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Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, Lott C, Olasveengen T, Paal P, Pellis T, Perkins GD, Sandroni C, Nolan JP. [Adult advanced life support]. Notf Rett Med 2021; 24:406-446. [PMID: 34121923 PMCID: PMC8185697 DOI: 10.1007/s10049-021-00893-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 12/19/2022]
Abstract
These European Resuscitation Council Advanced Life Support guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.
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Affiliation(s)
- Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, Universitätsklinikum Köln, Köln, Deutschland
| | - Pierre Carli
- SAMU de Paris, Center Hospitalier Universitaire Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, and Université Paris Descartes, Paris, Frankreich
| | - Keith Couper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
- Warwick Medical School, University of Warwick, Coventry, Großbritannien
| | - Charles D. Deakin
- University Hospital Southampton NHS Foundation Trust, Southampton, Großbritannien
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, Großbritannien
| | - Therese Djärv
- Dept of Acute and Reparative Medicine, Karolinska University Hospital, Stockholm, Schweden
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Schweden
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Theresa Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norwegen
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Tommaso Pellis
- Department of Anaesthesia and Intensive Care, Azienda Sanitaria Friuli Occidentale, Pordenone, Italien
| | - Gavin D. Perkins
- Warwick Medical School and University Hospitals Birmingham NHS Foundation Trust, University of Warwick, Coventry, Großbritannien
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rom, Italien
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rom, Italien
| | - Jerry P. Nolan
- Warwick Medical School, Coventry, Großbritannien, Consultant in Anaesthesia and Intensive Care Medicine Royal United Hospital, University of Warwick, Bath, Großbritannien
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Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, Lott C, Olasveengen T, Paal P, Pellis T, Perkins GD, Sandroni C, Nolan JP. European Resuscitation Council Guidelines 2021: Adult advanced life support. Resuscitation 2021; 161:115-151. [PMID: 33773825 DOI: 10.1016/j.resuscitation.2021.02.010] [Citation(s) in RCA: 454] [Impact Index Per Article: 151.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Advanced Life Support guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.
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Affiliation(s)
- Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Pierre Carli
- SAMU de Paris, Centre Hospitalier Universitaire Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, and Université Paris Descartes, Paris, France
| | - Keith Couper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry,UK
| | - Charles D Deakin
- University Hospital Southampton NHS Foundation Trust, Southampton, UK; South Central Ambulance Service NHS Foundation Trust, Otterbourne,UK
| | - Therese Djärv
- Dept of Acute and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden, Department of Medicine Solna, Karolinska Institutet,Stockholm, Sweden
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universitaet Mainz, Germany
| | - Theresa Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Tommaso Pellis
- Department of Anaesthesia and Intensive Care, Azienda Sanitaria Friuli Occidentale, Italy
| | - Gavin D Perkins
- University of Warwick, Warwick Medical School and University Hospitals Birmingham NHS Foundation Trust, Coventry, UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL; Royal United Hospital, Bath, UK
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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0330-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Soar J, Nolan JP, Böttiger BW, Perkins GD, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars MB, Smith GB, Sunde K, Deakin CD. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation 2016; 95:100-47. [PMID: 26477701 DOI: 10.1016/j.resuscitation.2015.07.016] [Citation(s) in RCA: 920] [Impact Index Per Article: 115.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Germany
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Pierre Carli
- SAMU de Paris, Department of Anaesthesiology and Intensive Care, Necker University Hospital, Paris, France
| | - Tommaso Pellis
- Anaesthesia, Intensive Care and Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Gary B Smith
- Centre of Postgraduate Medical Research & Education, Bournemouth University, Bournemouth, UK
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK
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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0085-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Alonso E, Eftestøl T, Aramendi E, Kramer-Johansen J, Skogvoll E, Nordseth T. Beyond ventricular fibrillation analysis: comprehensive waveform analysis for all cardiac rhythms occurring during resuscitation. Resuscitation 2014; 85:1541-8. [PMID: 25195072 DOI: 10.1016/j.resuscitation.2014.08.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 07/29/2014] [Accepted: 08/01/2014] [Indexed: 10/24/2022]
Abstract
AIM To propose a method which analyses the electrocardiogram (ECG) waveform of any cardiac rhythm occurring during resuscitation and computes the probability of that rhythm converting into another with better prognosis (Pdes). METHODS Rhythm transitions occurring spontaneously or due to defibrillation were analyzed. For each possible rhythm, ventricular fibrillation/ventricular tachycardia (VF/VT), pulseless electrical activity (PEA), pulse-generating rhythm (PR) and asystole (AS), the desired and undesired transitions were defined. ECG segments corresponding to the last 3s of rhythms prior to transition were used to extract waveform features. For each rhythm type, waveform features were combined into a logistic regression model to develop a rhythm specific classifier of desired transitions. This model was the monitoring function for the Pdes. The capacity of each rhythm specific classifier to discriminate between desired and undesired transitions was evaluated in terms of area under the curve (AUC). Pdes was integrated into a state sequence representation, which structures the information of cardiac arrest episodes, to analyze the effect of therapy on patient. As a case study, the effect of optimal/suboptimal cardiopulmonary resuscitation (CPR) on Pdes was analyzed. The mean Pdes was computed for the pre- and post-CPR intervals which presented the same underlying rhythm. The relationship between the optimal/suboptimal CPR and increase/decrease of Pdes was analyzed. RESULTS The AUC was 0.80, 0.79, 0.73 and 0.61 for VF/VT, PEA, PR and AS respectively. The Pdes quantified the probability of every rhythm of the episode developing to a better state, and the evolution of Pdes was coherent with the provided therapy. The case study indicated, for most rhythms, that positive trends in the dynamic behaviour could be associated with optimal CPR, whereas the opposite seemed true for negative trends. CONCLUSION A method for continuous ECG waveform analysis covering all cardiac rhythms during resuscitation has been proposed. This methodology can be further developed to be used in retrospective studies of CPR techniques, and, in the future, for potentially monitoring in real time the probability of survival of patients being resuscitated.
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Affiliation(s)
- Erik Alonso
- Department of Electrical Engineering and Computer Science, University of Stavanger, 4036 Stavanger, Norway; Communications Engineering Department, University of the Basque Country UPV/EHU, Alameda Urquijo S/N, 48013 Bilbao, Spain.
| | - Trygve Eftestøl
- Department of Electrical Engineering and Computer Science, University of Stavanger, 4036 Stavanger, Norway
| | - Elisabete Aramendi
- Communications Engineering Department, University of the Basque Country UPV/EHU, Alameda Urquijo S/N, 48013 Bilbao, Spain
| | - Jo Kramer-Johansen
- Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS), Oslo University Hospital and University of Oslo, N-0424 Oslo, Norway
| | - Eirik Skogvoll
- Institute for Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), N-7491 Trondheim, Norway; Department of Anesthesia and Intensive Care Medicine, St. Olav University Hospital, N-7014 Trondheim, Norway
| | - Trond Nordseth
- Institute for Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), N-7491 Trondheim, Norway; Department of Anesthesia and Intensive Care Medicine, St. Olav University Hospital, N-7014 Trondheim, Norway
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Median frequencies of prolonged ventricular fibrillation treated by V-A ECMO correspond to a return of spontaneous circulation rate. Int J Artif Organs 2014; 37:48-57. [PMID: 24634334 DOI: 10.5301/ijao.5000291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND The aim of our study was to analyze, in a pig model of prolonged ventricular fibrillation (VF) treated by veno-arterial extracorporeal membrane oxygenation (ECMO), the time dependent changes of VF wavelet frequency obtained from intracardial signals and its relations to return of spontaneous circulation (ROSC). METHODS 11 female pigs (50.3 ± 3.4 kg) under general anesthesia had undergone 15 min of VF with ECMO flow of 5 to 10 ml/kg per min simulating "untreated" VF followed by continued VF with full ECMO flow of 100 ml/kg per min. The median frequency (MF) of VF from right ventricular apex, coronary perfusion pressure, myocardial oxygen metabolism and resuscitability were determined. RESULTS Median (interquartile range) of MF of fibrillatory wavelets in minute 15 of low ECMO flow [9.7 Hz (8.3; 10.1)] was not significantly changed in comparison to minute 1 [10.5 Hz (9.8; 12.4)], p = 0.12. Five minutes after full ECMO initiation MF increased [11.6 Hz (10.6; 13.5)], p = 0.04 (compared to minute 15 of VF) and did not deteriorate during the rest of ECMO treatment. Out of all subjects, three animals did not reach ROSC. Those subjects demonstrated deeper decrease of MF at the VF minute 15 as compared to others [-2.4 Hz (-2.5; -2.3) vs. -0.6 Hz (-1.6; -0.1)] and continuously significantly higher increase in MF on full ECMO support [4.3 Hz (2.9; 5.6) vs. 1.1 Hz (0.6; 1.6)] with p = 0.05 for both observations, respectively. CONCLUSIONS The veno-arterial ECMO reperfusion influences MF of VF wavelet obtained from right ventricular apex. The course of changes in wavelet frequency corresponds to a presence of later ROSC.
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Eftestøl T, Eilevstjønn J, Steen PA. Advanced life support therapy on out-of-hospital cardiac arrest patients: an engineering perspective. Expert Rev Cardiovasc Ther 2014; 1:203-13. [PMID: 15030281 DOI: 10.1586/14779072.1.2.203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In the USA alone, several hundred thousand people die of sudden cardiac arrests each year. Basic life support, defined as chest compressions and ventilations, and early defibrillation are the only factors proven to increase the survival of patients with out-of-hospital cardiac arrest and are key elements in the chain of survival defined by the American Heart Association. The current cardiopulmonary resuscitation guidelines treat all patients the same but studies show a need for more individualization of treatment. This review focusses on ideas on how to strengthen the weak parts of the chain of survival including the ability to measure the effects of therapy, improve time efficiency and optimize the sequence and quality of the various components of cardiopulmonary resuscitation.
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Affiliation(s)
- Trygve Eftestøl
- Stavanger University College, Department of Electrical and Computer Engineering, Norway.
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Rhythm analysis during cardiopulmonary resuscitation: past, present, and future. BIOMED RESEARCH INTERNATIONAL 2014; 2014:386010. [PMID: 24527445 PMCID: PMC3910663 DOI: 10.1155/2014/386010] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 12/09/2013] [Indexed: 11/18/2022]
Abstract
Survival from out-of-hospital cardiac arrest depends largely on two factors: early cardiopulmonary resuscitation (CPR) and early defibrillation. CPR must be interrupted for a reliable automated rhythm analysis because chest compressions induce artifacts in the ECG. Unfortunately, interrupting CPR adversely affects survival. In the last twenty years, research has been focused on designing methods for analysis of ECG during chest compressions. Most approaches are based either on adaptive filters to remove the CPR artifact or on robust algorithms which directly diagnose the corrupted ECG. In general, all the methods report low specificity values when tested on short ECG segments, but how to evaluate the real impact on CPR delivery of continuous rhythm analysis during CPR is still unknown. Recently, researchers have proposed a new methodology to measure this impact. Moreover, new strategies for fast rhythm analysis during ventilation pauses or high-specificity algorithms have been reported. Our objective is to present a thorough review of the field as the starting point for these late developments and to underline the open questions and future lines of research to be explored in the following years.
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Lee JC, Suh GJ, Kim HC. Electrocardiogram frequency change by extracorporeal blood perfusion in a swine ventricular fibrillation model. Biomed Eng Online 2013; 12:123. [PMID: 24274395 PMCID: PMC4222265 DOI: 10.1186/1475-925x-12-123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 11/08/2013] [Indexed: 11/24/2022] Open
Abstract
Background Extracorporeal cardiopulmonary resuscitation (ECPR) refers to the application of extracorporeal blood circulation with oxygenation as a resuscitation tool. The objective of this study is to observe the frequency component changes in the electrocardiogram (ECG) by ECPR during prolonged ventricular fibrillation (VF). Methods Six swine were prepared as a VF model. Extracorporeal blood circulation with a pulsatile blood pump and oxygenator was set up for the model. ECG signals were measured for 13 min during VF and analyzed using frequency analysis methods. The median frequency (MF), dominant frequency (DF), and amplitude spectrum area (AMSA) were calculated from a spectrogram obtained using short-time Fourier transform (STFT). Results MF decreased from 11 Hz at the start to 9 Hz at 2 min after VF and then increased to 11 Hz at 4.5 min after VF. DF started at 7 Hz and increased to 11 Hz within the first min and decreased to 9 Hz at 2 min, then increased to 12 Hz at 4.5 min after VF. Both frequency components decreased gradually from 4.5 min until 10 min after VF. After the oxygenated blood perfusion was initiated, both MF and DF increased remarkably and exceeded 12 and 14 Hz, respectively. Similarly, AMSA decreased gradually for the first 10 min, but increased remarkably and varied beyond 13 mV∙Hz after the oxygenated blood supply started. Remarkable frequency increases in ECG due to the oxygenated blood perfusion during ECPR were observed in the swine VF model. Conclusions The ECG frequency analysis during ECPR can give the resuscitation provider important information about the cardiac perfusion status and the appropriateness of the ECPR setup as well as the prediction of defibrillation success.
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Affiliation(s)
- Jung Chan Lee
- Institute of Medical and Biological Engineering, Medical Research Center, Seoul National University, Yongon-dong 28, Jongro-gu, Seoul 110-744, Republic of Korea.
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Deakin CD. À la carte defibrillation poised to enter the fixed price resuscitation menu. Resuscitation 2013; 84:1639-40. [PMID: 24096011 DOI: 10.1016/j.resuscitation.2013.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Accepted: 09/24/2013] [Indexed: 01/21/2023]
Affiliation(s)
- Charles D Deakin
- University of Southampton, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK.
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Wu X, Bisera J, Tang W. Signal integral for optimizing the timing of defibrillation. Resuscitation 2013; 84:1704-7. [PMID: 23969193 DOI: 10.1016/j.resuscitation.2013.08.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 08/01/2013] [Accepted: 08/12/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The possibility of successful defibrillation decreases with an increased duration of ventricular fibrillation (VF). Futile electrical shocks are inversely correlated with myocardial contractile function and long-term survival. Previous studies have demonstrated that various ECG waveform analyses predict the success of defibrillation. This study investigated whether the absolute amplitude of pre-shock VF waveform is likely to predict the success of defibrillation. METHODS ECG recordings of 350 out-of-hospital cardiac arrest (OOHCA) patients were obtained from the automated external defibrillator (AED) and analyzed by the method of signal integral. Successful defibrillation was defined as organized rhythm with heart rate ≥40beat/min commencing within one min of post-shock period and persisting for a minimum of 30s. RESULTS Signal integral was significantly greater in successful defibrillation than unsuccessful defibrillation (81.76±32.3mV vs. 34.9±15.33mV, p<0.001). The intersection of the sensitivity and specificity curve provided a threshold value of 51mV. The corresponding values of sensitivity, specificity, positive predictive and negative predictive values for successful defibrillation were 90%, 86%, 80% and 93%, respectively. The receiver operator curve further revealed that signal integral predicted the likelihood of successful defibrillation (area under the curve=0.949). CONCLUSIONS Signal integral predicted successful electrical shocks on patients with ventricular fibrillation and have potential to optimize the timing of defibrillation and reduce the number of electrical shocks.
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Affiliation(s)
- Xiaobo Wu
- Weil Institute of Critical Care Medicine, Rancho Mirage, CA, United States.
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Lo MT, Lin LY, Hsieh WH, Ko PCI, Liu YB, Lin C, Chang YC, Wang CY, Young VHW, Chiang WC, Lin JL, Chen WJ, Ma MHM. A new method to estimate the amplitude spectrum analysis of ventricular fibrillation during cardiopulmonary resuscitation. Resuscitation 2013; 84:1505-11. [PMID: 23851191 DOI: 10.1016/j.resuscitation.2013.07.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Revised: 06/27/2013] [Accepted: 07/02/2013] [Indexed: 11/25/2022]
Abstract
AIMS Accurate ventricular fibrillation (VF) waveform analysis usually requires rescuers to discontinue cardiopulmonary resuscitation (CPR). However, prolonged "hands-off" time has a deleterious impact on the outcome. We developed a new filter technique that could clean the CPR artifacts and help preserve the shockability index of VF METHODS: We analyzed corrupted ECGs, which were constructed by randomly adding different scaled CPR artifacts to the VF waveforms. A newly developed algorithm was used to identify the CPR fluctuations. The algorithm contained two steps. First, decomposing the raw data by empirical mode decomposition (EMD) into several intrinsic mode fluctuations (IMFs) and combining the dominant IMFs to reconstruct a new signal. Second, calculating each CPR cycle frequency from the new signal and fitting the new signal to the original corrupted ECG by least square mean (LSM) method to derive the CPR artifacts. The estimated VF waveform was derived by subtraction of the CPR artifacts from the corrupted ECG. We then performed amplitude spectrum analysis (AMSA) for original VF, corrupted ECG and estimated VF. RESULTS A total of 150 OHCA subjects with initial VF rhythm were included for analysis. Ten CPR artifacts signals were used to construct corrupted ECG. Even though the correlations of AMSA between the corrupted ECG vs. the original VF and the estimated VF vs. the original VF are all high (all p<0.001), the values of AMSA were obviously biased in corrupted ECG with wide limits of agreement in Bland-Altman mean-difference plot. ROC analysis of the AMSA in the prediction of defibrillation success showed that the new algorithm could preserve the cut-off AMSA value for CPR artifacts with power ratio to VF from 0 to 6 dB. CONCLUSION The new algorithm could efficiently filter the CPR-related artifacts of the VF ECG and preserve the shockability index of the original VF waveform.
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Affiliation(s)
- Men-Tzung Lo
- Research Center for Adaptive Data Analysis & Center for Dynamical Biomarkers and Translational Medicine, National Central University, Taoyuan, Taiwan
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Stub D, Byrne M, Pellegrino V, Kaye DM. Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation in a sheep model of refractory ischaemic cardiac arrest. Heart Lung Circ 2013; 22:421-7. [PMID: 23375811 DOI: 10.1016/j.hlc.2012.11.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Accepted: 11/24/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Survival after out-of-hospital cardiac arrest remains limited. It is therefore imperative to develop new resuscitation techniques. We aimed to determine the potential role of extracorporeal membrane oxygenation assisted CPR (ECPR) in an animal model of refractory ischaemic cardiac arrest. METHODS Twelve sheep were assigned to either ECPR (n=6) or 'conventional' (n=6) resuscitation. All sheep had coronary occlusion, followed by induction of ventricular fibrillation (VF). CPR was than commenced for 10 min in both groups, followed by randomisation to ECPR or CPR for a further 10 min. At 23 min post induction of VF, advanced life support measures were commenced with direct cardioversion, adrenaline and amiodarone. Outcomes measures included rates of return of spontaneous circulation (ROSC), and analysis of VF wave form. RESULTS Baseline haemodynamics were similar between the two groups. CPR consistently produced coronary perfusion pressures (CPP) greater than 15 mmHg in both groups, with significantly increased CPP post commencement of ECMO in the ECPR group (17.84±2 mmHg vs 22.94±3 mmHg, p=0.04). Number of shocks, pH, lactate and oxygenation were also comparable. Significantly greater rates of ROSC were seen in the ECPR sheep, 3/6 (50%) vs 0/6 (0%) (p=0.032), which was also associated with significantly increased VF amplitude measures (0.51±0.08 mV vs 0.42±0.06 mV, p=0.04). CONCLUSIONS This study indicates that ECPR increases return of circulation and coronary perfusion pressure in a sheep model of ischaemic VF arrest. Our findings have supported the development of a pilot trial into the effectiveness and feasibility of ECPR in the clinical setting.
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Affiliation(s)
- Dion Stub
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia.
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Sun S, Weng Y, Wu X, Tang K, Ye S, Chen W, Weil MH, Tang W. Optimizing the duration of CPR prior to defibrillation improves the outcome of CPR in a rat model of prolonged cardiac arrest. Resuscitation 2012; 82 Suppl 2:S3-7. [PMID: 22208175 DOI: 10.1016/s0300-9572(11)70144-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS This study was to investigate whether optimal duration of CPR prior to defibrillation could be guided by Amplitude Spectrum Analysis (AMSA) in the setting of prolonged VF on outcome of CPR. METHODS VF was induced in thirty Sprague-Dawley rats and untreated for 8 minutes. Animals were then randomized into 3 groups prior to CPR: The duration of CPR prior to defibrillation was guided by AMSA (CC+AMSA); guidelines-based with delayed defibrillation that simulated the AED algorithm (GL+AED); and guidelines-based with immediate shock (GL+shock ready). RESULTS Regardless of groups, the majority of the animals (85%) required over 5 min of CPR to achieve restoration of spontaneous circulation (ROSC). Significantly greater rate of ROSC after first defibrillation (70% vs 0%, p < 0.01), lesser CPR interruptions and the number of defibrillations were observed in the CC+AMSA group when compared to both guidelines-based groups (p < 0.001). This was associated with a significantly better post-resuscitation myocardial and neurological function and longer durations of survival. CONCLUSIONS After prolonged VF, optimal duration of CPR prior to defibrillation guided by AMSA improves the outcome of CPR.
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Affiliation(s)
- Shijie Sun
- Weil Institute of Critical Care Medicine, Rancho Mirage, CA 92270, USA
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Reynolds JC, Salcido DD, Menegazzi JJ. Correlation between coronary perfusion pressure and quantitative ECG waveform measures during resuscitation of prolonged ventricular fibrillation. Resuscitation 2012; 83:1497-502. [PMID: 22562057 DOI: 10.1016/j.resuscitation.2012.04.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Revised: 04/12/2012] [Accepted: 04/23/2012] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The ventricular fibrillation (VF) waveform is dynamic and predicts defibrillation success. Quantitative waveform measures (QWMs) quantify these changes. Coronary perfusion pressure (CPP), a surrogate for myocardial perfusion, also predicts defibrillation success. The relationship between QWM and CPP has been preliminarily explored. We sought to further delineate this relationship in our porcine model and to determine if it is different between animals with/without ROSC (return of spontaneous circulation). HYPOTHESIS A relationship exists between QWM and CPP that is different between animals with/without ROSC. METHODS Utilizing a prior experiment in our porcine model of prolonged out-of-hospital VF cardiac arrest, we calculated mean CPP, cumulative dose CPP, and percent recovery of three QWM during resuscitation before the first defibrillation: amplitude spectrum area (AMSA), median slope (MS), and logarithm of the absolute correlations (LAC). A random effects linear regression model with an interaction term CPP ROSC investigated the association between CPP and percent recovery QWM and how this relationship changes with/without ROSC. RESULTS For 12 animals, CPP and QWM measures (except LAC) improved during resuscitation. A linear relationship existed between CPP and percent recovery AMSA (coefficient 0.27; 95%CI 0.23, 0.31; p<0.001) and percent recovery MS (coefficient 0.80; 95%CI 0.70, 0.90; p<0.001). A linear relationship existed between cumulative dose CPP and percent recovery AMSA (coefficient 2.29; 95%CI 2.0, 2.56; p<0.001) and percent recovery MS (coefficient 6.68; 95%CI 6.09, 7.26; p<0.001). Animals with ROSC had a significantly "steeper" dose-response relationship. CONCLUSIONS There is a linear relationship between QWM and CPP during chest compressions in our porcine cardiac arrest model that is different between animals with/without ROSC.
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Affiliation(s)
- Joshua C Reynolds
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States.
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Nolan JP, Soar J, Zideman DA, Biarent D, Bossaert LL, Deakin C, Koster RW, Wyllie J, Böttiger B. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 2011; 81:1219-76. [PMID: 20956052 DOI: 10.1016/j.resuscitation.2010.08.021] [Citation(s) in RCA: 847] [Impact Index Per Article: 65.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
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Barash DM, Raymond RP, Tan Q, Silver AE. A New Defibrillator Mode to Reduce Chest Compression Interruptions for Health Care Professionals and Lay Rescuers: A Pilot Study in Manikins. PREHOSP EMERG CARE 2011; 15:88-97. [DOI: 10.3109/10903127.2010.531375] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Schratter A, Holzer M, Sterz F, Janata A, Sipos W, Uray T, Losert U, Behringer W. New conventional long-term survival normovolemic cardiac arrest pig model. Resuscitation 2011; 82:90-6. [PMID: 20947240 DOI: 10.1016/j.resuscitation.2010.08.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Revised: 07/25/2010] [Accepted: 08/18/2010] [Indexed: 11/28/2022]
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Link MS, Atkins DL, Passman RS, Halperin HR, Samson RA, White RD, Cudnik MT, Berg MD, Kudenchuk PJ, Kerber RE. Part 6: Electrical Therapies. Circulation 2010; 122:S706-19. [DOI: 10.1161/circulationaha.110.970954] [Citation(s) in RCA: 223] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Elektrotherapie: automatisierte externe Defibrillatoren, Defibrillation, Kardioversion und Schrittmachertherapie. Notf Rett Med 2010. [DOI: 10.1007/s10049-010-1369-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Deakin CD, Nolan JP, Sunde K, Koster RW. European Resuscitation Council Guidelines for Resuscitation 2010 Section 3. Electrical therapies: Automated external defibrillators, defibrillation, cardioversion and pacing. Resuscitation 2010; 81:1293-304. [DOI: 10.1016/j.resuscitation.2010.08.008] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Abstract
OBJECTIVE Prior studies have shown that interruptions of chest compressions could result in high failure rates of resuscitation. Chest compression artifacts force the interruption of compressions before electrocardiographic rhythm analysis. It was the goal of this study to evaluate the accuracy of an automated electrocardiographic rhythm analysis algorithm designed to attenuate compression-induced artifact and minimize uninterrupted chest compressions. DESIGN Retrospective diagnostic analysis. SETTING Out-of-hospital cardiopulmonary resuscitation. SUBJECTS Eight hundred thirty-two patients. INTERVENTIONS Patients were treated with defibrillation and cardiopulmonary resuscitation. Continuous data were recorded using automated external defibrillators with concurrent measurement of electrocardiographic and sternal motion during chest compressions. MEASUREMENTS AND RESULTS Human electrocardiographics recorded by automated external defibrillators were annotated and randomly selected to build distinct training and testing databases. The artifact reduction and tolerant filter was applied to the electrocardiographic signal. The algorithm was optimized with the training database (sensitivity, 93.9%; specificity, 91.2%) and tested with the testing database (sensitivity, 92.1%; specificity, 90.5%). Average attenuation of compression-induced artifact was more than 35 dB. CONCLUSIONS Shockable ventricular arrhythmias can be differentiated from electrocardiographic rhythms not requiring defibrillation in the presence of chest compression-induced artifact with sensitivity and specificity above 90%. With the artifact reduction and tolerant filter, it is possible to effectively eliminate pre- and postshock compression pauses.
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Lederer W, Schlimp CJ, Ritter EM, Niederklapfer T, Baubin M, Amann A. Assessment of reperfusion following thrombolysis with mean fibrillation and amplitude spectrum area in patients with sustained ventricular fibrillation. J Med Eng Technol 2010; 34:148-53. [PMID: 20050762 DOI: 10.3109/03091900903480762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Improved microcirculatory reperfusion in patients with ventricular fibrillation (VF) enhances the electrical activity of the fibrillation process and increases the likelihood of successful defibrillation. METHODS Changes in amplitude spectrum area (AMSA) and mean fibrillation (MF) in patients with sustained VF were analysed after administration of rt-PA variant tenecteplase in out-of-hospital cardiac arrest (OHCA) during cardiopulmonary resuscitation (CPR). RESULTS A total of 69 ECG sequences from nine patients were evaluated. Patients who received tenecteplase showed significantly longer duration of VF (p = 0.016). While AMSA declined significantly during CPR (p = 0.001), MF did not differ between groups. There were two survivors in the treatment group and one in the control group. CONCLUSION When tenecteplase was administered during CPR, VF lasted significantly longer than in controls. Changes in MF and AMSA did not indicate improved myocardial perfusion in patients who received tenecteplase during CPR.
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Affiliation(s)
- W Lederer
- Department of Anaesthesiology and Critical Care Medicine, Anaesthesiology Research Laboratory, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria.
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Li Y, Yu T, Ristagno G, Chung SP, Bisera J, Quan W, Freeman G, Weil MH, Tang W. The optimal phasic relationship between synchronized shock and mechanical chest compressions. Resuscitation 2010; 81:724-9. [PMID: 20346567 DOI: 10.1016/j.resuscitation.2010.02.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 02/10/2010] [Accepted: 02/22/2010] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Pauses for shock delivery in chest compressions are detrimental to the success of resuscitation and may be eliminated with the use of mechanical chest compressors. However, the optimal phasic relationship between mechanical chest compression and defibrillation is still unknown. We therefore undertook a study to assess the effects of timing of defibrillation in the mechanical chest compression cycle on the defibrillation threshold (DFT) using a porcine model of cardiac arrest. METHODS Ventricular fibrillation was electrically induced and untreated for 10s in 8 domestic pigs weighing between 26 and 30 kg. Mechanical chest compression was then continuously performed for 25s, followed by a biphasic electrical shock which was delivered to the animal at 6 randomized coupling phases, including a control phase, with a pre-determined energy setting. The control phase was chosen at a constant 2s following discontinued chest compression. A novel grouped up-and-down DFT testing protocol was used to compare the success rate at different coupling phases. After a recovery interval of 4 min, the testing sequence was repeated, resulting in a total of 60 test shocks delivered to each animal. RESULTS No difference between the delivered shock energy, voltage and current were observed among the 6 study phases. The defibrillation success rate, however, was significantly higher when shocks were delivered in the upstroke phase of mechanical chest compression. CONCLUSION Defibrillation efficacy is maximal when electrical shock is delivered in the upstroke phase of mechanical chest compression.
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Affiliation(s)
- Yongqin Li
- Weil Institute of Critical Care Medicine, Rancho Mirage, CA, USA
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Li Y, Wang H, Cho JH, Quan W, Freeman G, Bisera J, Weil MH, Tang W. Defibrillation delivered during the upstroke phase of manual chest compression improves shock success. Crit Care Med 2010; 38:910-5. [PMID: 20042857 DOI: 10.1097/ccm.0b013e3181cc4944] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The current standard of manual chest compression during cardiopulmonary resuscitation requires pauses for rhythm analysis and shock delivery. However, interruptions of chest compression greatly decrease the likelihood of successful defibrillations, and significantly better outcomes are reported if this interruption is avoided. We therefore undertook a prospective randomized controlled animal study in an electrically induced ventricular fibrillation pig model to assess the effects of timing of defibrillation on the manual chest compression cycle on the defibrillation threshold. DESIGN Prospective, randomized, controlled animal study. SETTING University-affiliated research laboratory. SUBJECTS Yorkshire-X domestic pigs (Sus scrofa). INTERVENTIONS In eight domestic male pigs weighing between 24 and 31 kg, ventricular fibrillation was electrically induced and untreated for 10 secs. Manual chest compression was then performed and continued for 25 secs with the protection of an isolation blanket. The depth and frequency of chest compressions were guided by a cardiopulmonary resuscitation prompter. Animals were randomized to receive a biphasic electrical shock in five different compression phases with a predetermined energy setting. A control phase was chosen at a constant 2 secs after discontinued chest compression. A grouped up-down defibrillation threshold testing protocol was used to compare the success rate at different coupling phases. After a recovery interval of 4 mins, the sequence was repeated for a total of 60 test shocks for each animal. MEASUREMENTS AND MAIN RESULTS No difference in coronary perfusion pressure before delivering of the shock was observed among the six study phases. The defibrillation success rate, however, was significantly higher when shocks were delivered in the upstroke phase of manual chest compression. CONCLUSION Defibrillation efficacy is maximal when electrical shock is delivered during the upstroke phase of manual chest compression.
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Affiliation(s)
- Yongqin Li
- Weil Institute of Critical Care Medicine, Rancho Mirage, CA, USA
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Shock advisory system for heart rhythm analysis during cardiopulmonary resuscitation using a single ECG input of automated external defibrillators. Ann Biomed Eng 2010; 38:1326-36. [PMID: 20069371 DOI: 10.1007/s10439-009-9885-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Accepted: 12/23/2009] [Indexed: 10/20/2022]
Abstract
Minimum "hands-off" intervals during cardiopulmonary resuscitation (CPR) are required to improve the success rate of defibrillation. In support of such life-saving practice, a shock advisory system (SAS) for automatic analysis of the electrocardiogram (ECG) contaminated by chest compression (CC) artefacts is presented. Ease of use for the automated external defibrillators (AEDs) is aimed and therefore only processing of ECG from usual defibrillation pads is required. The proposed SAS relies on assessment of outstanding components of ECG rhythms and CC artefacts in the time and frequency domain. For this purpose, three criteria are introduced to derive quantitative measures of band-pass filtered CC-contaminated ECGs, combined with three more criteria for frequency-band evaluation of reconstructed ECGs (rECG). The rECGs are derived by specific techniques for CC waves similarity assessment and are reproducing to some extent the underlying ECG rhythms. The rhythm classifier embedded in SAS takes a probabilistic decision designed by statistics on the training dataset. Both training and testing are fully performed on real CC-contaminated strips of 10 s extracted from human ECGs of out-of-hospital cardiac arrest interventions. The testing is done on 172 shockable strips (ventricular fibrillations VF), 371 non-shockable strips (NR) and 330 asystoles (ASYS). The achieved sensitivity of 90.1% meets the AHA performance goal for noise-free VF (>90%). The specificity of 88.5% for NR and 83.3% for ASYS are comparable or even better than accuracy reported in literature. It is important to note that, the aim of this SAS is not to recommend shock delivery but to advice the rescuers to "Continue CPR" or to "Stop CPR and Prepare for Shock" thus minimizing "hands-off" intervals.
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BROOKS LEONARD, ZHANG YI, DENDI RAGHUVEER, ANDERSON ROGERH, ZIMMERMAN BRIDGET, KERBER RICHARDE. Selecting the Transthoracic Defibrillation Shock Directional Vector Based on VF Amplitude Improves Shock Success. J Cardiovasc Electrophysiol 2009; 20:1032-8. [DOI: 10.1111/j.1540-8167.2009.01483.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Olasveengen TM, Eftestøl T, Gundersen K, Wik L, Sunde K. Acute ischemic heart disease alters ventricular fibrillation waveform characteristics in out-of hospital cardiac arrest. Resuscitation 2009; 80:412-7. [DOI: 10.1016/j.resuscitation.2009.01.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Revised: 01/12/2009] [Accepted: 01/19/2009] [Indexed: 10/21/2022]
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Indik JH, Hilwig RW, Zuercher M, Kern KB, Berg MD, Berg RA. Preshock cardiopulmonary resuscitation worsens outcome from circulatory phase ventricular fibrillation with acute coronary artery obstruction in swine. Circ Arrhythm Electrophysiol 2009; 2:179-84. [PMID: 19808463 DOI: 10.1161/circep.108.824862] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Some clinical studies have suggested that chest compressions before defibrillation improve survival in cardiac arrest because of prolonged ventricular fibrillation (VF; ie, within the circulatory phase). Animal data have also supported this conclusion, and we have previously demonstrated that preshock chest compressions increase the VF median frequency and improve the likelihood of a return of spontaneous circulation in normal swine. We hypothesized that chest compressions before defibrillation in a swine model of acute myocardial ischemia would also increase VF median frequency and improve resuscitation outcome. METHODS AND RESULTS Twenty-six swine were subjected to balloon occlusion of the left anterior descending coronary artery for 2 hours. The balloon was removed and VF was induced and untreated for 8 minutes. Swine were then treated with up to 3 stacked defibrillation shocks (n=13, shock-first group) or 3 minutes of chest compressions before shock (n=13, preshock cardiopulmonary resuscitation group). In the preshock cardiopulmonary resuscitation group, median frequency was increased from 7.0+/-0.8 to 13.9+/-1.6 Hz after chest compressions (P=0.002). Despite the improved median frequency in the preshock cardiopulmonary resuscitation group, 24-hour survival with favorable neurological status was significantly worse in the preshock cardiopulmonary resuscitation group (1/13) compared with the shock-first group (8/13, P=0.01). CONCLUSIONS In a swine model of prolonged VF in acute myocardial ischemia, 24-hour survival with favorable neurological status was more likely when defibrillation was performed first without preceding chest compressions. Myocardial substrate is an important factor in determining the optimal resuscitation strategy.
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Affiliation(s)
- Julia H Indik
- Sarver Heart Center, Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona 85724-5037, USA.
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Abstract
PURPOSE OF REVIEW Ventricular fibrillation is the primary rhythm in many cardiac arrest patients. Since the late 1980s, the surface electrocardiogram of ventricular fibrillation has been subjected to analysis to obtain reliable information about the likelihood of successful countershock and to estimate the duration of cardiac arrest. Considerable efforts were made in the past 2 years to further improve the predictive power of rescue shock measures. RECENT FINDINGS In a retrospective clinical study, ventricular fibrillation single feature analysis was not able to reliably estimate duration between cardiac arrest onset and initial electrocardiogram. Combining ventricular fibrillation features in the time and frequency domain by employing neural networks did not further improve the best single feature prediction power taken from higher ventricular fibrillation frequency bands. Cardioversion outcome prediction based on the wavelet technique increased the specificity up to 66% at the 95% sensitivity level. SUMMARY Recent results question the ventricular fibrillation feature analysis as a reliable tool to estimate the duration of human cardiac arrest. Animal and clinical studies confirmed that ventricular fibrillation waveform analysis contains information to reliably predict the countershock success rate and further improved countershock outcome prediction. Prospective clinical studies are highly warranted to demonstrate that ventricular fibrillation waveform analysis definitely improves survival after cardiac arrest.
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The influence of myocardial substrate on ventricular fibrillation waveform: a swine model of acute and postmyocardial infarction. Crit Care Med 2008; 36:2136-42. [PMID: 18552696 DOI: 10.1097/ccm.0b013e31817d798c] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In cardiac arrest resulting from ventricular fibrillation, the ventricular fibrillation waveform may be a clue to its duration and predict the likelihood of shock success. However, ventricular fibrillation occurs in different myocardial substrates such as ischemia, heart failure, and structurally normal hearts. We hypothesized that ventricular fibrillation is altered by myocardial infarction and varies from the acute to postmyocardial infarction periods. DESIGN An animal intervention study was conducted with comparison to a control group. SETTING This study took place in a university animal laboratory. SUBJECTS Study subjects included 37 swine. INTERVENTIONS Myocardial infarction was induced by occlusion of the midleft anterior descending artery. Ventricular fibrillation was induced in control swine, acute myocardial infarction swine, and in postmyocardial infarction swine after a 2-wk recovery period. MEASUREMENTS AND MAIN RESULTS Ventricular fibrillation was recorded in 11 swine with acute myocardial infarction, ten postmyocardial infarction, and 16 controls. Frequency (mean, median, dominant, and bandwidth) and amplitude-related content (slope, slope-amp [slope divided by amplitude], and amplitude-spectrum area) were analyzed. Frequencies at 5 mins of ventricular fibrillation were altered in both acute myocardial infarction (p < .001 for all frequency characteristics) and postmyocardial infarction swine (p = .015 for mean, .002 for median, .002 for dominant frequency, and <.001 for bandwidth). At 5 mins, median frequency was highest in controls, 10.9 +/- .4 Hz; lowest in acute myocardial infarction, 8.4 +/- .5 Hz; and intermediate in postmyocardial infarction, 9.7 +/- .5 Hz (p < .001 for acute myocardial infarction and p = .002 for postmyocardial infarction compared with control). Slope and amplitude-spectrum area were similar among the three groups with a shallow decline after minute 2, whereas slope-amp remained significantly altered for acute myocardial infarction swine at 5 mins (p = .003). CONCLUSIONS Ventricular fibrillation frequencies depend on myocardial substrate and evolve from the acute through healing phases of myocardial infarction. Amplitude related measures, however, are similar among these groups. It is unknown how defibrillation may be affected by relying on the ventricular fibrillation waveform without considering myocardial substrate.
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Indik JH, Peters CM, Donnerstein RL, Ott P, Kern KB, Berg RA. Direction of signal recording affects waveform characteristics of ventricular fibrillation in humans undergoing defibrillation testing during ICD implantation. Resuscitation 2008; 78:38-45. [PMID: 18403087 DOI: 10.1016/j.resuscitation.2008.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2007] [Revised: 02/05/2008] [Accepted: 02/13/2008] [Indexed: 10/22/2022]
Abstract
INTRODUCTION In cardiac arrest due to prolonged ventricular fibrillation (VF), defibrillation is more likely to result in a perfusing rhythm if chest compressions are performed first. Furthermore, the VF waveform can predict the shockability of VF and thus automated external defibrillators (AEDs) are being designed to analyze the VF waveform to direct therapies. However, it is unknown whether the VF waveform is dependent on recording direction, which could be altered by incorrect placement of AED patches. MATERIALS AND METHODS VF was induced in 26 patients with ischemic cardiomyopathy and 19 patients with dilated cardiomyopathy and recorded in six limb leads. Frequency characteristics (mean, median, dominant frequency, and bandwidth) were computed as well as amplitude-based measures: amplitude spectral area (AMSA), slope, signal amplitude, and slope divide by signal amplitude (slope-amp). RESULTS Frequency characteristics were similar in all leads. However, AMSA, slope, and signal amplitude were significantly affected (P<0.001) by lead. In particular, for ischemic cardiomyopathy patients, between leads I and II, AMSA varied from 29.4+/-3.2 to 49.3+/-4.6 mV Hz (mean+/-SEM, P<0.001) and slope varied from 1.5+/-0.2 to 2.4+/-0.3 mV/s (P<0.001). Slope-amp was similar in all leads. There were no significant differences between ischemic and dilated cardiomyopathy patients. CONCLUSIONS Amplitude measures of VF are significantly affected by limb lead ECG recording direction. This work suggests that AED patches must be correctly and consistently placed if amplitude-based measures are used to decide whether to deliver a defibrillatory shock.
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Affiliation(s)
- Julia H Indik
- The Sarver Heart Center at The University of Arizona College of Medicine, Tucson, AZ 85724-5037, USA.
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Ristagno G, Gullo A, Berlot G, Lucangelo U, Geheb E, Bisera J. Prediction of successful defibrillation in human victims of out-of-hospital cardiac arrest: a retrospective electrocardiographic analysis. Anaesth Intensive Care 2008; 36:46-50. [PMID: 18326131 DOI: 10.1177/0310057x0803600108] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the present study we sought to examine the efficacy of an electrocardiographic parameter, 'amplitude spectrum area' (AMSA), to predict the likelihood that any one electrical shock would restore a perfusing rhythm during cardiopulmonary resuscitation in human victims of out-of-hospital cardiac arrest. AMSA analysis is not invalidated by artefacts produced by chest compression and thus it can be performed during CPR, avoiding detrimental interruptions of chest compression and ventilation. We hypothesised that a threshold value of AMSA could be identified as an indicator of successful defibrillation in human victims of cardiac arrest. Analysis was performed on a database of electrocardiographic records, representing lead 2 equivalent recordings from automated external defibrillators including 210 defibrillation attempts from 90 victims of out-of-hospital cardiac arrest. A 4.1 second interval of ventricular fibrillation or ventricular tachycardia, recorded immediately preceding the delivery of the shock, was analysed using the AMSA algorithm. AMSA represents a numerical value based on the sum of the magnitude of the weighted frequency spectrum between two and 48 Hz. AMSA values were significantly greater in successful defibrillation (restoration of a perfusing rhythm), compared to unsuccessful defibrillation (P < 0.0001). An AMSA value of 12 mV-Hz was able to predict the success of each defibrillation attempt with a sensitivity of 0.91 and a specificity of 0.97. In conclusion, AMSA analysis represents a clinically applicable method, which provides a real-time prediction of the success of defibrillation attempts. AMSA may minimise the delivery of futile and detrimental electrical shocks, reducing thereby post-resuscitation myocardial injury.
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Affiliation(s)
- G Ristagno
- Weil Institute of Critical Care Medicine, Rancho Mirage, California, USA
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35
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Cardiac Arrest and Cardiopulmonary Resuscitation. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50003-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Indik JH, Donnerstein RL, Berg RA, Hilwig RW, Berg MD, Kern KB. Ventricular fibrillation frequency characteristics are altered in acute myocardial infarction. Crit Care Med 2007; 35:1133-8. [PMID: 17334241 DOI: 10.1097/01.ccm.0000259540.52062.99] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Future automated external defibrillators are being designed to direct rescue efforts (chest compressions first vs. defibrillation) by inferring the duration of ventricular fibrillation based on its waveform characteristics such as frequency content. This approach assumes that the ventricular fibrillation waveform is an appropriate surrogate for ventricular fibrillation duration and is not affected by structural heart disease. We hypothesized that an acute myocardial infarction may alter the frequency content of ventricular fibrillation. DESIGN Animal intervention study with comparison to control group. SETTING University animal laboratory. SUBJECTS Twenty-seven swine. INTERVENTIONS Acute myocardial infarction was induced by occlusion of the mid-left anterior descending artery. Ventricular fibrillation was induced in swine with acute myocardial infarction and control swine. MEASUREMENTS AND MAIN RESULTS Ventricular fibrillation was induced in 11 swine with an acute myocardial infarction and in 16 control swine. Ventricular fibrillation waveforms were analyzed for mean, median, and dominant frequency, as well as bandwidth and amplitude. All frequency characteristics were significantly (p < .001) altered in swine with acute myocardial infarction compared with controls. Specifically, these characteristics were significantly depressed and varied little over time in swine with acute myocardial infarction compared with controls. CONCLUSIONS These data establish that ventricular fibrillation during an acute myocardial infarction has an altered frequency content and time evolution compared with ventricular fibrillation without coronary obstruction. Frequency characteristics such as mean, median, dominant, and bandwidth show little variation in time after an acute myocardial infarction and are not suitable surrogates for ventricular fibrillation duration. These findings have important implications for the development of "smart" automated external defibrillators designed to determine duration of ventricular fibrillation from the waveform characteristics.
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Affiliation(s)
- Julia H Indik
- The Sarver Heart Center, The University of Arizona College of Medicine, Tucson, AZ, USA.
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Neurauter A, Eftestøl T, Kramer-Johansen J, Abella BS, Sunde K, Wenzel V, Lindner KH, Eilevstjønn J, Myklebust H, Steen PA, Strohmenger HU. Prediction of countershock success using single features from multiple ventricular fibrillation frequency bands and feature combinations using neural networks. Resuscitation 2007; 73:253-63. [PMID: 17287063 DOI: 10.1016/j.resuscitation.2006.10.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2006] [Revised: 09/27/2006] [Accepted: 10/03/2006] [Indexed: 10/23/2022]
Abstract
Targeted defibrillation therapy is needed to optimise survival chances of ventricular fibrillation (VF) patients, but at present VF analysis strategies to optimise defibrillation timing have insufficient predictive power. From 197 patients with in-hospital and out-of-hospital cardiac arrest, 770 electrocardiogram (ECG) recordings of countershock attempts were analysed. Preshock VF ECG features in the time and frequency domain were tested retrospectively for outcome prediction. Using band pass filters, the ECG spectrum was split into various frequency bands of 2-26 Hz bandwidth in the range of 0-26 Hz. Neural networks were used for single feature combinations to optimise prediction of countershock success. Areas under curves (AUC) of receiver operating characteristics (ROC) were used to estimate prediction power of single and combined features. The highest ROC AUC of 0.863 was reached by the median slope in the interval 10-22 Hz resulting in a sensitivity of 95% and a specificity of 50%. The best specificity of 55% at the 95% sensitivity level was reached by power spectrum analysis (PSA) in the 6-26 Hz interval. Neural networks combining single predictive features were unable to increase outcome prediction. Using frequency band segmentation of human VF ECG, several single predictive features with high ROC AUC>0.840 were identified. Combining these single predictive features using neural networks did not further improve outcome prediction in human VF data. This may indicate that various simple VF features, such as median slope already reach the maximum prediction power extractable from VF ECG.
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Affiliation(s)
- Andreas Neurauter
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
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Jang S, Seong H, Lee J, Yoon Y, Hwang S, Lee H. Analysis of relation between coronary perfusion pressure and the extracted parameters from a ventricular fibrillation ECG signal. CONFERENCE PROCEEDINGS : ... ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL CONFERENCE 2007; 2004:3989-92. [PMID: 17271172 DOI: 10.1109/iembs.2004.1404114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This work presents an alternative return of spontaneous circulation (ROSC) estimate using indirectly induced presumption that coronary perfusion pressure (CPP) correlates with the extracted parameter from the ventricular fibrillation (VF) ECG signal. In past studies, it is revealed that successful cardiopulmonary resuscitation (CPR) needs at least 30 approximately 40 mmHg CPP during the aortic diastolic period. In 360 segments derived from 18 test dogs with experimental cardiac arrest of cardiac cause, we analyzed the ability of 4 spectral features of VF before countershock to discriminate or not between segments that correspond to CPP. The median frequency (MF), peak frequency (PF), average segment amplitude (ASA) and maximum segment amplitude (MSA) were studied. After preprocessing the raw data acquired from the specific experimental setup and protocol, we verified CPP is a serious estimate of ROSC, and then we analyzed the extracted parameters corresponding to CPP by multiple regression. In the specific conditional frequency domain (MF: 9.42 approximately 12.42 Hz, PF: 8.71 approximately 13.08 Hz, ASA: > 0.19 mV), CPP is correlated to the extracted parameter with 0.71 +/- 0.05 coefficient of multiple determination (R(2)). The combination of MF, PF, and ASA achieved a 79.47 +/- 3% sensitivity and 41.67 +/- 4% specificity in testing.
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Affiliation(s)
- S Jang
- Department of Biomedical Engineering, Health Science College, Yonsei University, Wonju, South Korea
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Snyder DE, White RD, Jorgenson DB. Outcome prediction for guidance of initial resuscitation protocol: Shock first or CPR first. Resuscitation 2007; 72:45-51. [PMID: 17107744 DOI: 10.1016/j.resuscitation.2006.05.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2006] [Revised: 05/11/2006] [Accepted: 05/15/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Ventricular fibrillation (VF) is treated optimally with a defibrillation shock shortly after patient collapse, but may benefit from initial cardiopulmonary resuscitation (CPR) if the shock is delayed. An objective measure of potential responsiveness to defibrillation could help decide optimal initial therapy. METHODS AND RESULTS a new electrocardiogram (ECG) analysis algorithm was compared with response interval (call-to-shock) for prediction of patient outcome in a population of 87 VF patients in the Rochester, Minnesota area. In a retrospective analysis, both call-to-shock interval (p = 0.009) and ECG analysis (p < 0.001) predicted neurologically intact survival, with ECG analysis the stronger predictor (p = 0.034). When applied to advising initial patient treatment, ECG analysis compared favorably with the call-to-shock interval. Using a 7 min call-to-shock time criterion, 69% of patients would receive shocks first treatment using ECG analysis versus 67% using the call-to-shock interval (p = NS), 94% of survivors would retain successful shocks first treatment versus 85% (p = NS), and 48% of non-survivors receive alternate CPR-first treatment versus 45% (p = NS). Similarly, no significant differences were observed between ECG analysis and call-to-shock interval using an 8 min criterion. CONCLUSIONS Both call-to-shock interval and a real-time ECG analysis are predictive of patient outcome. The ECG analysis is more predictive of neurologically intact survival. Moreover, the ECG analysis is dependent only upon the patient's condition at the time of treatment, with no need for knowledge of the response interval, which may be difficult to estimate at the time of treatment.
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Pytte M, Kramer-Johansen J, Eilevstjønn J, Eriksen M, Strømme TA, Godang K, Wik L, Steen PA, Sunde K. Haemodynamic effects of adrenaline (epinephrine) depend on chest compression quality during cardiopulmonary resuscitation in pigs. Resuscitation 2006; 71:369-78. [PMID: 17023108 DOI: 10.1016/j.resuscitation.2006.05.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Revised: 05/04/2006] [Accepted: 05/10/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Adrenaline (epinephrine) is used during cardiopulmonary resuscitation (CPR) based on animal experiments without supportive clinical data. Clinically CPR was reported recently to have much poorer quality than expected from international guidelines and what is generally done in laboratory experiments. We have studied the haemodynamic effects of adrenaline during CPR with good laboratory quality and with quality simulating clinical findings and the feasibility of monitoring these effects through VF waveform analysis. METHODS AND RESULTS After 4 min of cardiac arrest, followed by 4 min of basic life support, 14 pigs were randomised to ClinicalCPR (intermittent manual chest compressions, compression-to-ventilation ratio 15:2, compression depth 30-38 mm) or LabCPR (continuous mechanical chest compressions, 12 ventilations/min, compression depth 45 mm). Adrenaline 0.02 mg/kg was administered 30 s thereafter. Plasma adrenaline concentration peaked earlier with LabCPR than with ClinicalCPR, median (range), 90 (30, 150) versus 150 (90, 270) s (p = 0.007), respectively. Coronary perfusion pressure (CPP) and cortical cerebral blood flow (CCBF) increased and femoral blood flow (FBF) decreased after adrenaline during LabCPR (mean differences (95% CI) CPP 17 (6, 29) mmHg (p = 0.01), FBF -5.0 (-8.8, -1.2) ml min(-1) (p = 0.02) and median difference CCBF 12% of baseline (p = 0.04)). There were no significant effects during ClinicalCPR (mean differences (95% CI) CPP 4.7 (-3.2, 13) mmHg (p = 0.2), FBF -0.2 (-4.6, 4.2) ml min(-1)(p = 0.9) and CCBF 3.6 (-1.8, 9.0)% of baseline (p = 0.15)). Slope VF waveform analysis reflected changes in CPP. CONCLUSION Adrenaline improved haemodynamics during laboratory quality CPR in pigs, but not with quality simulating clinically reported CPR performance.
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Affiliation(s)
- Morten Pytte
- Department of Anaesthesiology, Ulleval University Hospital, Oslo, Norway.
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Aramendi E, de Gauna SR, Irusta U, Ruiz J, Arcocha MF, Ormaetxe JM. Detection of ventricular fibrillation in the presence of cardiopulmonary resuscitation artefacts. Resuscitation 2006; 72:115-23. [PMID: 17088016 DOI: 10.1016/j.resuscitation.2006.05.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2005] [Revised: 05/22/2006] [Accepted: 05/30/2006] [Indexed: 10/23/2022]
Abstract
Providing cardiopulmonary resuscitation (CPR) to a patient in cardiac arrest introduces artefacts into the electrocardiogram (ECG), corrupting the diagnosis of the underlying heart rhythm. CPR must therefore be discontinued for reliable shock advice analysis by an automated external defibrillator (AED). Detection of ventricular fibrillation (VF) during CPR would enable CPR to continue during AED rhythm analysis, thereby increasing the likelihood of resuscitation success. This study presents a new adaptive filtering method to clean the ECG. The approach consists of a filter that adapts its characteristics to the spectral content of the signal exclusively using the surface ECG that commercial AEDs capture through standard patches. A set of 200 VF and 25 CPR artefact samples collected from real out-of-hospital interventions were used to test the method. The performance of a shock advice algorithm was evaluated before and after artefact removal. CPR artefacts were added to the ECG signals and four degrees of corruption were tested. Mean sensitivities of 97.83%, 98.27%, 98.32% and 98.02% were achieved, producing sensitivity increases of 28.44%, 49.75%, 59.10% and 64.25%, respectively, sufficient for ECG analysis during CPR. Although satisfactory and encouraging sensitivity values have been obtained, further clinical and experimental investigation is required in order to integrate this type of artefact suppressing algorithm in current AEDs.
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Affiliation(s)
- Elisabete Aramendi
- Department of Electronics and Telecommunications, University of the Basque Country, Alameda de Urquijo s/n, 48013-Bilbao, Spain.
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Indik JH, Donnerstein RL, Kern KB, Goldman S, Gaballa MA, Berg RA. Ventricular fibrillation waveform characteristics are different in ischemic heart failure compared with structurally normal hearts. Resuscitation 2006; 69:471-7. [PMID: 16600470 DOI: 10.1016/j.resuscitation.2005.10.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2005] [Revised: 10/05/2005] [Accepted: 10/05/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND For prolonged VF, perfusion of the myocardium by pre-shock chest compressions can improve myocardial readiness for successful defibrillation. Characteristics of the VF waveform correlate with the duration of VF when there is no structural heart disease. A "smart" automated external defibrillator (AED) could therefore analyze the VF waveform, determine if VF has been prolonged, and then direct rescuers to either deliver a shock first or chest compressions first. We hypothesized that ischemic heart failure might alter the waveform content of ventricular fibrillation compared with normal hearts, complicating the determination of VF duration. METHODS Myocardial infarction was induced by ligating the proximal left coronary artery. Six weeks later, VF was then induced in 10 rats with myocardial infarction and heart failure (MI-CHF) and 9 control rats. Waveforms were analyzed for total signal amplitude, median frequency, dominant frequency and bandwidth (the frequency interval containing 50% of the total amplitude about the median frequency). RESULTS All of these VF waveform characteristics were altered substantially in MI-CHF rats compared to normal controls. In particular, MI-CHF rats had decreased signal amplitude early in VF (p=0.02), a broader bandwidth (p=0.001) and different frequency characteristics over time (p<0.001). CONCLUSIONS VF waveforms vary over time in a typical manner among rats with and without ischemic heart failure. However, the time-course and waveform characteristics of ventricular fibrillation are altered in rats with myocardial infarctions and ischemic heart failure compared to normal controls. These findings have important implications regarding the use of waveform analyses to determine the duration of VF.
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Affiliation(s)
- Julia H Indik
- Sarver Heart Center, University of Arizona College of Medicine, 1501 N. Campbell Avenue, Tucson, AZ 85724-5037, USA.
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Lederer W, Schlimp CJ, Niederklapfer T, Amann A. Altered electrical activity of fibrillation process following thrombolytic therapy in out-of-hospital cardiac arrest patients with sustained ventricular fibrillation. Med Hypotheses 2006; 67:333-5. [PMID: 16549275 DOI: 10.1016/j.mehy.2006.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Revised: 02/01/2006] [Accepted: 02/02/2006] [Indexed: 10/24/2022]
Abstract
The likelihood of successful defibrillation in patients with sustained ventricular fibrillation (VF) is increased after administering thrombolytics during cardiopulmonary resuscitation (CPR). While dissolution of coronary artery thrombosis resolves the underlying cause of myocardial infarction in the majority of patients, improved microcirculatory reperfusion and alteration of the electrical activity of the fibrillation process may increase the likelihood of restoring spontaneous circulation in cardiac arrest patients. Electrocardiography is a sensitive means of displaying current myocardial perfusion in VF using changes in the frequency and amplitude of fibrillation. Our hypothesis postulates that thrombolytic therapy during CPR increases fibrillation frequency, fibrillation amplitude and amplitude spectrum area, thus improving ventricular fibrillation status and the chance of successful defibrillation.
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Affiliation(s)
- Wolfgang Lederer
- Department of Anaesthesiology and Critical Care Medicine, Anaesthesiology Research Laboratory, Innsbruck Medical University, Anichstr. 35, A-6020 Innsbruck, Austria.
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Elektrische Therapie: automatisierte externe Defibrillatoren, Defibrillation, Kardioversion und Schrittmachertherapie. Notf Rett Med 2006. [DOI: 10.1007/s10049-006-0793-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
Postresuscitation syndrome is a state of myocardial dysfunction after the restoration of circulation by successful resuscitation. Despite several advances in the field of resuscitation, the management of out-of-hospital cardiac arrest is still suboptimal. The high fatality rate shortly after successful resuscitation is mainly related to postresuscitation myocardial dysfunction. Postresuscitation myocardial stunning is reversible, while stony heart is irreversible due to prolonged unsuccessful resuscitation. This article reviews most of the published articles concerning the causes, mechanism, pathophysiology, and the updated trials for management of postresuscitation myocardial dysfunction. Further studies are warranted to highlight postresuscitation disease and its hemodynamic sequences and then to intervene according to the different phases of cardiac arrest. By modifying the conventional modalities of resuscitation together with new promising agents, the rescuers will be able to salvage the jeopardized postresuscitation myocardium and prevent its progression to the dismal stony heart. Community awareness and staff education are crucial to shorten resuscitation time and improve short-term and long-term outcomes. There is an urgent need to revise the guidelines for cardiopulmonary resuscitation in community setting, but how? It is a matter of where and when it is of enough value to be efficacious and cost-effective.
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Affiliation(s)
- Ayman A El-Menyar
- Department of Cardiology and Cardiovascular Surgery, Hamad Medical Corporation and Hamad General Hospital, PO Box 3050, Doha, State of Qatar.
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Eftestøl T, Losert H, Kramer-Johansen J, Wik L, Sterz F, Steen PA. Independent evaluation of a defibrillation outcome predictor for out-of-hospital cardiac arrested patients. Resuscitation 2005; 67:55-61. [PMID: 16154680 DOI: 10.1016/j.resuscitation.2005.05.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2005] [Revised: 04/27/2005] [Accepted: 05/13/2005] [Indexed: 10/25/2022]
Abstract
We evaluated the ability of a previously derived outcome predictor to discriminate between ECG segments corresponding to return of spontaneous circulation (ROSC) or not in validation data from 136 patients with cardiac arrest. The new data used for validation were totally independent from the predictor derivation data used in the original study. Features corresponding to those used in the development of the original outcome predictor, centroid frequency, peak power frequency, spectral flatness and energy, were computed following which a second decorrelated feature set was generated. The outcome predictor was applied to the new data with good correspondence in performance (testing) to what was expected (training) with receiver operator characteristics (ROC) areas of 0.80 and 0.79, respectively. Outcome predictor performance was reproducible. As in the present study, future testing should be performed on totally independent data not included in the design of the outcome predictor to get a reliable impression of expected performance.
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Affiliation(s)
- Trygve Eftestøl
- University of Stavanger, Faculty of Science and Technology, Department of Electrical and Computer Engineering, N-4036 Stavanger, Norway.
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Abstract
PURPOSE OF REVIEW Ventricular fibrillation occurs during many cases of cardiac arrest and is treated with rescue shocks. Coarse ventricular fibrillation occurs earlier after the onset of cardiac arrest and is more likely to be converted to an organized rhythm with pulses by rescue shocks. Less organized or fine ventricular fibrillation occurs later, has less power concentrated within narrow frequency bands and lower amplitude, and is less likely to be converted to an organized rhythm by rescue shocks. Quantitative analysis of the ventricular fibrillation waveform may distinguish coarse ventricular fibrillation from fine ventricular fibrillation, allowing more appropriate delivery of rescue shocks. RECENT FINDINGS A variety of studies in animals and humans indicate that there is underlying structure within the ventricular fibrillation waveform. Highly organized or coarse ventricular fibrillation is characterized by large power contributions from a few component frequencies and higher amplitude. Amplitude, decomposition into power spectra, or probability-based, nonlinear measures all can quantify the organization of human ventricular fibrillation waveforms. Clinical data have accumulated that these quantitative measures, or combinations of these measures, can predict the likelihood of rescue shock success, restoration of circulation, and survival to hospital discharge. SUMMARY Many quantitative ventricular fibrillation measures could be implemented in current generations of monitors/defibrillators to assist the timing of rescue shocks during clinical care. Emerging data suggest that a period of chest compressions or reperfusion can increase the likelihood of successful defibrillation. Therefore, waveform-based prediction of defibrillation success could reduce the delivery of failed rescue shocks.
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Affiliation(s)
- Clifton W Callaway
- University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania 15213, USA.
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Indik JH, Donnerstein RL, Berg MD, Samson RA, Berg RA. Ventricular fibrillation frequency characteristics and time evolution in piglets: a developmental study. Resuscitation 2005; 63:85-92. [PMID: 15451590 DOI: 10.1016/j.resuscitation.2004.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Derived variables of ventricular fibrillation, such as the frequency distribution by fast Fourier transformation and its evolution over time, have been used to determine the optimum timing for defibrillation. We hypothesized that these frequency variables would differ among neonatal, young child and older child populations due to cardiac developmental and size differences. Such differences may have important implications for developing defibrillation algorithms for pediatric patients and for extrapolating adult defibrillation algorithms to children in VF. METHODS Ventricular fibrillation was induced and recorded for 6 min in 4 kg (n = 11), 14 kg (n = 10), and 24 kg (n = 16) piglets, corresponding to neonatal, young child and older children. Mean, median, and dominant frequencies were computed in 30 s intervals and compared among weight classes. RESULTS All frequency variables in all weight groups showed first a decline at 1.25-1.75 min, followed by a gradual rise and plateau. There were significant differences for mean, median and dominant frequencies among weight classes. Specifically, 14 kg piglets showed higher frequency variables overall with a time evolution that was different from that of 4 and 24 kg piglets. Mean frequency showed the most stable time evolution with the least moment-to-moment variability. CONCLUSION The frequency waveform characteristics and time course are somewhat different in 14 kg piglets compared with 4 and 24 kg piglets. If similar differences are demonstrable among children of different weights and ages, AEDs designed to determine optimal timing of defibrillation shocks in adults by frequency waveform characteristics may require modification for use in children with VF.
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Affiliation(s)
- Julia H Indik
- Sarver Heart Center, The University of Arizona College of Medicine, 1501 N. Campbell Avenue, Tucson, AZ 85724-5037, USA.
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