Cardiopulmonary resuscitation in poorly resourced settings: better to pre-empt than to wait until it is too late

Family-witnessed resuscitation in the emergency department in a low-income country

Cardiac arrest is often a sudden and traumatic event. Family-witnessed resuscitation was first recommended by the American Heart Association over two decades ago. Since then several global professional bodies have identified a range of potential benefits for relatives; however, it remains contentious. For nurses working in emergency departments (EDs) in low-income countries, the evidence for, and experience of, family-witnessed resuscitation is limited. This article critically appraises the literature relating to the perceptions of medical professionals and critically ill patients and their families about communication, family presence and their involvement during resuscitation in the ED. Three themes relating to family-witnessed resuscitation in the ED were identified by a focused literature search. These were: leadership and communication, limitation of policies and guidelines and relatives' views. The recommendations from this review will be used to develop emergency and trauma nursing practice guidelines in Zambia, a low-income country in sub-Saharan Africa.

Effectiveness of rescue Me CPR! smartphone app providing real-time guidance to untrained bystanders performing CPR

Background

Out-of-hospital cardiac arrest (OHCA) is a persistent global health challenge, owing, in part, to low rates of population CPR training. Smartphone applications have the potential to widely disseminate CPR basic training to a populace, but other studies have found multiple limitations in previously developed CPR guidance applications (CPR-GA). This study aims to use medical simulation to assess the relative CPR performance of novices using the 'Rescue Me CPR!' (RMC) app, a custom CPR-GA designed by this research team, to novices using 'PG-CPR!' (PGC), the most downloaded CPR-GA available in the USA, and to CPR certified medical personnel.

Methods

In a prospective randomized experimental trial of 60 individuals, subjects were either given the RMC app, the PGC app, or had active CPR certification. They were presented a cardio-pulmonary arrest scenario and were observed while performing CPR on a high-fidelity manikin. Data was collected through four cycles of CPR, during which time 24 pertinent performance metrics and CPR steps were timed and recorded. These metrics were assessed on their own and used to calculate average time to compressions, average chest compression fraction, and rate of high-quality CPR for each study group.

Results

CPR certified subjects called 911 in 100 % of simulation cases, started compressions 34 ± 10 s after first seeing the simulated patient, had an average chest compression fraction of 0.52, and performed high-quality CPR in 25 % of aggregate compression cycles. PGC app users called 911 in 70 % of simulation cases, started compressions 86 ± 17 s after first seeing the simulated patient, had an average chest compression fraction that could not be assessed due to inconsistent pauses during CPR, and performed high-quality CPR in 2.5 % of aggregate compression cycles. RMC app users called 911 in 100 % of simulation cases, started compressions 55 ± 6 s after first seeing the simulated patient, had an average chest compression fraction of 0.48, and performed high-quality CPR in 50 % of aggregate compression cycles.

Conclusion

The results of this study demonstrate that in all studied metrics, except time-to-first-compression, CPR provided by individuals using the RMC app is statistically equivalent or superior to CPR performed by a CPR certified individual and, in almost every metric, superior to CPR performed by users of the most downloaded android CPR guidance application, PG-CPR.

Resuscitation team training in Rwanda: A mixed method study exploring the combination of the VAST course with Advanced Cardiac Life Support training

Introduction

The influence of non-technical skills training on resuscitation performance in low-resource settings is unknown. This study investigates combining the Vital Anaesthesia Simulation Training Course with Advanced Cardiac Life Support training on resuscitation performance in Rwanda.

Methods

Participants in this mixed method study are members of resuscitation teams in three district hospitals in Rwanda. The intervention was participation in a 2-day Advanced Cardiac Life Support course followed by the 3-day Vital Anaesthesia Simulation Training Course. Quantitative primary endpoints were time to initiation of cardiopulmonary resuscitation, time to epinephrine administration, and time to defibrillation. Qualitative data on workplace implementation were gathered during focus groups held 3-months post-intervention.

Results

Forty-seven participants were recruited. Quantitative data showed a statistically significant decrease in time to cardiopulmonary resuscitation, epinephrine administration, and defibrillation from pre- to post-Advanced Cardiac Life Support, with times of [43.3 (49.7) seconds] versus [16.5 (20) sec], p = <0.001; [137.3 (108.9) sec] versus [51.3 (37.9)], p = <0.001; and [218.5 (105.8) sec] versus [110.8 (87.1) sec], p = <0.001; respectively. These improvements were maintained following the Vital Anaesthesia Simulation Training Course, and at 3-month retention testing. Qualitative analysis highlighted five key themes: ability to initiate cardiopulmonary resuscitation; team coordination for task allocation; empowerment; desire for training and mentorship; and advocacy for system improvement.

Conclusion

A modified 2-day Advanced Cardiac Life Support course improved resuscitation time indicators with retention 3-months later. Combining the Vital Anaesthesia Simulation Training Course and Advanced Cardiac Life Support led to better team coordination, empowerment to act, and advocacy for system improvement. This pairing of courses has promise for improving Advanced Cardiac Life Support skills amongst healthcare workers in low-resource settings.ClinicalTrials.gov Identifier: NCT05278884.

Outcome in Children Admitted to the First PICU in Malawi

OBJECTIVES

Dedicated PICUs are slowly starting to emerge in sub-Saharan Africa. Establishing these units can be challenging as there is little data from this region to inform which populations and approaches should be prioritized. This study describes the characteristics and outcome of patients admitted to the first PICU in Malawi, with the aim to identify factors associated with increased mortality.

DESIGN

Review of a prospectively constructed PICU database. Univariate analysis was used to assess associations between demographic, clinical and laboratory factors, and mortality. Univariate associations ( p < 0.1) for mortality were entered in two multivariable models.

SETTING

A recently opened PICU in a public tertiary government hospital in Blantyre, Malawi.

PATIENTS

Children admitted to PICU between August 1, 2017, and July 31, 2019.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Of 531 included PICU admissions, 149 children died (28.1%). Mortality was higher in neonates (88/167; 52.7%) than older children (61/364; 16.8%; p ≤ 0.001). On univariate analysis, gastroschisis, trachea-esophageal fistula, and sepsis had higher PICU mortality, while Wilms tumor, other neoplasms, vocal cord papilloma, and foreign body aspiration had higher survival rates compared with other conditions. On multivariable analysis, neonatal age (adjusted odds ratio [AOR], 4.0; 95% CI, 2.0-8.3), decreased mental state (AOR, 5.8; 95 CI, 2.4-13.8), post-cardiac arrest (AOR, 2.0; 95% CI, 1.0-8.0), severe hypotension (AOR, 6.3; 95% CI, 2.0-19.1), lactate greater than 5 mmol/L (AOR, 4.2; 95% CI, 1.5-11.2), pH less than 7.2 (AOR, 3.1; 95% CI, 1.2-8.0), and platelets less than 150 × 10 9 /L (AOR, 2.4; 95% CI, 1.1-5.2) were associated with increased mortality.

CONCLUSIONS

In the first PICU in Malawi, mortality was relatively high, especially in neonates. Surgical neonates and septic patients were identified as highly vulnerable, which stresses the importance of improvement of PICU care bundles for these groups. Several clinical and laboratory variables were associated with mortality in older children. In neonates, severe hypotension was the only clinical variable associated with increased mortality besides blood gas parameters. This stresses the importance of basic laboratory tests, especially in neonates. These data contribute to evidence-based approaches establishing and improving future PICUs in sub-Saharan Africa.

Survival of pediatric patients after cardiopulmonary resuscitation for in-hospital cardiac arrest: a systematic review and meta-analysis

BACKGROUND

In-hospital cardiac arrest is a major public health issue. It is a serious condition; most probably end up with death within a few minutes even with corrective measures. However, cardiopulmonary resuscitation is expected to increase the probability of survival and prevent neurological disabilities in patients with cardiac arrest. Having a pooled prevalence of survival to hospital discharge after cardiopulmonary resuscitation is vital to develop strategies targeted to increase probability of survival among patients with cardiac arrest. Therefore, this systematic review and meta-analysis was aimed to assess the pooled prevalence of survival to hospital discharge among pediatric patients who underwent cardiopulmonary resuscitation for in-hospital cardiac arrest.

METHODS

PubMed, Google Scholar, and Cochrane review databases were searched. To have current (five-year) evidence, only studies published in 2016 to 2020 were included. The weighted inverse variance random-effects model at 95%CI was used to estimate the pooled prevalence of survival. Heterogeneity assessment, test of publication bias, and subgroup analyses were also employed accordingly.

RESULTS

Twenty-five articles with a total sample size of 28,479 children were included in the final analysis. The pooled prevalence of survival to hospital discharge was found to be 46% (95% CI = 43.0-50.0%; I2 = 96.7%; p < 0.001). Based on subgroup analysis by "continent" and "income level", lowest prevalence of pooled survival was observed in Asia (six studies; pooled survival =36.0% with 95% CI = 19.01-52.15%; I2 = 97.4%; p < 0.001) and in low and middle income countries (six studies, pooled survival = 34.0% with 95% CI = 17.0-51.0%, I2 = 97.67%, p < 0.001) respectively.

CONCLUSION

Although there was an extremely high heterogeneity among reported results (I2 = 96.7%), in this meta-analysis more than half of pediatric patients (54%) who underwent cardiopulmonary resuscitation for in-hospital cardiac arrest did not survived to hospital discharge. Therefore, developing further strategies and encouraging researches might be crucial.

Twelve tips to maximise medical student learning during emergency medicine placements

Placements in the emergency department provide medical students with countless clinical and practical learning opportunities. However, medical education may not always be optimised for students in this busy, potentially overwhelming environment. Prior knowledge of how to make the most of emergency medicine placements helps to facilitate student learning and enjoyment. In this article, the authors compiled twelve tips based on the relevant literature and their experiences on emergency attachments. These tips will better prepare medical students for their emergency medicine placements and ensure that they experience the full benefits of working in the emergency department.