2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

Cognitive aids used in simulated resuscitation: A systematic review

Objectives

To compare the effectiveness of cognitive aid use during resuscitation with no use of cognitive aids on cardiopulmonary resuscitation quality and performance.

Methods

This systematic review followed the PICOST format. All randomised controlled trials and non-randomised studies evaluating cognitive aid use during (simulated) resuscitation were included in any setting. Unpublished studies were excluded. We did not include studies that reported cognitive aid use during training for resuscitation alone. Medline, Embase and Cochrane databases were searched from inception until July 2019 (updated August 2022, November 2023, and 23 April 2024). We did not search trial registries. Title and abstract screening, full-text screening, data extraction, risk of bias assessment (using RoB2 and ROBINS-I), and certainty of evidence (using GRADE) were performed by two researchers. PRISMA reporting standards were followed, and registration (PROSPERO CRD42020159162, version 19 July 2022) was performed. No funding has been obtained.

Results

The literature search identified 5029 citations. After removing 512 duplicates, reviewing the titles and abstracts of the remaining articles yielded 103 articles for full-text review. Hand-searching identified 3 more studies for full-text review. Of these, 29 studies were included in the final analysis. No clinical studies involving patients were identified. The review was limited to indirect evidence from simulation studies only. The results are presented in five different populations: healthcare professionals managing simulated resuscitations in neonates, children, adult advanced life support, and other emergencies; as well as lay providers managing resuscitations. Main outcomes were adherence to protocol or process, adherence to protocol or process assessed by performance score, CPR performance and retention, and feasibility of chatbot guidance. The risk of bias assessment ranged from low to high. Studies in neonatal, paediatric and adult life support delivered by healthcare professionals showed benefits of using cognitive aids, however, some studies evaluating resuscitations by lay providers reported undesirable effects. The performance of a meta-analysis was not possible due to significant methodological heterogeneity. The certainty of evidence was rated as moderate to very low due to serious indirectness, (very) serious risk of bias, serious inconsistency and (very) serious imprecision.

Conclusion

Because of the very low certainty evidence from simulation studies, we suggest that cognitive aids should be used by healthcare professionals during resuscitation. In contrast, we do not suggest use of cognitive aids for lay providers, based on low certainty evidence.

Good outcome prediction after out-of-hospital cardiac arrest: A prospective multicenter observational study in Korea (the KORHN-PRO registry)

AIM

To assess the ability of clinical examination, biomarkers, electrophysiology and brain imaging, individually or in combination to predict good neurological outcomes at 6 months after CA.

METHODS

This was a retrospective analysis of the Korean Hypothermia Network Prospective Registry 1.0, which included adult out-of-hospital cardiac arrest (OHCA) patients (≥18 years). Good outcome predictors were defined as both pupillary light reflex (PLR) and corneal reflex (CR) at admission, Glasgow Coma Scale Motor score (GCS-M) >3 at admission, neuron-specific enolase (NSE) <17 µg/L at 24-72 h, a median nerve somatosensory evoked potential (SSEP) N20/P25 amplitude >4 µV, continuous background without discharges on electroencephalogram (EEG), and absence of anoxic injury on brain CT and diffusion-weighted imaging (DWI).

RESULTS

A total of 1327 subjects were included in the final analysis, and their median age was 59 years; among them, 412 subjects had a good neurological outcome at 6 months. GCS-M >3 at admission had the highest specificity of 96.7% (95% CI 95.3-97.8), and normal brain DWI had the highest sensitivity of 96.3% (95% CI 92.9-98.4). When the two predictors were combined, the sensitivities tended to decrease (ranging from 2.7-81.1%), and the specificities tended to increase, ranging from81.3-100%. Through the explorative variation of the 2021 European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) prognostication strategy algorithms, good outcomes were predicted, with a specificity of 83.2% and a sensitivity of 83.5% in patients by the algorithm.

CONCLUSIONS

Clinical examination, biomarker, electrophysiology, and brain imaging predicted good outcomes at 6 months after CA. When the two predictors were combined, the specificity further improved. With the 2021 ERC/ESICM guidelines, the number of indeterminate patients and the uncertainty of prognostication can be reduced by using a good outcome prediction algorithm.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) during cardiac resuscitation increased cerebral perfusion to occurrence of cardiopulmonary resuscitation-induced consciousness, a case report

Consciousness or signs of life may be seen during cardiopulmonary resuscitation (CPR), without return of spontaneous circulation. Such CPR-induced consciousness includes breathing efforts, eye opening, movements of extremities or communication with the rescuers. The consciousness may be CPR-interfering or non-interfering, and typically ends when the resuscitation efforts end. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potential adjunct treatment to CPR and may increase the arterial blood pressure. We present a case where REBOA increased the arterial blood pressure to the extent that CPR-induced consciousness was seen.

Efficiency of two-member crews in delivering prehospital advanced life support cardiopulmonary resuscitation: A scoping review

Background

Advanced Life Support (ALS) during cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) is frequently administered by two-member crews. However, ALS CPR is mostly designed for larger crews, and the feasibility and efficacy of implementing ALS guidelines for only two rescuers remain unclear.

Objective

This scoping review aims to examine the existing evidence and identify knowledge gaps in the efficiency of pre-hospital ALS CPR performed by two-member teams.

Design

A comprehensive search was undertaken across the following databases: PubMed, Web of Science, SCOPUS, Cochrane Library Trials, and ClinicalTrials.gov. The search covered publications in English or German from January 1, 2005, to November 30, 2023. The review included studies that focused on ALS CPR procedures carried out by two-member teams in adult patients in either simulated or clinical settings.

Results

A total of 22 articles were included in the qualitative synthesis. Seven topics in two-person prehospital ALS/CPR delivery were identified: 1) effect of team configuration on clinical outcome and CPR quality, 2) early airway management and ventilation techniques, 3) mechanical chest compressions, 4) prefilled syringes, 5) additional equipment, 6) adaptation of recommended ALS/CPR protocols, and 7) human factors.

Conclusion

There is a lack of comprehensive data regarding the adaptation of the recommended ALS algorithm in CPR for two-member crews. Although simulation studies indicate potential benefits arising from the employment of mechanical chest compression devices, prefilled syringes, and automation-assisted protocols, the current evidence is too limited to support specific modifications to existing guidelines.

Randomized controlled trials in resuscitation

Randomized controlled trials (RCTs) are a gold standard in research and crucial to our understanding of resuscitation science. Many trials in resuscitation have had neutral findings, questioning which treatments are effective in cardiac resuscitation. While it is possible than many interventions do not improve patient outcomes, it is also possible that the large proportion of neutral findings are partially due to design limitations. RCTs can be challenging to implement, and require extensive resources, time, and funding. In addition, conducting RCTs in the out-of-hospital setting provides unique challenges that must be considered for a successful trial. This article will outline many important aspects of conducting trials in resuscitation in the out-of-hospital setting including patient and outcome selection, trial design, and statistical analysis.

Prehospital anaesthesiologists experience with cardiopulmonary resuscitation-induced consciousness in Norway - A national cross-sectional survey

Background

During cardiopulmonary resuscitation (CPR) cerebral blood flow may be sufficient to restore some cerebral function, and CPR-induced consciousness (CPRIC) may occur. CPRIC includes signs of life such as gasping, breathing efforts, eye opening, movements of extremities or communication with the rescuers. There is a lack in evidence for prevalence, experience, and possible treatment strategies for CPRIC. This survey aimed to assess prehospital anaesthesiologists experience with CPRIC in Norway.

Methods

A web-based cross-sectional survey. All physicians working at a Norwegian air ambulance, search-and-rescue base or physician-staffed rapid response car were invited to participate.

Result

Out of 177 invited, 115 responded. All were anaesthesiologist, with mean 12.7 (SD 7.2) years of prehospital experience, and 25% had attended more than 200 out-of-hospital cardiac arrests (OHCA). CPRIC was known amongst most physicians prior to the survey and experienced by 91%. Mechanical compression device was used in 79% of cases. The CPRIC were CPR-interfering in 31% of cases. Next-of-kin reported the CPRIC as upsetting in 5% of cases. Medication and/or physical restraint were administered in 75% patients. For patients with CPRIC 50% answered that sedation was needed. If sedation should be provided, 62% answered that this should only be performed by a physician, while 25% answered that both ambulance crew and physicians could provide sedation. Fentanyl, ketamine, and midazolam were suggested as the most appropriate sedation agents.

Conclusion

This nationwide survey indicates that CPRIC during OHCA are well known amongst prehospital anaesthesiologist in Norway. Most patients with CPRIC were treated with chest compression device. Most physicians recommend sedation of patients with CPRIC during resuscitation.

Drone-Facilitated Real-Time Video-Guided Feedback Helps to Improve the Quality of Lay Bystander Basic Life Support. A Randomized Controlled Simulation Trial

OBJECTIVES

Telephone instructions are commonly used to improve cardiopulmonary resuscitation (CPR) by lay bystanders. This usually implies an audio but no visual connection between the provider and the emergency medical telecommunicator. We aimed to investigate whether video-guided feedback via a camera drone enhances the quality of CPR.

METHODS

We conducted a randomized controlled simulation trial. Lay rescuers performed 8 min of CPR on an objective feedback manikin. Participants were randomized to receive telephone instructions with (intervention group) or without (control group) a drone providing a visual connection with the telecommunicator after a 2-min run-in phase. Performed work (total compression depth minus total lean depth) was the primary outcome. Secondary outcomes were the proportion of effective chest compressions, average compression depth, subjective physical strain measured every 2 min, and dexterity in the nine-hole peg test after the scenario. Outcomes were compared using the t- and Mann Whitney-U tests. A two-sided p-value of <0.05 was considered significant.

RESULTS

We included 27 individuals (14 (52%) female, mean age 41 ± 14 years). Performed work was greater in the intervention than in the control group (41.3 ± 7.0 vs. 33.9 ± 10.9 m; absolute difference 7.5, 95% CI 1.4 to 14.8; p = 0.046), with higher average compression depth (49 ± 7 vs. 40 ± 13 mm; p = 0.041), and higher proportions of adequate chest compressions (43 (IQR 14-60) vs. 3 (0-29) %; p = 0.041). We did not find any significant differences regarding the remaining secondary outcomes.

CONCLUSION

Video-guided feedback via drones might be a helpful tool to enhance the quality of telephone-assisted CPR in lay bystanders.

Advanced life support interventions during intra-operative cardiac arrest among adults as reported to the 7th National Audit Project of the Royal College of Anaesthetists

BACKGROUND

Few existing resuscitation guidelines include specific reference to intra-operative cardiac arrest, but its optimal treatment is likely to require some adaptation of standard protocols.

METHODS

We analysed data from the 7th National Audit Project of the Royal College of Anaesthetists to determine the incidence and outcome from intra-operative cardiac arrest and to summarise the advanced life support interventions reported as being used by anaesthetists.

RESULTS

In the baseline survey, > 50% of anaesthetists responded that they would start chest compressions when the non-invasive systolic pressure was < 40-50 mmHg. Of the 881 registry patients, 548 were adult patients (aged > 18 years) having non-obstetric procedures under the care of an anaesthetist, and who had arrested during anaesthesia (from induction to emergence). Sustained return of spontaneous circulation was achieved in 425 (78%) patients and 338 (62%) were alive at the time of reporting. In the 365 patients with pulseless electrical activity or bradycardia, adrenaline was given as a 1 mg bolus in 237 (65%). A precordial thump was used in 14 (3%) patients, and although this was associated with return of spontaneous circulation at the next rhythm check in almost three-quarters of patients, in only one of these was the initial rhythm shockable. Calcium (gluconate or chloride) and 8.4% sodium bicarbonate were given to 51 (9%) and 25 (5%) patients, but there were specific indications for these treatments in less than half of the patients. A thrombolytic drug was given to 5 (1%) patients, and extracorporeal cardiopulmonary resuscitation was used in 9 (2%) of which eight occurred during cardiac procedures.

CONCLUSIONS

The specific characteristics of intra-operative cardiac arrest imply that its optimal treatment requires modifications to standard advanced life support guidelines.

The Year in Electrophysiology: Selected Highlights From 2023

This special article is a continuation of an annual series for the Journal of Cardiothoracic and Vascular Anesthesia, highlighting the latest developments in the field of electrophysiology, particularly concerning cardiac anesthesiologists. The selected topics in the specialty for 2023 include consensus statements on left atrial appendage closure, outcomes in patients with atrial fibrillation and heart failure after ablation, further developments in the field of pulse field ablation, alternate defibrillation strategies for refractory ventricular fibrillation, updates on conduction system pacing, new devices such as the Aurora EV system and AVEIR leadless pacemaker system, artificial intelligence and its use in electrocardiogram-based diagnosis and latest evidence regarding the impact of anesthetic techniques on patient outcomes undergoing electrophysiology procedures.

Effects of cardiopulmonary resuscitation training on mortality rates after out-of-hospital cardiac arrest: protocol for a systematic review and meta-analysis

INTRODUCTION

An out-of-hospital cardiac arrest occurs at a rate of 67-170 cases per 100 000 inhabitants per year in Europe. The early recognition of the occurrence of a cardiac arrest, placing an emergency call, performing cardiopulmonary resuscitation (CPR) and performing defibrillation are the most important response measures. The objective of this systematic review and meta-analysis is to assess the effects of laypersons' CPR training with respect to CPR initiation rates, cardiovascular mortality rates, survival rate and the use of an automated external defibrillator.

METHODS AND ANALYSIS

The literature search will be performed in the following databases: MEDLINE, Web of Science, the Cochrane Central Register of Controlled Studies, CINAHL, HBI, TESEO and NTX. Intervention studies and quasi-experimental studies in which CPR training interventions were performed will be included. We will exclude studies in which the participants do not meet the inclusion criteria, without a control group and in which the methodology of the intervention applied is unclear. There will be no restrictions on publication date or language of publication. The risk of bias will be assessed using the Risk of Bias in Non-randomized Studies of Interventions tool for randomised controlled trials (RCT), non-RCT and quasi-experimental trials. Data analysis and synthesis will be performed using RevMan V.5.4.1 software. The findings will be reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance.

ETHICS AND DISSEMINATION

Ethical approval is not required, as only secondary data will be used. The findings will be published in a journal and presented at conferences.

PROSPERO REGISTRATION NUMBER

CRD42022365288.

Neurological outcomes and quality of life in post-cardiac arrest patients with return of spontaneous circulation supported by ECMO: A retrospective case series

Post-cardiac arrest brain injury constitutes a significant contributor to morbidity and mortality, leading to cognitive impairment and subsequent disability. Individuals within this patient cohort grapple with uncertainty regarding the potential advantages of extracorporeal life support (ECMO) cannulation. This study elucidates the neurological outcomes and quality of life of post-cardiac arrest patients who attained spontaneous circulation and underwent ECMO cannulation. This is a retrospective case study within a local context, the research involved 32 patients who received ECMO support following an intrahospital cardiac arrest with return of spontaneous circulation (ROSC). An additional 32 patients experienced cardiac arrest with ROSC before undergoing cannulation. The average age was 41 years, with the primary causes of cardiac arrest identified as acute coronary syndrome (46.8%), pulmonary thromboembolism (21.88%), and hypoxemia (18.7%). The most prevalent arrest rhythm was asystole (37.5%), followed by ventricular fibrillation (34.4%). The mean SOFA score was 7 points (IQR 6.5-9), APACHE II score was 12 (IQR 9-16), RESP score was -1 (IQR -1 to -4) in cases of respiratory ECMO, and SAVE score was -3 (IQR -5 to 2) in cases of cardiac ECMO. Overall survival was 71%, and at 6 months, the Barthel score was 75 points, modified Rankin score was 2, cerebral performance categories score was 1, and the SF-12 had an average score of 30. Notably, there were no significant associations between the time, cause, or rhythm of cardiac arrest and neurological outcomes. Importantly, cardiac arrest is not a contraindication for ECMO cannulation. A meticulous assessment of candidates who have achieved spontaneous circulation after cardiac arrest, considering the absence of early signs of poor neurological prognosis, is crucial in patient selection. Larger prospective studies are warranted to validate and extend these findings.

Assessing the influence of abdominal compression on time to return of circulation during resuscitation of asphyxiated newborn lambs: a randomised preclinical study

OBJECTIVE

During neonatal resuscitation, the return of spontaneous circulation (ROSC) can be achieved using epinephrine which optimises coronary perfusion by increasing diastolic pressure. Abdominal compression (AC) applied during resuscitation could potentially increase diastolic pressure and therefore help achieve ROSC. We assessed the use of AC during resuscitation of asystolic newborn lambs, with and without epinephrine.

METHODS

Near-term fetal lambs were instrumented for physiological monitoring and after delivery, asphyxiated until asystole. Resuscitation was commenced with ventilation followed by chest compressions. Lambs were randomly allocated to: intravenous epinephrine (20 µg/kg, n=9), intravenous epinephrine+continuous AC (n=8), intravenous saline placebo (5 mL/kg, n=6) and intravenous saline+AC (n=9). After three allocated treatment doses, rescue intravenous epinephrine was administered if ROSC had not occurred. Time to achieve ROSC was the primary outcome. Lambs achieving ROSC were ventilated and monitored for 60 min before euthanasia. Brain histology was assessed for micro-haemorrhage.

RESULTS

Use of AC did not influence mean time to achieve ROSC (epinephrine lambs 177 s vs epinephrine+AC lambs 179 s, saline lambs 602 s vs saline+AC lambs 585 s) or rate of ROSC (nine of nine lambs, eight of eight lambs, one of six lambs and two of eight lambs, respectively). Application of AC was associated with higher diastolic blood pressure (mean value >10 mm Hg), mean and systolic blood pressure and carotid blood flow during resuscitation. Cortex and deep grey matter micro-haemorrhage was more frequent in AC lambs.

CONCLUSION

Use of AC during resuscitation increased diastolic blood pressure, but did not impact time to ROSC.