Mechanical versus manual chest compressions for cardiac arrest

Factors analysis of lower probability of receiving bystander CPR in females: a web-based survey

BACKGROUND

Women are less likely to receive bystander cardiopulmonary resuscitation (CPR) during out-of-hospital cardiac arrest (OHCA) compared to men. This study aims to identify the factors influencing the willingness to perform CPR on women, providing insights to improve training and public awareness.

METHODS

A cross-sectional web-based survey was conducted among medical and non-medical populations in southeastern China. The questionnaire assessed demographics, CPR training experience, and attitudes toward gender-related CPR concerns. A total of 450 responses were collected, with 433 valid responses included after quality control. Statistical analyses were performed using R4.3.2 to evaluate the impact of gender, age, occupation, and education on CPR willingness.

RESULTS

Women exhibited a higher willingness to perform CPR on female victims compared to men. Many male respondents hesitated due to concerns about physical contact, particularly regarding removing clothing during resuscitation. Younger individuals (18-35 and 36-50 years) showed greater willingness to provide CPR than older respondents (51-75 years), who were more cautious due to privacy concerns and traditional beliefs. Healthcare professionals and non-medical workers were more likely to perform CPR than medical students, who, despite receiving CPR training, expressed hesitation due to a lack of confidence and practical experience. Higher education levels were associated with increased willingness to perform CPR on women, with postgraduate respondents being the most willing. Additionally, most participants had never practiced on female CPR mannequins, despite widespread support-especially among women-for incorporating female models into training.

CONCLUSION

The lower likelihood of women receiving CPR is influenced by gender bias, societal norms, and training limitations. Addressing this issue requires public education to eliminate gender-based hesitation, improvements in CPR training programs to include female mannequins, and enhanced legal protections to reduce rescuer concerns. These measures can be combined with other key factors such as community-wide CPR training programs and increasing the availability of automated external defibrillators (AEDs) to help promote equity in access to life-saving interventions. Targeted interventions can promote gender equity in emergency response, ultimately improving survival outcomes for women.

Cardiothoracic injuries and mechanical cardiopulmonary resuscitation - A forensic autopsy convenience control study on 436 cases

This study documents the types and frequencies of injuries related to chest compressions during resuscitation attempts in a cohort of 436 non-traumatic, forensic autopsy cases from Eastern Denmark. We hypothesized that there would be a difference in types and frequencies of injuries seen after mechanical cardiopulmonary resuscitation (mCPR) compared to manual basic life support (BLS). We included all non-traumatic deaths referred for a forensic autopsy in eastern Denmark in the period 2015-2017, for a total of 436 cases (females, n = 146; males, n = 290), of which 75 cases had mCPR performed. Data on injuries were obtained from forensic autopsy reports. The mCPR group was characterized by a statistically significantly higher incidence of myocardial rupture (4 % vs. 0 %, p < 0.0001). We found no other statistically significant differences in the incidence of visceral trauma (e.g. haemothorax, pericardial haemorrhage, pulmonary contusions, liver or spleen injuries) between the two groups. In addition, characteristic injuries recorded in both groups included a high frequency of multiple rib fractures in the upper and middle parts of the rib cage, primarily located anteriorly, as well as sternum fractures, but these findings occurred almost twice as much in the mCPR group (77.3 % vs. 46.8 %, p < 0.0001).

Mechanical chest compression increases intrathoracic hemorrhage complications in patients receiving extracorporeal cardiopulmonary resuscitation

Background

Mechanical cardiopulmonary resuscitation (CPR) devices address the limitations of manual CPR, but their impact on intrathoracic injuries during extracorporeal CPR (ECPR) remains unclear. This study investigated the relationship between mechanical CPR and severe intrathoracic hemorrhage during ECPR compared to manual CPR.

Methods

We conducted a single-center retrospective study of consecutive patients who underwent ECPR from April 2017 to March 2024 according to a standard institutional protocol. Patients were divided into a mechanical CPR group (piston-driven compressions before veno-arterial extracorporeal membrane oxygenation [VA-ECMO]) and a manual CPR group. The primary outcome was intrathoracic hemorrhage requiring transcatheter arterial embolization (TAE). Secondary outcomes included other intrathoracic injuries and 180-day survival.

Results

A total of 91 patients were enrolled (mechanical n = 48, manual n = 43). Intrathoracic hemorrhage requiring TAE occurred more frequently in the mechanical CPR group (18.8% vs. 2.3%, p = 0.030). On multivariate analysis, mechanical CPR was independently associated with this outcome (adjusted odds ratio 6.29; 95% confidence interval 1.20-65.10). In the mechanical group, older age and larger thoracic transverse diameter were significantly related to intrathoracic hemorrhage requiring TAE. Mediastinal hematoma (18.8% vs. 2.3%, p = 0.030) and hemothorax (20.8% vs. 4.7%, p = 0.049) were also more frequent in the mechanical group. The 180-day survival rates did not differ significantly between groups (27.7% vs. 25.0%, log-rank p = 0.540).

Conclusions

Mechanical CPR during ECPR is associated with an increased risk of severe intrathoracic hemorrhage. While mechanical CPR devices may provide benefits in certain scenarios, clinicians should carefully consider individual patient characteristics and closely monitor for complications.

Left of sternum compressions are associated with higher systolic blood pressure than lower half of sternum compressions in cardiac arrest

INTRODUCTION

Limited evidence supports guidelines to perform chest compressions at the lower half of the sternum. Imaging studies suggest this location may obstruct blood flow. Our primary aim was to compare the highest arterial line systolic blood pressure (SBP) during lower-half-of-sternum chest compressions (CC) versus those left-of-sternum, where the left ventricle is more likely located. Secondarily, we compared the highest end-tidal CO2 (ETCO2).

METHODS

We conducted a retrospective cohort study of video-recorded, adult Emergency Department (ED) cardiac arrest resuscitations where changes in CC location were attempted to improve physiologic parameters (SBP, ETCO2). We excluded epigastric and right-of-sternum compressions. Four CC zones were analyzed: recommended lower-half-of-sternum; left of lower-half-of-sternum; high left lateral; low left lateral. We combined all left-of-sternum compressions for analysis using linear mixed-effects models and multivariable mixed-effects controlling for manual vs. mechanical CCs.

RESULTS

Among 24 patients analyzed, 20 (83.3 %) had initial compressions at the lower-half-of-sternum. 11 patients had 28 lower-half-of-sternum and 32 left-of-sternum CC intervals with available SBPs. In the mixed-effects model, least squares mean (LSMean) SBP was higher with left-of-sternum CCs (108.5 mmHg [95 % CI 88.3-128.8 mmHg]) versus lower-half-of-sternum CCs (66.7 mmHg [95 % CI 46.5-86.9 mmHg], p < 0.001). 18 patients had 44 lower-half-of-sternum and 32 left-of-sternum CC intervals with available ETCO2. In the mixed-effects model, LSMean ETCO2 was similar at the lower-half-of-sternum (20.4 mmHg [95 % CI 16.0-24.9 mmHg]) and left-of-sternum (22.6 mmHg [95 % CI 17.6-27.6 mmHg], p = 0.300). Results were similar when controlling for manual vs. mechanical CCs.

CONCLUSIONS

In our pilot, retrospective, observational study of select ED cardiac arrest patients, left-of-sternum chest compressions are associated with higher SBP than lower-half-of-sternum compressions, while ETCO2 was similar.

Efficacy of mechanical against manual method in cardiopulmonary resuscitation for out‑of‑hospital cardiac arrest: A meta‑analysis

Out-of-hospital cardiac arrest (OHCA) remains a leading cause of mortality worldwide, with the efficacy of cardiopulmonary resuscitation (CPR) methods playing a crucial role in patient outcomes. The present study aimed to compare the effectiveness of mechanical and manual CPR in OHCA, focusing on three outcomes: Return of spontaneous circulation (ROSC), survival to admission and survival till discharge. A comprehensive meta-analysis was conducted, incorporating 39 studies for ROSC, 28 for survival to admission, and 30 for survival till discharge, totalling 144,430, 130,499 and 162,088 participants, respectively. The quality of evidence was evaluated using the GRADE approach, assessing risk of bias, inconsistency, indirectness, imprecision and publication bias. Statistical analysis included pooled odds ratios (ORs) with 95% confidence intervals (CIs) and sensitivity analyses. For ROSC, the pooled OR was 1.09 (95% CI: 0.92-1.29), demonstrating no significant difference between mechanical and manual CPR. Survival to admission favoured mechanical CPR with a pooled OR of 1.25 (95% CI: 1.09-1.43). No conclusive difference was found for survival till discharge, with a pooled OR of 0.79 (95% CI: 0.61-1.02). Substantial heterogeneity was observed across outcomes. Evidence of potential publication bias was noted, particularly in the survival to admission outcome. The overall quality of evidence was graded as very low, mainly due to high heterogeneity and indirectness of evidence. The study suggests that mechanical CPR may improve short-term outcomes such as survival to admission in patients with OHCA but does not demonstrate a significant long-term survival benefit over manual CPR.

Early prehospital mechanical cardiopulmonary resuscitation use for out-of-hospital cardiac arrest: an observational study

BACKGROUND

The use of mechanical cardiopulmonary resuscitation device has been very prevalent in out-of-hospital cardiac arrest rescue. This study aimed to investigate whether the timing of mechanical cardiopulmonary resuscitation device set-up correlated with the the outcome of cardiac arrest patients.

METHODS

We retrospectively reviewed adult nontrauma cardiac arrest cases in New Taipei City, Taiwan, from January to December 2022. Demographic data, intervention-related factors, and the time variables of mechanical cardiopulmonary resuscitation were collected. The outcomes included the return of spontaneous circulation and 24-hour survival. We compared patients who achieved spontaneous circulation and those who did not with univariate and multivariable regression analyses.

RESULTS

In total, 1680 patients who received mechanical cardiopulmonary resuscitation were included in the analysis. Reducing the time interval from manual chest compression initiation to device setup was independently associated with the return of spontaneous circulation and 24-hour survival, especially in the subgroup of patients of initial shockable rhythm. Receiver operating characteristic analysis revealed that the outcome of patients with an initial shockable rhythm could be predicted by the mechanical cardiopulmonary resuscitation setup time, with areas under the curve of 60.8% and 63.9% for ROSC and 24-hour survival, respectively. The cutoff point was 395.5 s for patients with an initial shockable rhythm.

CONCLUSION

A positive correlation was found between early mechanical cardiopulmonary resuscitation intervention and the outcomes of out-of-hospital cardiac arrest patients. The time between manual chest compression and device setup could predict the return of spontaneous circulation and 24-hour survival in the subgroup of patients with initially shockable rhythm with the optimal cutoff point at 395.5 s.

Clinicians' experience of barriers and facilitators to care delivery of an extracorporeal cardiopulmonary resuscitation service for out-of-hospital cardiac arrest: a qualitative survey

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) survival in the UK remains overall poor with fewer than 10% of patients surviving to hospital discharge. Extracorporeal cardiopulmonary resuscitation (ECPR) is a developing therapy option that can improve survival in select patients if treatment begins within an hour. Clinicians' perspectives are a pivotal consideration to the development of effective systems for OHCA ECPR, but they have been infrequently explored. This study investigates clinicians' views on the barriers and facilitators to establishing effective systems to facilitate transport of OHCA patients for in-hospital ECPR.

METHODS

In January 2023, Thames Valley Air Ambulance (TVAA) and Harefield Hospital developed an ECPR partnership pathway for conveyance of OHCA patients for in-hospital ECPR. The authors of this study conducted a survey of clinicians across both services looking to identify clear barriers and positive contributors to the effective implementation of the programme. The survey included questions about technical and non-technical barriers and facilitators, with free-text responses analysed thematically.

RESULTS

Responses were received from 14 pre-hospital TVAA critical care and 9 in-hospital clinicians' representative of various roles and experiences. Data analysis revealed 10 key themes and 19 subthemes. The interconnected themes, identified by pre-hospital TVAA critical care clinicians as important barriers or facilitators in this ECPR system included educational programmes; collectiveness in effort and culture; teamwork; inter-service communication; concurrent activity; and clarity of procedures. Themes from in-hospital clinicians' responses were distilled into key considerations focusing on learning and marginal gains, standardising and simplifying protocols, training and simulation; and nurturing effective teams.

CONCLUSION

This study identified several clear themes and subthemes from clinical experience that should be considered when developing and modelling an ECPR system for OHCA. These insights may inform future development of ECPR programmes for OHCA in other centres. Key recommendations identified include prioritising education and training (including regular simulations), standardising a 'pitstop style' handover process, establishing clear roles during the cannulation process and developing standardised protocols and selection criteria. This study also provides insight into the feasibility of using pre-hospital critical care teams for intra-arrest patient retrieval in the pre-hospital arena.

Mechanical versus manual cardiopulmonary resuscitation (CPR): an umbrella review of contemporary systematic reviews and more

BACKGROUND

High-quality cardiopulmonary resuscitation (CPR) can restore spontaneous circulation (ROSC) and neurological function and save lives. We conducted an umbrella review, including previously published systematic reviews (SRs), that compared mechanical and manual CPR; after that, we performed a new SR of the original studies that were not included after the last published SR to provide a panoramic view of the existing evidence on the effectiveness of CPR methods.

METHODS

PubMed, EMBASE, and Medline were searched, including English in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) SRs, and comparing mechanical versus manual CPR. A Measurement Tool to Assess Systematic Reviews (AMSTAR-2) and GRADE were used to assess the quality of included SRs/studies. We included both IHCA and OHCA, which compared mechanical and manual CPR. We analyzed at least one of the outcomes of interest, including ROSC, survival to hospital admission, survival to hospital discharge, 30-day survival, and survival to hospital discharge with good neurological function. Furthermore, subgroup analyses were performed for age, gender, initial rhythm, arrest location, and type of CPR devices.

RESULTS

We identified 249 potentially relevant records, of which 238 were excluded. Eleven SRs were analyzed in the Umbrella review (January 2014-March 2022). Furthermore, for a new, additional SR, we identified eight eligible studies (not included in any prior SR) for an in-depth analysis between April 1, 2021, and February 15, 2024. The higher chances of using mechanical CPR for male patients were significantly observed in three studies. Two studies showed that younger patients received more mechanical treatment than older patients. However, studies did not comment on the outcomes based on the patient's gender or age. Most SRs and studies were of low to moderate quality. The pooled findings did not show the superiority of mechanical compared to manual CPR except in a few selected subgroups.

CONCLUSIONS

Given the significant heterogeneity and methodological limitations of the included studies and SRs, our findings do not provide definitive evidence to support the superiority of mechanical CPR over manual CPR. However, mechanical CPR can serve better where high-quality manual CPR cannot be performed in selected situations.

Early Enteral Nutrition Could Be Associated with Improved Survival Outcome in Cardiac Arrest

Background

Although the latest European and US guidelines recommend that early enteral nutrition (EN) be attempted in critically ill patients, there is still a lack of research on feeding strategies for patients after cardiac arrest (CA). Due to the unique pathophysiology following CA, it remains unknown whether evidence from other diseases can be applied in this condition.

Objective

We aimed to explore the relationship between the timing of EN (within 48 hours or after 48 hours) and clinical outcomes and safety in CA.

Method

From the MIMIC-IV (version 2.2) database, we conducted this retrospective cohort study. A 1 : 1 propensity score matching (PSM) analysis was also conducted to prevent potential interference from confounders. Moreover, adjusted proportional hazards model regression models were used to adjust for prehospital and hospitalization characteristics to verify the independence of the association between early EN initiation and patient outcomes.

Results

Of the initial 1286 patients, 670 were equally assigned to the early EN or delayed EN group after PSM. Patients in the early EN group had improved survival outcomes than those in the delayed EN group within 30 days (HR = 0.779, 95% confidence interval [CI] [0.611-0.994], p = 0.041). Similar results were shown at 90 and 180 days. However, there was no significant difference in neurological outcome between the two groups at 30 days (51% vs. 57%, odds ratio [OR] = 0.786, 95% CI [0.580-1.066], p = 0.070). Patients who underwent early EN had a lower risk of ileus than patients who underwent delayed EN (4% vs. 8%, OR = 0.461, 95% CI [0.233-0.909], p = 0.016). Moreover, patients who underwent early EN had shorter hospital stays.

Conclusion

Early EN could be associated with improved survival outcomes for patients after CA. Further studies are needed to verify it. However, at present, we might consider early EN to be a more suitable feeding strategy for CA.

A smartwatch-based CPR feedback device improves chest compression quality among health care professionals and lay rescuers

Background

Cardiopulmonary resuscitation (CPR) quality significantly impacts patient outcomes during cardiac arrests. With advancements in health care technology, smartwatch-based CPR feedback devices have emerged as potential tools to enhance CPR delivery.

Objective

This study evaluated a novel smartwatch-based CPR feedback device in enhancing chest compression quality among health care professionals and lay rescuers.

Methods

A single-center, open-label, randomized crossover study was conducted with 30 subjects categorized into 3 groups based on rescuer category. The Relay Response BLS smartwatch application was compared to a defibrillator-based feedback device (Zoll OneStep CPR Pads). Following an introduction to the technology, subjects performed chest compressions in 3 modules: baseline unaided, aided by the smartwatch-based feedback device, and aided by the defibrillator-based feedback device. Outcome measures included effectiveness, learnability, and usability.

Results

Across all groups, the smartwatch-based device significantly improved mean compression depth effectiveness (68.4% vs 29.7%; P < .05) and mean rate effectiveness (87.5% vs 30.1%; P < .05), compared to unaided compressions. Compression variability was significantly reduced with the smartwatch-based device (coefficient of variation: 14.9% vs 26.6%), indicating more consistent performance. Fifteen of 20 professional rescuers reached effective compressions using the smartwatch-based device in an average 2.6 seconds. A usability questionnaire revealed strong preference for the smartwatch-based device over the defibrillator-based device.

Conclusion

The smartwatch-based device enhances the quality of CPR delivery by keeping compressions within recommended ranges and reducing performance variability. Its user-friendliness and rapid learnability suggest potential for widespread adoption in both professional and lay rescuer scenarios, contributing positively to CPR training and real-life emergency responses.

Termination of Cardiopulmonary Resuscitation in Mountain Rescue: A Scoping Review and ICAR MedCom 2023 Recommendations

Lugnet, Viktor, Miles McDonough, Les Gordon, Mercedes Galindez, Nicolas Mena Reyes, Alison Sheets, Ken Zafren, and Peter Paal. Termination of cardiopulmonary resuscitation in mountain rescue: a scoping review and ICAR MedCom 2023 recommendations. High Alt Med Biol. 24:274-286, 2023. Background: In 2012, the International Commission for Mountain Emergency Medicine (ICAR MedCom) published recommendations for termination of cardiopulmonary resuscitation (CPR) in mountain rescue. New developments have necessitated an update. This is the 2023 update for termination of CPR in mountain rescue. Methods: For this scoping review, we searched the PubMed and Cochrane libraries, updated the recommendations, and obtained consensus approval within the writing group and the ICAR MedCom. Results: We screened a total of 9,102 articles, of which 120 articles met the inclusion criteria. We developed 17 recommendations graded according to the strength of recommendation and level of evidence. Conclusions: Most of the recommendations from 2012 are still valid. We made minor changes regarding the safety of rescuers and responses to primary or traumatic cardiac arrest. The criteria for termination of CPR remain unchanged. The principal changes include updated recommendations for mechanical chest compression, point of care ultrasound (POCUS), extracorporeal life support (ECLS) for hypothermia, the effects of water temperature in drowning, and the use of burial times in avalanche rescue.

Outcomes of out-of-hospital cardiac arrest in Ireland 2012-2020: Protocol for an observational study

Background

Out-of-hospital cardiac arrest (OHCA) is a leading cause of preventable mortality that now affects almost 3,000 people each year in Ireland. Survival is low at 6-7%, compared to a European average of 8%. The Irish Out-of-Hospital Cardiac Registry (OHCAR) prospectively gathers data on all OHCA in Ireland where emergency medical services attempted resuscitation.The Irish health system has undergone several developments that are relevant to OHCA care in the period 2012-2020. OHCAR data provides a means of exploring temporal trends in OHCA incidence, care, and outcomes over time. It also provides a means of exploring whether system developments were associated with a change in key outcomes.This research aims to summarise key trends in available OHCAR data from the period 2012 - 2020, to explore and model predictors of bystander CPR, bystander defibrillation, and survival, and to explore the hypothesis that significant system level temporal developments were associated with improvements in these outcomes.

Methods

The following protocol sets out the relevant background and research approach for an observational study that will address the above aims. Key trends in available OHCAR data (2012 - 2020) will be described and evaluated using descriptive summaries and graphical displays. Multivariable logistic regression will be used to model predictors of 'bystander CPR', 'bystander defibrillation' and 'survival to hospital discharge' and to explore the effects (if any) of system level developments in 2015/2016 and the COVID-19 pandemic (2020) on these outcomes.

Discussion

The findings of this research will be used to understand temporal trends in the care processes and outcomes for OHCA in Ireland over the period 2012-2020. The results can further be used to optimise future health system developments for OHCA in both Ireland and internationally.

Prehospital factors associated with out-of-hospital cardiac arrest outcomes in a metropolitan city: a 4-year multicenter study

BACKGROUND

Prehospital factors play a vital role in out-of-hospital cardiac arrest (OHCA) survivability, and they vary between countries and regions. We investigated the prehospital factors associated with OHCA outcomes in a single metropolitan city in the Republic of Korea.

METHODS

This study included adult medical OHCA patients enrolled prospectively, using data from the citywide OHCA registry for patients registered between 2018 and 2021. The primary outcome was survival to hospital discharge. Multivariable logistic regression analysis was conducted to determine the factors associated with the study population's clinical outcomes, adjusting for covariates. We performed a sensitivity analysis for clinical outcomes only for patients without prehospital return of spontaneous circulation prior to emergency medical service departure from the scene.

RESULTS

In multivariable logistic regression analysis, older age (odds ratio [OR] 0.96; 95% confidence interval [CI] 0.95-0.97), endotracheal intubation (adjusted odds ratio [aOR] 0.29; 95% [CIs] 0.17-0.51), supraglottic airway (aOR 0.29; 95% CI 0.17-0.51), prehospital mechanical chest compression device use (OR 0.13; 95% CI 0.08-0.18), and longer scene time interval (OR 0.96; 95% CI 0.93-1.00) were negatively associated with survival. Shockable rhythm (OR 24.54; 95% CI 12.99-42.00), pulseless electrical activity (OR 3.11; 95% CI 1.74-5.67), and witnessed cardiac arrest (OR 1.59; 95% CI 1.07-2.38) were positively associated with survival. In the sensitivity analysis, endotracheal intubation, supraglottic airway, prehospital mechanical chest compression device use, and longer scene time intervals were associated with significantly lower survival to hospital discharge.

CONCLUSIONS

Regional resuscitation protocol should be revised based on the results of this study, and modifiable prehospital factors associated with lower survival of OHCA should be improved.

Left rib fractures during cardiopulmonary resuscitation are associated with hemodynamic variations in a pig model of cardiac arrest

Background

Chest compressions (CC) are the cornerstone of cardiopulmonary resuscitation (CPR). But CC are also known to cause injuries, specifically rib fractures. The effects of such fractures have not been examined yet. This study aimed to investigate hemodynamic effects of rib fractures during mechanical CPR in a porcine model of cardiac arrest (CA).

Methods

We conducted a retrospective hemodynamic study in 31 pigs that underwent mechanical CC. Animals were divided into three groups based on the location of rib fractures: No Broken Ribs group (n = 11), Left Broken Ribs group (n = 13), and Right Broken Ribs group (n = 7). Hemodynamic measurements were taken at 10 seconds before and 10, 30, and 60 seconds after rib fractures.

Results

Baseline hemodynamic parameters did not differ between the three groups. Systolic aortic pressure was overall higher in the Left Broken Ribs group than in the No Broken Ribs group at 10, 30, and 60 seconds after rib fracture (p = 0.02, 0.01, and 0.006, respectively). The Left Broken Ribs group had a significantly higher right atrial pressure compared to the No Broken Rib group after rib fracture (p = 0.02, 0.01, and 0.03, respectively). There was no significant difference for any parameter for the Right Broken Ribs group, when compared to the No Broken Ribs group.

Conclusion

An increase in main hemodynamic parameters was observed after left rib fractures while right broken ribs were not associated with any change in hemodynamic parameters. Reporting fractures and their location seems worthwhile for future experimental studies.

The effect of the COVID-19 pandemic on the incidence and survival outcomes of EMS-witnessed out-of-hospital cardiac arrest

AIM

We sought to examine the impact of the COVID-19 pandemic on the incidence and survival outcomes of emergency medical service (EMS)-witnessed out-of-hospital cardiac arrest (OHCA) in Victoria, Australia.

METHODS

We performed an interrupted time-series analysis of adult EMS-witnessed OHCA patients of medical aetiology. Patients treated during the COVID-19 period (1st March 2020 to 31st December 2021) were compared to a historical comparator period (1st January 2012 and 28th February 2020). Multivariable poisson and logistic regression models were used to examine changes in incidence and survival outcomes during the COVID-19 pandemic, respectively.

RESULTS

We included 5,034 patients, 3,976 (79.0%) in the comparator period and 1,058 (21.0%) in the COVID-19 period. Patients in the COVID-19 period had longer EMS response times, fewer public location arrests and were significantly more likely to receive mechanical CPR and laryngeal mask airways compared to the historical period (all p < 0.05). There were no significant differences in the incidence of EMS-witnessed OHCA between the comparator and COVID-19 periods (incidence rate ratio 1.06, 95% CI: 0.97-1.17, p = 0.19). Also, there was no difference in the risk-adjusted odds of survival to hospital discharge for EMS-witnessed OHCA occurring during COVID-19 period compared to the comparator period (adjusted odd ratio 1.02, 95% CI: 0.74-1.42; p = 0.90).

CONCLUSION

Unlike the reported findings in non-EMS-witnessed OHCA populations, changes during the COVID-19 pandemic did not influence incidence or survival outcomes in EMS-witnessed OHCA. This may suggest that changes in clinical practice that sought to limit the use of aerosol generating procedures did not influence outcomes in these patients.

Ethische Aspekte mechanischer Reanimationshilfen beim Kind

BACKGROUND

While the use of mechanical resuscitation devices can be considered for adult resuscitation, the European Resuscitation Council guidelines do not yet mention their use for pediatric resuscitation. Only one device has been partially approved for use in children; further pediatric appliances are currently being used off-label. Ethical considerations arising from the use of mechanical resuscitation devices have not yet been presented in a structured way.

OBJECTIVE

To elaborate ethical considerations in the development phase of mechanical resuscitation devices for children.

METHODS

Based on several fictitious case reports, an interdisciplinary expert focus group discussion was conducted. This was followed by a moderated discussion, summarizing the results. Guiding principles and research desiderata were formulated using these results as well as existing literature.

RESULTS

According to the group of experts, ethical considerations regarding mechanical resuscitation devices in pediatrics predominantly concern the subject of indication and discontinuation criteria. Ethical aspects concerning psychosocial impacts on affected families and intervention teams cannot be generalized and need to be analyzed on a case-by-case basis.

CONCLUSION

The considerations presented regarding the use of mechanical resuscitation devices in the pediatric context, which is still in its developmental stage, could also have practical implications for adult out-of-hospital resuscitation decisions. Concerning ethical aspects of out-of-hospital resuscitation decisions, especially using mechanical resuscitation devices, the need for accompanying empirical research is substantial.

What are ambulance crews' experiences of using a mechanical chest compression device for out-of-hospital resuscitation? A constructivist qualitative study utilising online focus groups

Introduction

Mechanical chest compression devices (MCCDs) provide chest compressions mechanically to a person in cardiac arrest. Those chest compressions would usually be provided manually. Previous studies into the use of MCCDs have focused on the quantitative outcomes, with little emphasis on the qualitative experiences of those using MCCDs.

Purpose

To collect and report ambulance crews' experiences of using MCCDs for out-of-hospital resuscitation attempts.

Methods

The philosophical approach was constructivist, the methodology qualitative and the data collection method online focus groups. Convenience sampling was used to recruit participants who met the inclusion criteria, which broadly were to have experience of using MCCDs for out-of-hospital resuscitation. There have been two types of MCCD used locally. Participants were included regardless of which type of device they had experience of. Similarly, participants were included whether they had active or passive experience of the devices. The focus groups were recorded, fully transcribed and then analysed using constant comparison.

Results

Four selective codes emerged. These were factors directly affecting ambulance crew members; practicalities of a resuscitation attempt; ambulance crew members' perceptions, experiences and thoughts; negatives of MCCDs.

Conclusion

The main perceptions arising from the participants' discussion in this work were that MCCD use could potentially provide psychological protection to ambulance crew members when reflecting on resuscitation attempts, and participants felt there is an overall reduction of cognitive load for ambulance crew members when using MCCDs for resuscitation attempts. There were particularly timely benefits expressed of MCCDs easing the physical fatigue of a resuscitation attempt when responding wearing personal protective equipment, as has been required during the COVID-19 pandemic. MCCDs were felt to be of benefit when transporting a patient in cardiac arrest but differences were expressed as to whether the LUCAS-2 in particular helps or hinders extrication of a patient.

Factors Associated with Return of Spontaneous Circulation following Pre-Hospital Cardiac Arrest in Daegu Metropolitan City, South Korea; a Cross-Sectional Study

INTRODUCTION

The probability of Return of Spontaneous Circulation (ROSC) in cardiac arrest cases in pre-hospital setting is still low. This study aimed to identify the factors that may improve the rate of ROSC in patients with pre-hospital cardiac arrest.

METHODS

This retrospective cross-sectional study is a secondary data analysis of cardiac arrest patients, who were managed by paramedics in the pre-hospital setting, from January 1, 2019, to December 31, 2019, in Daegu, South Korea. The association of ROSC with place of arrest occurrence, cardiac arrest being witnessed, performing cardiopulmonary resuscitation (CPR), using compression device and defibrillator, administration of epinephrine, and intubation was analyzed and independent predictive factors of ROSC were reported.

RESULTS

2750 out-of-hospital cardiac arrest cases, which were managed by paramedics in the pre-hospital setting were studied. 2034 (86.9%) cases of arrest had occurred at home, 2028 (73.7%) were not witnessed, and CPR was not performed for 1721 (64.1%) cases. ROSC before arriving to emergency department (ED) was more probable if the cardiac arrest was witnessed (p < 0.001), if CPR was performed (p = 0.044), if a mechanical compression device was used (p < 0.001), if a first-aid defibrillator was used (p < 0.001), and if intravenous access was secured (p < 0.001). Multivariate regression analysis revealed that using mechanical compression device (OR: 0.18; 95% CI = 0.08 - 0.40; p = 0.001), using first-aid defibrillator (OR: 3.13; 95% CI = 1.40 - 6.99; p = 0.005), administration of epinephrine (OR: 6.57; 95% CI = 2.16 - 19.53; p = 0.001), and intubation (OR: 1.82; 95% CI = 1.04-3.19; p = 0.001) were independent predictive factors of ROSC before arrival to ED.

CONCLUSION

It seems that chest compression by hand instead of using chest compression device, using defibrillator, epinephrine administration, and intubation my increase the probability of ROSC in pre-hospital arrest cases.

Disparities in Survival Outcomes of Out-of-Hospital Cardiac Arrest Patients between Urban and Rural Areas and the Identification of Modifiable Factors in an Area of South Korea

This retrospective study aimed to compare the survival outcomes of adult out-of-hospital cardiac arrest (OHCA) patients between urban (Busan, Ulsan, Changwon) and rural (Gyeongnam) areas in South Korea and identify modifiable factors in the chain of survival. The primary and secondary outcomes were survival to discharge and modifiable factors in the chain of survival were identified using logistic regression analysis. In total, 1954 patients were analyzed. The survival to discharge rates in the whole region and in urban and rural areas were 6.9%, 8.7% (Busan 8.7%, Ulsan 10.3%, Changwon 7.2%), and 3.4%, respectively. In the urban group, modifiable factors associated with survival to discharge were no advanced airway management (adjusted odds ratio (aOR) 2.065, 95% confidence interval (CI): 1.138–3.747), no mechanical chest compression (aOR 3.932, 95% CI: 2.015–7.674), and an emergency medical service (EMS) transport time of more than 8 min (aOR 3.521, 95% CI: 2.075–5.975). In the rural group, modifiable factors included an EMS scene time of more than 15 min (aOR 0.076, 95% CI: 0.006–0.883) and an EMS transport time of more than 8 min (aOR 4.741, 95% CI: 1.035–21.706). To improve survival outcomes, dedicated resources and attention to EMS practices and transport time in urban areas and EMS scene and transport times in rural areas are needed.

Retrospective Comparison of Prehospital Sustained Return of Spontaneous Circulation (ROSC) Rates Within a Single Basic Life Support Jurisdiction Using Manual vs Lund University Cardiac Assist System (LUCAS-2) Mechanical Cardiopulmonary Resuscitation

Objective

Several studies have examined the impact of mechanical cardiopulmonary resuscitation (CPR) devices among multi-jurisdictional emergency medical services (EMS) systems; however, the variability across such systems can inject bias and confounding variables. We focused our investigation on the effect of introducing the Lund University Cardiac Assist System 2 (LUCAS-2) into a single basic life support (BLS) fire department first response jurisdiction served by a single private advanced life support (ALS) agency, hypothesizing that the implementation of the device would increase prehospital return of spontaneous circulation (ROSC) rates as compared with manual CPR. 

Methods

A retrospective observational analysis of adult non-traumatic prehospital cardiac arrest ALS agency records was conducted. Descriptive statistics were computed, and logistic regression was used to assess the impact of CPR method, response time, age, gender, CPR initiator, witnessed status, automated external defibrillator (AED) initiator, and presence of an initial shockable rhythm on ROSC rates. A Chi-square analysis was used to compare ROSC rates among compression modalities both before and after the implementation of LUCAS-2 on July 1, 2011. 

Results

From an initial dataset of 857 cardiac arrest records, only 264 (74 pre-LUCAS period, 190 LUCAS-2 period) met inclusion criteria for the primary objective. The ROSC rates were 29.7% (22/74) and 29.5% (56/190), respectively, for manual-only and LUCAS-assisted CPR (p=0.9673). Logistic regression revealed a significant association between ROSC and two of the independent variables: arrest witnessed (OR 3.104; 95% CI 1.896-5.081; p<0.0001) and initial rhythm shockable (OR 2.785; 95% CI 1.492-5.199; p<0.0013). 

Conclusions

Analyses support the null hypothesis that there is no difference in prehospital ROSC rates among adult non-traumatic cardiac arrest patients when comparing mechanical-assisted and manual-only CPR. These results are consistent with other larger multi-jurisdictional mechanical CPR studies. Systems with limited personnel might consider augmenting their resuscitations with a mechanical CPR device, although cost and system design should be factored into the decision. Secondary analysis of independent variables suggests that prehospital cardiac arrest patients with a witnessed arrest or an initial rhythm that is shockable have a higher likelihood of attaining ROSC. The power of our primary objective was limited by the sample size. Additionally, we were not able to adequately assess the quality of CPR among the two comparison groups with a lack of consistent end-tidal carbon dioxide (EtCO2) data.  

Joint British Societies' guideline on management of cardiac arrest in the cardiac catheter laboratory

More than 300 000 procedures are performed in cardiac catheter laboratories in the UK each year. The variety and complexity of percutaneous cardiovascular procedures have both increased substantially since the early days of invasive cardiology, when it was largely focused on elective coronary angiography and single chamber (right ventricular) permanent pacemaker implantation. Modern-day invasive cardiology encompasses primary percutaneous coronary intervention, cardiac resynchronisation therapy, complex arrhythmia ablation and structural heart interventions. These procedures all carry the risk of cardiac arrest.We have developed evidence-based guidelines for the management of cardiac arrest in adult patients in the catheter laboratory. The guidelines include recommendations which were developed by collaboration between nine professional and patient societies that are involved in promoting high-quality care for patients with cardiovascular conditions. We present a set of protocols which use the skills of the whole catheter laboratory team and which are aimed at achieving the best possible outcomes for patients who suffer a cardiac arrest in this setting. We identified six roles and developed a treatment algorithm which should be adopted during cardiac arrest in the catheter laboratory. We recommend that all catheter laboratory staff undergo regular training for these emergency situations which they will inevitably face.

Comparison between Prehospital Mechanical Cardiopulmonary Resuscitation (CPR) Devices and Manual CPR for Out-of-Hospital Cardiac Arrest: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis

In pre-hospital settings, efficient cardiopulmonary resuscitation (CPR) is challenging; therefore, the application of mechanical CPR devices continues to increase. However, the evidence of the benefits of using mechanical CPR devices in pre-hospital settings for adult out-of-hospital cardiac arrest (OHCA) is controversial. This meta-analysis compared the effects of mechanical and manual CPR applied in the pre-hospital stage on clinical outcomes after OHCA. Cochrane Library, PubMed, Embase, and ClinicalTrials.gov were searched from inception until October 2021. Studies comparing mechanical and manual CPR applied in the pre-hospital stage for survival outcomes of adult OHCA were eligible. Data abstraction, quality assessment, meta-analysis, trial sequential analysis (TSA), and grading of recommendations, assessment, development, and evaluation were conducted. Seven randomized controlled and 15 observational studies were included. Compared to manual CPR, pre-hospital use of mechanical CPR showed a positive effect in achieving return of spontaneous circulation (ROSC) and survival to admission. No difference was found in survival to discharge and discharge with favorable neurological status, with inconclusive results in TSA. In conclusion, pre-hospital use of mechanical CPR devices may benefit adult OHCA in achieving ROSC and survival to admission. With low certainty of evidence, more well-designed large-scale randomized controlled trials are needed to validate these findings.

Effectiveness of Mechanical Chest Compression Devices over Manual Cardiopulmonary Resuscitation: A Systematic Review with Meta-analysis and Trial Sequential Analysis

Introduction

Our goal was to systematically review contemporary literature comparing the relative effectiveness of two mechanical compression devices (LUCAS and AutoPulse) to manual compression for achieving return of spontaneous circulation (ROSC) in patients undergoing cardiopulmonary resuscitation (CPR) after an out-of-hospital cardiac arrest (OHCA).

Methods

We searched medical databases systematically for randomized controlled trials (RCT) and observational studies published between January 1, 2000–October 1, 2020 that compared mechanical chest compression (using any device) with manual chest compression following OHCA. We only included studies in the English language that reported ROSC outcomes in adult patients in non-trauma settings to conduct random-effects metanalysis and trial sequence analysis (TSA). Multivariate meta-regression was performed using preselected covariates to account for heterogeneity. We assessed for risk of biases in randomization, allocation sequence concealment, blinding, incomplete outcome data, and selective outcome reporting.

Results

A total of 15 studies (n = 18474), including six RCTs, two cluster RCTs, five retrospective case-control, and two phased prospective cohort studies, were pooled for analysis. The pooled estimates’ summary effect did not indicate a significant difference (Mantel-Haenszel odds ratio = 1.16, 95% confidence interval, 0.97 to 1.39, P = 0.11, I2 = 0.83) between mechanical and manual compressions during CPR for ROSC. The TSA showed firm evidence supporting the lack of improvement in ROSC using mechanical compression devices. The Z-curves successfully crossed the TSA futility boundary for ROSC, indicating sufficient evidence to draw firm conclusions regarding these outcomes. Multivariate meta-regression demonstrated that 100% of the between-study variation could be explained by differences in average age, the proportion of females, cardiac arrests with shockable rhythms, witnessed cardiac arrest, bystander CPR, and the average time for emergency medical services (EMS) arrival in the study samples, with the latter three attaining statistical significance.

Conclusion

Mechanical compression devices for resuscitation in cardiac arrests are not associated with improved rates of ROSC. Their use may be more beneficial in non-ideal situations such as lack of bystander CPR, unwitnessed arrest, and delayed EMS response times. Studies done to date have enough power to render further studies on this comparison futile.

The role of automated compression devices in out-of- and in- hospital cardiac arrest. Can we spare rescuers’ hands?

Research regarding the use of mechanical compressions in the setting of a cardiac arrest, either outside of or inside the hospital environment has produced mixed results. The debate whether they can replace manual compressions still remains. The aim of this review is to present current literature contemplating the application of mechanical compressions in both settings, data comparing them to manual compressions as well as current guidelines regarding their implementation in everyday clinical use. Currently, their implementation in the resuscitation protocol seems to benefit the victims of an in-hospital cardiac arrest rather than the victims that sustain a cardiac arrest outside of the hospital.

Cardiopulmonary Resuscitation With Mechanical Chest Compression Device During Percutaneous Coronary Intervention. A Case Report

Sudden cardiac death is a leading cause of death worldwide, whereby myocardial infarction is considered the most frequent underlying condition. Percutaneous coronary intervention (PCI) is an important component of post-resuscitation care, while uninterrupted high-quality chest compressions are key determinants in cardiopulmonary resuscitation (CPR). In our paper, we evaluate a case of a female patient who suffered aborted cardiac arrest due to myocardial infarction. The ambulance crew providing prehospital care for sudden cardiac arrest used a mechanical chest compression device during advanced CPR, which enabled them to deliver ongoing resuscitation during transfer to the PCI laboratory located 20 km away from the scene. Mechanical chest compressions were continued during the primary coronary intervention. The resuscitation, carried out for 2 h and 35 min, and the coronary intervention were successful, as evidenced by the return of spontaneous circulation and by the fact that, after a short rehabilitation, the patient was discharged home with a favorable neurological outcome. Our case can serve as an example for the effective and safe use of a mechanical compression device during primary coronary intervention.

[Cardiac arrest under special circumstances]

These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).

[Adult advanced life support]

These European Resuscitation Council Advanced Life Support guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

Computed Tomographic Findings of Injuries After Mechanical and Manual Resuscitation: A Retrospective Study

Introduction

Cardiopulmonary resuscitation (CPR)-related injuries are complications of chest compressions during CPR. This study aimed to investigate the differences and complications between mechanical and manual CPR techniques by using computed tomography (CT).

Methods

Patients in whom return of spontaneous circulation was achieved after CPR and thorax CT imaging were performed for diagnostic purposes were included in the study.

Results

A total of 178 non-traumatic cardiac arrest patients were successfully resuscitated and had CT scans in the emergency department. The complications of CPR are sternum fracture, rib fracture, pleural effusion/hemothorax, and pneumothorax. There were no statistically significant differences in terms of age, first complaint, cardiac arrest rhythm, CPR duration, and complications between mechanical and manual CPR. The number of exitus in the emergency department was similar (p=0.638). The discharge from hospital rate was higher in the mechanical CPR group but there was no statistically significant difference (p=0.196). The duration of CPR was associated with the number of rib fractures and lung contusion, but it did not affect other CPR-related chest injuries.

Conclusion

There was no significant difference observed in terms of increased complications in patients who received mechanical compression as compared with those who received manual compression. According to our results, mechanical compression does not cause serious complications, and the discharge from hospital rate was higher than for manual CPR; therefore, its use should be encouraged.

Differences between manual CPR and corpuls cpr in regard to quality and outcome: study protocol of the comparing observational multi-center prospective registry study on resuscitation (COMPRESS)

Background

The effect of mechanical CPR is diversely described in the literature. Different mechanical CPR devices are available. The corpuls cpr is a new generation of piston-driven devices and was launched in 2015. The COMPRESS-trial analyzes quality of chest compression and CPR-related injuries in cases of mechanical CPR by the corpuls cpr and manual CPR.

Methods

This article describes the design and study protocol of the COMPRESS-trial. This observational multi-center study includes all patients who suffered an out-of-hospital cardiac arrest (OHCA) where CPR is attempted in four German emergency medical systems (EMS) between January 2020 and December 2022. EMS treatment, in-hospital-treatment and outcome are anonymously reported to the German Resuscitation Registry (GRR). This information is linked with data from the defibrillator, the feedback system and the mechanical CPR device for a complete dataset.

Primary endpoint is chest compression quality (complete release, compression rate, compression depth, chest compression fraction, CPR-related injuries). Secondary endpoint is survival (return of spontaneous circulation (ROSC), admission to hospital and survival to hospital discharge). The trial is sponsored by GS Elektromedizinische Geräte G. Stemple GmbH.

Discussion

This observational multi-center study will contribute to the evaluation of mechanical chest compression devices and to the efficacy and safety of the corpuls cpr.

Trial registration

DRKS, DRKS-ID DRKS00020819. Registered 31 July 2020.

Automated mechanical cardiopulmonary resuscitation devices versus manual chest compressions in the treatment of cardiac arrest: protocol of a systematic review and meta-analysis comparing machine to human

INTRODUCTION

Cardiac arrest is a leading cause of death in industrialised countries. Cardiopulmonary resuscitation (CPR) guidelines follow the principles of closed chest compression as described for the first time in 1960. Mechanical CPR devices are designed to improve chest compression quality, thus considering the improvement of resuscitation outcomes. This protocol outlines a systematic review and meta-analysis methodology to assess trials investigating the therapeutic effect of automated mechanical CPR devices at the rate of return of spontaneous circulation, neurological state and secondary endpoints (including short-term and long-term survival, injuries and surrogate parameters for CPR quality) in comparison with manual chest compressions in adults with cardiac arrest.

METHODS AND ANALYSIS

A sensitive search strategy will be employed in established bibliographic databases from inception until the date of search, followed by forward and backward reference searching. We will include randomised and quasi-randomised trials in qualitative analysis thus comparing mechanical to manual CPR. Studies reporting survival outcomes will be included in quantitative analysis. Two reviewers will assess independently publications using a predefined data collection form. Standardised tools will be used for data extraction, risks of bias and quality of evidence. If enough studies are identified for meta-analysis, the measures of association will be calculated by dint of bivariate random-effects models. Statistical heterogeneity will be evaluated by I²-statistics and explored through sensitivity analysis. By comprehensive subgroup analysis we intend to identify subpopulations who may benefit from mechanical or manual CPR techniques. The reporting follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

ETHICS AND DISSEMINATION

No ethical approval will be needed because data from previous studies will be retrieved and analysed. Most resuscitation studies are conducted under an emergency exception for informed consent. This publication contains data deriving from a dissertation project. We will disseminate the results through publication in a peer-reviewed journal and at scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42017051633.

ECMO in Cardiac Arrest: A Narrative Review of the Literature

Cardiac arrest (CA) is a frequent cause of death and a major public health issue. To date, conventional cardiopulmonary resuscitation (CPR) is the only efficient method of resuscitation available that positively impacts prognosis. Extracorporeal membrane oxygenation (ECMO) is a complex and costly technique that requires technical expertise. It is not considered standard of care in all hospitals and should be applied only in high-volume facilities. ECMO combined with CPR is known as ECPR (extracorporeal cardiopulmonary resuscitation) and permits hemodynamic and respiratory stabilization of patients with CA refractory to conventional CPR. This technique allows the parallel treatment of the underlying etiology of CA while maintaining organ perfusion. However, current evidence does not support the routine use of ECPR in all patients with refractory CA. Therefore, an appropriate selection of patients who may benefit from this procedure is key. Reducing the duration of low blood flow by means of performing high-quality CPR and promoting access to ECPR, may improve the survival rate of the patients presenting with refractory CA. Indeed, patients who benefit from ECPR seem to carry better neurological outcomes. The aim of this present narrative review is to present the most recent literature available on ECPR and to clarify its potential therapeutic role, as well as to provide an in-depth explanation of equipment and its set up, the patient selection process, and the patient management post-ECPR.

Mechanical Ventilation Management During Mechanical Chest Compressions

Ventilation during chest compressions can lead to an increase in peak inspiratory pressure. High inspiratory pressure can raise the risk of injury to the respiratory system and make it challenging to deliver the required tidal volume. The utilization of mechanical devices for chest compression has exacerbated this challenge. The aim of this narrative review was to summarize the different mechanical ventilation strategies applied during mechanical cardiopulmonary resuscitation (CPR). To this end, we searched the PubMed and BioMed Central databases from inception to January 2020, using the search terms "mechanical ventilation," "cardiac arrest," "cardiopulmonary resuscitation," "mechanical cardiopulmonary resuscitation," and their related terms. We included all studies (human clinical or animal-based research studies, as well as studies using simulation models) to explore the various ventilation settings during mechanical CPR. We identified 842 relevant articles on PubMed and 397 on BioMed Central; a total of 38 papers were judged to be specifically related to the subject of this review. Of this sample, 17 studies were conducted on animal models, 6 considered a simulated scenario, 13 were clinical studies (5 of which were retrospective), and 2 studies constituted literature review articles. The main finding arising from the assessment of these publications is that a high [Formula: see text] must be guaranteed during CPR. Low-grade evidence suggests turning off inspiratory triggering and applying PEEP ≥ 5 cm H₂O. The analysis also revealed that many uncertainties persist regarding the ideal choice of ventilation mode, tidal volume, the ventilation rate setting, and the inspiratory:expiratory ratio. None of the current international guidelines indicate the "best" mechanical ventilation strategy to apply during mechanical CPR. We propose an operating algorithm worthy of future discussion and study. Future studies specifically addressing the topics covered in this review are required.

[Extracorporeal cardiopulmonary resuscitation (eCPR) for out-of-hospital cardiac arrest (OHCA) : Retrospective analysis of a load and go strategy under the aspect of golden hour of eCPR]

BACKGROUND

Survival rates after an out-of-hospital cardiac arrest (OHCA) remain low. Extracorporeal cardiopulmonary resuscitation (eCPR) has been introduced as an attempt to increase survival in selected patients and observational studies have shown promising results. Nevertheless, inclusion criteria and timing of eCPR remain undefined.

OBJECTIVE

The current study analyzed a load and go strategy with respect to the golden hour of eCPR as a cut-off time for survival and favorable neurological outcome.

MATERIAL AND METHODS

This retrospective cohort study included 32 patients who underwent eCPR treatment due to an OHCA between January 2017 and September 2019. Routinely taken patient demographic data (age, BMI, sex) were analyzed. The main focus was set on processing times in the preclinical and clinical setting. Time intervals including OHCA until ambulance arrival, time on scene, transportation times and door to eCPR were extracted from emergency medical service (EMS) and resuscitation protocols. Low-flow times, survival and neurological outcome were analyzed.

RESULTS

The use of eCPR in OHCA was associated with survival to hospital discharge in 28% and a good neurological outcome in 19% of the cases. Both groups (survivor and nonsurvivor) did not differ in patient demographics except for age. Survivors were significantly younger (47 (30-60) vs. 59 (50-68) years, p = 0.035). Processing times as well as low-flow times were not significantly different (OHCA-eCPR survivor 64 (50-87) vs. non-survivor 74 (51-85) min; p-value 0.64); however, median low-flow times were outside the golden hour of eCPR (69 (52-86)).

CONCLUSION

Despite low-flow times of more than 60 min, eCPR was associated with survival in 28% after OHCA. Hence, exceeding the golden hour of eCPR cannot act as a definitive exclusion criterion for eCPR.

Metrics of mechanical chest compression device use in out-of-hospital cardiac arrest

OBJECTIVE

The quality of cardiopulmonary resuscitation (CPR) affects outcomes from cardiac arrest, yet manual CPR is difficult to administer. Although mechanical CPR (mCPR) devices offer high quality CPR, only limited data describe their deployment, their interaction with standard manual CPR (sCPR), and the consequent effects on chest compression continuity and patient outcomes. We sought to describe the interaction between sCPR and mCPR and the impact of the sCPR-mCPR transition upon outcomes in adult out-of-hospital cardiac arrest (OHCA).

METHODS

We analyzed all adult ventricular fibrillation OHCA treated by the Anchorage Fire Department (AFD) during calendar year 2016. AFD protocols include the immediate initiation of sCPR upon rescuer arrival and transition to mCPR, guided by patient status. We compared CPR timing, performance, and outcomes between those receiving sCPR only and those receiving sCPR transitioning to mCPR (sCPR + mCPR).

RESULTS

All 19 sCPR-only patients achieved return of spontaneous circulation (ROSC) after a median of 3.3 (interquartile range 2.2-5.1) minutes. Among 30 patients remaining pulseless after sCPR (median 6.9 [5.3-11.0] minutes), transition to mCPR occurred with a median chest compression interruption of 7 (5-13) seconds. Twenty-one of 30 sCPR + mCPR patients achieved ROSC after a median of 11.2 (5.7-23.8) additional minutes of mCPR. Survival differed between groups: sCPR only 14/19 (74%) versus sCPR + mCPR 13/30 (43%), P = 0.045.

CONCLUSION

In this series, transition to mCPR occurred in patients unresponsive to initial sCPR with only brief interruptions in chest compressions. Assessment of mCPR must consider the interactions with sCPR.

Cardiopulmonary resuscitation (CPR) during spaceflight - a guideline for CPR in microgravity from the German Society of Aerospace Medicine (DGLRM) and the European Society of Aerospace Medicine Space Medicine Group (ESAM-SMG)

BACKGROUND

With the "Artemis"-mission mankind will return to the Moon by 2024. Prolonged periods in space will not only present physical and psychological challenges to the astronauts, but also pose risks concerning the medical treatment capabilities of the crew. So far, no guideline exists for the treatment of severe medical emergencies in microgravity. We, as a international group of researchers related to the field of aerospace medicine and critical care, took on the challenge and developed a an evidence-based guideline for the arguably most severe medical emergency - cardiac arrest.

METHODS

After the creation of said international group, PICO questions regarding the topic cardiopulmonary resuscitation in microgravity were developed to guide the systematic literature research. Afterwards a precise search strategy was compiled which was then applied to "MEDLINE". Four thousand one hundred sixty-five findings were retrieved and consecutively screened by at least 2 reviewers. This led to 88 original publications that were acquired in full-text version and then critically appraised using the GRADE methodology. Those studies formed to basis for the guideline recommendations that were designed by at least 2 experts on the given field. Afterwards those recommendations were subject to a consensus finding process according to the DELPHI-methodology.

RESULTS

We recommend a differentiated approach to CPR in microgravity with a division into basic life support (BLS) and advanced life support (ALS) similar to the Earth-based guidelines. In immediate BLS, the chest compression method of choice is the Evetts-Russomano method (ER), whereas in an ALS scenario, with the patient being restrained on the Crew Medical Restraint System, the handstand method (HS) should be applied. Airway management should only be performed if at least two rescuers are present and the patient has been restrained. A supraglottic airway device should be used for airway management where crew members untrained in tracheal intubation (TI) are involved.

DISCUSSION

CPR in microgravity is feasible and should be applied according to the Earth-based guidelines of the AHA/ERC in relation to fundamental statements, like urgent recognition and action, focus on high-quality chest compressions, compression depth and compression-ventilation ratio. However, the special circumstances presented by microgravity and spaceflight must be considered concerning central points such as rescuer position and methods for the performance of chest compressions, airway management and defibrillation.

The Use of Mechanical Cardiopulmonary Resuscitation May Be Associated With Improved Outcomes Over Manual Cardiopulmonary Resuscitation During Inhospital Cardiac Arrests

We aimed to investigate the impact of mechanical cardiopulmonary resuscitation devices over manual cardiopulmonary resuscitation on outcomes from inhospital cardiac arrests.

DESIGN

Restrospective review.

SETTING

Single academic medical center.

PARTICIPANTS

Data were collected on all patients who suffered cardiac arrest from December 2015 to November 2019.

MAIN OUTCOMES AND MEASURES

Primary end point was return of spontaneous circulation. Secondary end points included survival to discharge and survival to discharge with favorable neurologic outcomes.

RESULTS

About 104 patients were included in the study: 59 patients received mechanical cardiopulmonary resuscitation and 45 patients received manual cardiopulmonary resuscitation during the enrollment period. Return of spontaneous circulation rate was 83% in the mechanical cardiopulmonary resuscitation group versus 48.8% in the manual group (p = 0.009). Survival-to-discharge rate was 32.2% in the mechanical cardiopulmonary resuscitation group versus 11.1% in those who received manual cardiopulmonary resuscitation (p = 0.02). Of the patients who survived to discharge and received mechanical cardiopulmonary resuscitation, 100% (n = 19) had a favorable neurologic outcome versus 40% (two out of five) of patients who survived and received manual cardiopulmonary resuscitation (p = 0.005).

CONCLUSIONS

Our findings demonstrate a significant association of improved outcomes with mechanical cardiopulmonary resuscitation over manual cardiopulmonary resuscitation during inhospital cardiac arrests. Mechanical cardiopulmonary resuscitation may improve rates of return of spontaneous circulation, survival to discharge, and favorable neurologic outcomes.

Mechanical chest compression devices in the helicopter emergency medical service in Switzerland

BACKGROUND

Over the past years, several emergency medical service providers have introduced mechanical chest compression devices (MCDs) in their protocols for cardiopulmonary resuscitation (CPR). Especially in helicopter emergency medical systems (HEMS), which have limitations regarding loading weight and space and typically operate in rural and remote areas, whether MCDs have benefits for patients is still unknown. The aim of this study was to evaluate the use of MCDs in a large Swiss HEMS system.

MATERIALS AND METHODS

We conducted a retrospective observational study of all HEMS missions of Swiss Air rescue Rega between January 2014 and June 2016 with the use of an MCD (Autopulse®). Details of MCD use and patient outcome are reported from the medical operation journals and the hospitals' discharge letters.

RESULTS

MCDs were used in 626 HEMS missions, and 590 patients (94%) could be included. 478 (81%) were primary missions and 112 (19%) were interhospital transfers. Forty-nine of the patients in primary missions were loaded under ongoing CPR with MCDs. Of the patients loaded after return of spontaneous circulation (ROSC), 20 (7%) experienced a second CA during the flight. In interhospital transfers, 102 (91%) only needed standby use of the MCD. Five (5%) patients were loaded into the helicopter with ongoing CPR. Five (5%) patients went into CA during flight and the MCD had to be activated. A shockable cardiac arrhythmia was the only factor significantly associated with better survival in resuscitation missions using MCD (OR 0.176, 95% confidence interval 0.084 to 0.372, p < 0.001).

CONCLUSION

We conclude that equipping HEMS with MCDs may be beneficial, with non-trauma patients potentially benefitting more than trauma patients.

A systematic review of current ECPR protocols. A step towards standardisation

Aim

Extracorporeal cardiopulmonary resuscitation (ECPR) can treat cardiac arrest refractory to conventional therapies. Our goal was to identify the best protocol for survival with good neurological outcome through the evaluation of current inclusion criteria, exclusion criteria, cannulation strategies and additional therapeutic measures.

Methods

A systematic literature search was used to identify eligible publications from PubMed, Embase, Web of Science and Cochrane for articles published from 29 June 2009 until 29 June 2019.

Results

The selection process led to a total of 24 eligible articles, considering 1723 patients in total. A good neurological outcome at hospital discharge was found in 21.3% of all patients. The most consistent criterion for inclusion was refractory cardiac arrest (RCA), used in 21/25 (84%) of the protocols. The preferred cannulation method was the percutaneous Seldinger technique (44%).

Conclusion

ECPR is a feasible option for cardiac arrest and should already be considered in an early stage of CPR. One of the key findings is that time-to-ECPR seems to be correlated with good neurological survival. An important contributing factor is the definition of RCA. Protocols defining RCA as >10 ​min had a mean good neurological survival of 26.7%. Protocols with a higher cut-off, between 15 and 30 ​min, had a mean good neurological survival of 14.5%. Another factor contributing to the time-to-ECPR is the preferred access technique. A percutaneous Seldinger technique combined with ultrasonography and fluoroscopic guidance leads to a reduced cannulation time and complication rate. Conclusive research around prehospital cannulation still needs to be conducted.

Impacts of chest compression cycle length and real-time feedback with a CPRmeter® on chest compression quality in out-of-hospital cardiac arrest: study protocol for a multicenter randomized controlled factorial plan trial

Background

With a survival rate of 6 to 11%, out-of-hospital cardiac arrest (OHCA) remains a healthcare challenge with room for improvement in morbidity and mortality. The guidelines emphasize the highest possible quality of cardiopulmonary resuscitation (CPR) and chest compressions (CC). It is essential to minimize CC interruptions, and therefore increase the chest compression fraction (CCF), as this is an independent factor for survival. Survival is significantly and positively correlated with the suitability of CCF targets, CC frequency, CC depth, and brief predefibrillation pause. CC guidance improves adherence to recommendations and allows closer alignment with the CC objectives. The possibility of improving CCF by lengthening the time between two CC relays and the effect of real-time feedback on the quality of the CC must be investigated.

Methods

Using a 2 × 2 factorial design in a multicenter randomized trial, two hypotheses will be tested simultaneously: (i) a 4-min relay rhythm improves the CCF (reducing the no-flow time) compared to the currently recommended 2-min relay rate, and (ii) a guiding tool improves the quality of CC. Primary outcomes (i) CCF and (ii) correct compression score will be recorded by a real-time feedback device. Five hundred adult nontraumatic OHCAs will be included over 2 years. Patients will be randomized in a 1:1:1:1 distribution receiving advanced CPR as follows: 2-min blind, 2 min with guidance, 4-min blind, or 4 min with guidance. Secondary outcomes are the depth, frequency, and release of CC; length (care, no-flow, and low-flow); rate of return of spontaneous circulation; characteristics of advanced CPR; survival at hospital admission; survival and neurological state on days 1 and 30 (or intensive care discharge); and dosage of neuron-specific enolase on days 1 and 3.

Discussion

This study will contribute to assessing the impact of real-time feedback on CC quality in practical conditions of OHCA resuscitation. It will also provide insight into the feasibility of extending the relay rhythm between two rescuers from the currently recommended 2 to 4 min.

Trial registration

ClinicalTrials.gov, NCT03817892. Registered on 28 January 2019

Mechanical, Team-Focused, Video-Reviewed Cardiopulmonary Resuscitation Improves Return of Spontaneous Circulation After Emergency Department Implementation

Background

Outcomes in cardiac arrest remain suboptimal. Mechanical cardiopulmonary resuscitation (CPR) has not demonstrated clear clinical benefit; however, video review provides the capability to monitor CPR quality and provide constructive feedback to individuals and teams to improve their performance. The aim of our study was to evaluate cardiac arrest outcomes before and after initiation of a mechanical, team‐focused, video‐reviewed CPR intervention.

Methods and Results

In 2018, our emergency department began using mechanical CPR; a new team‐focused strategy with nurse‐led Advanced Cardiovascular Life Support; and biweekly, multidisciplinary video review of cardiac arrests. A revised approach to resuscitation was generated from a performance improvement session, and in situ simulation was used to disseminate our approach. The primary outcome of this study was the return of spontaneous circulation rate before and after our mechanical, team‐focused, video‐reviewed CPR intervention. Secondary outcomes included survival to admission and discharge. Multivariable logistic regression modeling was used. The pre‐ and postintervention groups were similar at baseline. A total of 248 patients were included in our study (97 before and 151 after mechanical, team‐focused, video‐reviewed CPR). Return of spontaneous circulation was higher in the intervention group (41% versus 26%; P=0.014). There were nonsignificant increases in survival to admission (26% versus 20%; P=0.257) and survival to discharge (7% versus 3%; P=0.163). After controlling for covariates, the odds of return of spontaneous circulation remained higher after the intervention (odds ratio, 2.11; 95% CI, 1.14–3.89).

Conclusions

Implementation of our mechanical, team‐focused, video‐reviewed CPR intervention for cardiac arrest patients in our emergency department improved return of spontaneous circulation rates. Survival to hospital admission and discharge did not improve.

Prospective observational study of mechanical cardiopulmonary resuscitation, extracorporeal membrane oxygenation and early reperfusion for refractory cardiac arrest in Sydney: the 2CHEER study

BACKGROUND

Patients with prolonged cardiac arrest that is not responsive to conventional cardiopulmonary resuscitation have poor outcomes. The use of extracorporeal membrane oxygenation (ECMO) in refractory cardiac arrest has shown promising results in carefully selected cases. We sought to validate the results from an earlier extracorporeal cardiopulmonary resuscitation (ECPR) study (the CHEER trial).

METHODS

Prospective, consecutive patients with refractory in-hospital (IHCA) or out-of-hospital cardiac arrest (OHCA) who met predefined inclusion criteria received protocolised care, including mechanical cardiopulmonary resuscitation, initiation of ECMO, and early coronary angiography (if an acute coronary syndrome was suspected).

RESULTS

Twenty-five patients were enrolled in the study (11 OHCA, 14 IHCA); the median age was 57 years (interquartile range [IQR], 39-65 years), and 17 patients (68%) were male. ECMO was established in all patients, with a median time from arrest to ECMO support of 57 minutes (IQR, 38-73 min). Percutaneous coronary intervention was performed on 18 patients (72%). The median duration of ECMO support was 52 hours (IQR, 24-108 h). Survival to hospital discharge with favourable neurological recovery occurred in 11/25 patients (44%, of which 72% had IHCA and 27% had OHCA). When adjusting for lactate, arrest to ECMO flow time was predictive of survival (odds ratio, 0.904; P = 0.035).

CONCLUSION

ECMO for refractory cardiac arrest shows promising survival rates if protocolised care is applied in conjunction with predefined selection criteria.

Comparison of hemodynamic effects and resuscitation outcomes between automatic simultaneous sterno-thoracic cardiopulmonary resuscitation device and LUCAS in a swine model of cardiac arrest

Introduction

Mechanical cardiopulmonary resuscitation (CPR) devices are widely used to rescue patients from cardiac arrest. This study aimed to compare hemodynamic effects and resuscitation outcomes between a motor-driven, automatic simultaneous sterno-thoracic cardiopulmonary resuscitation device and the Lund University cardiac arrest system (LUCAS).

Material and methods

After 2 minutes of electrically induced ventricular fibrillation (VF), Yorkshire pigs (weight 35–60 kg) received CPR with an automatic simultaneous sterno-thoracic CPR device (X-CPR group, n = 13) or the Lund University cardiac arrest system (LUCAS group, n = 12). Basic life support for 6 minutes and advanced cardiovascular life support for 12 minutes, including defibrillation and epinephrine administration, were provided. Hemodynamic parameters and resuscitation outcomes, including return of spontaneous circulation (ROSC), 24-hour survival, and cerebral performance category (CPC) at 24 hours, were evaluated.

Results

Hemodynamic parameters, including aortic pressures, coronary perfusion pressure, carotid blood flow, and end-tidal carbon dioxide pressure were not significantly different between the two groups. Resuscitation outcomes were also not significantly different between the groups (X-CPR vs. LUCAS; rate of ROSC: 31% vs 25%, p = 1.000; 24-hour survival rate: 31% vs 17%, p = 0.645; neurological outcome with CPC ≤2: 31% vs 17%, p = 0.645). Also no significant difference in incidence complications associated with resuscitation was found between the groups.

Conclusions

CPR with a motor-driven X-CPR and CPR with the LUCAS produced similar hemodynamic effects and resuscitation outcomes in a swine model of cardiac arrest.