Quality of cardiopulmonary resuscitation in out-of-hospital cardiac arrest before and after introduction of a mechanical chest compression device, LUCAS-2; a prospective, observational study

Current animal models of extracorporeal cardiopulmonary resuscitation: A scoping review

Aim

Animal models of Extracorporeal Cardiopulmonary Resuscitation (ECPR) focusing on neurological outcomes are required to further the development of this potentially life-saving technology. The aim of this review is to summarize current animal models of ECPR.

Methods

A comprehensive database search of PubMed, EMBASE, and Web of Science was undertaken. Full-text publications describing animal models of ECPR between January 1, 2000, and June 30, 2022, were identified and included in the review. Data describing the conduct of the animal models of ECPR, measured variables, and outcomes were extracted according to pre-defined definitions.

Results

The search strategy yielded 805 unique reports of which 37 studies were included in the final analysis. Most studies (95%) described using a pig model of ECPR with the remainder (5%) describing a rat model. The most common method for induction of cardiac arrest was a fatal ventricular arrhythmia through electrical stimulation (70%). 10 studies reported neurological assessment of animals using physical examination, serum biomarkers, or electrophysiological findings, however, only two studies described a multimodal assessment. No studies reported the use of brain imaging as part of the neurological assessment. Return of spontaneous circulation was the most reported primary outcome, and no studies described the neurological status of the animal as the primary outcome.

Conclusion

Current animal models of ECPR do not describe clinically relevant neurological outcomes after cardiac arrest. Further work is needed to develop models that more accurately mimic clinical scenarios and can test innovations that can be translated to the application of ECPR in clinical medicine.

Impact of emergency medical service with advanced life support training for adults with out-of-hospital cardiac arrest in the Republic of Korea: A retrospective multicenter study

Prehospital advanced life support (ALS) has been offered in many countries for patients experiencing out-of-hospital cardiac arrest (OHCA); however, its effectiveness remains unclear. This study aimed to determine the impact of emergency medical service (EMS) with ALS training as a nationwide pilot project for adults with OHCA in the Republic of Korea. This retrospective multicenter observational study was conducted between July 2019 and December 2020 using the Korean Cardiac Arrest Research Consortium registry. The patients were categorized into an intervention group that received EMS with ALS training and a control group that did not receive EMS with ALS training. Conditional logistic regression analysis was performed using matched data to compare clinical outcomes between the two groups. Compared with the control group, the intervention group had a lower rate of supraglottic airway usage (60.5% vs. 75.6%) and a higher rate of undergoing endotracheal intubation (21.7% vs. 6.1%, P < 0.001). In addition, the intervention group was administered more intravenous epinephrine (59.8% vs. 14.2%, P < 0.001) and used mechanical chest compression devices more frequently in prehospital settings than the control group (59.0% vs. 23.8%, P < 0.001). Based on the results of multivariable conditional logistic regression analysis, survival to hospital discharge (odds ratio: 0.48, 95% confidence interval: 0.27-0.87) of the intervention group was significantly lower than that of the control group; however, good neurological outcome was not significantly different between the two groups. In this study, survival to hospital discharge was worse in patients with OHCA who received EMS with ALS training than in those who did not.

LUCAS Device Use Associated with Prolonged Pauses during Application and Long Chest Compression Intervals

BACKGROUND

Tenets of high-quality out-of-hospital cardiac arrest (OHCA) resuscitation include early recognition and treatment of shockable rhythms, and minimizing interruptions in compressions. Little is known about how use of a mechanical compression device affects these elements. We hypothesize that use of such a device is associated with prolonged pauses in compressions to apply the device, and long compression intervals overall.

METHODS

We systematically abstracted CPR metrics from 4 months of adult non-traumatic OHCA cases, each of which had at least 10 minutes of resuscitation, used a LUCAS device, and had a valid monitor file attached to the patient care report. Our primary outcomes of interest were the duration of each pause in compressions and the duration of compressions between pauses, stratified by whether or not the LUCAS device was used/applied during the segment. Each pause was further evaluated for a possible associated procedure based on pre-defined criteria. Descriptive statistics, chi-square, and Kruskal-Wallis tests were used as appropriate.

RESULTS

Fifty-eight cases were included, median age 62.5 years (IQR 49.3-70.8), 47% female, 66% nonwhite. Overall, 633 compression-pause segments were analyzed (517 with and 116 without LUCAS applied). Spacing of pauses was significantly longer with the LUCAS than without [median (IQR) 133 (82-213) seconds vs. 38 (18-62) seconds, p < 0.05]. When using a LUCAS, compressions were continuous for at least 3 min in 166/517 segments, at least 4 min in 89/517 segments, and at least 5 min in 56/517 segments. Without a LUCAS, compressions were longer than 3 min in 7/116 segments. Pauses exceeded 10 s more frequently with LUCAS application (32/38) than airway management or defibrillation (27/80, p < 0.05). Peri-LUCAS pauses exceeded 30 s in 6/38 cases.

CONCLUSION

LUCAS use was associated with long compression intervals without identifiable pauses to assess for pulse or cardiac rhythm, and device application was associated with longer pauses than airway management or defibrillation. The clinical significance and effect on patient outcomes remain uncertain and require further study.

Selection of patients for mechanical circulatory support for refractory out-of-hospital cardiac arrest

OBJECTIVE

To describe characteristics of patients admitted with refractory cardiac arrest for possible extracorporeal cardiopulmonary resuscitation (ECPR) and gain insight into the reasons for refraining from treatment in some.

METHODS

Nationwide retrospective cohort study involving all tertiary centres providing ECPR in Denmark. Consecutive patients admitted with ongoing chest compression for evaluation for ECPR treatment were enrolled. Presenting characteristics, duration of no-flow and low-flow time, end-tidal carbon dioxide (ETCO₂), lactate and pH, and recording of reasons for refraining from ECPR documented by the treating team were recorded. Outcomes were survival to intensive care unit admission and survival to hospital discharge.

RESULTS

Of 579 patients admitted with refractory cardiac arrest for possible ECPR, 221 patients (38%) proceeded to ECPR and 358 patients (62%) were not considered candidates. Median prehospital low-flow time was 70 min (IQR 56 to 85) in ECPR patients and 62 min (48 to 81) in no-ECPR patients, p<0.001. Intra-arrest transport was more than 50 km in 92 (42%) ECPR patients and 135 in no-ECPR patients (38%), p=0.25. The leading causes for not initiating ECPR stated by the treating team were duration of low-flow time in 39%, severe metabolic derangement in 35%, and in 31% low ETCO₂. The prevailing combination of contributing factors were non-shockable rhythm, low ETCO₂, and metabolic derangement or prehospital low-flow time combined with low ETCO₂. Survival to discharge was only achieved in six patients (1.7%) in the no-ECPR group.

CONCLUSIONS

In this large nationwide study of patients admitted for possible ECPR, two-thirds of patients were not treated with ECPR. The most frequent reasons to abstain from ECPR were long duration of prehospital low-flow time, metabolic derangement and low ETCO₂.

Suction cup on a piston-based chest compression device improves coronary perfusion pressure and cerebral oxygenation during experimental cardiopulmonary resuscitation

Introduction

The presented study aimed to investigate whether a mechanical chest compression piston device with a suction cup assisting chest recoil could impact the hemodynamic status when compared to a bare piston during cardiopulmonary resuscitation.

Methods

16 piglets were anesthetized and randomized into 2 groups. After 3 minutes of induced ventricular fibrillation, a LUCAS 3 device was used to perform chest compressions, in one group a suction cup was mounted on the device’s piston, while in the other group, compressions were performed by the bare piston. The device was used in 30:2 mode and the animals were manually ventilated. Endpoints of the study were: end tidal carbon dioxide, coronary and cerebral perfusion pressures, and brain oxygenation (measured using near infrared spectroscopy). At the end of the protocol, the animals that got a return to spontaneous circulation were observed for 60 minutes, then euthanized.

Results

No difference was found in end tidal carbon dioxide or tidal volumes. Coronary perfusion pressure and cerebral oxygenation were higher in the Suction cup group over the entire experiment time, while cerebral perfusion pressure was higher only in the last 5 minutes of CPR. A passive tidal volume (air going in and out the airways during compressions) was detected and found correlated to end tidal carbon dioxide.

Conclusions

The use of a suction cup on a piston-based chest compression device did not increase end tidal carbon dioxide, but it was associated to a higher coronary perfusion pressure.

Intra-Cardiac Arrest Transport and Survival from Out-of-Hospital Cardiac Arrest: A Nationwide Observational Study

AIM

To assess whether intra-cardiac arrest transport as compared to continued on-scene resuscitation was associated with improved clinical outcomes among out-of-hospital cardiac arrest patients in Denmark.

METHODS

This was an observational study using data from population-based registries in Denmark. Adults (aged ≥18 to ≤65 years) with an out-of-hospital cardiac arrest attended by Emergency Medical Services (EMS) between 2016 and 2018 were included. The primary outcome was survival to 30 days. Time-dependent propensity score matching was used to match patients transported to the hospital within 20 minutes of EMS arrival to patients with assumed on-scene resuscitation (with or without subsequent intra-cardiac arrest transport) at risk of being transported within the same minute.

RESULTS

The full cohort included 2,873 cardiac arrests. The median age was 56 (quartiles: 48 to 62) years, 1987 (69%) were male, and 104 (4%) were transported within 20 minutes. A total of 87 transported patients were matched to 87 patients at risk of being transported based on the propensity score. Although not reaching statistical significance, in comparison with on-scene resuscitation, intra-cardiac arrest transport was associated with increased survival to 30 days (risk ratio, 1.55; 95%CI, 0.99 to 2.44; P = 0.06). Similar associations were observed for return of spontaneous circulation and survival to one year.

CONCLUSIONS

Among patients aged 18 to 65 years, intra-cardiac arrest transport was associated with a non-significant increase in survival within 20 minutes of EMS on-scene arrival. However, the results did not eliminate the potential for bias and the results should be interpreted carefully.

Manual cardiopulmonary resuscitation versus mechanical cardiopulmonary resuscitation: Which one is more effective during ambulance transport?

OBJECTIVES:

Although studies in the field of emergency medical services (EMS) generally compare survival and hospital discharge rates, there are not many studies measuring the quality of cardiopulmonary resuscitation (CPR). In this study, we aimed to compare the mechanical chest compression device and paramedics in terms of CPR quality.

METHODS:

This is an experimental trial. This study was performed by the EMS of Ankara city (capital of Turkey). Twenty (ten males and ten females) paramedics participated in the study. We used LUCAS™ 2 as a mechanical chest compression device in the study. Paramedics applied chest compression in twenty rounds, whereas mechanical chest compression device applied chest compression in another set of twenty rounds. The depth, rate, and hands-off time of chest compression were measured by means of the model's recording system.

RESULTS:

The median chest compression rate was 120.1 compressions per minute (interquartile range [IQR]: 25%–75% = 117.9–133.5) for the paramedics, whereas it was 102.3 compressions per minute for the mechanical chest compression device (IQR: 25%–75% = 102.1–102.7) (P < 0.001). The median chest compression depth was 38.9 mm (IQR: 25%–75% = 32.9–45.5) for the paramedics, whereas it was 52.7 mm for the mechanical chest compression device (IQR: 25%–75% = 51.8–55.0) (P < 0.001). The median hands-off time during CPR was 6.9% (IQR: 25–75 = 5.0%–10.1%) for the paramedics and 9% for the mechanical chest compression device (IQR: 25%–75% = 8.2%–12.5%) (P = 0.09).

CONCLUSION:

During patient transport, according to the chest compression performed by the health-care professionals, it was found that those performed by the mechanical chest compression device were more suitable than that performed by the guides in terms of both speed and duration.

Impact of automatic chest compression devices in out-of-hospital cardiac arrest

Background

High quality chest compressions (CCs) are of crucial importance during cardio-pulmonary resuscitation (CPR). Currently, there are no clear evidences that the use of automatic chest compression devices (ACCD) are superior to manual CCs during out-of-hospital CPR. This study aimed to estimate if availability of ACCDs for two-man rescue teams had any impact on CPR efficiency and a rate of successful transport of patients after out-of-hospital cardiac arrest (OHCA) to emergency departments.

Methods

The study was designed as a retrospective cohort study. The research tool was the analysis of medical charts of Emergency Medical Service (EMS) in one million agglomeration in Poland in 2018. ACCDs were available for two-man paramedical teams in a half of ambulances and this fact was criterion of group division [ACCD (n=181) and manual CC (MCC) (n=303)]. The following variables such as gender (male/female), age, area of intervention (town/countryside), return of spontaneous circulation (ROSC) followed by successful transport to hospital were compared between subgroups.

Results

Among 71,282 interventions in 2018, there were 484 resuscitations undertaken with complete medical data. ROSC and transport to hospital was achieved in 54.9% of individuals, statistically more often among ACCD subjects (63.5%) than those compressed manually (49.8%) (P=0.003). Moreover, the use of ACCD was associated with higher chances of ROSC in younger patients (P=0.027) and if cardiac arrest had place in the town centre (P=0.002).

Conclusions

Our observation revealed that the use of ACCD in the pre-hospital emergency care involving two-man rescue teams may increase the prevalence of ROSC among OHCA patients.

Resuscitation of the patient with suspected/confirmed COVID-19 when wearing personal protective equipment: A randomized multicenter crossover simulation trial

BACKGROUND

The aim of the study was to evaluate various methods of chest compressions in patients with suspected/confirmed SARS-CoV-2 infection conducted by medical students wearing full personal protective equipment (PPE) for aerosol generating procedures (AGP).

METHODS

This was prospective, randomized, multicenter, single-blinded, crossover simulation trial. Thirty-five medical students after an advanced cardiovascular life support course, which included performing 2-min continuous chest compression scenarios using three methods: (A) manual chest compression (CC), (B) compression with CPRMeter, (C) compression with LifeLine ARM device. During resuscitation they are wearing full personal protective equipment for aerosol generating procedures.

RESULTS

The median chest compression depth using manual CC, CPRMeter and LifeLine ARM varied and amounted to 40 (38-45) vs. 45 (40-50) vs. 51 (50-52) mm, respectively (p = 0.002). The median chest compression rate was 109 (IQR; 102-131) compressions per minute (CPM) for manual CC, 107 (105-127) CPM for CPRMeter, and 102 (101-102) CPM for LifeLine ARM (p = 0.027). The percentage of correct chest recoil was the highest for LifeLine ARM - 100% (95-100), 80% (60-90) in CPRMeter group, and the lowest for manual CC - 29% (26-48).

CONCLUSIONS

According to the results of this simulation trial, automated chest compression devices (ACCD) should be used for chest compression of patients with suspected/confirmed COVID-19. In the absence of ACCD, it seems reasonable to change the cardiopulmonary resuscitation algorithm (in the context of patients with suspected/confirmed COVID-19) by reducing the duration of the cardiopulmonary resuscitation cycle from the current 2-min to 1-min cycles due to a statistically significant reduction in the quality of chest compressions among rescuers wearing PPE AGP.

Tension Hemopneumothorax in the Setting of Mechanical CPR during Prehospital Cardiac Arrest

INTRODUCTION

There are several complications associated with automated mechanical CPR (AM-CPR), including tension pneumothoraces. The incidence of these complications and the risk factors for their development remain poorly characterized. Tension hemopneumothorax is a previously unreported complication of AM-CPR. The authors present a case of a suspected tension hemopneumothorax that developed during the use of an automated mechanical CPR device. Case Description: A 67 year-old woman with a history of COPD and CABG was observed by an off-duty firefighter to be slumped behind the wheel of an ice cream truck that drifted off the road at a low rate of speed and was stopped by a wooden fence, resulting in only minor paint scratches. The patient was found to be in cardiac arrest with a shockable rhythm. No signs of trauma were noted, and equal bilateral breath sounds were present with BVM ventilation. After 13 minutes of manual CPR, fire department personnel applied their Defibtech LifeLine ARM mechanical CPR device to the patient. During resuscitation, the device had to be repositioned twice due to rightward piston migration off of the sternum. Seven minutes after AM-CPR application, the patient had absent right-sided breath sounds and ventilations were more difficult. Needle decompression was performed with an audible release of air. A chest tube was placed by an EMS physician and roughly 400 mL of blood were immediately returned. At the next 2-minute pulse check, ROSC was noted, and the patient was transported to the hospital. She had an ischemic EKG and elevated troponin. Chest CT showed emphysematous lungs, bilateral rib fractures, and a small right-sided pneumothorax. Despite aggressive measures, the patient's condition gradually worsened, and she died 48 hours after presentation. Discussion/Conclusion: Migration of AM-CPR device pistons may contribute to the development of iatrogenic injuries such as hemopneumothoraces. Patients with underlying lung disease may be at a higher risk of developing pneumothoraces or hemopneumothoraces during the course of AM-CPR. Awareness of these potential complications may aid first responders by improving vigilance of piston location and by providing quicker recognition of iatrogenic injuries that need immediate attention to improve the opportunity for ROSC.

Quality Comparison of the Manual Chest Compression and the Mechanical Chest Compression During Difficult Transport Conditions

BACKGROUND

Although there are several studies comparing the quality of manual and mechanical chest compressions, we decided to conduct this study because results of previous studies were not sufficient for us to arrive at a definite conclusion.

OBJECTIVE

In this study, our goal was to evaluate the quality of cardiopulmonary resuscitation (CPR) performed manually and by mechanical chest compression device (MCCD) when removing out-of-hospital cardiac arrest patients from their homes via stairs.

METHODS

A total of 20 paramedics participated in the study. The patient simulator manikin was moved down the stairs while each of 20 paramedics performed chest compressions, then it was moved down the stairs again 20 times while the MCCD performed chest compressions. Compression depth, compression rate, and hands-on times were recorded and the data were compared.

RESULTS

The median chest compression rate was 142.0 compressions/min (interquartile [25^th to 75^th percentile] range [IQR] 134.9-148.7 compressions/min) for the paramedics and 102.3 compressions/min for the MCCD (IQR 102.2-102.5 compressions/min) (p < 0.01). The median chest compression depth was 25.2 mm (IQR 23.2-30.9 mm) for the paramedics and 52.0 mm for the MCCD (IQR 51.4-52.6 mm) (p < 0.001). The rate of hands-on time for chest compressions performed by the paramedic participants was 92.0% (IQR 86.5-100%). Hands-on rate of the MCCD was 100% (p = 0.09).

CONCLUSIONS

In our study, while carrying the patient simulator manikin to the lower floor, it was found that the MCCD achieved high-quality CPR targets recommended by resuscitation guidelines in terms of compression rate, depth, and hands-on-time.

Mechanical chest compression with LUCAS device does not improve clinical outcome in out-of-hospital cardiac arrest patients: A systematic review and meta-analysis

BACKGROUND

Cardiac arrest (CA) is a serious threat to human health. Cardiopulmonary resuscitation (CPR) is an effective treatment for CA. Early and high-quality CPR is closely related to the survival rate of patients with CA. But manual chest compression has a lot of defects. To solve the defects and improve the quality of CPR, mechanical CPR device was invented. However, it has still controversy whether manual chest compression or mechanical chest compression is better. This systematic review was aimed to investigate the difference in clinical outcomes between manual chest compression and Lund University Cardiac Assist System (LUCAS) assisted CPR in patients with out-hospital CA.

METHODS

Original research studies, conducted on adult out-of-hospital CA, were included. PubMed/Medline, EMBASE, Scopus, Cochrane Library, CNKI, and Wanfang database were searched from the setting to February 21, 2019. Odds ratio (OR) with 95% confidence interval (CI) was selected as effect scale index for evaluation of the difference in return of spontaneous circulation (ROSC), survival to hospital admission, survival to hospital discharge, and survival to 30 days. Random effects model was used in this study to estimate overall mean effects.

RESULTS

A total of 6 articles, including 4 randomized controlled trials and 2 nonrandomized controlled trials, were selected. And 8501 subjects were involved to analyze the clinical outcomes of LUCAS and manual chest compression for patients with out-hospital CA. Comparisons of ROSC (33.3% vs 33.0%, P = .98; OR = 1; 95% CI: [0.89,1.13]), survival to hospital admission (22.7% vs 24.3%, P = .32; OR = 0.86; 95% CI: [0.65,1.15]), survival to hospital discharge (8.6% vs 10.7%, P = .50; OR = 0.92; 95% CI: [0.73,1.17]), and survival to 30 days (7.5% vs 8.5%, P = .50; OR = 0.92; 95% CI: [0.73,1.17]) were made. No significant difference was found.

CONCLUSION

The synthesis of available evidence does not support that mechanical chest compression with LUCAS device improves clinical outcome in out-of-hospital CA patients compared with manual chest compression. Large scale studies with improved designs are still needed in the future.

Comparison of in-hospital use of mechanical chest compression devices for out-of-hospital cardiac arrest patients: AUTOPULSE vs LUCAS

This study aimed to investigate the prognostic difference between AUTOPULSE and LUCAS for out-of-hospital cardiac arrest (OHCA) adult patients.A retrospective observational study was performed nationwide. Adult OHCA patients after receiving in-hospital mechanical chest compression from 2012 to 2016 were included. The primary outcomes were sustained return of spontaneous circulation (ROSC) of more than 20 minutes and survival to discharge.Among 142,906 OHCA patients, 820 patients were finally included. In multivariate analysis, female (OR, 0.57; 95% CI, 0.33-0.99), witnessed arrest (OR, 2.10; 95% CI, 1.20-3.69), and arrest cause of non-cardiac origin (OR, 0.25; 95% CI, 0.10-0.62) were significantly associated with the increase in ROSC. LUCAS showed a lower survival than AUTOPULSE (OR, 0.23; 95% CI, 0.06-0.84), although it showed no significant association with ROSC. Percutaneous coronary intervention (OR, 6.30; 95% CI, 1.53-25.95) and target temperature management (TTM; OR, 7.30; 95% CI, 2.27-23.49) were the independent factors for survival. We categorized mechanical CPR recipients by witness to compare prognostic effectiveness of AUTOPULSE and LUCAS. In the witnessed subgroup, female (OR, 0.46; 95% CI, 0.24-0.89) was a prognostic factor for ROSC and shockable rhythm (OR, 5.04; 95% CI, 1.00-25.30), percutaneous coronary intervention (OR, 12.42; 95% CI, 2.04-75.53), and TTM (OR, 9.03; 95% CI, 1.86-43.78) for survival. In the unwitnessed subgroup, no prognostic factors were found for ROSC, and TTM (OR, 99.00; 95% CI, 8.9-1100.62) was found to be an independent factor for survival. LUCAS showed no significant increase in ROSC or survival in comparison with AUTOPULSE in both subgroups.The in-hospital use of LUCAS may have a deleterious effect for survival compared with AUTOPULSE.

An observational study on survival rates of patients with out-of-hospital cardiac arrest in the Netherlands after improving the 'chain of survival'

OBJECTIVES

To evaluate the impact of implemented procedures for out-of-hospital cardiac arrests (OHCAs) by determining patient outcome defined as the percentage return of spontaneous circulation at arrival at the emergency department, and 3-month and 1-year-survival rates.

DESIGN

Observational study.

SETTING

Primary emergency medical care consisting of Advanced Life Support is given by ambulance nurses and secondary care by hospitals within the mid-western part of the Netherlands covering 750 000 inhabitants.

PARTICIPANTS

433 of 500 consecutive patients with OHCA were included in the study over a 1.5 -year period.

OUTCOME MEASURES

Analysis included number of patients with return of spontaneous circulation (ROSC) when handed over to the emergency department, survival at 3 months and 1 year including a comparison with global outcome rates. We further considered the influence of gender, delays, bystander Basic Life Support, use of an automated external defibrillator, initial rhythm and mechanical thorax compression in combination with Boussignac tube ventilation.

RESULTS

13% (67/500) of the initial patient population was excluded from the analysis as reanimation in these patients was aborted due to expressed wish not to be resuscitated. Resuscitation was started by bystanders, police and/or first responders in 312/433 (72%) cases. An automated external defibrillator was used in 198 of these 312 cases (63%) of which it defibrillated 108 times. Mechanical thorax compression in combination with Boussignac tube ventilation was necessary in 277/433 patients (64%). Spontaneous circulation returned in 96/277 (35%) patients of this group. In the overall studied population, ROSC percentage at arrival at the hospital was 214/433 (49%). The 3-month and 12-month-survival rates were 123/433 (28%) and 119/433 (27%), respectively.

CONCLUSIONS

Optimised 'chain of survival' for patients with OHCA resulted in ROSC in 49% of the cases and a 1-year-survival rate of 27% in the studied population.

Cardiovascular risk factors differently affect the survival of patients undergoing manual or mechanical resuscitation

Background

Chest compression is a decisive element of cardio-pulmonary resuscitation (CPR). By applying a mechanical CPR device, compression interruptions can be minimised. We examined the efficiency of manual and device-assisted resuscitation as well as the effects of cardiovascular risk factors on the outcome of resuscitation.

Methods

In our retrospective, randomised 3-year study the data of adult patients suffering non-traumatic, out-of-hospital, sudden cardiac death (SCD) were analysed (n = 287). The data were retrieved by processing case reports, Utstein sheets and acute coronary syndrome sheets. We compared the data of patients undergoing manual (n = 232) and device-assisted resuscitation (LUCAS-2, n = 55). The primary endpoint was the on-site restoration of spontaneous circulation (ROSC).

Results and conclusion

In 37% of the cases ROSC happened. With respect to ROSC an insignificantly more favourable tendency was demonstrated in the case of device-assisted resuscitation (p = 0.072). In the Lucas group, a higher success rate occurred even in the case of prolonged resuscitation. We found a better outcome in the Lucas group in the case of CPR started a longer time after the SCD (p < 0.05). A positive correlation was established between age and unsuccessful resuscitation (p = < 0.017; r = 0.125). An unfavourable correlation was observed between hypertension and the outcome of resuscitation (p = 0.018; r = 0.143). According to our results the presence of left ventricular hypertrophy poses 5.1-fold risk of unsuccessful CPR (CI: 4.97–5.29).

Advanced age and structural heart diseases can play a role in the genesis of SCD. Importantly, left ventricular hypertrophy and hypertension negatively affect survival.

Manual Versus Mechanical Cardiopulmonary Resuscitation: A Case Against the Machine

Cardiopulmonary resuscitation (CPR) quality, including chest compression rate, depth, and fraction of hands-on time, is integral to cardiac arrest survival. Introducing mechanized devices to target these measures of quality in the challenging prehospital environment holds great promise. Comparing mechanical to manual CPR, animal models deliver favorable results on markers of perfusion and manikin studies demonstrate improved consistency of high-quality CPR performance with device use. Factoring in real-world application with prospective randomized human trials; however, repeatedly fails to show improvements in patient-centered outcomes and thus cannot be supported by current scientific evidence.

Controversial Issues: Pro Mechanical Cardiopulmonary Resuscitation

High-quality cardiopulmonary resuscitation, in particular chest compressions, is a key aspect of out-of-hospital cardiac arrest (OHCA) resuscitation. Manual chest compressions remain the standard of care; however, the extrication and transport of patients with OHCA undermine the quality of manual chest compressions and risk the safety of paramedics. Therefore, in circumstances whereby high-quality manual chest compressions are difficult or unsafe, paramedics should consider using a mechanical device. By combining high-quality manual chest compressions and judicious application of mechanical chest compressions, emergency medical service agencies can optimize paramedic safety and patient outcomes.

Chest compression-associated injuries in cardiac arrest patients treated with manual chest compressions versus automated chest compression devices (LUCAS II) - a forensic autopsy-based comparison

The aim of this autopsy study was to investigate chest-compression associated injuries to the trunk in out-of-hospital and in-hospital non-traumatic cardiac arrest patients treated with automated external chest compression devices (ACCD; all with LUCAS II devices) versus exclusive manual chest compressions (mCC). In this retrospective single-center study, all forensic autopsies between 2011 and 2017 were included. Injuries following cardiopulmonary resuscitation (CPR) in patients treated with mCC or ACCD were investigated and statistically compared using a bivariate logistic regression. In the seven-year period with 4433 autopsies, 614 were analyzed following CPR (mCC vs. ACCD: n = 501 vs. n = 113). The presence of any type of trunk injury was correlated with longer resuscitation intervals (30 ± 15 vs. 44 ± 25 min, p < 0.05). In comparison with mCC, treatment with ACCD led to more frequent skin emphysema (5 vs 0%, p = 0.012), pneumothorax (6 vs. 1%, p = 0.008), lung lesions (19 vs. 4%, p = 0.008), hemopericardium (3 vs 1%, p = 0.025) and liver lesions (10 vs. 1%, p = 0.001), all irrespective of confounding aspects. Higher age and longer CPR durations statistically influenced frequency of sternal and rib fractures (p < 0.001). The mean number of fractured ribs did not vary significantly between the groups (6 ± 3 vs. 7 ± 2, p = 0.09). In this cohort with unsuccessful CPR, chest compression-related injuries were more frequent following ACCD application than in the mCC group, but with only minutely increased odds ratios. The severity of injuries did not differ between the groups, and no iatrogenic injury was declared by the forensic pathologist as being fatal. In the clinical routine after successful return of spontaneous circulation a computed tomography scan for CPR-associated injuries is recommended as soon as possible.

Corpuls CPR Generates Higher Mean Arterial Pressure Than LUCAS II in a Pig Model of Cardiac Arrest

According to the European Resuscitation Council guidelines, the use of mechanical chest compression devices is a reasonable alternative in situations where manual chest compression is impractical or compromises provider safety. The aim of this study is to compare the performance of a recently developed chest compression device (Corpuls CPR) with an established system (LUCAS II) in a pig model. Methods. Pigs (n = 5/group) in provoked ventricular fibrillation were left untreated for 5 minutes, after which 15 min of cardiopulmonary resuscitation was performed with chest compressions. After 15 min, defibrillation was performed every 2 min if necessary, and up to 3 doses of adrenaline were given. If there was no return of spontaneous circulation after 25 min, the experiment was terminated. Coronary perfusion pressure, carotid blood flow, end-expiratory CO₂, regional oxygen saturation by near infrared spectroscopy, blood gas, and local organ perfusion with fluorescent labelled microspheres were measured at baseline and during resuscitation. Results. Animals treated with Corpuls CPR had significantly higher mean arterial pressures during resuscitation, along with a detectable trend of greater carotid blood flow and organ perfusion. Conclusion. Chest compressions with the Corpuls CPR device generated significantly higher mean arterial pressures than compressions performed with the LUCAS II device.

Comparison between manual and mechanical chest compressions during resuscitation in a pediatric animal model of asphyxial cardiac arrest

Aims

Chest compressions (CC) during cardiopulmonary resuscitation are not sufficiently effective in many circumstances. Mechanical CC could be more effective than manual CC, but there are no studies comparing both techniques in children. The objective of this study was to compare the effectiveness of manual and mechanical chest compressions with Thumper device in a pediatric cardiac arrest animal model.

Material and methods

An experimental model of asphyxial cardiac arrest (CA) in 50 piglets (mean weight 9.6 kg) was used. Animals were randomized to receive either manual CC or mechanical CC using a pediatric piston chest compressions device (Life-Stat®, Michigan Instruments). Mean arterial pressure (MAP), arterial blood gases and end-tidal CO2 (etCO2) values were measured at 3, 9, 18 and 24 minutes after the beginning of resuscitation.

Results

There were no significant differences in MAP, DAP, arterial blood gases and etCO2 between chest compression techniques during CPR. Survival rate was higher in the manual CC (15 of 30 = 50%) than in the mechanical CC group (3 of 20 = 15%) p = 0.016. In the mechanical CC group there was a non significant higher incidence of haemorrhage through the endotracheal tube (45% vs 20%, p = 0.114).

Conclusions

In a pediatric animal model of cardiac arrest, mechanical piston chest compressions produced lower survival rates than manual chest compressions, without any differences in hemodynamic and respiratory parameters.

Extracorporeal cardiopulmonary resuscitation after out-of-hospital cardiac arrest in a Danish health region

BACKGROUND

Extracorporeal Cardiopulmonary Resuscitation (ECPR) has emerged as a feasible rescue therapy for refractory, normothermic out-of-hospital cardiac arrest (OHCA). Reported survival rates vary and comparison between studies is hampered by heterogeneous study populations, differences in bystander intervention and in pre-hospital emergency service organisation. We aimed to describe the first experiences, treatment details, complications and outcome with ECPR for OHCA in a Danish health region.

METHODS

Retrospective study of adult patients admitted at Aarhus University Hospital, Denmark between 1 January 2011 and 1 July 2015 with witnessed, refractory, normothermic OHCA treated with ECPR. OHCA was managed with pre-hospital advanced airway management and mechanical chest compression during transport. Relevant pre-hospital and in-hospital data were collected with special focus on low-flow time and ECPR duration. Survival to hospital discharge with Cerebral Performance Category (CPC) of 1 and 2 at hospital discharge was the primary endpoint.

RESULTS

Twenty-one patients were included. Median pre-hospital low-flow time was 54 min [range 5-100] and median total low-flow time was 121 min [range 55-192]. Seven patients survived (33%). Survivors had a CPC score of 1 or 2 at hospital discharge. Five survivors had a shockable initial rhythm. In all survivors coronary occlusion was the presumed cause of cardiac arrest.

CONCLUSION

Extracorporeal cardiopulmonary resuscitation is feasible as a rescue therapy in normothermic refractory OHCA in highly selected patients. Low-flow time was longer than previously reported. Survival with favourable neurological outcome is possible despite prolonged low-flow duration.

CPR using the lifeline ARM mechanical chest compression device: a randomized, crossover, manikin trial

INTRODUCTION

European Resuscitation Council as well as American Heart Association guidelines for cardiopulmonary resuscitation (CPR) stress the importance of uninterrupted and effective chest compressions (CCs). Manual CPR decreases in quality of CCs over time because of fatigue which impacts outcome. We report the first study with the Lifeline ARM automated CC device for providing uninterrupted CCs.

METHODS

Seventy-eight paramedics participated in this randomized, crossover, manikin trial. We compared the fraction of effective CCs between manual CPR and automated CPR using the ARM.

RESULTS

Using the ARM during resuscitation resulted in a higher percentage of effective CCs (100/min [interquartile range, 99-100]) compared with manual CCs (43/min [interquartile range, 39-46]; P<.001). The number of effective CCs decreased less over time with the ARM (P<.001), more often reached the required depth of 5 cm (97% vs 63%, P<.001), and more often reached the recommended CC rate (P<.001). The median tidal volume was higher and hands-off time was lower when using the ARM.

CONCLUSION

Mechanical CCs in our study adhere more closely to current guidelines than manual CCs. The Lifeline ARM provides more effective CCs, more ventilation time and minute volume, less hands-off time, and less decrease in effective CCs over time compared with manual Basic Life Support and might therefore impact outcome.

Ruptured subcapsular liver haematoma following mechanically-assisted cardiopulmonary resuscitation

A 64-year-old man with a history of ascending aortic surgery and pulmonary embolus presented with shortness of breath. He rapidly decompensated, prompting intubation, after which he lost pulses. Manual resuscitation was initiated immediately, with subsequent use of a LUCAS-2 mechanical compression device. The patient was given bolus thrombolytic therapy and regained pulses after 7 min of CPR. Compressions were reinitiated with the LUCAS-2 twice more during resuscitation over the subsequent hour for brief episodes of PEA. After confirmation of massive pulmonary embolism on CT, the patient underwent interventional radiology-guided ultrasonic catheter placement with local thrombolytic therapy and experienced immediate improvement in oxygenation. He later developed abdominal compartment syndrome, despite cessation of thrombolytic and anticoagulation therapy. Bedside exploratory abdominal laparotomy revealed a ruptured subcapsular haematoma of the liver. The patient's haemodynamics improved following surgery and he was extubated 11 days postarrest with intact neurological function.