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Azcarate I, Urigüen JA, Leturiondo M, Sandoval CL, Redondo K, Gutiérrez JJ, Russell JK, Wallmüller P, Sterz F, Daya MR, Ruiz de Gauna S. The Role of Chest Compressions on Ventilation during Advanced Cardiopulmonary Resuscitation. J Clin Med 2023; 12:6918. [PMID: 37959385 PMCID: PMC10647836 DOI: 10.3390/jcm12216918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/25/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
Background: There is growing interest in the quality of manual ventilation during cardiopulmonary resuscitation (CPR), but accurate assessment of ventilation parameters remains a challenge. Waveform capnography is currently the reference for monitoring ventilation rate in intubated patients, but fails to provide information on tidal volumes and inspiration-expiration timing. Moreover, the capnogram is often distorted when chest compressions (CCs) are performed during ventilation compromising its reliability during CPR. Our main purpose was to characterize manual ventilation during CPR and to assess how CCs may impact on ventilation quality. Methods: Retrospective analysis were performed of CPR recordings fromtwo databases of adult patients in cardiac arrest including capnogram, compression depth, and airway flow, pressure and volume signals. Using automated signal processing techniques followed by manual revision, individual ventilations were identified and ventilation parameters were measured. Oscillations on the capnogram plateau during CCs were characterized, and its correlation with compression depth and airway volume was assessed. Finally, we identified events of reversed airflow caused by CCs and their effect on volume and capnogram waveform. Results: Ventilation rates were higher than the recommended 10 breaths/min in 66.7% of the cases. Variability in ventilation rates correlated with the variability in tidal volumes and other ventilatory parameters. Oscillations caused by CCs on capnograms were of high amplitude (median above 74%) and were associated with low pseudo-volumes (median 26 mL). Correlation between the amplitude of those oscillations with either the CCs depth or the generated passive volumes was low, with correlation coefficients of -0.24 and 0.40, respectively. During inspiration and expiration, reversed airflow events caused opposed movement of gases in 80% of ventilations. Conclusions: Our study confirmed lack of adherence between measured ventilation rates and the guideline recommendations, and a substantial dispersion in manual ventilation parameters during CPR. Oscillations on the capnogram plateau caused by CCs did not correlate with compression depth or associated small tidal volumes. CCs caused reversed flow during inspiration, expiration and in the interval between ventilations, sufficient to generate volume changes and causing oscillations on capnogram. Further research is warranted to assess the impact of these findings on ventilation quality during CPR.
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Affiliation(s)
- Izaskun Azcarate
- Group of Signal and Communications, Bilbao School of Engineering, University of the Basque Country UPV/EHU, Plaza Torres Quevedo 1, 48013 Bilbao, Spain; (J.A.U.); (M.L.); (K.R.); (J.J.G.); (S.R.d.G.)
- Department of Applied Mathematics, Bilbao School of Engineering, University of the Basque Country UPV/EHU, Plaza Torres Quevedo 1, 48013 Bilbao, Spain
| | - Jose Antonio Urigüen
- Group of Signal and Communications, Bilbao School of Engineering, University of the Basque Country UPV/EHU, Plaza Torres Quevedo 1, 48013 Bilbao, Spain; (J.A.U.); (M.L.); (K.R.); (J.J.G.); (S.R.d.G.)
- Department of Applied Mathematics, Bilbao School of Engineering, University of the Basque Country UPV/EHU, Plaza Torres Quevedo 1, 48013 Bilbao, Spain
| | - Mikel Leturiondo
- Group of Signal and Communications, Bilbao School of Engineering, University of the Basque Country UPV/EHU, Plaza Torres Quevedo 1, 48013 Bilbao, Spain; (J.A.U.); (M.L.); (K.R.); (J.J.G.); (S.R.d.G.)
| | | | - Koldo Redondo
- Group of Signal and Communications, Bilbao School of Engineering, University of the Basque Country UPV/EHU, Plaza Torres Quevedo 1, 48013 Bilbao, Spain; (J.A.U.); (M.L.); (K.R.); (J.J.G.); (S.R.d.G.)
| | - José Julio Gutiérrez
- Group of Signal and Communications, Bilbao School of Engineering, University of the Basque Country UPV/EHU, Plaza Torres Quevedo 1, 48013 Bilbao, Spain; (J.A.U.); (M.L.); (K.R.); (J.J.G.); (S.R.d.G.)
| | - James Knox Russell
- Center for Policy and Research in Emergency Medicine (CPR-EM), Department of Emergency Medicine, Oregon Health & Science University, Portland, OR 97239, USA; (J.K.R.); (M.R.D.)
| | - Pia Wallmüller
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (P.W.); (F.S.)
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (P.W.); (F.S.)
| | - Mohamud Ramzan Daya
- Center for Policy and Research in Emergency Medicine (CPR-EM), Department of Emergency Medicine, Oregon Health & Science University, Portland, OR 97239, USA; (J.K.R.); (M.R.D.)
| | - Sofía Ruiz de Gauna
- Group of Signal and Communications, Bilbao School of Engineering, University of the Basque Country UPV/EHU, Plaza Torres Quevedo 1, 48013 Bilbao, Spain; (J.A.U.); (M.L.); (K.R.); (J.J.G.); (S.R.d.G.)
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Braithwaite S, Stephens C, Remick K, Barrett W, Guyette FX, Levy M, Colwell C. Prehospital Trauma Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:64-71. [PMID: 35001817 DOI: 10.1080/10903127.2021.1994069] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Definitive management of trauma is not possible in the out-of-hospital environment. Rapid treatment and transport of trauma casualties to a trauma center are vital to improve survival and outcomes. Prioritization and management of airway, oxygenation, ventilation, protection from gross aspiration, and physiologic optimization must be balanced against timely patient delivery to definitive care. The optimal prehospital airway management strategy for trauma has not been clearly defined; the best choice should be patient-specific. NAEMSP recommends:The approach to airway management and the choice of airway interventions in a trauma patient requires an iterative, individualized assessment that considers patient, clinician, and environmental factors.Optimal trauma airway management should focus on meeting the goals of adequate oxygenation and ventilation rather than on specific interventions. Emergency medical services (EMS) clinicians should perform frequent reassessments to determine if there is a need to escalate from basic to advanced airway interventions.Management of immediately life-threatening injuries should take priority over advanced airway insertion.Drug-assisted airway management should be considered within a comprehensive algorithm incorporating failed airway options and balanced management of pain, agitation, and delirium.EMS medical directors must be highly engaged in assuring clinician competence in trauma airway assessment, management, and interventions.
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. [Cardiac arrest under special circumstances]. Notf Rett Med 2021; 24:447-523. [PMID: 34127910 PMCID: PMC8190767 DOI: 10.1007/s10049-021-00891-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/10/2023]
Abstract
These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Deutschland
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Tschechien
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Tschechien
| | - Anette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife Großbritannien
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Teaching and research Unit, Emergency Territorial Agency ARES 118, Catholic University School of Medicine, Rom, Italien
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spanien
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Köln, Deutschland
| | - Jerry P. Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, CV4 7AL Coventry, Großbritannien
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, BA1 3NG Bath, Großbritannien
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | - Karl-Christian Thies
- Dep. of Anesthesiology and Critical Care, Bethel Evangelical Hospital, University Medical Center OLW, Bielefeld University, Bielefeld, Deutschland
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021; 161:152-219. [PMID: 33773826 DOI: 10.1016/j.resuscitation.2021.02.011] [Citation(s) in RCA: 328] [Impact Index Per Article: 109.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany.
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Catholic University School of Medicine, Teaching and Research Unit, Emergency Territorial Agency ARES 118, Rome, Italy
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spain
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jerry P Nolan
- Resuscitation Medicine, University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl-Christian Thies
- Department of Anesthesiology, Critical Care and Emergency Medicine, Bethel Medical Centre, OWL University Hospitals, Bielefeld University, Germany
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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Groulx M, Emond M, Boudreau-Drouin F, Cournoyer A, Nadeau A, Blanchard PG, Mercier E. Continuous flow insufflation of oxygen for cardiac arrest: Systematic review of human and animal model studies. Resuscitation 2021; 162:292-303. [PMID: 33766663 DOI: 10.1016/j.resuscitation.2021.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/26/2021] [Accepted: 03/10/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To synthetize the evidence regarding the effect of constant flow insufflation of oxygen (CFIO) on the rate of return of spontaneous circulation (ROSC) and other clinical outcomes during cardiac arrest (CA). METHODS A systematic review was performed using four databases (PROSPERO: CRD42020071960). Studies reporting on adult CA patients or on animal models simulating CA and assessing the effect of CFIO on ROSC or other clinical outcomes were considered. RESULTS A total of 3540 citations were identified, of which 16 studies were included. Four studies (two randomized controlled trials (RCT), two cohort studies), reported on humans while 12 studies used animal models. No meta-analysis was performed due to clinical heterogeneity. There were no differences in the ROSC (18.9% vs 20.8%, p = 0.99; 27.1% vs 21.3%, p = 0.51) and sustained ROSC rates (16.1% vs 17.3%, p = 0.81; 12.5% vs 14.9%, p = 0.73) with CFIO compared to intermitant positive pressure ventilation (IPPV) in the two human RCTs. Survival to ICU discharge was similar between CFIO (2.3%) and IPPV (2.3%) in the largest RCT (p = 0.96). Human studies were at serious or high risk of bias. In animal models' studies, ROSC rates were presented in seven RCTs. CFIO was superior to IPPV in one trial, but was associated with similar ROSC rates using different ventilation strategies in the remaining six studies. CONCLUSIONS No definitive association between CFIO and ROSC, sustained ROSC or survival compared to other ventilation strategies could be demonstrated. Future studies should assess CFIO effect on post-survival neurological functions and patient-important CA outcomes.
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Affiliation(s)
- Mathieu Groulx
- Faculté de Médecine, Université Laval, Québec, Canada; Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
| | - Marcel Emond
- Faculté de Médecine, Université Laval, Québec, Canada; Centre de recherche du CHU de Québec-Université Laval, Québec, Canada; VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Canada
| | - Felix Boudreau-Drouin
- Faculté de Médecine, Université Laval, Québec, Canada; VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Canada
| | - Alexis Cournoyer
- Faculté de médecine, Université de Montréal, Québec, Canada; Département de médecine d'urgence, Hôpital du Sacré-Cœur, Montréal, Québec, Canada; Département de médecine d'urgence, Hôpital Maisonneuve-Rosemont, Montréal, Canada
| | - Alexandra Nadeau
- VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Canada
| | - Pierre-Gilles Blanchard
- Faculté de Médecine, Université Laval, Québec, Canada; VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Canada
| | - Eric Mercier
- Faculté de Médecine, Université Laval, Québec, Canada; Centre de recherche du CHU de Québec-Université Laval, Québec, Canada; VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Canada.
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Neth MR, Idris A, McMullan J, Benoit JL, Daya MR. A review of ventilation in adult out-of-hospital cardiac arrest. J Am Coll Emerg Physicians Open 2020; 1:190-201. [PMID: 33000034 PMCID: PMC7493547 DOI: 10.1002/emp2.12065] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 03/20/2020] [Accepted: 03/23/2020] [Indexed: 12/17/2022] Open
Abstract
Out-of-hospital cardiac arrest continues to be a devastating condition despite advances in resuscitation care. Ensuring effective gas exchange must be weighed against the negative impact hyperventilation can have on cardiac physiology and survival. The goals of this narrative review are to evaluate the available evidence regarding the role of ventilation in out-of-hospital cardiac arrest resuscitation and to provide recommendations for future directions. Ensuring successful airway patency is fundamental for effective ventilation. The airway management approach should be based on professional skill level and the situation faced by rescuers. Evidence has explored the influence of different ventilation rates, tidal volumes, and strategies during out-of-hospital cardiac arrest; however, other modifiable factors affecting out-of-hospital cardiac arrest ventilation have limited supporting data. Researchers have begun to explore the impact of ventilation in adult out-of-hospital cardiac arrest outcomes, further stressing its importance in cardiac arrest resuscitation management. Capnography and thoracic impedance signals are used to measure ventilation rate, although these strategies have limitations. Existing technology fails to reliably measure real-time clinical ventilation data, thereby limiting the ability to investigate optimal ventilation management. An essential step in advancing cardiac arrest care will be to develop techniques to accurately and reliably measure ventilation parameters. These devices should allow for immediate feedback for out-of-hospital practitioners, in a similar way to chest compression feedback. Once developed, new strategies can be established to guide out-of-hospital personnel on optimal ventilation practices.
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Affiliation(s)
- Matthew R. Neth
- Department of Emergency MedicineOregon Health and Science UniversityPortlandOregon
| | - Ahamed Idris
- Department of Emergency MedicineUT SouthwesternDallasTexas
| | - Jason McMullan
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhio
| | - Justin L. Benoit
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhio
| | - Mohamud R. Daya
- Department of Emergency MedicineOregon Health and Science UniversityPortlandOregon
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Airway and ventilation management strategies for hemorrhagic shock. To tube, or not to tube, that is the question! J Trauma Acute Care Surg 2018; 84:S77-S82. [DOI: 10.1097/ta.0000000000001822] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Skytioti M, Søvik S, Elstad M. Respiratory pump maintains cardiac stroke volume during hypovolemia in young, healthy volunteers. J Appl Physiol (1985) 2018; 124:1319-1325. [DOI: 10.1152/japplphysiol.01009.2017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Spontaneous breathing has beneficial effects on the circulation, since negative intrathoracic pressure enhances venous return and increases cardiac stroke volume. We quantified the contribution of the respiratory pump to preserve stroke volume during hypovolemia in awake, young, healthy subjects. Noninvasive stroke volume, cardiac output, heart rate, and mean arterial pressure (Finometer) were recorded in 31 volunteers (19 women), 19–30 yr old, during normovolemia and hypovolemia (approximating 450- to 500-ml reduction in central blood volume) induced by lower-body negative pressure. Control-mode noninvasive positive-pressure ventilation was employed to reduce the effect of the respiratory pump. The ventilator settings were matched to each subject’s spontaneous respiratory pattern. Stroke volume estimates during positive-pressure ventilation and spontaneous breathing were compared with Wilcoxon matched-pairs signed-rank test. Values are overall medians. During normovolemia, positive-pressure ventilation did not affect stroke volume or cardiac output. Hypovolemia resulted in an 18% decrease in stroke volume and a 9% decrease in cardiac output ( P < 0.001). Employing positive-pressure ventilation during hypovolemia decreased stroke volume further by 8% ( P < 0.001). Overall, hypovolemia and positive-pressure ventilation resulted in a reduction of 26% in stroke volume ( P < 0.001) and 13% in cardiac output ( P < 0.001) compared with baseline. Compared with the situation with control-mode positive-pressure ventilation, spontaneous breathing attenuated the reduction in stroke volume induced by moderate hypovolemia by 30% (i.e., −26 vs. −18%). In the patient who is critically ill with hypovolemia or uncontrolled hemorrhage, spontaneous breathing may contribute to hemodynamic stability, whereas controlled positive-pressure ventilation may result in circulatory decompensation. NEW & NOTEWORTHY Maintaining spontaneous respiration has beneficial effects on hemodynamic compensation, which is clinically relevant for patients in intensive care. We have quantified the contribution of the respiratory pump to cardiac stroke volume and cardiac output in healthy volunteers during normovolemia and central hypovolemia. The positive hemodynamic effect of the respiratory pump was abolished by noninvasive, low-level positive-pressure ventilation. Compared with control-mode positive-pressure ventilation, spontaneous negative-pressure ventilation attenuated the fall in stroke volume by 30%.
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Affiliation(s)
- Maria Skytioti
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Signe Søvik
- Department of Anaesthesia and Intensive Care, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Maja Elstad
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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McEvoy MD, Thies KC, Einav S, Ruetzler K, Moitra VK, Nunnally ME, Banerjee A, Weinberg G, Gabrielli A, Maccioli GA, Dobson G, O’Connor MF. Cardiac Arrest in the Operating Room. Anesth Analg 2018; 126:889-903. [DOI: 10.1213/ane.0000000000002595] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Truhlář A, Deakin CD, Soar J, Khalifa GEA, Alfonzo A, Bierens JJLM, Brattebø G, Brugger H, Dunning J, Hunyadi-Antičević S, Koster RW, Lockey DJ, Lott C, Paal P, Perkins GD, Sandroni C, Thies KC, Zideman DA, Nolan JP, Böttiger BW, Georgiou M, Handley AJ, Lindner T, Midwinter MJ, Monsieurs KG, Wetsch WA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation 2015; 95:148-201. [PMID: 26477412 DOI: 10.1016/j.resuscitation.2015.07.017] [Citation(s) in RCA: 537] [Impact Index Per Article: 59.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic.
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, Southampton University Hospital NHS Trust, Southampton, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | | | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | | | - Guttorm Brattebø
- Bergen Emergency Medical Services, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Hermann Brugger
- EURAC Institute of Mountain Emergency Medicine, Bozen, Italy
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Rudolph W Koster
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - David J Lockey
- Intensive Care Medicine and Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK; School of Clinical Sciences, University of Bristol, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universitaet, Mainz, Germany
| | - Peter Paal
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, Queen Mary University of London, London, UK; Department of Anaesthesiology and Critical Care Medicine, University Hospital Innsbruck, Austria
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | | | - David A Zideman
- Department of Anaesthetics, Imperial College Healthcare NHS Trust, London, UK
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
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Yannopoulos D, Aufderheide TP, Abella BS, Duval S, Frascone RJ, Goodloe JM, Mahoney BD, Nadkarni VM, Halperin HR, O’Connor R, Idris AH, Becker LB, Pepe PE. Quality of CPR: An important effect modifier in cardiac arrest clinical outcomes and intervention effectiveness trials. Resuscitation 2015; 94:106-13. [DOI: 10.1016/j.resuscitation.2015.06.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 05/27/2015] [Accepted: 06/02/2015] [Indexed: 10/23/2022]
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13
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Spaite DW, Bobrow BJ, Stolz U, Sherrill D, Chikani V, Barnhart B, Sotelo M, Gaither JB, Viscusi C, Adelson PD, Denninghoff KR. Evaluation of the impact of implementing the emergency medical services traumatic brain injury guidelines in Arizona: the Excellence in Prehospital Injury Care (EPIC) study methodology. Acad Emerg Med 2014; 21:818-30. [PMID: 25112451 PMCID: PMC4134700 DOI: 10.1111/acem.12411] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 02/18/2014] [Accepted: 02/28/2014] [Indexed: 11/28/2022]
Abstract
Traumatic brain injury (TBI) exacts a great toll on society. Fortunately, there is growing evidence that the management of TBI in the early minutes after injury may significantly reduce morbidity and mortality. In response, evidence-based prehospital and in-hospital TBI treatment guidelines have been established by authoritative bodies. However, no large studies have yet evaluated the effectiveness of implementing these guidelines in the prehospital setting. This article describes the background, design, implementation, emergency medical services (EMS) treatment protocols, and statistical analysis of a prospective, controlled (before/after), statewide study designed to evaluate the effect of implementing the EMS TBI guidelines-the Excellence in Prehospital Injury Care (EPIC) study (NIH/NINDS R01NS071049, "EPIC"; and 3R01NS071049-S1, "EPIC4Kids"). The specific aim of the study is to test the hypothesis that statewide implementation of the international adult and pediatric EMS TBI guidelines will significantly reduce mortality and improve nonmortality outcomes in patients with moderate or severe TBI. Furthermore, it will specifically evaluate the effect of guideline implementation on outcomes in the subgroup of patients who are intubated in the field. Over the course of the entire study (~9 years), it is estimated that approximately 25,000 patients will be enrolled.
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Affiliation(s)
- Daniel W Spaite
- The Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Tucson, AZ; The Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ
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Elmer J, Pallin DJ, Liu S, Pearson C, Chang Y, Camargo CA, Greenberg SM, Rosand J, Goldstein JN. Prolonged emergency department length of stay is not associated with worse outcomes in patients with intracerebral hemorrhage. Neurocrit Care 2013; 17:334-42. [PMID: 21912953 DOI: 10.1007/s12028-011-9629-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Prolonged emergency department length of stay (EDLOS) has been associated with worse patient outcomes, longer inpatient stays, and failure to meet quality measures in several acute medical conditions, but these findings have not been consistently reproduced. We performed this study to explore the hypothesis that longer EDLOS would be associated with worse outcomes in a large cohort of patients presenting with spontaneous intracerebral hemorrhage (ICH). METHODS We performed a secondary analysis of a prospective cohort of consecutive patients with spontaneous ICH who presented to a single academic referral center from February 2005 to October 2009. The primary exposure variable was EDLOS, and our primary outcome was neurologic status at hospital discharge, measured with a modified Rankin scale (mRS). Secondary outcomes were ICU length of stay, total hospital length of stay, and total hospital costs. RESULTS Our cohort included 616 visits of which 42 were excluded, leaving 574 patient encounters for analysis. Median age was 75 years (IQR 63-82), median EDLOS 5.1 h (IQR 3.7-7.1) and median discharge mRS 4 (IQR 3-6). Thirty percent of the subjects died in-hospital. Multivariable proportional odds logistic regression, controlling for age, initial Glasgow Coma Scale, initial hematoma volume, ED occupancy at registration, and the need for intubation or surgical intervention, demonstrated no association between EDLOS and outcome. Furthermore, multivariable analysis revealed no association of increased EDLOS with ICU or hospital length of stay or hospital costs. CONCLUSION We found no effect of EDLOS on neurologic outcome or resource utilization for patients presenting with spontaneous ICH.
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Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.
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Examining prehospital intubation for penetrating trauma in a swine hemorrhagic shock model. J Trauma Acute Care Surg 2013; 74:1246-51. [DOI: 10.1097/ta.0b013e31828dab10] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Examining prehospital intubation for penetrating trauma in a swine hemorrhagic shock model. J Trauma Acute Care Surg 2013. [DOI: 10.1097/01586154-201305000-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Chadi BH. Reply letter: Passive leg elevation aids cardiopulmonary resuscitation. Resuscitation 2013; 84:e63. [PMID: 23410712 DOI: 10.1016/j.resuscitation.2013.02.005] [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: 02/05/2013] [Accepted: 02/06/2013] [Indexed: 11/16/2022]
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Comparison of times of intervention during pediatric CPR maneuvers using ABC and CAB sequences: a randomized trial. Resuscitation 2012; 83:1473-7. [PMID: 22579678 DOI: 10.1016/j.resuscitation.2012.04.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Revised: 04/07/2012] [Accepted: 04/22/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND The proposed introduction of the CAB (circulation, airway, breathing) sequence for cardiopulmonary resuscitation has raised some perplexity within the pediatric community. We designed a randomized trial intended to verify if and how much timing of intervention in pediatric cardiopulmonary resuscitation is affected by the use of the CAB vs. the ABC (airway, breathing, circulation) sequence. PATIENTS AND METHODS 340 volunteers, paired into 170 two-person teams, performed 2-rescuer healthcare provider BLS with both a CAB and ABC sequence. Their performances were audio-video recorded and times of intervention in the two scenarios, cardiac and respiratory arrest, were monitored. RESULTS The CAB sequence compared to ABC prompts quicker recognition of respiratory (CAB vs. ABC=17.48 ± 2.19 vs. 19.17 ± 2.38s; p<0.05) or cardiac arrest (CAB vs. ABC=17.48 ± 2.19 vs. 41.67 ± 4.95; p<0.05) and faster start of ventilatory maneuvers (CAB vs. ABC=19.13 ± 1.47s vs. 22.66 ± 3.07; p<0.05) or chest compressions (CAB vs. ABC=19.27 ± 2.64 vs. 43.40 ± 5.036; p<0.05). CONCLUSIONS Compared to ABC the CAB sequence prompts shorter time of intervention both in diagnosing respiratory or cardiac arrest and in starting ventilation or chest compression. However, this does not necessarily entail prompter resumption of spontaneous circulation and significant reduction of neurological sequelae, an issue that requires further studies.
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Soar J, Perkins GD, Abbas G, Alfonzo A, Barelli A, Bierens JJLM, Brugger H, Deakin CD, Dunning J, Georgiou M, Handley AJ, Lockey DJ, Paal P, Sandroni C, Thies KC, Zideman DA, Nolan JP. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2011; 81:1400-33. [PMID: 20956045 DOI: 10.1016/j.resuscitation.2010.08.015] [Citation(s) in RCA: 362] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
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Wenzel V, Russo SG, Arntz HR, Bahr J, Baubin MA, Böttiger BW, Dirks B, Kreimeier U, Fries M, Eich C. [Comments on the 2010 guidelines on cardiopulmonary resuscitation of the European Resuscitation Council]. Anaesthesist 2011; 59:1105-23. [PMID: 21125214 DOI: 10.1007/s00101-010-1820-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
ADULTS Administer chest compressions (minimum 100/min, minimum 5 cm depth) at a ratio of 30:2 with ventilation (tidal volume 500-600 ml, inspiration time 1 s, F(I)O₂ if possible 1.0). Avoid any interruptions in chest compressions. After every single defibrillation attempt (initially biphasic 120-200 J, monophasic 360 J, subsequently with the respective highest energy), chest compressions are initiated again immediately for 2 min independent of the ECG rhythm. Tracheal intubation is the optimal method for securing the airway during resuscitation but should be performed only by experienced airway management providers. Laryngoscopy is performed during ongoing chest compressions; interruption of chest compressions for a maximum of 10 s to pass the tube through the vocal cords. Supraglottic airway devices are alternatives to tracheal intubation. Drug administration routes for adults and children: first choice i.v., second choice intraosseous (i.o.). Vasopressors: 1 mg epinephrine every 3-5 min i.v. After the third unsuccessful defibrillation amiodarone (300 mg i.v.), repetition (150 mg) possible. Sodium bicarbonate (50 ml 8.4%) only for excessive hyperkaliemia, metabolic acidosis, or intoxication with tricyclic antidepressants. Consider aminophylline (5 mg/kgBW). Thrombolysis during spontaneous circulation only for myocardial infarction or massive pulmonary embolism; during on-going cardiopulmonary resuscitation (CPR) only when indications of massive pulmonary embolism. Active compression-decompression (ACD-CPR) and inspiratory threshold valve (ITV-CPR) are not superior to good standard CPR. CHILDREN Most effective improvement of outcome by prevention of full cardiorespiratory arrest. Basic life support: initially five rescue breaths, followed by chest compressions (100-120/min depth about one third of chest diameter), compression-ventilation ratio 15:2. Foreign body airway obstruction with insufficient cough: alternate back blows and chest compressions (infants), or abdominal compressions (children >1 year). Treatment of potentially reversible causes: ("4 Hs and 4 Ts") hypoxia and hypovolaemia, hypokalaemia and hyperkalaemia, hypothermia, and tension pneumothorax, tamponade, toxic/therapeutic disturbances, thrombosis (coronary/pulmonary). Advanced life support: adrenaline (epinephrine) 10 µg/kgBW i.v. or i.o. every 3-5 min. Defibrillation (4 J/kgBW; monophasic or biphasic) followed by 2 min CPR, then ECG and pulse check. NEWBORNS: Initially inflate the lungs with bag-valve mask ventilation (p(AW) 20-40 cmH₂O). If heart rate remains <60/min, start chest compressions (120 chest compressions/min) and ventilation with a ratio 3:1. Maintain normothermia in preterm babies by covering them with foodgrade plastic wrap or similar. POSTRESUSCITATION PHASE: Early protocol-based intensive care stabilization; initiate mild hypothermia early regardless of initial cardiac rhythm [32-34°C for 12-24 h (adults) or 24 h (children); slow rewarming (<0.5°C/h)]. Consider percutaneous coronary intervention (PCI) in patients with presumed cardiac ischemia. Prediction of CPR outcome is not possible at the scene, determine neurological outcome <72 h after cardiac arrest with somatosensory evoked potentials, biochemical tests and neurological examination. ACUTE CORONARY SYNDROME: Even if only a weak suspicion of an acute coronary syndrome is present, record a prehospital 12-lead ECG. In parallel to pain therapy, administer aspirin (160-325 mg p.o. or i.v.) and clopidogrel (75-600 mg depending on strategy); in ST-elevation myocardial infarction (STEMI) and planned PCI also prasugrel (60 mg p.o.). Antithrombins, such as heparin (60 IU/kgBW, max. 4000 IU), enoxaparin, bivalirudin or fondaparinux depending on the diagnosis (STEMI or non-STEMI-ACS) and the planned therapeutic strategy. In STEMI define reperfusion strategy depending on duration of symptoms until PCI, age and location of infarction. TRAUMA: In severe hemorrhagic shock, definitive control of bleeding is the most important goal. For successful CPR of trauma patients a minimal intravascular volume status and management of hypoxia are essential. Aggressive fluid resuscitation, hyperventilation and excessive ventilation pressure may impair outcome in patients with severe hemorrhagic shock. TRAINING Any CPR training is better than nothing; simplification of contents and processes is the main aim.
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Affiliation(s)
- V Wenzel
- Univ.-Klinik für Anaesthesie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich.
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Reanimación cardiopulmonar avanzada (segunda parte) los cambios que deben efectuarse para la reanimación cardiovascular avanzada según las guías 2010 presentadas en chicago. REVISTA COLOMBIANA DE CARDIOLOGÍA 2011. [DOI: 10.1016/s0120-5633(11)70168-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Soar J, Perkins G, Abbas G, Alfonzo A, Barelli A, Bierens J, Brugger H, Deakin C, Dunning J, Georgiou M, Handley A, Lockey D, Paal P, Sandroni C, Thies KC, Zideman D, Nolan J. Kreislaufstillstand unter besonderen Umständen: Elektrolytstörungen, Vergiftungen, Ertrinken, Unterkühlung, Hitzekrankheit, Asthma, Anaphylaxie, Herzchirurgie, Trauma, Schwangerschaft, Stromunfall. Notf Rett Med 2010. [DOI: 10.1007/s10049-010-1374-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Camacho HM. Las nuevas guías de resucitación cerebro-cardiopulmonar básica del año 2010. análisis crítico. REVISTA COLOMBIANA DE CARDIOLOGÍA 2010. [DOI: 10.1016/s0120-5633(10)70248-5] [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] Open
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Hinchey PR, Myers JB, Lewis R, De Maio VJ, Reyer E, Licatese D, Zalkin J, Snyder G. Improved out-of-hospital cardiac arrest survival after the sequential implementation of 2005 AHA guidelines for compressions, ventilations, and induced hypothermia: the Wake County experience. Ann Emerg Med 2010; 56:348-57. [PMID: 20359771 DOI: 10.1016/j.annemergmed.2010.01.036] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2009] [Revised: 01/02/2010] [Accepted: 01/12/2010] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE We assess survival from out-of-hospital cardiac arrest after community-wide implementation of 2005 American Heart Association guidelines. METHODS This was an observational multiphase before-after cohort in an urban/suburban community (population 840,000) with existing advanced life support. Included were all adults treated for cardiac arrest by emergency responders. Excluded were patients younger than 16 years and trauma patients. Intervention phases in months were baseline 16; phase 1, new cardiopulmonary resuscitation 12; phase 2, impedance threshold device 6; and phase 3, full implementation including out-of-hospital-induced hypothermia 12. Primary outcome was survival to discharge. Other survival and neurologic outcomes were compared between study phases, and adjusted odds ratios with 95% confidence intervals (CIs) for survival by phase were determined by multivariate regression. RESULTS One thousand three hundred sixty-five cardiac arrest patients were eligible for inclusion: baseline n=425, phase 1 n=369, phase 2 n=161, phase 3 n=410. Across phases, patients had similar demographic, clinical, and emergency medical services characteristics. Overall and witnessed ventricular fibrillation and ventricular tachycardia survival improved throughout the study phases: respectively, baseline 4.2% and 13.8%, phase 1 7.3% and 23.9%, phase 2 8.1% and 34.6%, and phase 3 11.5% and 40.8%. The absolute increase for overall survival from baseline to full implementation was 7.3% (95% CI 3.7% to 10.9%); witnessed ventricular fibrillation/ventricular tachycardia survival was 27.0% (95% CI 13.6% to 40.4%), representing an additional 25 lives saved annually in this community. CONCLUSION In the context of a community-wide focus on resuscitation, the sequential implementation of 2005 American Heart Association guidelines for compressions, ventilations, and induced hypothermia significantly improved survival after cardiac arrest. Further study is required to clarify the relative contribution of each intervention to improved survival outcomes.
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Cardiopulmonary Resuscitation. AACN Adv Crit Care 2009; 20:373-83. [DOI: 10.1097/nci.0b013e3181baf5e4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Myers JB, Slovis CM, Eckstein M, Goodloe JM, Isaacs SM, Loflin JR, Mechem CC, Richmond NJ, Pepe PE. Evidence-Based Performance Measures for Emergency Medical Services Systems: A Model for Expanded EMS Benchmarking. PREHOSP EMERG CARE 2009; 12:141-51. [DOI: 10.1080/10903120801903793] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Automated emergency ventilation devices in a simulated unprotected airway. J Emerg Med 2009; 41:246-51. [PMID: 19201138 DOI: 10.1016/j.jemermed.2008.08.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Revised: 08/14/2008] [Accepted: 08/31/2008] [Indexed: 11/24/2022]
Abstract
BACKGROUND Automated ventilation devices are becoming more popular for emergency ventilation, but there is still not much experience concerning the optimal ventilation mode. METHODS In a bench model representing a non-intubated patient in respiratory and cardiac arrest, we compared a pressure-cycled with a time- and volume-cycled automated ventilation device in their completely automated modes. The main study endpoints were inspiratory time, respiratory rate, stomach inflation, and lung tidal volumes. RESULTS The pressure-cycled device inspired for 6.7 s in the respiratory arrest setting (respiratory rate 5.6/min), and never reached its closing pressure in the cardiac arrest setting (respiratory rate 1 breath/min). The time- and volume-cycled device inspired in both settings for 1.7 s (respiratory rate 13 breaths/min). In the respiratory arrest setting, mask leakage was 620 ± 20 mL for the pressure-cycled device vs. 290 ± 10 mL for the time- and volume-cycled device (p < 0.0001); lung tidal volume was 1080 ± 50 mL vs. 490 ± 20 mL, respectively (p < 0.0001); and there was no stomach inflation for either device. In the cardiac arrest setting, pressure-cycled device mask leakage was 5460 ± 60 mL vs. 240 ± 20 mL (p < 0.0001) for the time- and volume-cycled device (p < 0.0001); stomach inflation was 13,100 ± 100 mL vs. 90 ± 10 mL, respectively (p < 0.0001); and lung tidal volume 740 ± 60 mL vs. 420 ± 20 mL, respectively (p < 0.0001). CONCLUSION In a simulated respiratory arrest setting, ventilation with an automated pressure-cycled ventilation device resulted in lower respiratory frequency and larger tidal volumes compared to a time- and volume-cycled device. In a simulated cardiac arrest setting, ventilation with an automated pressure-cycled ventilation device, but not a time- and volume-cycled device, resulted in continuous gastric insufflation.
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Clinical trials in the out-of-hospital setting: rationale and strategies for successful implementation. Crit Care Med 2009; 37:S91-101. [PMID: 19104231 DOI: 10.1097/ccm.0b013e318192154d] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Cardiopulmonary arrest and trauma are two of the major epidemics of our time. In most cases, the final outcome is altered, for better or for worse, by how interventions are provided in the prehospital setting, making that venue critical for lifesaving community research efforts. In certain venues, out-of-hospital emergency medical services personnel are highly skilled at managing resuscitations and routinely operate under strict, highly scrutinized protocols, resulting in extraordinary study compliance. Larger patient enrollment derived from population-based investigations can lead to faster study completion, less selection bias, higher-powered data, and enhanced subgroup analysis. Most importantly, the concomitant training, expert protocol development, and rigid scrutiny all lead to improved patient outcomes, regardless of study intervention. For successful implementation, emergency medical services personnel should be involved in study design, and utilize routine, automated data collection. Technologies should be provided that simplify tasks and diminish confounding variables. Considering that exception to informed consent is a critical component, prospective education and involvement of the medical community, community leaders, employee groups and the media, long before protocol implementation, is essential. Such efforts should be led by respected, academically authoritative, grassroots emergency medical services medical directors and trauma chiefs, preferably those based at the main trauma centers or public receiving facilities.
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Griesdale DEG, Bosma TL, Kurth T, Isac G, Chittock DR. Complications of endotracheal intubation in the critically ill. Intensive Care Med 2008; 34:1835-42. [PMID: 18604519 DOI: 10.1007/s00134-008-1205-6] [Citation(s) in RCA: 285] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 06/10/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Assess the risk of complications during endotracheal intubation (ETI) and their association with the skill level of the intubating physician. DESIGN Prospective cohort study of 136 patients intubated by the intensive care team during a 5-month period. Standardized data forms were used to collect detailed information on the intubating physicians, supervisors, techniques, medications and complications. SETTING Canadian academic intensive care unit. MEASUREMENTS AND RESULTS All intubations were successful and there were no deaths during intubation. Non-experts were supervised in 92% of procedures. Expert operators were successful within two attempts in 94%, compared to only 82% of non-experts (P = 0.03), with 13.2% of all intubations requiring > or =3 attempts. Furthermore, 10.3% of intubations required 10 or more minutes. Difficult intubation (3 or more attempts by an expert) occurred in 6.6%. Overall risk of complications was 39%, including: severe hypoxemia (19.1%), severe hypotension (9.6%), esophageal intubation (7.4%) and frank aspiration (5.9%). ICU and hospital mortality were 15.4 and 29.4%, respectively. Compared with non-expert intubating physicians, propensity score-adjusted odds ratios (95% confidence interval) for expert physicians were 0.92 (95% CI: 0.28, 3.05, P = 0.89) for any complication, 0.45 (95% CI: 0.09, 2.20, P = 0.32) for ICU mortality and 0.47 (95% CI: 0.13, 1.70, P = 0.25) for hospital mortality. Two or more attempts at ETI was independently associated with an increased risk of severe complications (OR 3.31, 95% CI: 1.30, 8.40, P = 0.01). CONCLUSIONS These prospective data show a high risk of serious complications, and difficult intubations, that are associated with ETI of the critically ill. DESCRIPTOR Artificial airways and complications.
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Affiliation(s)
- Donald E G Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada.
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Warner KJ, Bulger EM. Does pre-hospital ventilation effect outcome after significant brain injury? TRAUMA-ENGLAND 2007. [DOI: 10.1177/1460408607088317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Traumatic brain injury has a devastating impact on society, utilizing many resources and disproportionately affecting the young. Recent evidence demonstrates the early care of the brain injured patient impacts patient outcomes. While prevention of systolic hypotension and hypoxia are mainstays of prehospital management of the injured patient ventilatory management performed in the prehospital environment has recently been shown to impact outcomes. Hypocapnea from hyperventilation has been shown in several trials to cause deleterious effects from cerebral vasoconstriction and ischemia. The importance of balancing the prevention of both hypocapnea and hypercapnea has led to the idea of a target ventilation range for arterial carbon dioxide tension, the ideal way to achieve this balance in the prehospital setting remains elusive. This article reviews the background, physiologic effects, impact on outcomes, and implications for prehospital care of prehospital ventilation.
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Affiliation(s)
- Keir J Warner
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Eileen M Bulger
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA,
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Warner KJ, Cuschieri J, Copass MK, Jurkovich GJ, Bulger EM. The impact of prehospital ventilation on outcome after severe traumatic brain injury. ACTA ACUST UNITED AC 2007; 62:1330-6; discussion 1336-8. [PMID: 17563643 DOI: 10.1097/ta.0b013e31804a8032] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation, which is detrimental after traumatic brain injury (TBI), and impairs venous return in patients with hypovolemia. We sought to determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the impact of ventilation on outcome after severe TBI. METHODS Data were prospectively collected for all intubated trauma patients transported directly from the field for a period of 14 months (n = 574). An arrival Pco2 <30 mm Hg was termed severe hypocapnea and considered a marker of hyperventilation. Patients with a Pco2 >45 mm Hg were considered severely hypercapneic. Targeted ventilation was defined as a Pco2 between 30 and 35 mm Hg based on the Brain Trauma Foundation guidelines. RESULTS The rate of severe hypocapnea was 18% and women were more likely to be hyperventilated (p < 0.05). Patients with severe hypercapnia had higher Injury Severity Scores and were more likely hypotensive, hypoxic, and acidodic (p < 0.05). Patients in the targeted ventilation range were less likely to die than were those outside the range even after excluding the severe hypercapnea group (odds ratio, 0.57; 95% confidence interval, 0.33-0.99). This effect was even greater among patients with isolated TBI (odds ratio, 0.31; 95% confidence interval, 0.10-0.96). CONCLUSION Targeted prehospital ventilation is associated with lower mortality after severe TBI.
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Affiliation(s)
- Keir J Warner
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington 98104, USA
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Strittmatter RR, Schadt JC. Sex differences in the respiratory response to hemorrhage in the conscious, New Zealand white rabbit. Am J Physiol Regul Integr Comp Physiol 2007; 292:R1963-9. [PMID: 17272667 DOI: 10.1152/ajpregu.00494.2006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In conscious animals, the response to hemorrhage is biphasic. During phase 1, arterial pressure is maintained. Phase 2 is characterized by profound hypotension. Despite allied roles, less is known about the integrated cardiovascular and respiratory response to blood loss in conscious animals. We evaluated cardiorespiratory changes during hemorrhage to test the hypotheses that 1) respiratory rate (RR) and blood gases do not change during phase 1; 2) RR increases during phase 2; and 3) RR and blood gas changes during hemorrhage are similar in males and females. We measured mean arterial pressure, RR, and blood gases during hemorrhage in 16 conscious, chronically prepared, male and female New Zealand white rabbits. We removed venous blood until mean arterial pressure was ≤40 mmHg. Sex did not affect mean arterial pressure, heart rate, PaO2, PaCO2, or pH during hemorrhage or the blood loss required to induce phase 2. PaCO2 decreased significantly from 37 ± 1 to 33 ± 1 and 29 ± 1 mmHg ( P < 0.001) during phase 1 and 2, respectively. Before hemorrhage, PaO2 was 87 ± 2 mmHg. PaO2 was unchanged in phase 1 (92 ± 2 mmHg) but increased in phase 2 (101 ± 2 mmHg; P < 0.001). Body temperature, PvCO2 (thoracic vena cava), and ventilation-perfusion mismatch (A-a gradient) were unchanged during phases 1 and 2. Neither sex increased RR during phase 1. While males doubled RR during phase 2, RR in females did not change ( P < 0.001). Thus, while PaCO2 decreases in phase 1 and phase 2, the decreases are achieved in different ways across the two phases and in the two sexes.
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Aufderheide TP. The problem with and benefit of ventilations: should our approach be the same in cardiac and respiratory arrest? Curr Opin Crit Care 2006; 12:207-12. [PMID: 16672778 DOI: 10.1097/01.ccx.0000224863.55711.56] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Recent advances in cardiopulmonary resuscitation have led to greater understanding of cardio-cerebral-pulmonary interactions during the process. The purpose of this discussion is to update the physiologic understanding of these interactions during cardiopulmonary resuscitation, review the detrimental and beneficial effects of ventilation, and identify implications for clinical practice. RECENT FINDINGS There is an inversely proportional relationship between mean intrathoracic pressure, coronary perfusion pressure, and survival from cardiac arrest. Increased ventilation rates and increased ventilation duration impede venous blood return to the heart, decreasing hemodynamics and coronary perfusion pressure during cardiopulmonary resuscitation. It has also been shown that there is a direct and immediate transfer of the increase in intrathoracic pressure to the cranial cavity with each positive pressure ventilation, also reducing cerebral perfusion pressure. The reduced amount of blood flowing through the pulmonary bed during cardiopulmonary resuscitation tends to be overventilated, compromising hemodynamics to both the heart and brain and resulting in ventilation/perfusion mismatch. SUMMARY The fundamental hemodynamic principle of intrathoracic pressure defines cardio-cerebral-pulmonary interactions during cardiopulmonary resuscitation. Further research is essential to optimize these interactions during treatment of profound shock.
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Affiliation(s)
- Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
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Soar J, Deakin CD, Nolan JP, Abbas G, Alfonzo A, Handley AJ, Lockey D, Perkins GD, Thies K. European Resuscitation Council guidelines for resuscitation 2005. Section 7. Cardiac arrest in special circumstances. Resuscitation 2006; 67 Suppl 1:S135-70. [PMID: 16321711 DOI: 10.1016/j.resuscitation.2005.10.004] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Wang HE, Yealy DM. Out-of-hospital endotracheal intubation: where are we? Ann Emerg Med 2006; 47:532-41. [PMID: 16713780 DOI: 10.1016/j.annemergmed.2006.01.016] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2005] [Revised: 01/09/2006] [Accepted: 01/11/2006] [Indexed: 11/21/2022]
Abstract
While remaining prominent in paramedic care and beneficial to some patients, out-of-hospital endotracheal intubation has not clearly improved survival or reduced morbidity from critical illness or injury when studied more broadly. Recent studies identify equivocal or unfavorable clinical effects, adverse events and errors, interaction with other important resuscitation interventions, and challenges in providing and maintaining procedural skill. We provide an overview of current data evaluating the overall effectiveness, safety, and feasibility of paramedic out-of-hospital endotracheal intubation. These studies highlight our limited understanding of out-of-hospital endotracheal intubation and the need for new strategies to improve airway support in the out-of-hospital setting.
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Affiliation(s)
- Henry E Wang
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
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Kreislaufstillstand unter besonderen Umständen. Notf Rett Med 2006. [DOI: 10.1007/s10049-006-0798-y] [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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