed by using Spearman rank correlation. Regression analyses were used for time-dependent variables.

Results

The participants enjoyed the training and reported a self-perceived benefit as a consequence of training. The mean rating for self-efficacy increased from 5.8/7 (SD 0.72) to 6.5/7 (SD 0.57, P<.001). In the Swedish follow-up, it subsequently increased from 5.7/7 (SD 0.56) to 6.3/7 (SD 0.38, P=.006). In the Swedish group, the mean concentration value increased from 52.4/100 (SD 9.8) to 62.7/100 (SD 8.9, P=.05); in the US group, the concentration value increased from 70.8/100 (SD 7.9) to 82.5/100 (SD 4.7, P<.001). We found a significant positive correlation (P<.001) between self-efficacy and concentration scores. Overall, the participants were moderately or highly immersed and the software was easy to use.

Conclusions

By using online MMVWs, team training in CPR is feasible and reliable for this international group of high school students (Sweden and United States). A high level of appreciation was reported among these adolescents and their self-efficacy increased significantly. The described training is a novel and interesting way to learn CPR teamwork, and in the future could be combined with psychomotor skills training.

Emergency response time after out-of-hospital cardiac arrest

OBJECTIVES

To investigate the emergency response time after out-of-hospital cardiac arrest (OHCA) in four cities in Serbia.

METHODS

A prospective, two-year, multicenter study was designed. Using the Utstein template we recorded out-of-hospital CPR (OHCPR) and analyzed the time sequence segment of the variables in OHCA and CPR gold standards. Multivariable logistic regression models were developed using emergency response time as the primary independent variable and survival to return of spontaneous circulation (ROSC), survival to hospital discharge (HD), and one-year survival (1y) as the dependent variable. ROC curves represent cut off time dependent survival data.

RESULTS

During the study period, the median time of recognition OHCA was 5.5 min, call receipt was 1 min and the call-response interval was 7 min. The median time required to verify OHCA and ALS onset was 10 min. ALS was carried on for 30.5 min (SD=21.3). Abandonment of further CPR/death occurred after 29 min. The first defibrillation shock was performed after 13.3±9.0 min, endotracheal tube was placed after 16.8±9.4 min and the first adrenaline dose was injected after 18.9±9.3 min. Higher survival (ROSC, HD, 1y) rate was found when CPR is performed within the first 4 min after OHCA.

CONCLUSION

The emergency response time within 4 min was associated with improved survival to ROSC, HD and 1y after OHCA. Despite the fact that our results are in accordance with the findings published in other papers, there is still a need to take all appropriate measures in order to decrease the emergency response time after OHCA.

Exploring virtual worlds for scenario-based repeated team training of cardiopulmonary resuscitation in medical students

Background

Contemporary learning technologies, such as massively multiplayer virtual worlds (MMVW), create new means for teaching and training. However, knowledge about the effectiveness of such training is incomplete, and there are no data regarding how students experience it. Cardiopulmonary resuscitation (CPR) is a field within medicine in high demand for new and effective training modalities.

Objective

In addition to finding a feasible way to implement CPR training, our aim was to investigate how a serious game setting in a virtual world using avatars would influence medical students’ subjective experiences as well as their retention of knowledge.

Methods

An MMVW was refined and used in a study to train 12 medical students in CPR in 3-person teams in a repeated fashion 6 months apart. An exit questionnaire solicited reflections over their experiences. As the subjects trained in 4 CPR scenarios, measurements of self-efficacy, concentration, and mental strain were made in addition to measuring knowledge. Engagement modes and coping strategies were also studied. Parametric and nonparametric statistical analyses were carried out according to distribution of the data.

Results

The majority of the subjects reported that they had enjoyed the training, had found it to be suitable, and had learned something new, although several asked for more difficult and complex scenarios as well as a richer virtual environment. The mean values for knowledge dropped during the 6 months from 8.0/10 to 6.25/10 (P = .002). Self-efficacy increased from before to after each of the two training sessions, from 5.9/7 to 6.5/7 (P = .01) after the first and from 6.0/7 to 6.7/7 (P = .03) after the second. The mean perceived concentration value increased from 54.2/100 to 66.6/100 (P = .006), and in general the mental strain was found to be low to moderate (mean = 2.6/10).

Conclusions

Using scenario-based virtual world team training with avatars to train medical students in multi-person CPR was feasible and showed promising results. Although we found no evidence of stimulated recall of CPR procedures in our test-retest study, the subjects were enthusiastic and reported increased concentration during the training. We also found that subjects’ self-efficacy had increased after the training. Despite the need for further studies, these findings imply several possible uses of MMVW technology for future emergency medical training.

Are New Resuscitation Guidelines Better? Experience of an Asian Metropolitan Hospital

Introduction: Cardiopulmonary resuscitation (CPR) guidelines were revised in 2005 based on new evidence and expert consensus. However, the benefits of the new guidelines remain undetermined and their influence has not been published in Asia. This study aimed to evaluate the impact of implementing the new resuscitation guidelines and identify factors that influence the discharge survival of out-of-hospital cardiac arrest (OHCA) patients in an Asian metropolitan city. Materials and Methods: This was an observational cohort study of all OHCA patients seen by the emergency medical service during the period before (Nov 2003 to Oct 2005) and after (May 2006 to Oct 2008) implementing the new resuscitation guidelines. Detailed clinical information was recorded using the Ustein style template. Statistical analysis was done using X2 test or t-test for univariate analysis and the logistic regression model for multivariate analysis. Results: There were 463 patients before and 430 patients after the new guidelines who received resuscitation. The rate of recovery of spontaneous circulation (ROSC), survival-to-intensive care unit (ICU) admission, and survival-to-hospital discharge all showed no benefits regarding the new resuscitation guidelines (ROSC: 42% vs 39%, P = 0.32; Survival-to-ICU admission: 33% vs 30%, P = 0.27; survival-to-hospital discharge: 10% vs 7%, P = 0.09). The rate of ventricular fibrillation/pulseless ventricular tachycardia (VF/pulseless VT), rate of witnessed arrest, and rate of bystander CPR were much lower than in Western studies. After multivariate logistic regression, factors related to discharge survival were witnessed arrest and initial rhythm with VF/pulseless VT. The new resuscitation guidelines did not significantly influence the discharge survival. Conclusions: We did not observe any improvement in survival after implementing the new guidelines. Independent factors of survival-to-hospital discharge are witnessed arrest and initial rhythm with VF/pulseless VT. Because the rates of VF/pulseless VT and bystander CPR in Asia are low, popularising CPR training programmes and increasing the rate of bystander CPR may be more important for improving OHCA survival rates than frequent guideline changes. Key words: Asia, Outcome, Out-of-hospital cardiac arrest, Survival

Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis

BACKGROUND

Prior studies have identified key predictors of out-of-hospital cardiac arrest (OHCA), but differences exist in the magnitude of these findings. In this meta-analysis, we evaluated the strength of associations between OHCA and key factors (event witnessed by a bystander or emergency medical services [EMS], provision of bystander cardiopulmonary resuscitation [CPR], initial cardiac rhythm, or the return of spontaneous circulation). We also examined trends in OHCA survival over time.

METHODS AND RESULTS

An electronic search of PubMed, EMBASE, Web of Science, CINAHL, Cochrane DSR, DARE, ACP Journal Club, and CCTR was conducted (January 1, 1950 to August 21, 2008) for studies reporting OHCA of presumed cardiac etiology in adults. Data were extracted from 79 studies involving 142 740 patients. The pooled survival rate to hospital admission was 23.8% (95% CI, 21.1 to 26.6) and to hospital discharge was 7.6% (95% CI, 6.7 to 8.4). Stratified by baseline rates, survival to hospital discharge was more likely among those: witnessed by a bystander (6.4% to 13.5%), witnessed by EMS (4.9% to 18.2%), who received bystander CPR (3.9% to 16.1%), were found in ventricular fibrillation/ventricular tachycardia (14.8% to 23.0%), or achieved return of spontaneous circulation (15.5% to 33.6%). Although 53% (95% CI, 45.0% to 59.9%) of events were witnessed by a bystander, only 32% (95% CI, 26.7% to 37.8%) received bystander CPR. The number needed to treat to save 1 life ranged from 16 to 23 for EMS-witnessed arrests, 17 to 71 for bystander-witnessed, and 24 to 36 for those receiving bystander CPR, depending on baseline survival rates. The aggregate survival rate of OHCA (7.6%) has not significantly changed in almost 3 decades.

CONCLUSIONS

Overall survival from OHCA has been stable for almost 30 years, as have the strong associations between key predictors and survival. Because most OHCA events are witnessed, efforts to improve survival should focus on prompt delivery of interventions of known effectiveness by those who witness the event.

Transoesophageal cardiac pacing is effective for cardiopulmonary resuscitation in a rat of asphyxial model

OBJECTIVE

To investigate effectiveness of transoesophageal cardiac pacing in a rat model of asphyxial cardiac arrest.

METHODS

Ten minutes after the tracheal tube had been clamped, cardiac arrest (CA) occurred in 20 Sprague-Dawley rats, and the rats were assigned randomly to receive cardiopulmonary resuscitation (CPR) in a control group or CPR combined with transoesophageal cardiac pacing in a pacing group. Restoration of spontaneous circulation (ROSC) was defined as an unassisted pulse with a mean arterial pressure (MAP) of >or=20 mmHg for >or=1 min.

RESULTS

ROSC was significantly more frequent in the pacing group compared with the control group (7/10 versus 1/10, P<0.05). Faster ROSC and longer survival trend in the pacing group were seen compared with the control group.

CONCLUSION

Transoesophageal cardiac pacing is effective for CPR in a rat of asphyxial model. However, the precise mechanism is not clear and further experiments will be necessary.

Cardiopulmonary resuscitation after traumatic cardiac arrest is not always futile

INTRODUCTION

The use of guidelines regarding the termination or withholding of cardiopulmonary resuscitation (CPR) in traumatic cardiac arrest patients remains controversial. This study aimed to describe the outcomes for victims of penetrating and blunt trauma who received prehospital CPR.

METHODS

We conducted a retrospective review of a statewide major trauma registry using data from 2001 to 2004. Subjects suffered penetrating or blunt trauma, received CPR in the field by paramedics and were transported to hospital. Demographics, vital signs, injury severity, prehospital time, length of stay and mortality data were collected and analysed.

RESULTS

Eighty-nine patients met inclusion criteria. Eighty percent of these were blunt trauma victims, with a mortality rate of 97%, while penetrating trauma patients had a mortality rate of 89%. The overall mortality rate was 95%. Sixty-six percent of patients had a length of stay of less than 1 day. Four patients survived to discharge, of which two were penetrating and two were blunt injuries. Hypoxia and electrical injury were probable associated causes of two cardiac arrests seen in survivors of blunt injury.

CONCLUSIONS

While only a small number of penetrating and blunt trauma patients receiving CPR survived to discharge, this therapy is not always futile. Prehospital emergency personnel need to be aware of possible hypoxic and electrical causes for cardiac arrest appearing in combination with traumatic injuries.