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Wolf J, Buckley GJ, Rozanski EA, Fletcher DJ, Boller M, Burkitt-Creedon JM, Weigand KA, Crews M, Fausak ED. 2024 RECOVER Guidelines: Advanced Life Support. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR. J Vet Emerg Crit Care (San Antonio) 2024; 34 Suppl 1:44-75. [PMID: 38924633 DOI: 10.1111/vec.13389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 04/25/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE To systematically review the evidence and devise clinical recommendations on advanced life support (ALS) in dogs and cats and to identify critical knowledge gaps. DESIGN Standardized, systematic evaluation of literature pertinent to ALS following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by Evidence Evaluators, and findings were reconciled by ALS Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk:benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization. SETTING Transdisciplinary, international collaboration in university, specialty, and emergency practice. RESULTS Seventeen questions pertaining to vascular access, vasopressors in shockable and nonshockable rhythms, anticholinergics, defibrillation, antiarrhythmics, and adjunct drug therapy as well as open-chest CPR were reviewed. Of the 33 treatment recommendations formulated, 6 recommendations addressed the management of patients with nonshockable arrest rhythms, 10 addressed shockable rhythms, and 6 provided guidance on open-chest CPR. We recommend against high-dose epinephrine even after prolonged CPR and suggest that atropine, when indicated, is used only once. In animals with a shockable rhythm in which initial defibrillation was unsuccessful, we recommend doubling the defibrillator dose once and suggest vasopressin (or epinephrine if vasopressin is not available), esmolol, lidocaine in dogs, and/or amiodarone in cats. CONCLUSIONS These updated RECOVER ALS guidelines clarify the approach to refractory shockable rhythms and prolonged CPR. Very low quality of evidence due to absence of clinical data in dogs and cats continues to compromise the certainty with which recommendations can be made.
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Affiliation(s)
- Jacob Wolf
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Elizabeth A Rozanski
- Department of Clinical Sciences, Tufts University School of Veterinary Medicine, North Grafton, Massachusetts, USA
| | - Daniel J Fletcher
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Manuel Boller
- VCA Canada Central Victoria Veterinary Hospital, Victoria, British Columbia, Canada
- Faculty of Veterinary Medicine, Department of Veterinary Clinical and Diagnostic Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jamie M Burkitt-Creedon
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Kelly A Weigand
- Cary Veterinary Medical Library, Auburn University, Auburn, Alabama, USA
- Flower-Sprecher Veterinary Library, Cornell University, Ithaca, New York, USA
| | - Molly Crews
- Department of Small Animal Clinical Sciences, Texas A&M University College of Veterinary Medicine & Biomedical Sciences, College Station, Texas, USA
| | - Erik D Fausak
- University Library, University of California, Davis, Davis, California, USA
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Abstract
Cardiac arrest is the loss of organized cardiac activity. Unfortunately, survival to hospital discharge is poor, despite recent scientific advances. The goals of cardiopulmonary resuscitation (CPR) are to restore circulation and identify and correct an underlying etiology. High-quality compressions remain the foundation of CPR, optimizing coronary and cerebral perfusion pressure. High-quality compressions must be performed at the appropriate rate and depth. Interruptions in compressions are detrimental to management. Mechanical compression devices are not associated with improved outcomes but can assist in several situations.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA. https://twitter.com/MGottliebMD
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LeSueur MC, Rozanski EA, Karlin ET, LaMastro J, Rush JE. Evaluation of automated external defibrillator designed for people in dogs. J Vet Emerg Crit Care (San Antonio) 2023; 33:173-179. [PMID: 36815755 DOI: 10.1111/vec.13285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 02/04/2022] [Accepted: 03/17/2022] [Indexed: 02/24/2023]
Abstract
OBJECTIVE To determine if human automated external defibrillators (AEDs) could successfully record cardiac electrical activity in dogs, make appropriate recommendations regarding shock delivery, and characterize skin preparation required for a readable ECG based on dog haircoat characteristics. DESIGN Prospective study of AED use in dogs conducted between January and March 2021. SETTING University teaching hospital. ANIMALS Three groups of client-owned dogs were evaluated. Group 1 consisted of 23 healthy dogs with sinus rhythms, group 2 consisted of 9 dogs with documented cardiac arrhythmias, and group 3 consisted of 9 dogs receiving CPR following naturally occurring cardiopulmonary arrest. MATERIALS AND METHODS Haircoat characteristics and clipping or ECG paste required to obtain a readable ECG were recorded. The time interval from a readable ECG by the investigator until AED shock advisement was measured. Correctness of shock advice was recorded. Analyses were performed using commercial statistical software. P-values <0.05 were considered significant. RESULTS The attending veterinarian judged the ECG on the AED to be readable in all dogs. Time to shock advisement in all dogs was median 18 (range: 7-180) seconds. Dogs with heavy, long, or double haircoats required clipping in 24 of 27 (89%) cases to obtain a readable ECG. ECG paste on the AED pad was required in 36 of 40 dogs (90%) in order to obtain a readable ECG. The AED advice for delivery of shock was appropriate in 51 of 52 (98%) queries of the machine across all groups. CONCLUSIONS Human AEDs can successfully record cardiac electrical activity in dogs. AEDs appropriately recommend delivery of a shock most times, contingent on skin preparation. Dogs with double, long, or heavy haircoats should be clipped prior to pad application. ECG paste will aid AED reading in all haircoat types. Further investigation is warranted into AED use in dogs, particularly in general practices.
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Affiliation(s)
- Meriel C LeSueur
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA
| | - Elizabeth A Rozanski
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA
| | - Emily T Karlin
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA
| | - Joey LaMastro
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA
| | - John E Rush
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA
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Brooks SC, Clegg GR, Bray J, Deakin CD, Perkins GD, Ringh M, Smith CM, Link MS, Merchant RM, Pezo-Morales J, Parr M, Morrison LJ, Wang TL, Koster RW, Ong MEH. Optimizing Outcomes After Out-of-Hospital Cardiac Arrest With Innovative Approaches to Public-Access Defibrillation: A Scientific Statement From the International Liaison Committee on Resuscitation. Circulation 2022; 145:e776-e801. [PMID: 35164535 DOI: 10.1161/cir.0000000000001013] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.
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Brooks SC, Clegg GR, Bray J, Deakin CD, Perkins GD, Ringh M, Smith CM, Link MS, Merchant RM, Pezo-Morales J, Parr M, Morrison LJ, Wang TL, Koster RW, Ong MEH. Optimizing outcomes after out-of-hospital cardiac arrest with innovative approaches to public-access defibrillation: A scientific statement from the International Liaison Committee on Resuscitation. Resuscitation 2022; 172:204-228. [PMID: 35181376 DOI: 10.1016/j.resuscitation.2021.11.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.
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Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM, Arafeh J, Benoit JL, Chase M, Fernandez A, de Paiva EF, Fischberg BL, Flores GE, Fromm P, Gazmuri R, Gibson BC, Hoadley T, Hsu CH, Issa M, Kessler A, Link MS, Magid DJ, Marrill K, Nicholson T, Ornato JP, Pacheco G, Parr M, Pawar R, Jaxton J, Perman SM, Pribble J, Robinett D, Rolston D, Sasson C, Satyapriya SV, Sharkey T, Soar J, Torman D, Von Schweinitz B, Uzendu A, Zelop CM, Magid DJ. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S366-S468. [DOI: 10.1161/cir.0000000000000916] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Babini G, Ameloot K, Skrifvars MB. Cardiac function after cardiac arrest: what do we know? Minerva Anestesiol 2020; 87:358-367. [PMID: 32959631 DOI: 10.23736/s0375-9393.20.14574-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Postcardiac arrest myocardial dysfunction (PCAMD) is a frequent complication faced during post-resuscitation care that adversely impacts survival and neurological outcome. Both mechanical and electrical factors contribute to the occurrence of PCAMD. Prearrest ventricular function, the cause of cardiac arrest, global ischemia, resuscitation factors, ischemia/reperfusion injury and post-resuscitation treatments contribute to the severity of PCMAD. The pathophysiology of PCAMD is complex and include myocytes energy failure, impaired contractility, cardiac edema, mitochondrial damage, activation of inflammatory pathways and the coagulation cascade, persistent ischemic injury and myocardial stiffness. Hypotension and low cardiac output with vasopressor/inotropes need are frequent after resuscitation. However, clinical, hemodynamic and laboratory signs of shock are frequently altered by cardiac arrest pathophysiology and post-resuscitation treatment, potentially being misleading and not fully reflecting the severity of postcardiac arrest syndrome. Even if validated criteria are lacking, an extensive hemodynamic evaluation is useful to define a "benign" and a "malign" form of myocardial dysfunction and circulatory shock, potentially having treatment and prognostic implications. Cardiac output is frequently decreased after cardiac arrest, particularly in patients treated with target temperature management (TTM); however, it is not independently associated with outcome. Sinus bradycardia during TTM seems independently associated with survival and good neurological outcome, representing a promising prognostic indicator. Higher mean arterial pressure (MAP) seems to be associated with improved survival and cerebral function after cardiac arrest; however, two recent randomized clinical trials failed to replicate these results. Recommendations on hemodynamic optimization are relatively poor and are largely based on general principle of intensive care medicine.
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Affiliation(s)
- Giovanni Babini
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Emergency Medicine and Services, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium.,Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Markus B Skrifvars
- Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland -
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8
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Kawase K, Ujiie H, Takaki M, Yamashita K. Clinical outcome of canine cardiopulmonary resuscitation following the RECOVER clinical guidelines at a Japanese nighttime animal hospital. J Vet Med Sci 2018; 80:518-525. [PMID: 29375087 PMCID: PMC5880836 DOI: 10.1292/jvms.17-0107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A set of evidence-based consensus guidelines for cardiopulmonary resuscitation (CPR) in dogs and cats (RECOVER guidelines) was published in 2012. The purpose of this study was to investigate the clinical outcomes of CPR
performed according to those guidelines in dogs. A total of 141 dogs with cardiopulmonary arrest (CPA) were identified and underwent CPR between January 2012 and December 2015 at the Sapporo Nighttime Animal Hospital.
CPR was performed according to no-consensus traditional veterinary CPR procedures in 68 dogs (TRADITIONAL group), and according to the RECOVER guidelines in 73 dogs (RECOVER group). There was no significant difference in
the age, body weight, or time from CPA identification to initiation of CPR between the TRADITIONAL and RECOVER groups (median [range]: 10 [0–16] vs. 11 [0–16] years; 6.6 [1.0–58.6] vs. 5.5 [1.1–30.4] kg; and 0 [0–30] vs.
0 [0–30] min, respectively). In the TRADITIONAL group, 12 dogs (17%) achieved a return of spontaneous circulation (ROSC), but none survived to hospital discharge. However, 32 dogs (43%) in the RECOVER group achieved
ROSC, and 4 dogs (5%) were discharged from the hospital. Incorporating the RECOVER guidelines into clinical practice significantly improved the ROSC rate (P<0.001). However, the rate of survival to
hospital discharge was still low. This may suggest that a superior intensive care unit that provides advanced post-CPA care could benefit veterinary CPR patients.
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Affiliation(s)
- Koudai Kawase
- Sapporo Nighttime Animal Hospital, Sapporo, Hokkaido 060-0062, Japan.,Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8591, Japan
| | - Hazuki Ujiie
- Sapporo Nighttime Animal Hospital, Sapporo, Hokkaido 060-0062, Japan
| | - Motonori Takaki
- Sapporo Nighttime Animal Hospital, Sapporo, Hokkaido 060-0062, Japan
| | - Kazuto Yamashita
- Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8591, Japan
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9
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Hagihara A, Onozuka D, Ono J, Nagata T, Hasegawa M. Interaction of defibrillation waveform with the time to defibrillation or the number of defibrillation attempts on survival from out-of-hospital cardiac arrest. Resuscitation 2017; 122:54-60. [PMID: 29175354 DOI: 10.1016/j.resuscitation.2017.11.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 11/17/2017] [Accepted: 11/20/2017] [Indexed: 10/18/2022]
Abstract
AIM Early biphasic defibrillation is effective in out-of-hospital cardiac arrest (OHCA) cases. In the resuscitation of patients with OHCA, it is not clear how the defibrillation waveform interacts with the time to defibrillation to influence patient survival. The second, and any subsequent, shocks need to be administered by an on-line physician in Japan. Thus, we investigated the interaction between the defibrillation waveform and time to or the number of defibrillation on resuscitation outcomes. METHODS This prospective observational study used data for all OHCAs that occurred between 2005 and 2014 in Japan. To investigate the interaction effect between the defibrillation waveform and the time to defibrillation or the number of defibrillations on the return to spontaneous circulation (ROSC), 1-month survival, and cerebral performance category (CPC) (1, 2), we assessed the modifying effects of the defibrillation waveform and the time to or the number of defibrillation on additive scale (i.e., the relative excessive risk due to interaction, RERI) and multiplicative scale (i.e., ratio of odds ratios (ORs)). RESULTS In total, 71,566 cases met the inclusion criteria. For the measure of interaction between the defibrillation waveform and the time to defibrillation, ratio of ORs for ROSC was 0.84 (0.75-0.94), implying that the effect of time to first defibrillation on ROSC was negatively modified by defibrillation waveform. For the interaction between the defibrillation waveform and the number of defibrillations, RERI and ratio of ORs for CPC (1, 2) was -0.25 (-0.47 to -0.06) and 0.79 (0.67-0.93), respectively. It is implied that the effect of number of defibrillation on CPC (1, 2) was negatively modified by defibrillation waveform. CONCLUSIONS An increased number of defibrillations was associated with a decreased ROSC in the case of biphasic and monophasic defibrillation, while an increased number of defibrillations was related to an increased 1-month survival rate and CPC (1, 2) only in the case of biphasic defibrillation. When two or more defibrillations were performed, a biphasic waveform was more effective in terms of long-term survival than a monophasic waveform.
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Affiliation(s)
- Akihito Hagihara
- Department of Health Services Management and Policy, Kyushu University Graduate School of Medicine, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Daisuke Onozuka
- Department of Health Services Management and Policy, Kyushu University Graduate School of Medicine, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Junko Ono
- Department of Health Services Management and Policy, Kyushu University Graduate School of Medicine, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takashi Nagata
- Department of Emergency and Critical Care Center, Kyushu University Hospital, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Manabu Hasegawa
- Shimonoseki-City Welfare Department, 1-1 Nanbu-cho, Shimonoseki-city, Yamaguchi 750-8521, Japan
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Aiello S, Perez M, Cogan C, Baetiong A, Miller SA, Radhakrishnan J, Kaufman CL, Gazmuri RJ. Real-Time Ventricular Fibrillation Amplitude-Spectral Area Analysis to Guide Timing of Shock Delivery Improves Defibrillation Efficacy During Cardiopulmonary Resuscitation in Swine. J Am Heart Assoc 2017; 6:JAHA.117.006749. [PMID: 29102980 PMCID: PMC5721767 DOI: 10.1161/jaha.117.006749] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The ventricular fibrillation amplitude spectral area (AMSA) predicts whether an electrical shock could terminate ventricular fibrillation and prompt return of spontaneous circulation. We hypothesized that AMSA can guide more precise timing for effective shock delivery during cardiopulmonary resuscitation. Methods and Results Three shock delivery protocols were compared in 12 pigs each after electrically induced ventricular fibrillation, with the duration of untreated ventricular fibrillation evenly stratified into 6, 9, and 12 minutes: AMSA‐Driven (AD), guided by an AMSA algorithm; Guidelines‐Driven (GD), according to cardiopulmonary resuscitation guidelines; and Guidelines‐Driven/AMSA‐Enabled (GDAE), as per GD but allowing earlier shocks upon exceeding an AMSA threshold. Shocks delivered using the AD, GD, and GDAE protocols were 21, 40, and 62, with GDAE delivering only 2 AMSA‐enabled shocks. The corresponding 240‐minute survival was 8/12, 6/12, and 2/12 (log‐rank test, P=0.035) with AD exceeding GDAE (P=0.026). The time to first shock (seconds) was (median [Q1–Q3]) 272 (161–356), 124 (124–125), and 125 (124–125) (P<0.001) with AD exceeding GD and GDAE (P<0.05); the average coronary perfusion pressure before first shock (mm Hg) was 16 (9–30), 10 (6–12), and 3 (−1 to 9) (P=0.002) with AD exceeding GDAE (P<0.05); and AMSA preceding the first shock (mV·Hz, mean±SD) was 13.3±2.2, 9.0±1.6, and 8.6±2.0 (P<0.001) with AD exceeding GD and GDAE (P<0.001). The AD protocol delivered fewer unsuccessful shocks (ie, less shock burden) yielding less postresuscitation myocardial dysfunction and higher 240‐minute survival. Conclusions The AD protocol improved the time precision for shock delivery, resulting in less shock burden and less postresuscitation myocardial dysfunction, potentially improving survival compared with time‐fixed, guidelines‐driven, shock delivery protocols.
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Affiliation(s)
- Salvatore Aiello
- Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Michelle Perez
- Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Chad Cogan
- Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Alvin Baetiong
- Resuscitation Institute, Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Steven A Miller
- Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Jeejabai Radhakrishnan
- Resuscitation Institute, Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | | | - Raúl J Gazmuri
- Resuscitation Institute, Rosalind Franklin University of Medicine and Science, North Chicago, IL
- Critical Care Medicine Captain James A. Lovell Federal Health Care Center, North Chicago, IL
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11
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Liang LN, Zhong X, Zhou Y, Hou ZQ, Hu HR, Zhu FF, Chen JB, Ji XF, Shang DY. Cardioprotective effect of nicorandil against myocardial injury following cardiac arrest in swine. Am J Emerg Med 2017; 35:1082-1089. [PMID: 28285861 DOI: 10.1016/j.ajem.2017.02.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 02/27/2017] [Accepted: 02/28/2017] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Nicorandil, a vasodilatory drug used to treat angina, was reported to protect against myocardial ischemia-reperfusion injury in various animal models. However, its cardioprotective action following cardiac arrest is unknown. We examined the cardioprotective effects of nicorandil in a porcine model of cardiac arrest and resuscitation. METHODS Ventricular fibrillation was induced electrically for 4min in anesthetized domestic swine, followed by cardiopulmonary resuscitation. Sixteen successfully resuscitated animals were randomized to saline control (n=8) or nicorandil (n=8) groups. Nicorandil (150μg/kg) was administered by central intravenous injection at onset of restoration of spontaneous circulation (ROSC), followed by 3μg/kg/min infusion until reperfusion end. Sham-operated animals received surgery only (n=4). Hemodynamic parameters were monitored continuously. Blood samples were taken at baseline, 5, 30, 180, and 360min after ROSC. Left ventricular ejection fraction was assessed by echocardiography at baseline and 6h after ROSC. The animals were euthanized 6h after ROSC, and the cardiac tissue was removed for analysis. RESULTS 6 h after ROSC, nicorandil had significantly improved all hemodynamic variables (all P<0.05) except the maximum rate of left ventricular pressure decline and heart rate (P>0.05) compared with the control group. Control animals showed elevated cardiac troponin I and lactate levels compared with sham animals, which were significantly decreased following nicorandil treatment (P<0.05). In the saline control group, the adenosine triphosphate (ATP) content was largely reduced but subsequently rescued by nicorandil (P<0.05). Histopathologic injury was reduced with nicorandil treatment. Nicorandil reduced cardiomyocyte apoptosis as evidenced by reduced terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL)-positive cells, decreased Bax and caspase-3 expression, and increased Bcl-2 expression in the myocardium (all P<0.05). CONCLUSION Nicorandil exhibited cardioprotective effects on myocardial injury following cardiac arrest via improvement in post-resuscitation myocardial dysfunction and energy metabolism, reduction in myocardial histopathologic injury, and antiapoptotic effects.
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Affiliation(s)
- Li-Ning Liang
- Department of Emergency, Shandong Provincial Hospital affiliated to Shandong University, No. 324, Jingwu Road, Jinan 250021, Shandong, China
| | - Xia Zhong
- Department of Emergency, Shandong Provincial Hospital affiliated to Shandong University, No. 324, Jingwu Road, Jinan 250021, Shandong, China
| | - Yi Zhou
- Department of Emergency, Shandong Provincial Hospital affiliated to Shandong University, No. 324, Jingwu Road, Jinan 250021, Shandong, China
| | - Zhi-Qiang Hou
- Department of Emergency, Shandong Provincial Hospital affiliated to Shandong University, No. 324, Jingwu Road, Jinan 250021, Shandong, China
| | - Hao-Ran Hu
- Department of Emergency, Shandong Provincial Hospital affiliated to Shandong University, No. 324, Jingwu Road, Jinan 250021, Shandong, China
| | - Fang-Fang Zhu
- Department of Emergency, Shandong Provincial Hospital affiliated to Shandong University, No. 324, Jingwu Road, Jinan 250021, Shandong, China
| | - Ji-Bin Chen
- Department of Emergency, Shandong Provincial Hospital affiliated to Shandong University, No. 324, Jingwu Road, Jinan 250021, Shandong, China
| | - Xian-Fei Ji
- Department of Emergency, Shandong Provincial Hospital affiliated to Shandong University, No. 324, Jingwu Road, Jinan 250021, Shandong, China.
| | - De-Ya Shang
- Department of Emergency, Shandong Provincial Hospital affiliated to Shandong University, No. 324, Jingwu Road, Jinan 250021, Shandong, China.
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12
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Anantharaman V, Tay SY, Manning PG, Lim SH, Chua TSJ, Tiru M, Charles RA, Sudarshan V. A multicenter prospective randomized study comparing the efficacy of escalating higher biphasic versus low biphasic energy defibrillations in patients presenting with cardiac arrest in the in-hospital environment. Open Access Emerg Med 2017; 9:9-17. [PMID: 28144168 PMCID: PMC5248978 DOI: 10.2147/oaem.s109339] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Biphasic defibrillation has been practiced worldwide for >15 years. Yet, consensus does not exist on the best energy levels for optimal outcomes when used in patients with ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT). Methods This prospective, randomized, controlled trial of 235 adult cardiac arrest patients with VF/VT was conducted in the emergency and cardiology departments. One group received low-energy (LE) shocks at 150–150–150 J and the other escalating higher-energy (HE) shocks at 200–300–360 J. If return of spontaneous circulation (ROSC) was not achieved by the third shock, LE patients crossed over to the HE arm and HE patients continued at 360 J. Primary end point was ROSC. Secondary end points were 24-hour, 7-day, and 30-day survival. Results Both groups were comparable for age, sex, cardiac risk factors, and duration of collapse and VF/VT. Of the 118 patients randomized to the LE group, 48 crossed over to the HE protocol, 24 for persistent VF, and 24 for recurrent VF. First-shock termination rates for HE and LE patients were 66.67% and 64.41%, respectively (P=0.78, confidence interval: 0.65–1.89). First-shock ROSC rates were 25.64% and 29.66%, respectively (P=0.56, confidence interval: 0.46–1.45). The 24-hour, 7-day, and 30-day survival rates were 85.71%, 74.29%, and 62.86% for first-shock ROSC LE patients and 70.00%, 50.00%, and 46.67% for first-shock ROSC HE patients, respectively. Conversion rates for further shocks at 200 J and 300 J were low, but increased to 38.95% at 360 J. Conclusion First-shock termination and ROSC rates were not significantly different between LE and HE biphasic defibrillation for cardiac arrest patients. Patients responded best at 150/200 J and at 360 J energy levels. For patients with VF/pulseless VT, consideration is needed to escalate quickly to HE shocks at 360 J if not successfully defibrillated with 150 or 200 J initially.
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Affiliation(s)
| | - Seow Yian Tay
- Department of Emergency Medicine, Tan Tock Seng Hospital
| | | | - Swee Han Lim
- Department of Emergency Medicine, Singapore General Hospital
| | | | - Mohan Tiru
- Accident and Emergency Department, Changi General Hospital, Singapore
| | | | - Vidya Sudarshan
- Department of Emergency Medicine, Singapore General Hospital
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Liu X, Asirvatham S, Kabell GG. Orthostatic increase in defibrillation threshold leading to defibrillation failure and prolonged cardiac arrest in a sitting position: Lessons from a patient’s near-fatal experience. HeartRhythm Case Rep 2016; 2:313-317. [PMID: 28491699 PMCID: PMC5419841 DOI: 10.1016/j.hrcr.2016.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Xiaoke Liu
- Division of Cardiology, Borgess Medical Center, and Department of Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan
- Address reprints and correspondence: Dr Xiaoke Liu, Director, Device and EP Clinic, Borgess Medical Center, 1722 Shaffer St, Kalamazoo, MI 49048Device and EP Clinic, Borgess Medical Center, 1722 Shaffer St, Kalamazoo, MI 49048
| | | | - G. Glenn Kabell
- Division of Cardiology, Borgess Medical Center, and Department of Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan
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Biphasic versus monophasic defibrillation in out-of-hospital cardiac arrest: a systematic review and meta-analysis. Am J Emerg Med 2013; 31:1472-8. [PMID: 24035505 DOI: 10.1016/j.ajem.2013.07.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Revised: 06/09/2013] [Accepted: 07/18/2013] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Biphasic defibrillation is more effective than monophasic one in controlled in-hospital conditions. The present review evaluated the performance of both waveforms in the defibrillation of patients of out-of-hospital cardiac arrest (OHCA) with initial ventricular fibrillation (Vf) rhythm under the context of current recommendations for cardiopulmonary resuscitation. METHODS From inception to June 2012, Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched systemically for randomized controlled trials (RCTs) and observational cohort studies that compared the effects of biphasic and monophasic shocks on Vf termination, return of spontaneous circulation (ROSC), and survival to hospital discharge in OHCA patients with initial Vf rhythm. No restrictions were applied regarding language, population, or publication year. RESULTS Four RCTs including 572 patients were identified from 131 potentially relevant references for meta-analysis. The synthesis of these RCTs yielded fixed-effect pooled risk ratios (RRs) for biphasic and monophasic waveforms on Vf termination survival to hospital discharge (RR, 1.14; 95% CI, [0.84-1.54]). CONCLUSION Biphasic waveforms did not seem superior to monophasic ones with respect to Vf termination, ROSC, or survival to hospital discharge in OHCA patients with initial Vf rhythm under the context of current guidelines. However, most trials were conducted in accordance with previous guidelines for cardiopulmonary resuscitation. Therefore, further trials are needed to clarify this issue.
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L'italien AJ. Critical cardiovascular skills and procedures in the emergency department. Emerg Med Clin North Am 2013. [PMID: 23200332 DOI: 10.1016/j.emc.2012.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The management of cardiovascular emergencies is a fundamental component of the practice of an emergency practitioner. Delays in the evaluations and management can lead to significant morbidity or mortality. It is of vital importance to be familiar with procedures such as pericardiocentesis, cardioversion, defibrillation, temporary pacing, and options for the management of tachyarrhythmias. This article discusses the most common cardiovascular procedures encountered in an emergency setting, including the indications, contraindications, equipment, technique, and complications for each procedure.
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Affiliation(s)
- Anita J L'italien
- Department of Emergency Medicine, Wake Emergency Physicians, PA, 3000 New Bern Avenue, Medical Office Building, Raleigh, NC 27610, USA. l'
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Fletcher DJ, Boller M, Brainard BM, Haskins SC, Hopper K, McMichael MA, Rozanski EA, Rush JE, Smarick SD. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 7: Clinical guidelines. J Vet Emerg Crit Care (San Antonio) 2012; 22 Suppl 1:S102-31. [PMID: 22676281 DOI: 10.1111/j.1476-4431.2012.00757.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To present a series of evidence-based, consensus guidelines for veterinary CPR in dogs and cats. DESIGN Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality, and development of consensus on conclusions for application of the concepts to clinical practice. Questions in five domains were examined: Preparedness and Prevention, Basic Life Support, Advanced Life Support, Monitoring, and Post-Cardiac Arrest Care. Standardized worksheet templates were used for each question, and the results reviewed by the domain members, by the RECOVER committee, and opened for comments by veterinary professionals for 4 weeks. Clinical guidelines were devised from these findings and again reviewed and commented on by the different entities within RECOVER as well as by veterinary professionals. SETTING Academia, referral practice and general practice. RESULTS A total of 74 worksheets were prepared to evaluate questions across the five domains. A series of 101 individual clinical guidelines were generated. In addition, a CPR algorithm, resuscitation drug-dosing scheme, and postcardiac arrest care algorithm were developed. CONCLUSIONS Although many knowledge gaps were identified, specific clinical guidelines for small animal veterinary CPR were generated from this evidence-based process. Future work is needed to objectively evaluate the effects of these new clinical guidelines on CPR outcome, and to address the knowledge gaps identified through this process.
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Affiliation(s)
- Daniel J Fletcher
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA.
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Abstract
Recognition and appropriate treatment of ventricular fibrillation or pulseless ventricular tachycardia is an essential skill for healthcare providers. Appropriate defibrillation can improve survival and benefit patient outcome. Similarly, increased public access to automatic electronic defibrillators has been shown to improve out-of-hospital survival for cardiac arrest. When combined with high-quality cardiopulmonary resuscitation, electrical therapies are an important aspect of resuscitation in the patient with cardiac arrest. This article focuses on the use of electrical therapies, including defibrillation, cardiac pacing, and automated external defibrillators, in cardiac arrest.
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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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Walcott GP, Melnick SB, Killingsworth CR, Ideker RE. Comparison of low-energy versus high-energy biphasic defibrillation shocks following prolonged ventricular fibrillation. PREHOSP EMERG CARE 2010; 14:62-70. [PMID: 19947869 DOI: 10.3109/10903120903349838] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Since the initial development of the defibrillator, there has been concern that, while delivery of a large electric shock would stop fibrillation, it would also cause damage to the heart. This concern has been raised again with the development of the biphasic defibrillator. OBJECTIVE To compare defibrillation efficacy, postshock cardiac function, and troponin I levels following 150-J and 360-J shocks. METHODS Nineteen swine were anesthetized with isoflurane and instrumented with pressure catheters in the left ventricle, aorta, and right atrium. The animals were fibrillated for 6 minutes, followed by defibrillation with either low-energy (n = 8) or high-energy (n = 11) shocks. After defibrillation, chest compressions were initiated and continued until return of spontaneous circulation (ROSC). Epinephrine, 0.01 mg/kg every 3 minutes, was given for arterial blood pressure < 50 mmHg. Hemodynamic parameters were recorded for four hours. Transthoracic echocardiography was performed and troponin I levels were measured at baseline and four hours following ventricular fibrillation (VF). RESULTS Survival rates at four hours were not different between the two groups (low-energy, 5 of 8; high-energy, 7 of 11). Results for arterial blood pressure, positive dP/dt (first derivative of pressure measured over time, a measure of left ventricular contractility), and negative dP/dt at the time of lowest arterial blood pressure (ABP) following ROSC were not different between the two groups (p = not significant [NS]), but were lower than at baseline. All hemodynamic measures returned to baseline by four hours. Ejection fractions, stroke volumes, and cardiac outputs were not different between the two groups at four hours. Troponin I levels at four hours were not different between the two groups (12 +/- 11 ng/mL versus 21 +/- 26 ng/mL, p = NS) but were higher at four hours than at baseline (19 +/- 19 ng/mL versus 0.8 +/- 0.5 ng/mL, p < 0.05, groups combined). CONCLUSION Biphasic 360-J shocks do not cause more cardiac damage than biphasic 150-J shocks in this animal model of prolonged VF and resuscitation.
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Affiliation(s)
- Gregory P Walcott
- Department of Medicine-Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA.
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Stothert JC, Hatcher TS, Gupton CL, Love JE, Brewer JE. RECTILINEARBIPHASICWAVEFORMDEFIBRILLATION OFOUT-OF-HOSPITALCARDIACARREST. PREHOSP EMERG CARE 2009. [DOI: 10.1080/312704000760] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Freeman K, Hendey GW, Shalit M, Stroh G. Biphasic Defibrillation Does not Improve Outcomes Compared to Monophasic Defibrillation in Out-of-Hospital Cardiac Arrest. PREHOSP EMERG CARE 2009; 12:152-6. [DOI: 10.1080/10903120801907240] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Bright JM, Wright BD. Successful biphasic transthoracic defibrillation of a dog with prolonged, refractory ventricular fibrillation. J Vet Emerg Crit Care (San Antonio) 2009; 19:275-9. [DOI: 10.1111/j.1476-4431.2009.00408.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
What is the successful cardiopulmonary resuscitation? It is the few minutes postcardiopulmonary arrest that can answer. Twenty to 40 percent of patients who sustained cardiac arrest are initially resuscitated, but only 10% survive to hospital discharge, and more than 60% of victims succumb within 24 hours. This high fatality rate in the early hours and days after successful resuscitation is mainly related to the acute, intense, and reversible form of postresuscitation myocardial dysfunction (stunning) together with the ventricular tachyarrhythmia. It is a reversible process, provided that we are aware of the pertinent pathophysiology and then intervene accordingly. Herein I reviewed most of the published relevant articles concerning the causes, underlying mechanism, and the updated trials for management of postresuscitation myocardial stunning. I do agree that not only the restoration of the circulation but also long-term outcome should be the aim of resuscitation, and I readdress the role of epinephrine, dobutamine, biphasic defibrillator, with the new promising agent (ie, potassium channel opener), Delta-opioid receptor agonist, unloading intracellular calcium, antioxidants, and therapeutic hypothermia to halt this period of stunning. This will improve the outcome of the resuscitation efforts.
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Augenstein S, Wenzel V, Krismer AC, Lindner KH. In-hospital resuscitation. Curr Opin Anaesthesiol 2007; 14:423-30. [PMID: 17019125 DOI: 10.1097/00001503-200108000-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A recent world expert conference on resuscitation and emergency cardiac care led to evidence-based international guidelines for cardiopulmonary resuscitation (CPR). Several changes to CPR interventions were recommended, and will have to be implemented into clinical practice. The poor prognosis of patients who suffer in-hospital cardiac arrest may be improved with developments in CPR interventions. In the present review the most important changes recommended by the new CPR guidelines and the latest promising CPR investigations are described, focusing on their impact on in-hospital resuscitation.
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Affiliation(s)
- S Augenstein
- Department of Anesthesiology and Critical Care Medicine, Leopold-Franzens-University, Innsbruck, Austria.
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Niemann JT, Rosborough JP, Youngquist S, Thomas J, Lewis RJ. Is all ventricular fibrillation the same? A comparison of ischemically induced with electrically induced ventricular fibrillation in a porcine cardiac arrest and resuscitation model. Crit Care Med 2007; 35:1356-61. [PMID: 17414084 DOI: 10.1097/01.ccm.0000261882.47616.7d] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The standard porcine cardiac arrest model uses electrical induction of ventricular fibrillation. Reported restoration of spontaneous circulation and survival rates in this model are as high as 90% for ventricular fibrillation durations of 7-10 mins, values substantially greater than rates in the clinical population (i.e., 20% to 30%). A high first shock success rate, infrequent refibrillation, and short times for restoration of spontaneous circulation are typical of the model. The purpose of this study was to determine whether ischemic induction of ventricular fibrillation in swine followed by standard advanced cardiac life support would result in short-term outcomes approximating those observed in human victims of out-of-hospital ventricular fibrillation. DESIGN Randomized comparative trial. SETTING Translational research laboratory. SUBJECTS Domestic swine (n = 40, mean weight 40 +/- 4 kg, range 34-47 kg) of both genders. INTERVENTIONS Swine were instrumented and randomized to either electrical ventricular fibrillation induction or ischemic ventricular fibrillation, produced by balloon occlusion of the mid-left anterior descending coronary artery (n = 20 per group). Transthoracic impedance was measured and 30 Omega added in series for all animals. The balloon remained inflated during resuscitation efforts in ischemic ventricular fibrillation animals. After 7 mins of ventricular fibrillation, cardiopulmonary resuscitation was initiated and defibrillation was attempted 1 min later. Epinephrine and antiarrhythmics were administered as per guidelines. Resuscitation was terminated if restoration of spontaneous circulation had not occurred after 15 mins of advanced cardiac life support. MEASUREMENTS AND MAIN RESULTS Although the number of countershocks required to initially terminate ventricular fibrillation was not different (electrical ventricular fibrillation 1.9 +/- 1.6, ischemic ventricular fibrillation 2.4 +/- 2.0), the refibrillation rate was higher in the ischemic ventricular fibrillation group (4.9 +/- 4 vs. 0.8 +/- 1 episodes/animal, p < .001), resulting in a greater number of shocks before restoration of spontaneous circulation (total shocks for ischemic ventricular fibrillation 9.4 +/- 5.6 vs. electrical ventricular fibrillation 2.7 +/- 2.2, p < .001). Time to restoration of spontaneous circulation was longer in the ischemic ventricular fibrillation group (430 +/- 234 secs vs. 149 +/- 120 secs, p < .001). Restoration of spontaneous circulation rates were not different (electrical ventricular fibrillation 90% vs. ischemic ventricular fibrillation 65%). However, survival to 6 hrs was greater in the electrical ventricular fibrillation group (18 of 20, 90%) than in the ischemic ventricular fibrillation group (8 of 20, 40%, p = .002). CONCLUSIONS Resuscitation from ischemic ventricular fibrillation is more difficult than electrical ventricular fibrillation and is characterized by greater time to restoration of spontaneous circulation, frequent refibrillation, greater number of countershocks, higher epinephrine dose during resuscitation efforts, profound cardiac dysfunction, and a short-term survival rate approaching clinical experience. Ischemically induced ventricular fibrillation is a more clinically relevant model for the evaluation of resuscitation interventions.
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Samson RA, Berg MD, Berg RA. Cardiopulmonary resuscitation algorithms, defibrillation and optimized ventilation during resuscitation. Curr Opin Anaesthesiol 2006; 19:146-56. [PMID: 16552221 DOI: 10.1097/01.aco.0000192799.87548.d3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW In 2005, the American Heart Association released its Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. This article reviews the treatment algorithms for Advanced Cardiac Life Support, citing the evidence on which the Guidelines are based. Additional focus is placed on defibrillation and optimized ventilation. RECENT FINDINGS Major changes include a reorganization of the algorithms for cardiac arrest. Emphasis on effective cardiopulmonary resuscitation is placed as the key to improved survival. Single defibrillation shocks are recommended (compared with three 'stacked' shocks) with immediate provision of cardiopulmonary resuscitation and minimal interruptions in chest compressions. The recommended chest compression : ventilation rate for single rescuers has been changed to 30:2. SUMMARY Despite advances in resuscitation science, basic life support remains the key to improving survival outcomes. Ultimately, as new knowledge is gained, we believe resuscitation therapies will be more individualized, on the basis of pathophysiology and etiology of the initial cardiac arrest.
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Affiliation(s)
- Ricardo A Samson
- Department of Pediatrics, Steele Children's Research Center, The University of Arizona, Tucson, Arizona, USA
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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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Gelzer AR, Moïse NS, Koller ML. Defibrillation of German shepherds with inherited ventricular arrhythmias and sudden death. J Vet Cardiol 2005; 7:97-107. [DOI: 10.1016/j.jvc.2005.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2005] [Revised: 09/23/2005] [Accepted: 09/25/2005] [Indexed: 10/25/2022]
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Berg RA. Attenuated adult biphasic shocks for prolonged pediatric ventricular fibrillation: support for pediatric automated defibrillators. Crit Care Med 2004; 32:S352-5. [PMID: 15508658 DOI: 10.1097/01.ccm.0000134225.42482.dc] [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: 11/27/2022]
Abstract
OBJECTIVE To evaluate published data regarding the treatment of prolonged pediatric defibrillation, with special emphasis on the use of attenuated adult biphasic shocks for pediatric defibrillation. DESIGN Review relevant human and animal literature. RESULTS Rhythm analysis algorithms from two manufacturers of automated external defibrillators can accurately distinguish shockable from nonshockable rhythms in children. Theoretical considerations and transthoracic impedance data from animals and children suggest that pediatric defibrillation doses should not necessarily vary in a simple weight-based manner. Two piglet studies have established that an attenuated adult biphasic dosage can be successfully used for 3.5- to 24-kg animals in ventricular fibrillation. One study established that the attenuated adult biphasic dosage was at least as safe and effective as the standard monophasic weight-based dosing. CONCLUSION This review supports the American Heart Association's new guidelines for pediatric automated external defibrillator usage: "Automated external defibrillators may be used for children 1 to 8 yrs of age who have no signs of circulation. Ideally the device should deliver a pediatric dose. The arrhythmia detection system used in the device should demonstrate high specificity for pediatric shockable rhythms, i.e., it will not recommend delivery of a shock for nonshockable rhythms."
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Affiliation(s)
- Robert A Berg
- University of Arizona Steele Memorial Children's Research Center and Sarver Heart Center, Department of Pediatrics, Tucson, AZ, USA
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Berg RA, Chapman FW, Berg MD, Hilwig RW, Banville I, Walker RG, Nova RC, Sherrill D, Kern KB. Attenuated adult biphasic shocks compared with weight-based monophasic shocks in a swine model of prolonged pediatric ventricular fibrillation. Resuscitation 2004; 61:189-97. [PMID: 15135196 DOI: 10.1016/j.resuscitation.2003.12.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2003] [Revised: 12/18/2003] [Accepted: 12/18/2003] [Indexed: 10/26/2022]
Abstract
AIM To compare the safety and efficacy of attenuated adult biphasic shocks with standard monophasic weight-based shocks in a piglet model of prolonged prehospital ventricular fibrillation (VF). BACKGROUND If attenuated adult shocks are safe and effective for prehospital pediatric VF, automated external defibrillators (AEDs) can be easily adapted for pediatric use. METHODS After 7 min of untreated VF, piglets were randomized to treatment with attenuated adult biphasic shocks or weight-based monophasic shocks. The attenuated adult biphasic group received 200/300/360 J shocks, attenuated by specialized pediatric electrodes to 51/78/81 J and the monophasic weight-based control group received 2/4/4 J/kg shocks. Forty-eight female piglets were studied, 16 in each of three weight categories: 4 kg (neonatal), 14 kg (younger child) and 24 kg (older child). The primary outcome measures of efficacy and safety were 24h survival with good neurological outcome and post-resuscitation left ventricular ejection fraction (LVEF), respectively. RESULTS For the 24 kg piglets, attenuated adult biphasic shocks resulted in superior 24 h survival with good neurological outcome (6/8 versus 0/8, P < 0.001) and greater LVEF 4 h post-resuscitation (34 +/- 4% versus 18 +/- 5%, P < 0.05). For the 14 and 4 kg piglets, 24 h survival with good neurological outcome occurred in 7/8 versus 5/8 and 7/8 versus 3/8, respectively, and LVEF 4 h post-resuscitation was 30 +/- 3% versus 36 +/- 6% and 30 +/- 3% versus 22 +/- 4%, respectively. CONCLUSIONS The escalating attenuated adult biphasic dosage strategy was at least as safe and effective as the standard weight-based monophasic dose over a wide range of weights in this piglet model of prehospital VF. This work supports the concept of using an attenuated adult biphasic dosage in children.
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Affiliation(s)
- Robert A Berg
- The University of Arizona Steele Memorial Children's Research Center, Tuscon, AZ 85724-5073, USA.
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Niemann JT, Rosborough JP, Walker RG. A Model of Ischemically Induced Ventricular Fibrillation for Comparison of Fixed-dose and Escalating-dose Defibrillation Strategies. Acad Emerg Med 2004. [DOI: 10.1111/j.1553-2712.2004.tb02403.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Samson RA, Berg RA, Bingham R. Use of automated external defibrillators for children: an update--an advisory statement from the Pediatric Advanced Life Support Task Force, International Liaison Committee on Resuscitation. Pediatrics 2003; 112:163-8. [PMID: 12837882 DOI: 10.1542/peds.112.1.163] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ricardo A Samson
- Department of Pediatrics, 1501 N Campbell, Tucson, AZ 85724-5073, USA.
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Samson R, Berg R, Bingham R. Use of automated external defibrillators for children: an update. An advisory statement from the Pediatric Advanced Life Support Task Force, International Liaison Committee on Resuscitation. Resuscitation 2003; 57:237-43. [PMID: 12858859 DOI: 10.1016/s0300-9572(03)00202-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
PURPOSE OF REVIEW Successful treatment of cardiac arrest requires that an electrically stable and mechanically competent cardiac activity be promptly reestablished. However, many interventions used to attempt to reestablish cardiac activity may also inflict additional myocardial injury and, in turn, compromise resuscitability. In this review, we examine mechanisms of such myocardial injury and discuss potential new strategies for myocardial protection during resuscitation from cardiac arrest. RECENT FINDINGS Efforts are currently directed at understanding underlying mechanisms of myocardial injury associated with current resuscitation methods, with the purpose of developing alternative approaches that are safer and more effective. These new approaches include, among others, the development of alternative low-energy defibrillation waveforms, methods for optimizing the timing for attempting defibrillation, and the use of vasopressor agents devoid of beta-agonist effects. There is also interest in understanding the role that activation of pathways of ischemic and reperfusion injury could play during resuscitation from cardiac arrest. To this end, activation of the sarcolemmal sodium-hydrogen exchanger isoform 1 seems to play an important role. Other potentially important pathways involve adenosine metabolism, activation of potassium ATP channels, and generation of oxygen radical species. These pathways may become novel pharmacologic targets for cardiac resuscitation. SUMMARY The growing body of research in these areas is bringing hope that in a not so distant future new approaches and interventions for cardiac resuscitation could be available for resuscitation of humans in various clinical settings.
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Affiliation(s)
- Raúl J Gazmuri
- Department of Medicine, Finch University of Health Sciences/The Chicago Medical School, North Chicago, Illinois, USA.
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Zhang Y, Davies LR, Coddington WJ, Zimmerman MB, Wuthrich S, Jones JL, Kerber RE. Open-chest epicardial "surgical" defibrillation: biphasic versus monophasic waveform shocks. Pacing Clin Electrophysiol 2003; 26:711-8. [PMID: 12698671 DOI: 10.1046/j.1460-9592.2003.00121.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of the study was to compare biphasic versus monophasic shocks for open-chest epicardial defibrillation. Transthoracic biphasic waveform shocks require less energy to terminate ventricular fibrillation compared to monophasic waveform shocks. However, if biphasic shocks are effective for open-chest epicardial ("surgical") defibrillation has not been established. Twenty-eight anesthetized adult swine (15-25 kg) underwent a midline sternotomy. Ventricular fibrillation was electrically induced. After 15 seconds of ventricular fibrillation, each pig in group 1 (n = 16) randomly received damped sinusoidal monophasic epicardial shocks and truncated exponential biphasic epicardial shocks from large (44.2 cm2) paddle electrodes at eight energy levels (2-50 J). Pigs in group 2 (n = 12) received monophasic and truncated exponential biphasic shocks from small (15.9 cm2) paddle electrodes. In group 1 (large paddle electrodes), the overall percent shock success rose from 15 +/- 9% at 2 J to 97 +/- 3% at 50 J. In this group there was no significant difference in percent of shock success between damped sinusoidal monophasic and biphasic waveform shocks. In group 2 (small paddle electrodes), biphasic shocks yielded a significantly higher percent of shock success than monophasic shocks at mid-energy levels from 7 to 20 J (all P < 0.01). With small surgical paddle electrodes, biphasic waveform shocks demonstrated a significantly higher percent of shock success rate compared to monophasic waveform shocks. With large paddle electrodes, the two waveforms were equally effective.
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Affiliation(s)
- Yi Zhang
- Cardiovascular Center, College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Niemann JT, Garner D, Lewis RJ. Transthoracic impedance does not decrease with rapidly repeated countershocks in a swine cardiac arrest model. Resuscitation 2003; 56:91-5. [PMID: 12505744 DOI: 10.1016/s0300-9572(02)00292-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
STUDY PURPOSE Successful defibrillation is dependent upon the delivery of adequate electrical current to the myocardium. One of the major determinant of current flow is transthoracic impedance. Prior work has suggested that impedance falls with repeated shocks during sinus rhythm. The purpose of this study was to evaluate changes in transthoracic impedance with repeated defibrillation shocks in an animal model of cardiac arrest due to ventricular fibrillation (VF). METHODS VF was electrically induced in anesthetized swine. After 5 min of untreated VF, monophasic or biphasic waveform defibrillation was attempted using a standard sequence of 'stacked shocks' (200, 300, then 360 J, if necessary) administered via adhesive electrodes. If one of the first three shocks failed to convert VF, conventional CPR was initiated and defibrillation (360 J) attempted 1 min later. Strength-duration curves for delivered voltage and current were measured during each shock and transthoracic impedance calculated. Animals requiring a minimum of four shocks were selected for study inclusion. Impedance data from sequential shocks were analyzed using mixed linear models to account for the repeated-measures design and the variability of the initial impedance of individual animals. RESULTS Thirteen animals (monophasic waveform, n=7, biphasic waveform, n=6) required at least four shocks to terminate VF (range 4-6). Transthoracic impedance did not change from the first shock in the 13 animals (46+/-8 Omega) to the fourth shock (46+/-9 Omega). In animals receiving more than four shocks, transthoracic impedance likewise did not change significantly from the first to the last shock, which terminated VF. The lack of a significant change in impedance was also observed when animals were analyzed according to defibrillation waveform. CONCLUSION Transthoracic impedance does not change significantly with repeated shocks in a VF cardiac arrest model. This is likely due to the lack of reactive skin and soft tissue hyperemia and edema observed in non-arrest models.
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Affiliation(s)
- James T Niemann
- Department of Emergency Medicine, UCLA School of Medicine, Harbor-UCLA Medical Center, Box 21, 1000 West Carson Street, Torrance, CA 90509, USA.
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Knaggs AL, Delis KT, Spearpoint KG, Zideman DA. Automated external defibrillation in cardiac surgery. Resuscitation 2002; 55:341-5. [PMID: 12458072 DOI: 10.1016/s0300-9572(02)00285-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Revision open heart surgery may be impeded by a dense network of pericardial adhesions rendering cardiac mobilization laborious or incomplete, and internal defibrillation impossible. External defibrillation, the current alternative to internal defibrillation, may result in myocardial stunning secondary to the delivery of escalating, monophasic, high-energy shocks. Automated external defibrillation, by delivering consecutive, non-escalating, impedance-compensated, low-energy, biphasic electric shocks to the myocardium, may provide a more effective and safer option whilst reducing the risk of myocardial stunning.
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Affiliation(s)
- A L Knaggs
- Department of Anaesthetics, St. Mary's Hospital, 4th Floor QEQM Wing, Praed Street, Paddington, London W2 1NY, UK.
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Achleitner U, Rheinberger K, Furtner B, Amann A, Baubin M. Waveform analysis of biphasic external defibrillators. Resuscitation 2001; 50:61-70. [PMID: 11719131 DOI: 10.1016/s0300-9572(01)00326-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND OBJECTIVE All internal defibrillators and some external defibrillators use biphasic waveforms. The study analysed the discharged waveform pulses of two manual and two semi-automated biphasic external defibrillators. METHODS AND RESULTS The defibrillators were discharged into resistive loads of 25, 50 and 100 Omega simulating the patient's transthoracic impedance. The tested biphasic defibrillators differed in initial current as well as initial voltage, varying from 10.9 to 73.3 A and from 482.8 to 2140.0 V, respectively. The energies of the manual defibrillators set at 100, 150 and 200 J deviated by up to +19.1 or -28.9% from the selected energy. Impedance-normalised delivered energy varied from 1.0 to 12.5 J/Omega. Delivered energy, shock duration and charge flow were examined with respect to the total pulse, its splitting into positive and negative phases and their impedance dependence. For three defibrillators pulse duration increased with the resistive load, whereas one defibrillator always required 9.9 ms. All tested defibrillators showed a higher charge flow in the positive phase. Defibrillator capacitance varied between approximately 200 and 100 mu F and internal resistance varied from 2.0 to 7.6 Omega. Defibrillator waveform tilt ranged from -13.1 to 61.4%. CONCLUSIONS The tested defibrillators showed remarkable differences in their waveform design and their varying dependence on transthoracic impedance.
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Affiliation(s)
- U Achleitner
- Department of Anaesthesiology and Critical Care, University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
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White RD. Technologic advances and program initiatives in public access defibrillation using automated external defibrillators. Curr Opin Crit Care 2001; 7:145-51. [PMID: 11436520 DOI: 10.1097/00075198-200106000-00002] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Widespread provision of early defibrillation following cardiac arrest holds major promise for improved survival from ventricular fibrillation. The critical element in predicting a successful outcome is the rapidity with which defibrillation is achieved. A worldwide awareness of this potential and its advocacy by such organizations as the American Heart Association have been pivotal in the evolution of initiatives to make defibrillation more widely and more rapidly available. The feasibility of this initiative, known as public access defibrillation, is in large measure a direct consequence of major technologic advances in automated external defibrillators (AEDs). New low-energy waveforms with biphasic morphology have been shown to be more effective in terminating ventricular fibrillation and may do so with less myocardial injury. Placement of AEDs in a variety of nontraditional settings such as police cars, aircraft and airport terminals, and gambling casinos has been shown to yield an impressive number of survivors of cardiac arrest in ventricular fibrillation. Questions yet to be answered center on the appropriate disposition of AEDs in public access defibrillation settings, training and retraining issues, device maintenance, and collection of accurate data to document benefit and to identify areas of needed improvement or expansion of AED availability.
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Affiliation(s)
- R D White
- Department of Anesthesiology, Mayo Medical School and Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Martens PR, Russell JK, Wolcke B, Paschen H, Kuisma M, Gliner BE, Weaver WD, Bossaert L, Chamberlain D, Schneider T. Optimal Response to Cardiac Arrest study: defibrillation waveform effects. Resuscitation 2001; 49:233-43. [PMID: 11719116 DOI: 10.1016/s0300-9572(01)00321-5] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Advances in early defibrillation access, key to the "Chain of Survival", will depend on innovations in defibrillation waveforms, because of their impact on device size and weight. This study compared standard monophasic waveform automatic external defibrillators (AEDs) to an innovative biphasic waveform AED. MATERIAL AND METHODS Impedance-compensated biphasic truncated exponential (ICBTE) and either monophasic truncated exponential (MTE) or monophasic damped sine (MDS) AEDs were prospectively, randomly assigned by date in four emergency medical services. The study design compared ICBTE with MTE and MDS combined. This subset analysis distinguishes between the two classes of monophasic waveform, MTE and MDS, and compares their performance to each other and to the biphasic waveform, contingent on significant overall effects (ICBTE vs. MTE vs. MDS). Primary endpoint: Defibrillation efficacy with < or =3 shocks. Secondary endpoints: shock efficacy with < or =1 shock, < or =2 shocks, and survival to hospital admission and discharge. Observations included return of spontaneous circulation (ROSC), refibrillation, and time to first shock and to first successful shock. RESULTS Of 338 out-of-hospital cardiac arrests, 115 had a cardiac aetiology, presented with ventricular fibrillation, and were shocked by an AED. Defibrillation efficacy for the first "stack" of up to 3 shocks, for up to 2 shocks and for the first shock alone was superior for the ICBTE waveform than for either the MTE or the MDS waveform, while there was no difference between the efficacy of MTE and MDS. Time from the beginning of analysis by the AED to the first shock and to the first successful shock was also superior for the ICBTE devices compared to either the MTE or the MDS devices, while again there was no difference between the MTE and MDS devices. More ICBTE patients achieved ROSC pre-hospital than did MTE patients. While the rates of ROSC were identical for MTE and MDS patients, the difference between ICBTE and MDS was not significant. Rates of refibrillation and survival to hospital admission and discharge did not differ among the three populations. CONCLUSIONS ICBTE was superior to MTE and MDS in defibrillation efficacy and speed and to MTE in ROSC. MTE and MDS did not differ in efficacy. There were no differences among the waveforms in refibrillation or survival.
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Affiliation(s)
- P R Martens
- Emergency Medicine Department, St. Jan Hospital, Ruddershove 10, 8000 Brugge, Belgium.
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Abstract
External cardioversion is a technique used electively or emergently to terminate arrhythmias such as atrial fibrillation, ventricular tachycardia, and ventricular fibrillation. There have been several advances made to modern defibrillators, including an improvement in the efficacy of the delivered shock. Biphasic shock waveforms have been shown to be superior to monophasic shocks and these are being incorporated into modern units. This paper reviews several reports on biphasic defibrillation. In addition, initiatives to make defibrillators more accessible are also being tested. Although not a technological advance, this initiative may significantly improve the survival of victims of out of hospital cardiac arrests.
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Affiliation(s)
- J T Dell'Orfano
- State University of New York at Stony Brook, Stony Brook, New York, USA. The Pennsylvania State University, Hershey, Pennsylvania, USA
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