Can correct closed-chest compressions be performed during prehospital transport?

Children and Restraints Study in Emergency Ambulance Transport-Cardiopulmonary Resuscitation (CARSEAT-CPR): An Observational Cohort Study of a Simulated Pediatric Cardiac Arrest

OBJECTIVES

To compare the ability to perform basic life support (BLS) skills on children and infants in a moving ambulance whether or not they are properly secured to the stretcher.

METHODS

Emergency Medicine Services provider ability to perform BLS skills was measured in moving ambulances on a closed course using an analog for child and infant cardiac arrest. Data were compared for child and infant manikins secured to the stretcher via different methods in simulated patient resuscitations performed by 24 participants.

RESULTS

We found that there was no significant difference in mean rate ( P  = 0.104), depth ( P  = 0.21), or chest compression fraction ( P  = 0.92) between tests on restrained and unrestrained pediatric manikins. For infants, there was a 4-mm difference in compression depth ( P  = 0.0018). The clinical significance of this difference is not readily apparent. Infant tests did not show a difference in compression rate ( P  = 0.35) or compression fraction ( P  = 0.26). Across all tests, the rate and depth of compressions were adequate, but compression fraction was not adequate in the infant simulations. There were no differences in ventilations between restrained and unrestrained simulations (child P  = 0.15; infant P  = 0.13) but both were less than the American Heart Association recommendation.

CONCLUSIONS

In this simulation study, it was found that there was no significant difference noted in BLS adequacy between unrestrained pediatric patients and those restrained with commercial devices. Overall, the ability to perform appropriate BLS on children was equivocal and our simulations suggested BLS could not be adequately performed on infants regardless of restraint type/status.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimising pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Resuscitation guideline highlights

PURPOSE OF REVIEW

The purpose of this review was to give an overview of the most significant updates in resuscitation guidelines and provide some insights into the new topics being considered in upcoming reviews.

RECENT FINDINGS

Recent updates to resuscitation guidelines have highlighted the importance of the earlier links in the chain-of-survival aimed to improve early recognition, early cardiopulmonary resuscitation (CPR) and defibrillation. Empowering lay rescuers with the support of emergency medical dispatchers or telecommunicators and engaging the community through dispatching volunteers and Automated External Defibrillators, are considered key in improving cardiac arrest outcomes. Novel CPR strategies such as passive insufflation and head-up CPR are being explored, but lack high-certainty evidence. Increased focus on survivorship also highlights the need for more evidence based guidance on how to facilitate the necessary follow-up and rehabilitation after cardiac arrest. Many of the systematic and scoping reviews performed within cardiac arrest resuscitation domains identifies significant knowledge gaps on key elements of our resuscitation practices. There is an urgent need to address these gaps to further improve survival from cardiac arrest in all settings.

SUMMARY

A continuous evidence evaluation process for resuscitation after cardiac arrest is triggered by new evidence or request by the resuscitation community, and provides more current and relevant guidance for clinicians.

Biomechanical analysis of force distribution in one-handed and two-handed adult chest compression: a randomised crossover observational study

INTRODUCTION

The standard method of chest compression for adults is a two-handed procedure. One-handed external chest compression (ECC) is used in some situations such as during transport of patients who had an out-of-hospital cardiac arrest, but the quality of one-handed ECC is still not well known. The distribution of force is related to the quality of chest compression and may affect the risk of injury. This study aimed to determine the differences in the quality and potential safety concern between one-handed ECC and two- handed ECC.

METHODS

In this randomised crossover study, participants recruited from National Cheng Kung University Hospital and the ambulance team from the fire bureau were asked to perform one-handed and two-handed ECC on the Resusci Anne manikin according to standard 2015 ECC guidelines. The MatScan Pressure Measurement system was used to investigate the compression pressure and force distribution.

RESULTS

Two-handed ECC had better results than one-handed ECC in terms of the median (IQR) depth (51.00 (41.50-54.75) mm vs 42.00 (27.00-49.00) mm, p=0.018), the proportion of depth accuracy (82.05% (13.95%-99.86%) vs 11.17% (0.00%-42.13%), p=0.028) and the proportion of incomplete recoil (0.23% (0.01%-0.44%) vs 2.42% (0.60%-4.21%), p=0.002). The maximum force (45.72 (36.10-80.84) kgf vs 35.64 (24.13-74.34) kgf, p<0.001) and ulnar-radial force difference (7.13 (-16.58 to 21.07) kgf vs 23.93 (11.19-38.74) kgf, p<0.001) showed statistically significant differences. The perceived fatigue of two-handed ECC versus one-handed ECC was 5.00 (3.00-6.00) vs 6.00 (5.00-8.00), p<0.001.

CONCLUSION

The quality of one-handed ECC, based on depth and recoil, is worse than that of standard two-handed ECC. The pressure and force distribution of one-handed ECC result in greater ulnar pronation of the hand than that of two-handed ECC. One-handed ECC more easily causes operator fatigue. Acknowledging these findings and adjusting training for one-handed ECC would potentially improve the quality of cardiopulmonary resuscitation during transport.

Transportation during and after cardiac arrest: who, when, how and where?

PURPOSE OF REVIEW

Out-of-hospital cardiac arrest (OHCA) is the most devastating and time-critical medical emergency. Survival after OHCA requires an integrated system of care, of which transport by emergency medical services is an integral component. The transport system serves to commence and ensure uninterrupted high-quality resuscitation in suitable patients who would benefit, terminate resuscitation in those that do not, provide critical interventions, as well as convey patients to the next appropriate venue of care. We review recent evidence surrounding contemporary issues in the transport of OHCA, relating to who, where, when and how to transport these patients.

RECENT FINDINGS

We examine the clinical and systems-related evidence behind issues including: contemporary approaches to field termination of resuscitation in patients in whom continued resuscitation and transport to hospital would be medically futile, OHCA patients and organ donation, on-scene versus intra-transport resuscitation, significance of response time, intra-transport interventions (mechanical chest compression, targeted temperature management, ECMO-facilitated cardiopulmonary resuscitation), OHCA in high-rise locations and cardiac arrest centers. We highlight gaps in current knowledge and areas of active research.

SUMMARY

There remains limited evidence to guide some decisions in transporting the OHCA patient. Evidence is urgently needed to elucidate the roles of cardiac arrest centers and ECPR in OHCA.

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.

Effect of chest compression with kneeling on the bed in clinical situations

Aim

Cardiopulmonary resuscitation is vital for survival after cardiac arrest, and chest compressions are an important aspect of this. When performing chest compression in a hospital setting, the rescuer often has to kneel on the bed to overcome inconvenient differences in height between the rescuer and the bed. However, as yet no study has evaluated the quality of chest compressions in this position. The aim of this study was to examine the impact on the quality of chest compressions while kneeling on the bed.

Methods

Fifteen female students performed 2‐min chest compressions on a manikin placed on the floor and a bed. Measurement parameters included compression depth, heart rate, integrated electromyogram, and a visual analog scale. The parameters were measured every 30 s and were statistically compared between the conditions.

Results

Compression depth at 30, 60, 90, and 120 s differed significantly between the conditions. Heart rate values at 150 and 210 s of recovery significantly differed between the conditions. Integrated electromyogram values for the trapezius, rectus femoris, and biceps femoris differed between the floor and bed conditions during 2‐min chest compressions, whereas the external oblique muscle significantly differed at 60 and 120 s. Visual analog scales for fatigue, effectiveness, and stability significantly differed between the conditions.

Conclusion

Kneeling on the bed does not enable grounding of the toe, causing the upper body to be unstable and limiting generation of the power required for chest compression. Our results suggest that rotation every minute is necessary to maintain effective cardiopulmonary resuscitation while kneeling on the bed.

Controversial Issues: Pro Mechanical Cardiopulmonary Resuscitation

High-quality cardiopulmonary resuscitation, in particular chest compressions, is a key aspect of out-of-hospital cardiac arrest (OHCA) resuscitation. Manual chest compressions remain the standard of care; however, the extrication and transport of patients with OHCA undermine the quality of manual chest compressions and risk the safety of paramedics. Therefore, in circumstances whereby high-quality manual chest compressions are difficult or unsafe, paramedics should consider using a mechanical device. By combining high-quality manual chest compressions and judicious application of mechanical chest compressions, emergency medical service agencies can optimize paramedic safety and patient outcomes.

Wilderness First Responder: Are Skills Soon Forgotten?

Wilderness first responders are trained to provide competent medical care in wilderness settings or until evacuation for more advanced treatment can be obtained. In light of the isolated environments in which they are called upon to respond to illnesses and injuries, their ability to effectively apply their training is crucial. Despite the responsibility assigned to them, there is an absence of research assessing the skill and knowledge retention of wilderness first responders, creating a gap in understanding whether a deficit in their ability to perform exists between certifications. Without such research, it is important to review knowledge and skill retention in related responder groups. The literature over the past 4 decades documents the loss over time of skills and knowledge across an array of trained responders, both professional and laypeople. Although the findings reviewed suggest that WFRs will exhibit a similar pattern of increasing skill loss beginning shortly after certification and a slower, but concurrent, decrease in knowledge, research is needed to document or refute this assumption.

Evaluation of the Effect of a Clinical Pathway on the Quality of Simulated Pre-Hospital Cardiopulmonary Resuscitation: Primary Experience from a Chinese Pre-Hospital Care Centre

Objective

The aim of this study was to assess the quality of simulated cardiopulmonary resuscitation (CPR) in local pre-hospital care teams and the improvement achieved by using clinical pathways.

Methods

A prospective observation study. The 2010 American Heart Association Guidelines for CPR, the personnel characteristics of ambulance staff, China's legal system requirements, and the available medical resources were used to design a clinical pathway for pre-hospital care of cardiac arrest. Case simulations were used to evaluate the quality of CPR before and after implementation of the clinical pathway.

Results

The number of teams which successfully implemented electrocardiogram monitoring, endotracheal intubation and intravenous access before training were 8 (17.8%), 5 (11.1%) and 6 (13.3%) respectively. These increased to 45 (100%), 43 (95.6%) and 43 (95.6%), respectively, after training. The number of teams with successful implementation of artificial ventilation, airway management and insertion of oropharyngeal airway before training were 43 (95.6%), 38 (84.4%) and 12 (26.7%) respectively. These increased to 45 (100%), 42 (93.3%) and 43 (95.6%), respectively, after training. Nine (20%) teams decided CPR onsite before training and 35 (77.8%) after training. The average rate of chest compressions before and after training was 120.3 ± 17.9 and 123.2 ± 17.1 compressions per minute, respectively (p>0.05).

Conclusion

Training using established clinical pathway significantly improves the quality of CPR and increases the use of ALS techniques. CPR training requires ongoing validation and optimisation to maintain effectiveness. (Hong Kong j.emerg.med. 2015;22:14-22)

The Efficacy of Alternative Cardiopulmomonary Resuscitation Methods When Compared to Standard Cardiopulmonary Resuscitation: A Simulation Study

Objective

There are limited data comparing the alternative cardiopulmomary resuscitation (CPR) methods (over the head CPR, straddle CPR and one hand CPR) to standard CPR performed by emergency medical technicians (EMTs). Therefore we investigated the efficacy of the alternative CPRs compared to that of standard CPR performed by EMTs in simulated cardiac arrest scenarios.

Methods

Thirty EMTs of intermediate level participated in this study. The performance of CPR was defined as the average depth, the total number of chest compressions, and the rate of compressions. EMTs performed three minutes of standard CPR and of alternative CPR on standard simulation mannequins with recording devices. Recorded performance was measured and compared between subgroups by the type of CPR, gender of EMTs and gender with various methods of CPR using ANOVA and t test statistics.

Results

The average depth of compressions was 42.3±5.8, 42.6±4.7, 43.5±3.7, 33.8±6.6 mm (mean±standard deviation) respectively in standard CPR, over the head CPR, straddle CPR and one hand CPR. The total number of chest compression was 330.4±38.1, 334.8±70.2, 334.0±34.9, 312.1±53.5 in 3 minutes. The rate of compressions was found to be 111.5±10.3, 113.8±11.6, 110.5±11.2, 110.7±11.8 times per minute. The comparison of the performance qualities for the four types of CPR showed that the compression depth was significantly lower in one-hand CPR (p<0.000). No EMT gender difference in the quality of performance of total CPR was noted.

Conclusions

The efficacy of alternative CPRs are shown to be similar to that of standard CPR in a compression-only simulation cardiac arrest model.

Prehospital Advanced Cardiac Life Support for Out-of-hospital Cardiac Arrest: A Cohort Study

OBJECTIVES

Out-of-hospital advanced cardiac life support (ACLS) has not consistently shown a positive impact on survival. Extracorporeal cardiopulmonary resuscitation (E-CPR) could render prolonged on-site resuscitation (ACLS or basic cardiac life support [BCLS]) undesirable in selected cases. The objectives of this study were to evaluate, in patients suffering from out-of-hospital cardiac arrest (OHCA) and in a subgroup of potential E-CPR candidates, the association between the addition of prehospital ACLS to BCLS and survival to hospital discharge, prehospital return of spontaneous circulation (ROSC), and delay from call to hospital arrival.

METHODS

This cohort study targets adult patients treated for OHCA between April 2010 and December 2015 in the city of Montreal, Canada. We defined potential E-CPR candidates using clinical criteria previously described in the literature (65 years of age or younger, initial shockable rhythm, absence of ROSC after 15 minutes of prehospital resuscitation, and emergency medical services-witnessed collapse or witnessed collapse with bystander cardiopulmonary resuscitation). Associations were evaluated using multivariate regression models.

RESULTS

A total of 7,134 patients with OHCA were included, 761 (10.7%) of whom survived to discharge. No independent association between survival to hospital discharge and the addition of prehospital ACLS to BCLS was found in either the entire cohort (adjusted odds ratio [AOR] = 1.05 [95% confidence interval {CI} = 0.84-1.32], p = 0.68) or among the 246 potential E-CPR candidates (AOR = 0.82 [95% CI = 0.36-1.84], p = 0.63). The addition of prehospital ACLS to BCLS was associated with a significant increase in the rate of prehospital ROSC in all patients experiencing OHCA (AOR = 3.92 [95% CI = 3.38-4.55], p < 0.001) and in potential E-CPR candidates (AOR = 3.48 [95% CI = 1. 76-6.88], p < 0.001) compared to isolated prehospital BCLS. Delay from call to hospital arrival was longer in the ACLS group than in the BCLS group (difference = 16 minutes [95% CI = 15-16 minutes], p < 0.001).

CONCLUSIONS

In a tiered-response urban emergency medical service setting, prehospital ACLS is not associated with an improvement in survival to hospital discharge in patients suffering from OHCA and in potential E-CPR candidates, but with an improvement in prehospital ROSC and with longer delay to hospital arrival.

Chest compression fraction in ambulance while transporting patients with out-of-hospital cardiac arrest to the hospital in rural Taiwan

INTRODUCTION

Maintaining the standard two-handed chest compression is difficult in high-speed ambulances in rural areas.

METHODS

A retrospective, video-based, observational study was conducted from June to September 2013 in Nantou, a rural county of central Taiwan, to evaluate the chest compression fraction in an ambulance carriage during the travel from the scene to the hospital. The chest compression fraction was calculated as the chest compression time period divided by the ambulance travelling time period; the one-handed and two-handed chest compression fractions were also calculated.

RESULTS

During the 4-month study period, a total of 102 videos that were recorded in an ambulance carriage were reviewed, including 97 cases of manual chest compressions. When there was only one emergency medical technician (EMT) in the carriage, the combined chest compression fraction was 50.6±20.7%; when there were two EMTs, the fraction was 58.3±16.0% and the fraction was 58.3±21.0% in a three-EMT scenario (p=0.221). Moreover, in the carriage, EMTs usually performed one-handed chest compressions.

CONCLUSIONS

The chest compression fraction was low for patients with out-of-hospital cardiac arrest in a moving ambulance, irrespective of the number of providers. Reasons for this observation, as well as the effectiveness of the one-handed chest compression require further evaluation.

A Comparison of Chest Compression Quality Delivered During On-Scene and Ground Transport Cardiopulmonary Resuscitation

Introduction

American Heart Association (AHA) guidelines recommend cardiopulmonary resuscitation (CPR) chest compressions 1.5 to 2 inches (3.75–5 cm) deep at 100 to 120 per minute. Recent studies demonstrated that manual CPR by emergency medical services (EMS) personnel is substandard. We hypothesized that transport CPR quality is significantly worse than on-scene CPR quality.

Methods

We analyzed adult patients receiving on-scene and transport chest compressions from nine EMS sites across Minnesota and Wisconsin from May 2008 to July 2010. Two periods were analyzed: before and after visual feedback. CPR data were collected and exported with the Zoll M series monitor and a sternally placed accelerometer measuring chest compression rate and depth. We compared compression data with 2010 AHA guidelines and Zoll RescueNet Code Review software. CPR depth and rate were “above (deep),” “in,” or “below (shallow)” the target range according to AHA guidelines. We paired on-scene and transport data for each patient; paired proportions were compared with the nonparametric Wilcoxon signed rank test.

Results

In the pre-feedback period, we analyzed 105 of 140 paired cases (75.0%); in the post-feedback period, 35 of 140 paired cases (25.0%) were analyzed. The proportion of correct depths during on-scene compressions (median, 41.9%; interquartile range [IQR], 16.1–73.1) was higher compared to the paired transport proportion (median, 8.7%; IQR, 2.7–48.9). Proportions of on-scene median correct rates and transport median correct depths did not improve in the post-feedback period.

Conclusion

Transport chest compressions are significantly worse than on-scene compressions. Implementation of visual real-time feedback did not affect performance.

For how long can two emergency medical technicians perform high-quality cardiopulmonary resuscitation?

OBJECTIVE

To determine the duration and obstacles to prolonged on-scene cardiopulmonary resuscitation (CPR), and establish how long a pair of emergency medical technicians (EMTs) can provide high-quality CPR.

METHOD

Intermediate-level EMTs in Gyeonggi-do Province, Republic of Korea completed a survey regarding on-scene CPR. EMTs undergoing routine training took part in a simulation using mannequins. Parameters including compression depth, total number and rate of compressions; occurrence of incorrect hand position and incomplete chest recoil were collected over 16 2-min cycles of CPR (32 min total), with EMTs working in pairs.

RESULT

The simulation study included 43 EMTs. The median duration of on-scene CPR was 3.7 min. Fear of decrease in performance was the main obstacle to continued CPR (n = 188/254 [74.0%]). Standards for high-quality CPR were met at each of the 16 steps of the simulation. Compression rate increased significantly with time. There were no significant changes in any other parameter.

CONCLUSION

Pairs of EMTs maintained high-quality CPR for 16 cycles (32 min) with no decrease in performance. Our findings could provide evidence to recommend guidelines for duration of on-scene CPR for cardiac arrest, particularly in countries where the level and number of ambulance crews are limited.

A stabilization device that promotes the efficiency of cardiopulmonary resuscitation during ambulance transportation to the level as under non-moving conditions

Background

The survival rate of patients with out-of-hospital cardiac arrest is low, and measures to improve the quality of cardiopulmonary resuscitation (CPR) during ambulance transportation are desirable. We designed a stabilization device, and in a randomized crossover trial we found performing CPR in a moving ambulance with the device (MD) could achieve better efficiency than that without the device (MND), but the efficiency was lower than that in a non-moving ambulance (NM).

Purpose

To evaluate whether a modified version of the stabilization device, can promote further the quality of CPR during ambulance transportation.

Methods

Participants of the previous study were recruited, and they performed CPR for 10 minutes in a moving ambulance with the modified version of the stabilization device (MVSD). The primary outcomes were effective chest compressions and no-flow fraction recorded by a skill-reporter manikin. The secondary outcomes included back pain, physiological parameters, and the participants' rating about the device after performing CPR.

Results

The overall effective compressions in 10 minutes were 86.4±17.5% for NM, 60.9±14.6% for MND, 69.7±22.4% for MD, and 86.6%±13.2% for MVSD (p<0.001). Whereas changes in back pain severity and physiology parameters were similar under all conditions, MVSD had the lowest no-flow fraction. Differences in effective compressions and the no-flow fraction between MVSD and NM did not reach statistical significance.

Conclusions

The use of the modified device can improve quality of CPR in a moving ambulance to a level similar to that in a non-moving condition without increasing the severity of back pain.

Mapping the use of simulation in prehospital care - a literature review

Background

High energy trauma is rare and, as a result, training of prehospital care providers often takes place during the real situation, with the patient as the object for the learning process. Such training could instead be carried out in the context of simulation, out of danger for both patients and personnel. The aim of this study was to provide an overview of the development and foci of research on simulation in prehospital care practice.

Methods

An integrative literature review were used. Articles based on quantitative as well as qualitative research methods were included, resulting in a comprehensive overview of existing published research. For published articles to be included in the review, the focus of the article had to be prehospital care providers, in prehospital settings. Furthermore, included articles must target interventions that were carried out in a simulation context.

Results

The volume of published research is distributed between 1984- 2012 and across the regions North America, Europe, Oceania, Asia and Middle East. The simulation methods used were manikins, films, images or paper, live actors, animals and virtual reality. The staff categories focused upon were paramedics, emergency medical technicians (EMTs), medical doctors (MDs), nurse and fire fighters. The main topics of published research on simulation with prehospital care providers included: Intubation, Trauma care, Cardiac Pulmonary Resuscitation (CPR), Ventilation and Triage.

Conclusion

Simulation were described as a positive training and education method for prehospital medical staff. It provides opportunities to train assessment, treatment and implementation of procedures and devices under realistic conditions. It is crucial that the staff are familiar with and trained on the identified topics, i.e., intubation, trauma care, CPR, ventilation and triage, which all, to a very large degree, constitute prehospital care. Simulation plays an integral role in this. The current state of prehospital care, which this review reveals, includes inadequate skills of prehospital staff regarding ventilation and CPR, on both children and adults, the lack of skills in paediatric resuscitation and the lack of knowledge in assessing and managing burns victims. These circumstances suggest critical areas for further training and research, at both local and global levels.

The quality of manual chest compressions during transport--effect of the mattress assessed by dual accelerometers

BACKGROUND

The quality of cardiopulmonary resuscitation (CPR) has an impact on survival. The quality may be impaired if the patient needs to be transported to the hospital with ongoing CPR. The aim of this study was to analyse whether the quality of CPR can be improved during transportation by using real-time audiovisual feedback. In addition, we sought to evaluate the real compression depths taking into account the mattress and stretcher effect.

METHODS

Paramedics (n = 24) performed standard CPR on a Resusci Anne Mannequin in a moving ambulance. Participants were instructed to perform CPR according to European Resuscitation Council Resuscitation guidelines 2010. Each pair acted as their own controls performing CPR first without and then with the feedback device. Compression depth, rate and no-flow fraction and also the mattress effect were recorded by using dual accelerometers by two Philips, HeartStart MRx Q-CPR defibrillators.

RESULTS

In the feedback phase, the mean compression depth increased from 51 (10) to 56 (5) mm (P < 0.001), and the percentage of compression fractions with adequate depth was 60% vs. 89% (P < 0.001). However, taking account of the mattress effect, the real depth was only 41 (8) vs. 44 (5) mm without and with feedback, respectively (P < 0.001). The values for compression rate did not differ.

CONCLUSIONS

CPR quality was good during transportation in general. However, the results suggest that the feedback system improves CPR quality. Dual accelerometer measurements show, on the other hand, that the mattress effect may be a clinically relevant impediment to high quality CPR.

Muscles used for chest compression under static and transportation conditions

BACKGROUND

Unstable conditions during ambulance transportation are not conducive to the performance of high-quality cardiopulmonary resuscitation by emergency medical technicians.

OBJECTIVE

The present study was conducted to clarify differences in the quality of chest compression and associated muscle activity between static and ambulance transportation conditions.

METHODS

Nine paramedic students performed chest compression for 5 minutes on the floor and during ambulance transportation. Compression rate and depth and success and error rates of chest compression were determined using the Resusci Anne manikin with a PC SkillReporting System (Laerdal Medical). Integrated electromyography (i-EMG) values of eight different muscles were also recorded bilaterally during the first and last 30 seconds of compression.

RESULTS

There was no significant difference in compression rate per minute (p = 0.232) and depth of chest compression (p = 0.174) between the two conditions. The success rate was significantly lower under the ambulance transportation condition than under the static condition (p = 0.0161). Compared with those under the static condition, the total i-EMG values were significantly lower for the multifidus (p = 0.0072) and biceps femoris (p < 0.0001) muscles and significantly higher for the deltoid (p = 0.0032), pectoralis major (p = 0.0037), triceps brachii (p = 0.0014), vastus lateralis (p < 0.0001), and gastrocnemius (p = 0.0004) muscles under the ambulance transportation condition.

CONCLUSIONS

Chest compression is performed mainly through flexion and extension of the hip joint while kneeling on the floor and through the elbow and shoulder joints while standing in a moving ambulance. Therefore, the low quality of chest compression during ambulance transportation may be attributable to an altered technique of performing the procedure.

CPR variability during ground ambulance transport of patients in cardiac arrest

AIM OF STUDY

High-quality CPR is associated with improved outcomes from out-of-hospital cardiac arrest (OHCA). The purpose of this investigation was to compare the quality of CPR provided at the prehospital scene, during ambulance transport, and during the early minutes in the emergency department (ED).

METHODS

A prospective observational review of consecutive adult patients with non-traumatic OHCA was conducted between September 2008 and February 2010. Patients with initiation of prehospital CPR were included as part of a statewide cardiac resuscitation quality improvement program. A monitor-defibrillator with accelerometer-based CPR measurement capability (E-series, ZOLL Medical) was utilized. CPR quality measures included variability in chest compression (CC) depth and rate, mean depth and rate, and the CC fraction. Variability of CC was defined as the mean of minute-to-minute standard deviation in CC depth or rate. CC fraction was defined as the percent of time that CPR was being performed when appropriate throughout resuscitation.

RESULTS

Fifty-seven adult patients with OHCA had electronic CPR data recorded at the scene, in the ambulance, and upon arrival in the ED. Across time periods, there was increased variability in CC depth (scene: 0.20 in.; transport: 0.26 in.; ED: 0.31 in., P<0.01) and rate (scene: 18.2 CC min(-1); transport: 26.1 CC min(-1); ED: 26.3 CC min(-1), P<0.01). The mean CC depth, rate, and the CC fraction did not differ significantly between groups.

CONCLUSIONS

There was increased CC variability from the prehospital scene to the ED though there was no difference in mean CC depth, rate, or in CC fraction. The clinical significance of CC variability remains to be determined.

Delayed high-quality CPR does not improve outcomes

AIM OF STUDY

The quality of cardiopulmonary resuscitation (CPR) is an important factor in the outcome of cardiac arrest. Our objective was to compare outcomes following either immediate low-quality (LQ) CPR or delayed high-quality (HQ) CPR. We hypothesized that delayed HQ CPR will improve the outcomes of CPR in comparison to immediately performing LQ CPR.

METHODS

Eighteen Sprague-Dawley rats were randomized into two groups: (1) Delayed HQ CPR (HQ group, n = 9). (2) Immediate LQ CPR (LQ group, n = 9). Ventricular fibrillation (VF) was induced and untreated for 8 mins. CPR was immediately performed in LQ group for 5 mins. Compression depth was set at 70% of the "optimal compression depth". VF was untreated for an additional 5 mins in HQ group. HQ CPR was started together with ventilation (100% oxygen) and external hypothermia for 8 mins in both groups. The "optimal compression depth" was approximately 30% of the anteroposterior chest diameter. Epinephrine was administrated 3 mins prior to defibrillation attempt. Restoration of spontaneous circulation, postresuscitation myocardial function and survival time were monitored.

RESULTS

All animals in the LQ group and 7 of 9 animals in the HQ group were resuscitated. Myocardial function, including ejection fraction and cardiac output was better in the LQ group than in the HQ group (p < 0.05) and survival time was longer in the LQ group (p < 0.05).

CONCLUSION

The outcomes after immediate LQ CPR, were better than those after delayed HQ CPR in this rat model of cardiac arrest and resuscitation.

Randomized crossover trial comparing physical strain on advanced life support providers during transportation using real-time automated feedback

BACKGROUND

Feedback devices provide verbal and visual real-time information on cardiopulmonary resuscitation (CPR) quality. Feedback devices can improve the quality of CPR during transportation. It remains unclear if feedback has an effect on the physical strain felt by providers during ongoing CPR.

OBJECTIVES

The objective was to assess the influence of real-time automated feedback on physical strain of rescuers during ongoing chest compressions in different means of transportation.

METHODS

The study was a randomized crossover trial comparing physical strain on advanced life support (ALS) providers during chest compressions using real-time automated feedback in different transport environments: 1) a moving ambulance and 2) a flying helicopter. The authors measured objective and subjective measures of physical strain and calculated the difference in the rate pressure product (RPP) after 8 minutes of external chest compressions.

RESULTS

There was no difference in the RPP (mean intraindividual difference = 21; 95% confidence interval [CI] = -1,438 to 1,480; p = 0.98) between using the feedback device versus no feedback. There was no significant interaction of vehicle type on the effect of feedback on the RPP. Feedback resulted in a significant mean perceived exertion reduction of a Borg scale score by 0.89 points (95% CI = 0.42 to 1.35; p < 0.001). For systolic and diastolic blood pressure, for serum lactate concentrations, and for the modified Nine Hole Peg Test (NHPT; measurement of fine motor skills), we found no statistically significant differences.

CONCLUSIONS

Feedback devices for CPR during transportation do not have an effect on objective components of physical strain, but decrease perceived exertion in experienced rescuers in an experimental setting.

On-site hospital helipads: resource document for the NAEMSP position paper on on-site hospital helipads

The purpose of this article is to address the question of helipad location for hospitals using helicopter emergency medical services (HEMS). A helipad is defined as off-site, or remote, if a ground ambulance is required for patient transport between the helicopter and the hospital's patient care area. On-site helipads are those for which no ground ambulance transport is required between the hospital and the helicopter. The article describes the attributes of on-site helipads, which include elimination of the inherent risks of additional patient transfers, enhanced availability of emergency medical services (EMS) resources that would otherwise be used for extra transfer, and decreased time to arrival at the receiving treatment site. It is acknowledged that helipad placement decisions are informed by non-patient care issues and a paucity of research. Nevertheless, when the choice is viewed from a patient care perspective, there is a clear preference for on-site helipad location.

The effect of transport on quality of cardiopulmonary resuscitation in out-of-hospital cardiac arrest

INTRODUCTION

Most manikin and clinical studies have found decreased quality of CPR during transport to hospital. We wanted to study quality of CPR before and during transport for out-of-hospital cardiac arrest patients and also whether quality of CPR before initiation of transport was different from the quality in patients only receiving CPR on scene.

MATERIALS AND METHODS

Quality of CPR was prospectively registered with a modified defibrillator for consecutive cases of out-of-hospital cardiac arrest in three ambulance services during 2002-2005. Ventilations were registered via changes in transthoracic impedance and chest compressions were measured with an extra chest compression pad placed on the patients' sternum. Paired t-tests were used to analyse quality of CPR before vs. during transport with ongoing CPR. Unpaired t-tests were used to compare CPR quality prior to transport to CPR quality in patients with CPR terminated on site.

RESULTS

Quality of CPR did not deteriorate during transport, but as previously reported overall quality of CPR was substandard. Quality of CPR performed on site was significantly better when transport was not initiated with ongoing CPR compared to episodes with initiation of transport during CPR: fraction of time without chest compressions was 0.45 and 0.53 (p<0.001), compression depth 37 mm and 34 mm (p=0.04), and number of chest compressions per minute 61 and 56 (p=0.01), respectively.

CONCLUSION

CPR quality was sub-standard both before and during transport. Early decision to transport might have negatively affected CPR quality from the early stages of resuscitation.

Quality of cardiopulmonary resuscitation before and during transport in out-of-hospital cardiac arrest

AIM OF THE STUDY

To evaluate quality of cardiopulmonary resuscitation (CPR) performed during transport after out-of-hospital cardiac arrest.

MATERIALS AND METHODS

Retrospective, observational study of all non-traumatic cardiac arrest patients older than 18 years who received CPR both before and during transport between May 2003 and December 2006 from the community run EMS system in Oslo. Chest compressions and ventilations were detected from impedance changes in routinely collected ECG signals, and hands-off ratio calculated as time without chest compressions divided by total CPR time.

RESULTS

Seventy-five of 787 consecutive out-of-hospital cardiac arrest patients met the inclusion criteria. Quality data were available from 36 of 66 patients receiving manual CPR and 7 of 9 receiving mechanical CPR. CPR was performed for mean 21+/-11 min before and 12+/-8 min during transport. With manual CPR hands-off ratio increased from 0.19+/-0.09 on-scene to 0.27+/-0.15 (p=0.002) during transport. Compression and ventilation rates were unchanged causing a reduction in compressions per minute from 94+/-14 min(-1) to 82+/-19 min(-1) (p=0.001). Quality was significantly better with mechanical than manual CPR. Four patients (5%) survived to hospital discharge; two with manual CPR (Cerebral performance categories (CPC) 1 and 2), and two with mechanical CPR (CPC scores 3 and 4). No discharged patients had any spontaneous circulation during transport.

CONCLUSIONS

The fraction of time without chest compressions increased during transport of out-of-hospital cardiac arrest patients. Every effort should therefore be made to stabilise patients on-scene before transport to hospital, but all transport with ongoing CPR is not futile.

The feasibility of a regional cardiac arrest receiving system

BACKGROUND

Patients suffering out-of-hospital cardiac arrest (OOHCA) are generally transported to the closest ED, presumably to expedite a hospital level of care and improve the chances of return for spontaneous circulation (ROSC) or provide post-resuscitative care for patients with prehospital ROSC. As hospital-based therapies for survivors of OOHCA are identified, such as hypothermia and emergency primary coronary interventions (PCI), certain hospitals may be designated as cardiac arrest receiving facilities. The safety of bypassing non-designated facilities with such a regional system is not known.

OBJECTIVES

To explore the potential ED contribution in OOHCA victims without prehospital ROSC and document the relationship between transport time and outcome in patients with prehospital ROSC.

METHODS

This was a prospective, observational study conducted in a large, urban EMS system over an 18-month period. Data were collected using the Utstein template for OOHCA. The incidence of prehospital ROSC was calculated for patients who were declared dead on scene, transported but died in the ED, died in the hospital, and survived to hospital discharge. The relationship between transport time and survival was also explored for patients with prehospital ROSC.

RESULTS

A total of 1141 cardiac arrest patients were enrolled over the 18-month period. A strong association between prehospital ROSC and final disposition was observed (chi-square test for trend p<0.001). Only two patients who survived to hospital discharge did not have prehospital ROSC. Mean transport times were not significantly different for patients with prehospital ROSC who were declared dead in the ED (8.3min), died following hospital admission (7.8min), and survived to hospital discharge (8.5min). Outcomes in patients with prehospital ROSC who had shorter (7min or less) versus longer transport times were similar, and receiver-operator curve analysis indicated no predictive ability of transport time with regard to survival to hospital admission (area under the curve=0.52).

CONCLUSIONS

In this primarily urban EMS system, the vast majority of survivors from OOHCA are resuscitated in the field. A relationship between transport time and survival to hospital admission or discharge was not observed. This supports the feasibility of developing a regional cardiac arrest system with designated receiving facilities.

Quality of closed chest compression in ambulance vehicles, flying helicopters and at the scene

CONTEXT

Transport of patients during resuscitation is a critical procedure. In both, ambulances and helicopters the quality of resuscitation is potentially hampered due to the movement of the vehicle and confined space. To date, however, no direct comparison of the quality of resuscitation at the scene, during a helicopter flight and in a moving ambulance has been made.

OBJECTIVE

Direct comparison of the quality of resuscitation at the scene, during a helicopter flight and in a moving ambulance.

DESIGN

The study was performed in July 2005 as a randomised cross-over trial comparing different environments for resuscitation.

SETTING

Medical University of Vienna.

PARTICIPANTS

Eleven European Resuscitation Council (ERC) approved health care professionals.

INTERVENTIONS

Interventions during resuscitation: (a) in a moving ambulance, (b) in a flying helicopter, were compared to those staying at the (c) scene (control). Each participant performed resuscitation in all three environments.

MAIN OUTCOME MEASURES

Quality of chest compression during resuscitation.

RESULTS

Compared to resuscitation at the scene, efficiency of chest compressions during a helicopter flight was 86% and 95% in the moving ambulance 95%. There were no differences in secondary outcomes (time without chest compression, total number of incorrect hand position relative to total compressions, and total number of incorrect pressure release relative to total compressions).

CONCLUSIONS

Resuscitation during transport is feasible and relatively efficient. There is some difference between the environments, but there is no relevant difference between helicopters and ambulances regarding the effectiveness of CPR.

A randomized, controlled comparison of cardiopulmonary resuscitation performed on the floor and on a moving ambulance stretcher

BACKGROUND

Recent studies have demonstrated that cardiopulmonary resuscitation (CPR) of poor quality is associated with worsened outcomes.

OBJECTIVE

To compare the quality of CPR delivered on the floor with the quality of CPR delivered on a moving stretcher. The authors hypothesized that CPR performed on the floor would be superior to that performed on a moving stretcher.

METHODS

A randomized, crossover experimental design was used. Subjects included emergency medical technician students, paramedic students, and emergency medicine residents. Two-member teams were randomly assigned to perform two-rescuer CPR on a manikin either on the floor or on a moving stretcher. After a 5-minute rest, the teams performed CPR under the opposite condition. Compression and ventilation data were collected using a recording resuscitation manikin. Dependent variables were compression depth, compression rate per minute, percentage of correct chest compressions, tidal volume, and percentage of correct ventilations. Data were compared using two-tailed paired t-test.

RESULTS

Sixty-two subjects completed the study. The mean compression depth performed on the floor (39 +/- 9 mm) was greater than that on a moving stretcher (28 +/- 9 mm) (p < 0.001). The mean rates of chest compressions on the floor (110 +/- 17 beats/min) and on a moving stretcher (113 +/- 21 beats/min) were not different (p = 0.49). The percentage of correct compressions performed on the floor (54% +/- 40%) exceeded that on a moving stretcher (21% +/- 29%)(p < 0.001). The percentage of correct ventilations performed on the floor (43% +/- 26%) was greater than that on a moving stretcher (24% +/- 21%)(p < 0.04).

CONCLUSIONS

Chest compression and ventilation quality of CPR performed on the floor was superior to that of CPR performed on a moving stretcher in this manikin model. The quality of CPR while moving was significantly compromised.

Relationship between knowledge of cardiopulmonary resuscitation guidelines and performance

OBJECTIVE

Despite widespread training with CPR guidelines, CPR is often poorly performed. We explore relationships between knowledge of CPR guidelines and performance (compression rate, compression depth, compression to ventilation ratio, and ventilation volume).

METHODS

Sixty professional EMTs were sampled at 26 randomly ordered EMS response stations from an urban system of 31 stations. A recording manikin and video model were used to assess performance in a standardized scenario, and a survey was used to assess guideline knowledge. Survey and performance outcomes were categorized prospectively as correct or incorrect based on the International CPR Guidelines from 2000. Relationships were modeled with logistic regression. Covariates included years of work experience, frequency of CPR performance, and ALS versus BLS EMT level.

RESULTS

Compression rate was between 80 and 120 min(-1) in 56% (33/59) of trials. Compression depth was 1.5-2 in. in 39% (23/59), compression to ventilation ratio approximated to 15:2 in 42% (25/59), and ventilation volume was 800-1,200 cm(3) in 13% (8/60). Accurate knowledge of the CPR guidelines was associated with better performance of chest compression rate and compression to ventilation ratio. Adjusted OR (95% CI) were 4.6 (1.2-18.1) for compression rate, 1.7 (0.4-6.5) for compression depth, 4.5 (1.1-18.5) for compression to ventilation ratio, and 9.0 (0.2-351) for ventilation volume.

CONCLUSIONS

Although accurate knowledge of guidelines is associated with increased odds of correct performance of some aspects of CPR, overall performance remains poor.

Effectiveness of mechanical versus manual chest compressions in out-of-hospital cardiac arrest resuscitation: a pilot study

A prospective, randomized effectiveness trial was undertaken to compare mechanical versus manual chest compressions as measured by end-tidal CO2 (ETCO2) in out-of-hospital cardiac arrest patients receiving advanced cardiac life support (ACLS) resuscitation from a municipal third-service, emergency medical services (EMS) agency. The EMS agency responds to approximately 6,700 emergencies annually, 79 of which were cardiac arrests in 1994, the study year. Following endotracheal intubation, all cardiac arrest patients were placed on 100% oxygen via the ventilator circuit of the mechanical cardiopulmonary resuscitation (CPR) device. Patients were randomized to receive mechanical CPR (TCPR) or human/manual CPR (HCPR) based on an odd/even day basis, with TCPR being performed on odd days. ETCO2 readings were obtained 5 minutes after the initiation of either TCPR or HCPR and again at the initiation of patient transport to the hospital. All patients received standard ACLS pharmacotherapy during the monitoring interval with the exception of sodium bicarbonate. CPR was continued until the patient was delivered to the hospital emergency department. Age, call response interval, initial electrocardiogram (ECG) rhythm, scene time, ETCO2 measurements, and arrest outcome were identified for all patients. Twenty patients were entered into the study, with 10 in each treatment group. Three patients in the TCPR group were excluded. Measurements in the HCPR group revealed a decreasing ETCO2 during the resuscitation in 8 of 10 patients (80%) and an increasing ETCO2 in the remaining 2 patients. No decrease in ETCO2 was noted in the TCPR group, with 4 of 7 patients (57%) actually showing an increased reading and 3 of 7 patients (43%) showing a constant ETCO2 reading. The differences in the ETCO2 measurements between TCPR and HCPR groups were statistically significant. Both groups were similar with regards to call response intervals, patient ages, scene times, and initial ECG rhythms. One patient in the TCPR group was admitted to the hospital but later died, leaving no survivors in the study. TCPR appears to be superior to standard HCPR as measured by ETCO2 in maintaining cardiac output during ACLS resuscitation of out-of-hospital cardiac arrest patients.