Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study

Aims

Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.

Methods and results

We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002).

Conclusions

In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.

[Leg ischemia complicating the intraosseous infusion of epinephrine for a Djiboutian child]

Intraosseous infusion is increasingly used as an alternative to intravenous infusion. It is recommended for the cardiac arrest of a child in the first instance and after two failed attempts of intravenous infusion in the cardiac arrest of adults. Its rapid use and its low failure rate justify its use in all life-threatening emergencies. It can be used to administer the same treatments as intravenous infusion. It does, nonetheless, present some rare complications, such as acute leg ischemia by extravasation of epinephrine, as we report here. Awareness of these complications is necessary to ensure compliance with the rules of placing this type of infusion.

Auscultation in flight: comparison of conventional and electronic stethoscopes

OBJECTIVES

The ability to auscultate during air medical transport is compromised by high ambient-noise levels. The aim of this study was to assess the capabilities of a traditional and an electronic stethoscope (which is expected to amplify sounds and reduce ambient noise) to assess heart and breath sounds during medical transport in a Boeing C135.

METHODS

We tested one model of a traditional stethoscope (3MTM Littmann Cardiology IIITM) and one model of an electronic stethoscope (3MTM Littmann Stethoscope Model 3000). We studied heart and lung auscultation during real medical evacuations aboard a medically configured C135. For each device, the quality of auscultation was described using a visual rating scale (ranging from 0 to 100 mm, 0 corresponding to "I hear nothing," 100 to "I hear perfectly"). Comparisons were accomplished using a t-test for paired values.

RESULTS

A total of 36 comparative evaluations were performed. For cardiac auscultation, the value of the visual rating scale was 53 ± 24 and 85 ± 11 mm, respectively, for the traditional and electronic stethoscope (paired t-test: P = .0024). For lung sounds, quality of auscultation was estimated at 27 ± 17 mm for traditional stethoscope and 68 ± 13 for electronic stethoscope (paired t-test: P = .0003). The electronic stethoscope was considered to be better than the standard model for hearing heart and lung sounds.

CONCLUSION

Flight practitioners involved in air medical evacuation in the C135 aircraft are better able to practice auscultation with this electronic stethoscope than with a traditional one.

Acid aspiration prophylaxis in obstetrics in France: a comparative survey of 1998 vs. 1988 French practice

BACKGROUND AND OBJECTIVE

To survey French anaesthetic practice regarding acid aspiration prophylaxis and compare it with an earlier survey.

METHODS

A confidential questionnaire was sent to all 800 maternity units in France to assess three major topics: (a) drugs used for pharmacological prophylaxis; (b) regional anaesthesia for labour and Caesarean section and (c) techniques used for general anaesthesia and endotracheal intubation.

RESULTS

Two-hundred-and-two units responded. Pharmacological prophylaxis was regularly used for labouring women in 78% of the responding units in 1998 (compared with 63% in 1988, P < 0.05). Antacid drug use before Caesarean section had increased from 75% in 1988 to 97% in 1998 (P < 0.05). General anaesthesia was used for Caesarean section by less than 2% of responding units (vs. 21% in 1988, P < 0.05). In contrast, there was little change in the use of endotracheal intubation for instrumental delivery (53% vs. 50%) or manual removal of the placenta (15% vs. 16%) between 1988 and 1998. The use of cricoid pressure increased significantly during the 10 yr period (50% vs. 88%, P < 0.05) and the technique was correctly described by 80% of the responding units (vs. 50%, P < 0.05). Similarly, the use of succinylcholine increased significantly from 25% (1988) to 479 (1998) (P < 0.05).

CONCLUSIONS

There was a significant overall improvement of French practice regarding acid aspiration prophylaxis in obstetrics. However, the complete prophylaxis strategy is still not used in every patient emphasizing the need for continuing medical education.

Tachycardia and convulsions induced by accidental intravascular ropivacaine injection during sciatic block

Ropivacaine, a recently introduced local anesthetic of the amide family (1), seems to show less toxicity than bupivacaine (2-4). Nevertheless, both neurologic and cardiovascular toxicities are possible. Six cases of ropivacaine-induced convulsions have previously been reported (5-10), of which three cases also showed cardiovascular toxicity. In three cases, total plasma concentrations were measured (Table 1).