Sternal wall pressure comparable to leaning during CPR impacts intrathoracic pressure and haemodynamics in anaesthetized children during cardiac catheterization

A Dynamic Model of Rescuer Parameters for Optimizing Blood Gas Delivery during Cardiopulmonary Resuscitation

Introduction

The quality of cardiopulmonary resuscitation (CPR) has been shown to impact patient outcomes. However, post-CPR morbidity and mortality remain high, and CPR optimization is an area of active research. One approach to optimizing CPR involves establishing reliable CPR performance measures and then modifying CPR parameters, such as compressions and ventilator breaths, to enhance these measures. We aimed to define a reliable CPR performance measure, optimize the CPR performance based on the defined measure and design a dynamically optimized scheme that varies CPR parameters to optimize CPR performance.

Materials and Methods

We selected total blood gas delivery (systemic oxygen delivery and carbon dioxide delivery to the lungs) as an objective function for maximization. CPR parameters were divided into three categories: rescuer dependent, patient dependent, and constant parameters. Two optimization schemes were developed using simulated annealing method: a global optimization scheme and a sequential optimization scheme.

Results and Discussion

Variations of CPR parameters over CPR sequences (cycles) were analyzed. Across all patient groups, the sequential optimization scheme resulted in significant enhancement in the effectiveness of the CPR procedure when compared to the global optimization scheme.

Conclusions

Our study illustrates the potential benefit of considering dynamic changes in rescuer-dependent parameters during CPR in order to improve performance. The advantage of the sequential optimization technique stemmed from its dynamically adapting effect. Our CPR optimization findings suggest that as CPR progresses, the compression to ventilation ratio should decrease, and the sequential optimization technique can potentially improve CPR performance. Validation in vivo is needed before implementing these changes in actual practice.

Effect of knee positions on cardiac compression variables in cardiopulmonary resuscitation of rescuer; Manikin study

The aim of the study was to analyze the effect of knee positions on cardiac compression variables in cardiopulmonary resuscitation (CPR) using the manikin. Adult with career of CPR instructor (n=9; mean age, 27.11±6.60 years; mean heights, 177.39±4.40 cm; mean weights, 69.45±14.85 kg) participated in the experiment, and each participant performed cardiac compression from two different knee positions. Cardiac compression was 30 times per minute for each position with order of position randomized. The results obtained from variables of cardiac compression force were composed of compression velocity, elapsed time, decay rate, and loading rate in maximum and minimum medial-lateral, anterior-posterior (AP), vertical direction respectively. The above variables in 20.3 cm of knee position showed effective result than that of 50 cm of knee position, while maximum AP compression force increased. Given the often predictable setting of sports and exercise rehabilitation related with cardiac arrest, CPR relative to change of knee position were significantly associated with more efficient cardiac compression variables. These data have significant implications for health services program in fields of sports and exercise rehabilitation.

Randomised crossover trial of rate feedback and force during chest compressions for paediatric cardiopulmonary resuscitation

OBJECTIVE

To determine the effect of visual feedback on rate of chest compressions, secondarily relating the forces used.

DESIGN

Randomised crossover trial.

SETTING

Tertiary teaching hospital.

SUBJECTS

Fifty trained hospital staff.

INTERVENTIONS

A thin sensor-mat placed over the manikin's chest measured rate and force. Rescuers applied compressions to the same paediatric manikin for two sessions. During one session they received visual feedback comparing their real-time rate with published guidelines.

OUTCOME MEASURES

Primary: compression rate. Secondary: compression and residual forces.

RESULTS

Rate of chest compressions (compressions per minute (compressions per minute; cpm)) varied widely (mean (SD) 111 (13), range 89-168), with a fourfold difference in variation during session 1 between those receiving and not receiving feedback (108 (5) vs 120 (20)). The interaction of session by feedback order was highly significant, indicating that this difference in mean rate between sessions was 14 cpm less (95% CI -22 to -5, p=0.002) in those given feedback first compared with those given it second. Compression force (N) varied widely (mean (SD) 306 (94); range 142-769). Those receiving feedback second (as opposed to first) used significantly lower force (adjusted mean difference -80 (95% CI -128 to -32), p=0.002). Mean residual force (18 N, SD 12, range 0-49) was unaffected by the intervention.

CONCLUSIONS

While visual feedback restricted excessive compression rates to within the prescribed range, applied force remained widely variable. The forces required may differ with growth, but such variation treating one manikin is alarming. Feedback technologies additionally measuring force (effort) could help to standardise and define effective treatments throughout childhood.

Sudden Cardiac Death in the Young

Although the occurrence of sudden cardiac death (SCD) in a young person is a rare event, it is traumatic and often widely publicized. In recent years, SCD in this population has been increasingly seen as a public health and safety issue. This review presents current knowledge relevant to the epidemiology of SCD and to strategies for prevention, resuscitation, and identification of those at greatest risk. Areas of active research and controversy include the development of best practices in screening, risk stratification approaches and postmortem evaluation, and identification of modifiable barriers to providing better outcomes after resuscitation of young SCD patients. Institution of a national registry of SCD in the young will provide data that will help to answer these questions.

Effect of the Cardio First Angel™ device on CPR indices: a randomized controlled clinical trial

Background

A number of cardiopulmonary resuscitation (CPR) adjunct devices have been developed to improve the consistency and quality of manual chest compressions. We investigated whether a CPR feedback device would improve CPR quality and consistency, as well as patient survival.

Methods

We conducted a randomized controlled study of patients undergoing CPR for cardiac arrest in the mixed medical-surgical intensive care units of four academic teaching hospitals. Patients were randomized to receive either standard manual CPR or CPR using the Cardio First Angel™ CPR feedback device. Recorded variables included guideline adherence, CPR quality, return of spontaneous circulation (ROSC) rates, and CPR-associated morbidity.

Results

A total of 229 subjects were randomized; 149 were excluded; and 80 were included. Patient demographics were similar. Adherence to published CPR guidelines and CPR quality was significantly improved in the intervention group (p < 0.0001), as were ROSC rates (72 % vs. 35 %; p = 0.001). A significant decrease was observed in rib fractures (57 % vs. 85 %; p = 0.02), but not sternum fractures (5 % vs. 17 %; p = 0.15).

Conclusions

Use of the Cardio First Angel™ CPR feedback device improved adherence to published CPR guidelines and CPR quality, and it was associated with increased rates of ROSC. A decrease in rib but not sternum fractures was observed with device use. Further independent prospective validation is warranted to determine if these results are reproducible in other acute care settings.

Trial registration

ClinicalTrials.gov identifier: NCT02394977. Registered on 5 Mar 2015.

Part 3: Adult Basic Life Support and Automated External Defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This review comprises the most extensive literature search and evidence evaluation to date on the most important international BLS interventions, diagnostics, and prognostic factors for cardiac arrest victims. It reemphasizes that the critical lifesaving steps of BLS are (1) prevention, (2) immediate recognition and activation of the emergency response system, (3) early high-quality CPR, and (4) rapid defibrillation for shockable rhythms. Highlights in prevention indicate the rational and judicious deployment of search-and-rescue operations in drowning victims and the importance of education on opioid-associated emergencies. Other 2015 highlights in recognition and activation include the critical role of dispatcher recognition and dispatch-assisted chest compressions, which has been demonstrated in multiple international jurisdictions with consistent improvements in cardiac arrest survival. Similar to the 2010 ILCOR BLS treatment recommendations, the importance of high quality was reemphasized across all measures of CPR quality: rate, depth, recoil, and minimal chest compression pauses, with a universal understanding that we all should be providing chest compressions to all victims of cardiac arrest. This review continued to focus on the interface of BLS sequencing and ensuring high-quality CPR with other important BLS interventions, such as ventilation and defibrillation. In addition, this consensus statement highlights the importance of EMS systems, which employ bundles of care focusing on providing high-quality chest compressions while extricating the patient from the scene to the next level of care. Highlights in defibrillation indicate the global importance of increasing the number of sites with public-access defibrillation programs. Whereas the 2010 ILCOR Consensus on Science provided important direction for the “what” in resuscitation (ie, what to do), the 2015 consensus has begun with the GRADE methodology to provide direction for the quality of resuscitation. We hope that resuscitation councils and other stakeholders will be able to translate this body of knowledge of international consensus statements to build their own effective resuscitation guidelines.

Measuring and improving cardiopulmonary resuscitation quality inside the emergency department

AIM OF STUDY

To evaluate CPR quality during cardiac resuscitation attempts in an urban emergency department (ED) and determine the influence of the combination of scenario-based training, real-time audiovisual feedback (RTAVF), and post-event debriefing on CPR quality.

METHODS

CPR quality was recorded using an R Series monitor-defibrillator (ZOLL Medical) during the treatment of adult cardiac arrest patients. Phase 1 (P1; 11/01/2010-11/15/2012) was an observation period of CPR quality. Phase 2 (P2; 11/15/2012-11/08/2013) was after a 60-min psychomotor skills CPR training and included RTAVF and post-event debriefing.

RESULTS

A total of 52 cardiac arrest patients were treated in P1 (median age 56 yrs, 63.5% male) and 49 in P2 (age 60 yrs, 83.7% male). Chest compression (CC) depth increased from 46.7 ± 3.8mm in P1 to 61.6 ± 2.8mm in P2 (p < 0.001), with the percentage of CC ≥ 51 mm increasing from 30.6% in P1 to 87.4% in P2 (p < 0.001). CC release velocity increased from 314 ± 25 mm/s in P1 to 442 ± 20 mm/s in P2 (p < 0.001). No significant differences were identified in CC fraction (84.3% P1 vs. 88.4% P2, p = 0.1), CC rate (125 ± 3 cpm P1 vs. 125 ± 3 cpm P2, p = 0.7), or pre-shock pause (9.7s P1 vs. 5.9s P2, p = 0.5), though CC fraction and pre-shock pause were within guideline recommendations.

CONCLUSION

Implementation of the bundle of scenario-based training, real-time audiovisual CPR feedback, and post-event debriefing was associated with improved CPR quality and compliance with CPR guidelines in this urban teaching emergency department.

Chest compression release velocity: Association with survival and favorable neurologic outcome after out-of-hospital cardiac arrest

PURPOSE

We evaluated the association between chest compression release velocity (CCRV) and outcomes after out-of-hospital cardiac arrest (OHCA).

MATERIALS AND METHODS

CPR quality was measured using a defibrillator with accelerometer-based technology (E Series, ZOLL Medical) during OHCA resuscitations by 2 EMS agencies in Arizona between 10/2008 and 06/2013. All non-EMS-witnessed adult (≥ 18 years) arrests of presumed cardiac etiology were included. The association between mean CCRV (assessed as an appropriate measure of central tendency) and both survival to hospital discharge and neurologic outcome (Cerebral Performance Category score = 1 or 2) was analyzed using multivariable logistic regression to control for known and potential confounders and multiple imputation to account for missing data.

RESULTS

981 OHCAs (median age 68 years, 65% male, 11% survival to discharge) were analyzed with 232 (24%) missing CPR quality data. All-rhythms survival varied significantly with CCRV [fast (≥ 400 mm/s) = 18/79 (23%); moderate (300-399.9 mm/s) = 50/416 (12%); slow (<300 mm/s) 17/255 (7%); p < 0.001], as did favorable neurologic outcome [fast = 14/79 (18%); moderate = 43/415 (10%); slow = 11/255 (4%); p < 0.001]. Fast CCRV was associated with increased survival compared to slow [adjusted odds ratio (aOR) 4.17 (95% CI: 1.61, 10.82) and moderate CCRV [aOR 3.08 (1.39, 6.83)]. Fast CCRV was also associated with improved favorable neurologic outcome compared to slow [4.51 (1.57, 12.98)]. There was a 5.2% increase in the adjusted odds of survival for each 10mm/s increase in CCRV [aOR 1.052 (1.001, 1.105)].

CONCLUSION

CCRV was independently associated with improved survival and favorable neurologic outcome at hospital discharge after adult OHCA.

Prevalence and hemodynamic effects of leaning during CPR

BACKGROUND

Cardiopulmonary resuscitation (CPR) guidelines recommend complete release between chest compressions (CC).

OBJECTIVE

Evaluate the hemodynamic effects of leaning (incomplete chest wall release) during CPR and the prevalence of leaning during CPR.

RESULTS

In piglet ventricular fibrillation cardiac arrests, 10% and 20% (1.8 kg and 3.6 kg, respectively), leaning during CPR increased right atrial pressures, decreased coronary perfusion pressures, and decreased cardiac index and left ventricular myocardial blood flow by nearly 50%. In contrast, residual leaning of a 260 g accelerometer/force feedback device did not adversely affect cardiac index or myocardial blood flow. Among 108 adult in-hospital CPR events, leaning ≥ 2.5 kg was demonstrable in 91% of the events and 12% of the evaluated CC. For 12 children with in-hospital CPR, 28% of CC had residual leaning ≥ 2.5 kg and 89% had residual leaning ≥ 0.5 kg.

CONCLUSIONS

Leaning during CPR increases intrathoracic pressure, decreases coronary perfusion pressure, and decreases cardiac output and myocardial blood flow. Leaning is common during CPR.