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Use of an end-tidal carbon dioxide-guided algorithm during cardiopulmonary resuscitation improves short-term survival in paediatric swine. Resusc Plus 2021; 8:100174. [PMID: 34820656 PMCID: PMC8600153 DOI: 10.1016/j.resplu.2021.100174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/28/2021] [Accepted: 09/28/2021] [Indexed: 01/09/2023] Open
Abstract
Aim To evaluate an algorithm that uses an end-tidal carbon dioxide (ETCO2) target of ≥ 30 torr to guide specific changes in chest compression rate and epinephrine administration during cardiopulmonary resuscitation (CPR) in paediatric swine. Methods Swine underwent asphyxial cardiac arrest followed by resuscitation with either standard or ETCO2-guided algorithm CPR. The standard group received chest compressions at a rate of 100/min and epinephrine every 4 min during advanced life support consistent with the American Heart Association paediatric resuscitation guidelines. In the ETCO2-guided algorithm group, chest compression rate was increased by 10 compressions/min for every minute that the ETCO2 was < 30 torr, and the epinephrine administration interval was decreased to every 2 min if the ETCO2 remained < 30 torr. Short-term survival and physiologic data during active resuscitation were compared. Results Short-term survival was significantly greater in the ETCO2-guided algorithm CPR group than in the standard CPR group (16/28 [57.1%] versus 4/28 [14.3%]; p = 0.002). Additionally, the algorithm group had higher predicted mean ETCO2, chest compression rate, diastolic and mean arterial pressure, and myocardial perfusion pressure throughout resuscitation. Swine in the algorithm group also exhibited significantly greater improvement in diastolic and mean arterial pressure and cerebral perfusion pressure after the first dose of epinephrine than did those in the standard group. Incidence of resuscitation-related injuries was similar in the two groups. Conclusions Use of a resuscitation algorithm with stepwise guidance for changes in the chest compression rate and epinephrine administration interval based on a goal ETCO2 level improved survival and intra-arrest hemodynamics in this porcine cardiac arrest model.
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Kienzle MF, Morgan RW, Faerber JA, Graham K, Katcoff H, Landis WP, Topjian AA, Kilbaugh TJ, Nadkarni VM, Berg RA, Sutton RM. The Effect of Epinephrine Dosing Intervals on Outcomes from Pediatric In-Hospital Cardiac Arrest. Am J Respir Crit Care Med 2021; 204:977-985. [PMID: 34265230 DOI: 10.1164/rccm.202012-4437oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Animal studies of cardiac arrest suggest shorter epinephrine dosing intervals than currently recommended (every 3-5 minutes) may be beneficial in select circumstances. OBJECTIVES To evaluate the association between epinephrine dosing intervals and pediatric cardiac arrest outcomes. METHODS Single-center retrospective cohort study of children (<18 years of age) who received ≥1 minute of cardiopulmonary resuscitation and ≥2 doses of epinephrine for an index in-hospital cardiac arrest. Exposure was epinephrine dosing interval: ≤2 minutes (frequent epinephrine) vs. >2 minutes. Primary outcome was survival to hospital discharge with a favorable neurobehavioral outcome (Pediatric Cerebral Performance Category score 1-2 or unchanged). Logistic regression evaluated the association between dosing interval and outcomes; additional analyses explored duration of CPR as a mediator. In a subgroup, the effect of dosing interval on diastolic blood pressure was investigated. MEASUREMENTS AND MAIN RESULTS Between January 2011 and December 2018, 125 patients met inclusion/exclusion criteria; 33 (26%) received frequent epinephrine. Frequent epinephrine was associated with increased odds of survival with favorable neurobehavioral outcome (aOR 2.56; CI95 1.07, 6.14; p=0.036), with 66% of the association mediated by CPR duration. Delta diastolic blood pressure was greater after the second dose of epinephrine among patients who received frequent epinephrine (median [IQR] 6.3 [4.1, 16.9] vs. 0.13 [-2.3, 1.9] mmHg, p=0.034). CONCLUSIONS In patients who received at least two doses of epinephrine, dosing intervals ≤2 minutes were associated with improved neurobehavioral outcomes compared to dosing intervals >2 minutes. Mediation analysis suggests improved outcomes are largely due to frequent epinephrine shortening duration of CPR.
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Affiliation(s)
- Martha F Kienzle
- The Children's Hospital of Philadelphia, 6567, Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Ryan W Morgan
- The Children's Hospital of Philadelphia, 6567, Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Jennifer A Faerber
- The Children's Hospital of Philadelphia, 6567, CPCE, Philadelphia, Pennsylvania, United States
| | - Kathryn Graham
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care, Philadelphia, Pennsylvania, United States
| | - Hannah Katcoff
- The Children's Hospital of Philadelphia, 6567, Department of Biomedical and Health Informatics, Philadelphia, Pennsylvania, United States
| | - William P Landis
- The Children's Hospital of Philadelphia, 6567, Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Alexis A Topjian
- University of Pennsylvania Perelman School of Medicine, 14640, Philadelphia, Pennsylvania, United States
| | - Todd J Kilbaugh
- The Children's Hospital of Philadelphia, 6567, Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Vinay M Nadkarni
- The Children's Hospital of Philadelphia, 6567, Anesthesia and Critical Care, Philadelphia, Pennsylvania, United States
| | - Robert A Berg
- The Children's Hospital of Philadelphia, 6567, Anesthesiology Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,University of Pennsylvania Perelman School of Medicine, 14640, Philadelphia, Pennsylvania, United States
| | - Robert M Sutton
- The Children's Hospital of Philadelphia, 6567, Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States;
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Mavroudis CD, Ko TS, Morgan RW, Volk LE, Landis WP, Smood B, Xiao R, Hefti M, Boorady TW, Marquez A, Karlsson M, Licht DJ, Nadkarni VM, Berg RA, Sutton RM, Kilbaugh TJ. Epinephrine's effects on cerebrovascular and systemic hemodynamics during cardiopulmonary resuscitation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:583. [PMID: 32993753 PMCID: PMC7522922 DOI: 10.1186/s13054-020-03297-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 09/17/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Despite controversies, epinephrine remains a mainstay of cardiopulmonary resuscitation (CPR). Recent animal studies have suggested that epinephrine may decrease cerebral blood flow (CBF) and cerebral oxygenation, possibly potentiating neurological injury during CPR. We investigated the cerebrovascular effects of intravenous epinephrine in a swine model of pediatric in-hospital cardiac arrest. The primary objectives of this study were to determine if (1) epinephrine doses have a significant acute effect on CBF and cerebral tissue oxygenation during CPR and (2) if the effect of each subsequent dose of epinephrine differs significantly from that of the first. METHODS One-month-old piglets (n = 20) underwent asphyxia for 7 min, ventricular fibrillation, and CPR for 10-20 min. Epinephrine (20 mcg/kg) was administered at 2, 6, 10, 14, and 18 min of CPR. Invasive (laser Doppler, brain tissue oxygen tension [PbtO2]) and noninvasive (diffuse correlation spectroscopy and diffuse optical spectroscopy) measurements of CBF and cerebral tissue oxygenation were simultaneously recorded. Effects of subsequent epinephrine doses were compared to the first. RESULTS With the first epinephrine dose during CPR, CBF and cerebral tissue oxygenation increased by > 10%, as measured by each of the invasive and noninvasive measures (p < 0.001). The effects of epinephrine on CBF and cerebral tissue oxygenation decreased with subsequent doses. By the fifth dose of epinephrine, there were no demonstrable increases in CBF of cerebral tissue oxygenation. Invasive and noninvasive CBF measurements were highly correlated during asphyxia (slope effect 1.3, p < 0.001) and CPR (slope effect 0.20, p < 0.001). CONCLUSIONS This model suggests that epinephrine increases CBF and cerebral tissue oxygenation, but that effects wane following the third dose. Noninvasive measurements of neurological health parameters hold promise for developing and directing resuscitation strategies.
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Affiliation(s)
- Constantine D Mavroudis
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA. .,Division of Cardiovascular Surgery, The University of Pennsylvania, Philadelphia, PA, USA.
| | - Tiffany S Ko
- Department of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lindsay E Volk
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Benjamin Smood
- Division of Cardiovascular Surgery, The University of Pennsylvania, Philadelphia, PA, USA
| | - Rui Xiao
- Department of Pediatrics, Division of Biostatistics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marco Hefti
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Timothy W Boorady
- Department of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexandra Marquez
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Daniel J Licht
- Department of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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The Effect of Asphyxia Arrest Duration on a Pediatric End-Tidal CO2-Guided Chest Compression Delivery Model. Pediatr Crit Care Med 2019; 20:e352-e361. [PMID: 31149967 PMCID: PMC6612600 DOI: 10.1097/pcc.0000000000001968] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the effect of the duration of asphyxial arrest on the survival benefit previously seen with end-tidal CO2-guided chest compression delivery. DESIGN Preclinical randomized controlled study. SETTING University animal research laboratory. SUBJECTS Two-week-old swine. INTERVENTIONS After either 17 or 23 minutes of asphyxial arrest, animals were randomized to standard cardiopulmonary resuscitation or end-tidal CO2-guided chest compression delivery. Standard cardiopulmonary resuscitation was optimized by marker, monitor, and verbal feedback about compression rate, depth, and release. End-tidal CO2-guided delivery used adjustments to chest compression rate and depth to maximize end-tidal CO2 level without other feedback. Cardiopulmonary resuscitation for both groups proceeded from 10 minutes of basic life support to 10 minutes of advanced life support or return of spontaneous circulation. MEASUREMENTS AND MAIN RESULTS After 17 minutes of asphyxial arrest, mean end-tidal CO2 during 10 minutes of cardiopulmonary resuscitation was 18 ± 9 torr in the standard group and 33 ± 15 torr in the end-tidal CO2 group (p = 0.004). The rate of return of spontaneous circulation was three of 14 (21%) in the standard group rate and nine of 14 (64%) in the end-tidal CO2 group (p = 0.05). After a 23-minute asphyxial arrest, neither end-tidal CO2 values (20 vs 26) nor return of spontaneous circulation rate (3/14 vs 1/14) differed between the standard and end-tidal CO2-guided groups. CONCLUSIONS Our previously observed survival benefit of end-tidal CO2-guided chest compression delivery after 20 minutes of asphyxial arrest was confirmed after 17 minutes of asphyxial arrest. The poor survival after 23 minutes of asphyxia shows that the benefit of end-tidal CO2-guided chest compression delivery is limited by severe asphyxia duration.
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Tiba MH, McCracken BM, Cummings BC, Colmenero CI, Rygalski CJ, Hsu CH, Sanderson TH, Nallamothu BK, Neumar RW, Ward KR. Use of resuscitative balloon occlusion of the aorta in a swine model of prolonged cardiac arrest. Resuscitation 2019; 140:106-112. [PMID: 31121206 DOI: 10.1016/j.resuscitation.2019.05.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/01/2019] [Accepted: 05/13/2019] [Indexed: 12/20/2022]
Abstract
AIM We examined the use of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) catheter during cardiopulmonary resuscitation (CPR) after cardiac arrest (CA) to assess its effect on haemodynamics such as coronary perfusion pressure (CPP), common carotid artery blood flow (CCA-flow) and end-tidal CO2 (PetCO2) which are associated with increased return of spontaneous circulation (ROSC). METHODS Six male swine were instrumented to measure CPP, CCA-Flow, and PetCO2. A 7Fr REBOA was advanced into zone-1 of the aorta through the femoral artery. Ventricular fibrillation was induced and untreated for 8 min. CPR (manual then mechanical) was initiated for 24 min. Continuous infusion of adrenaline (epinephrine) was started at minute-4 of CPR. The REBOA balloon was inflated at minute-16 for 3 min and then deflated/inflated every 3 min for 3 cycles. Animals were defibrillated up to 6 times after the final cycle. Animals achieving ROSC were monitored for 25 min. RESULTS Data showed significant differences between balloon deflation and inflation periods for CPP, CCA-Flow, and PetCO2 (p < 0.0001) with an average difference (SD) of 13.7 (2.28) mmHg, 15.5 (14.12) mL min-1 and -4 (2.76) mmHg respectively. Three animals achieved ROSC and had significantly higher mean CPP (54 vs. 18 mmHg), CCA-Flow (262 vs. 135 mL min-1) and PetCO2 (16 vs. 8 mmHg) (p < 0.0001) throughout inflation periods than No-ROSC animals. Aortic histology did not reveal any significant changes produced by balloon inflation. CONCLUSION REBOA significantly increased CPP and CCA-Flow in this model of prolonged CA. These increases may contribute to the ability to achieve ROSC.
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Affiliation(s)
- Mohamad Hakam Tiba
- University of Michigan, Department of Emergency Medicine, United States; University of Michigan, Department of Michigan Center for Integrative Research in Critical Care, United States.
| | - Brendan M McCracken
- University of Michigan, Department of Emergency Medicine, United States; University of Michigan, Department of Michigan Center for Integrative Research in Critical Care, United States.
| | - Brandon C Cummings
- University of Michigan, Department of Emergency Medicine, United States; University of Michigan, Department of Michigan Center for Integrative Research in Critical Care, United States.
| | - Carmen I Colmenero
- University of Michigan, Department of Emergency Medicine, United States; University of Michigan, Department of Michigan Center for Integrative Research in Critical Care, United States.
| | - Chandler J Rygalski
- University of Michigan, Department of Emergency Medicine, United States; University of Michigan, Department of Molecular and Integrative Physiology, United States.
| | - Cindy H Hsu
- University of Michigan, Department of Emergency Medicine, United States; University of Michigan, Department of Michigan Center for Integrative Research in Critical Care, United States; University of Michigan, Department of Surgery.
| | - Thomas H Sanderson
- University of Michigan, Department of Emergency Medicine, United States; University of Michigan, Department of Molecular and Integrative Physiology, United States; University of Michigan, Department of Michigan Center for Integrative Research in Critical Care, United States.
| | - Brahmajee K Nallamothu
- University of Michigan, Department of Internal Medicine, Division of Cardiology, United States; University of Michigan, Department of Michigan Center for Integrative Research in Critical Care, United States.
| | - Robert W Neumar
- University of Michigan, Department of Emergency Medicine, United States; University of Michigan, Department of Michigan Center for Integrative Research in Critical Care, United States.
| | - Kevin R Ward
- University of Michigan, Department of Emergency Medicine, United States; University of Michigan, Department of Biomedical Engineering, United States; University of Michigan, Department of Michigan Center for Integrative Research in Critical Care, United States.
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End-Tidal CO2-Guided Chest Compression Delivery Improves Survival in a Neonatal Asphyxial Cardiac Arrest Model. Pediatr Crit Care Med 2017; 18:e575-e584. [PMID: 28817508 PMCID: PMC5669831 DOI: 10.1097/pcc.0000000000001299] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine whether end-tidal CO2-guided chest compression delivery improves survival over standard cardiopulmonary resuscitation after prolonged asphyxial arrest. DESIGN Preclinical randomized controlled study. SETTING University animal research laboratory. SUBJECTS 1-2-week-old swine. INTERVENTIONS After undergoing a 20-minute asphyxial arrest, animals received either standard or end-tidal CO2-guided cardiopulmonary resuscitation. In the standard group, chest compression delivery was optimized by video and verbal feedback to maintain the rate, depth, and release within published guidelines. In the end-tidal CO2-guided group, chest compression rate and depth were adjusted to obtain a maximal end-tidal CO2 level without other feedback. Cardiopulmonary resuscitation included 10 minutes of basic life support followed by advanced life support for 10 minutes or until return of spontaneous circulation. MEASUREMENTS AND MAIN RESULTS Mean end-tidal CO2 at 10 minutes of cardiopulmonary resuscitation was 34 ± 8 torr in the end-tidal CO2 group (n = 14) and 19 ± 9 torr in the standard group (n = 14; p = 0.0001). The return of spontaneous circulation rate was 7 of 14 (50%) in the end-tidal CO2 group and 2 of 14 (14%) in the standard group (p = 0.04). The chest compression rate averaged 143 ± 10/min in the end-tidal CO2 group and 102 ± 2/min in the standard group (p < 0.0001). Neither asphyxia-related hypercarbia nor epinephrine administration confounded the use of end-tidal CO2-guided chest compression delivery. The response of the relaxation arterial pressure and cerebral perfusion pressure to the initial epinephrine administration was greater in the end-tidal CO2 group than in the standard group (p = 0.01 and p = 0.03, respectively). The prevalence of resuscitation-related injuries was similar between groups. CONCLUSIONS End-tidal CO2-guided chest compression delivery is an effective resuscitation method that improves early survival after prolonged asphyxial arrest in this neonatal piglet model. Optimizing end-tidal CO2 levels during cardiopulmonary resuscitation required that chest compression delivery rate exceed current guidelines. The use of physiologic feedback during cardiopulmonary resuscitation has the potential to provide optimized and individualized resuscitative efforts.
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Ryu SJ, Lee SJ, Park CH, Lee SM, Lee DH, Cho YS, Jung YH, Lee BK, Jeung KW. Arterial pressure, end-tidal carbon dioxide, and central venous oxygen saturation in reflecting compression depth. Acta Anaesthesiol Scand 2016; 60:1012-23. [PMID: 27080141 DOI: 10.1111/aas.12728] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/03/2016] [Accepted: 03/06/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND We sought to investigate the utility of arterial pressure, end-tidal carbon dioxide (ETCO2 ), and central venous oxygen saturation (SCVO2 ) to guide compression depth adjustment. Thus, in a pig model of cardiac arrest, we observed these parameters during cardiopulmonary resuscitation (CPR) with optimal and suboptimal compression depths. METHODS Sixteen pigs underwent three experimental sessions after induction of ventricular fibrillation. First, the animals received two 4-min CPR trials with either optimal (20% of the anteroposterior diameter) or suboptimal (70% of the optimal depth) compression depth. Second, the animals received two 5-min CPR trials with optimal compression depth, in which adrenaline (0.02 mg/kg) or saline placebo was administered. Third, the animals randomly received compression with either optimal or suboptimal depth during advanced cardiovascular life support. RESULTS The systolic arterial pressure reflected compression depth most accurately and immediately (area under the curve [AUC], 0.895-0.939 without adrenaline and 0.928-1.000 with adrenaline). Although the response of ETCO2 to the change in compression depth was 0.5 min slower than that of the systolic arterial pressure, the performance of ETCO2 was comparable with that of systolic arterial pressure. SCVO2 did not reflect compression depth. Adrenaline administration remarkably increased systolic arterial pressure, diastolic arterial pressure, and coronary perfusion pressure but did not affect the ETCO2 readings. CONCLUSION In a pig model of cardiac arrest, systolic arterial pressure reflected compression depth immediately and accurately. The performance of ETCO2 was comparable with that of systolic arterial pressure. SCVO2 did not reflect compression depth.
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Affiliation(s)
- S-J. Ryu
- Department of Emergency Medicine; Chonnam National University Hospital; Gwangju Korea
| | - S-J. Lee
- Department of Emergency Medicine; Myongji Hospital; Goyang Gyeonggi-do Korea
| | - C-H. Park
- Department of Emergency Medicine; Myongji Hospital; Goyang Gyeonggi-do Korea
| | - S-M. Lee
- Department of Emergency Medicine; Chonnam National University Hospital; Gwangju Korea
| | - D-H. Lee
- Department of Emergency Medicine; Chonnam National University Hospital; Gwangju Korea
| | - Y-S. Cho
- Department of Emergency Medicine; Chonnam National University Hospital; Gwangju Korea
| | - Y-H. Jung
- Department of Emergency Medicine; Chonnam National University Hospital; Gwangju Korea
| | - B-K. Lee
- Department of Emergency Medicine; Chonnam National University Hospital; Gwangju Korea
| | - K-W. Jeung
- Department of Emergency Medicine; Chonnam National University Hospital; Gwangju Korea
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Lundin A, Djärv T, Engdahl J, Hollenberg J, Nordberg P, Ravn-Fischer A, Ringh M, Rysz S, Svensson L, Herlitz J, Lundgren P. Drug therapy in cardiac arrest: a review of the literature. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 2:54-75. [DOI: 10.1093/ehjcvp/pvv047] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 10/28/2015] [Indexed: 01/01/2023]
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Maconochie IK, Bingham R, Eich C, López-Herce J, Rodríguez-Núñez A, Rajka T, Van de Voorde P, Zideman DA, Biarent D, Monsieurs KG, Nolan JP. European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2015; 95:223-48. [DOI: 10.1016/j.resuscitation.2015.07.028] [Citation(s) in RCA: 217] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Hahn C, Breil M, Schewe JC, Messelken M, Rauch S, Gräsner JT, Wnent J, Seewald S, Bohn A, Fischer M. Hypertonic saline infusion during resuscitation from out-of-hospital cardiac arrest: A matched-pair study from the German Resuscitation Registry. Resuscitation 2014; 85:628-36. [DOI: 10.1016/j.resuscitation.2013.12.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 12/05/2013] [Accepted: 12/19/2013] [Indexed: 12/23/2022]
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Even four minutes of poor quality of CPR compromises outcome in a porcine model of prolonged cardiac arrest. BIOMED RESEARCH INTERNATIONAL 2013; 2013:171862. [PMID: 24364028 PMCID: PMC3865628 DOI: 10.1155/2013/171862] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 11/09/2013] [Indexed: 11/29/2022]
Abstract
Objective. Untrained bystanders usually delivered suboptimal chest compression to victims who suffered from cardiac arrest in out-of-hospital settings. We therefore investigated the hemodynamics and resuscitation outcome of initial suboptimal quality of chest compressions compared to the optimal ones in a porcine model of cardiac arrest. Methods. Fourteen Yorkshire pigs weighted 30 ± 2 kg were randomized into good and poor cardiopulmonary resuscitation (CPR) groups. Ventricular fibrillation was electrically induced and untreated for 6 mins. In good CPR group, animals received high quality manual chest compressions according to the Guidelines (25% of animal's anterior-posterior thoracic diameter) during first two minutes of CPR compared with poor (70% of the optimal depth) compressions. After that, a 120-J biphasic shock was delivered. If the animal did not acquire return of spontaneous circulation, another 2 mins of CPR and shock followed. Four minutes later, both groups received optimal CPR until total 10 mins of CPR has been finished. Results. All seven animals in good CPR group were resuscitated compared with only two in poor CPR group (P < 0.05). The delayed optimal compressions which followed 4 mins of suboptimal compressions failed to increase the lower coronary perfusion pressure of five non-survival animals in poor CPR group.
Conclusions. In a porcine model of prolonged cardiac arrest, even four minutes of initial poor quality of CPR compromises the hemodynamics and survival outcome.
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Weiner GM, Niermeyer S. Medications in neonatal resuscitation: epinephrine and the search for better alternative strategies. Clin Perinatol 2012; 39:843-55. [PMID: 23164182 DOI: 10.1016/j.clp.2012.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Epinephrine remains the primary vasopressor for neonatal resuscitation complicated by asystole or prolonged bradycardia not responsive to adequate ventilation and chest compressions. Epinephrine increases coronary perfusion pressure primarily through peripheral vasoconstriction. Current guidelines recommend intravenous epinephrine administration (0.01-0.03 mg/kg). Endotracheal epinephrine administration results in unpredictable absorption. High-dose intravenous epinephrine poses additional risks and does not result in better long-term survival. Vasopressin has been considered an alternative to epinephrine in adults, but there is insufficient evidence to recommend its use in newborn infants. Future research will focus on the best sequence for epinephrine administration and chest compressions.
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Affiliation(s)
- Gary M Weiner
- Department of Pediatrics, St. Joseph Mercy Hospital, 5301 East Huron River Drive, Ann Arbor, MI 48106, USA.
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Bonny A, De Sisti A, Márquez MF, Megbemado R, Hidden-Lucet F, Fontaine G. Low doses of intravenous epinephrine for refractory sustained monomorphic ventricular tachycardia. World J Cardiol 2012; 4:296-301. [PMID: 23110246 PMCID: PMC3482623 DOI: 10.4330/wjc.v4.i10.296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 09/25/2012] [Accepted: 10/02/2012] [Indexed: 02/06/2023] Open
Abstract
We report three cases of sustained monomorphic ventricular tachycardia (VT) in the setting of coronary artery disease, resistant to beta-blockers in two patients and to amiodarone in all, successfully terminated by low doses of intravenous (IV) epinephrine. VT was the first manifestation of coronary artery disease in one patient, whereas the other two patients had a previous history of myocardial infarction and were recipients of an implantable cardioverter-defibrillator (ICD). One of these two patients experienced an arrhythmic storm. All had hemodynamic instability at the time of epinephrine administration. A single slow administration of IV epinephrine (0.5 to 1 mg administered over 30 to 60 s) restored sinus rhythm after 30-90 s with only minor side effects. In the ICD patient with recurrent VT and several cardioversions due to transformation of VT to ventricular fibrillation, epinephrine injection led to the avoidance of further shocks. Although potentially harmful, low doses of IV epinephrine used alone or in combination with beta-blocker treatment and electrical cardioversion may be an alternative effective therapy for sustained monomorphic VT refractory to amiodarone. The role of epinephrine in the termination of VT should be studied further, especially in patients pre-treated with amiodarone in combination with beta-blockers.
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Affiliation(s)
- Aimé Bonny
- Aimé Bonny, Antonio De Sisti, Françoise Hidden-Lucet, Guy Fontaine, Hôpital Pitié-Salpêtrière, Unité de Rythmologie, 47-83 Boulevard de l'Hôpital, 75651 Paris, France
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Sunde K, Steen PA. The Use of Vasopressor Agents During Cardiopulmonary Resuscitation. Crit Care Clin 2012; 28:189-98. [PMID: 22433482 DOI: 10.1016/j.ccc.2011.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Burnett AM, Segal N, Salzman JG, McKnite MS, Frascone RJ. Potential negative effects of epinephrine on carotid blood flow and ETCO2 during active compression-decompression CPR utilizing an impedance threshold device. Resuscitation 2012; 83:1021-4. [PMID: 22445865 DOI: 10.1016/j.resuscitation.2012.03.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 02/25/2012] [Accepted: 03/05/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study examines the effects of IV epinephrine administration on carotid blood flow (CBF) and end tidal CO(2) (ETCO(2)) production in a swine model of active compression-decompression CPR with an impedance threshold device (ACD-CPR+ITD). METHODS Six female swine (32 ± 1 kg) were anesthetized, intubated and ventilated. Intracranial, thoracic aorta and right atrial pressures were measured via indwelling catheters. CBF was recorded. ETCO(2), SpO(2) and EKG were monitored. V-fib was induced and went untreated for 6 min. Three minutes each of standard CPR (STD), STD-CPR+impedance threshold device (ITD) and active compression-decompression (ACD)-CPR+ITD were performed. At minute 9 of the resuscitation, 40 μg/kg of IV Epinephrine was administered and ACD-CPR+ITD was continued for 1 min. Statistical analysis was performed with a paired t-test. p values of <0.05 were considered statistically significant and all values are reported in mmHg unless otherwise noted. RESULTS Aortic pressure, cerebral and coronary perfusion pressures increased from STD<STD+ITD<ACD-CPR+ITD (p<0.001). Epinephrine administered during ACD-CPR+ITD signficantly increased mean aortic pressure (29 ± 5 vs 42 ± 12, p = 0.01), cerebral perfusion pressure (12 ± 5 vs 22 ± 10, p = 0.01), and coronary perfusion pressure (8 ± 7 vs 17 ± 4, p = 0.02); however, mean CBF and ETCO(2) decreased (respectively 29 ± 15 vs 14 ± 7.0 ml/min, p = 0.03; 20 ± 7 vs 18 ± 6, p = 0.04). CONCLUSIONS In this model, administration of epinephrine during ACD-CPR+ITD significantly increased markers of macrocirculation, while significantly decreasing carotid blood flow and ETCO(2). This calls into question the ability of calculated perfusion pressures to accurately reflect oxygen delivery to end organs. The administration of epinephrine during ACD-CPR+ITD does not improve cerebral tissue perfusion.
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Affiliation(s)
- Aaron M Burnett
- Department of Emergency Medicine, Regions Hospital, Saint Paul, MN, United States.
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Pallás Beneyto LA, Rodríguez Luis O, Miguel Bayarri V. Reanimación cardiocerebral intrahospitalaria. Med Clin (Barc) 2012; 138:120-6. [DOI: 10.1016/j.medcli.2011.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 05/15/2011] [Accepted: 05/19/2011] [Indexed: 11/16/2022]
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Biarent D, Bingham R, Eich C, López-Herce J, Maconochie I, Rodríguez-Núñez A, Rajka T, Zideman D. European Resuscitation Council Guidelines for Resuscitation 2010 Section 6. Paediatric life support. Resuscitation 2011; 81:1364-88. [PMID: 20956047 DOI: 10.1016/j.resuscitation.2010.08.012] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Dominique Biarent
- Paediatric Intensive Care, Hôpital Universitaire des Enfants, 15 av JJ Crocq, Brussels, Belgium.
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de Caen AR, Kleinman ME, Chameides L, Atkins DL, Berg RA, Berg MD, Bhanji F, Biarent D, Bingham R, Coovadia AH, Hazinski MF, Hickey RW, Nadkarni VM, Reis AG, Rodriguez-Nunez A, Tibballs J, Zaritsky AL, Zideman D. Part 10: Paediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e213-59. [PMID: 20956041 DOI: 10.1016/j.resuscitation.2010.08.028] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Allan R de Caen
- Stollery Children's Hospital, University of Alberta, Canada.
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Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S729-67. [PMID: 20956224 DOI: 10.1161/circulationaha.110.970988] [Citation(s) in RCA: 880] [Impact Index Per Article: 62.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.
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Biarent D, Bingham R, Eich C, López-Herce J, Maconochie I, Rodrίguez-Núñez A, Rajka T, Zideman D. Lebensrettende Maßnahmen bei Kindern („paediatric life support“). Notf Rett Med 2010. [DOI: 10.1007/s10049-010-1372-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Kleinman ME, de Caen AR, Chameides L, Atkins DL, Berg RA, Berg MD, Bhanji F, Biarent D, Bingham R, Coovadia AH, Hazinski MF, Hickey RW, Nadkarni VM, Reis AG, Rodriguez-Nunez A, Tibballs J, Zaritsky AL, Zideman D. Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010; 126:e1261-318. [PMID: 20956433 PMCID: PMC3784274 DOI: 10.1542/peds.2010-2972a] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Kleinman ME, de Caen AR, Chameides L, Atkins DL, Berg RA, Berg MD, Bhanji F, Biarent D, Bingham R, Coovadia AH, Hazinski MF, Hickey RW, Nadkarni VM, Reis AG, Rodriguez-Nunez A, Tibballs J, Zaritsky AL, Zideman D. Part 10: Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S466-515. [PMID: 20956258 PMCID: PMC3748977 DOI: 10.1161/circulationaha.110.971093] [Citation(s) in RCA: 143] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Note From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, “Family Presence During ResuscitationPeds-003”). These callouts are hyperlinked to evidence-based worksheets, which were used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets are available in PDF format and are open access.
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Chen MH, Lu JY, Xie L, Zheng JH, Song FQ. What is the optimal dose of epinephrine during cardiopulmonary resuscitation in a rat model? Am J Emerg Med 2010; 28:284-90. [PMID: 20223384 DOI: 10.1016/j.ajem.2008.11.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Revised: 11/24/2008] [Accepted: 11/25/2008] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Because different species may require different doses of drug to produce the same physiologic response, we were provoked to evaluate the dose-response of epinephrine during cardiopulmonary resuscitation (CPR) and identify what is the optimal dose of epinephrine in a rat cardiac arrest model. METHODS Rat cardiac arrest was induced via asphyxia, and then the effects of different doses of epinephrine (0.04, 0.2, and 0.4 mg/kg IV, respectively) and saline on the outcome of CPR were compared (n = 10/each group). The primary outcome measure was restoration of spontaneous circulation (ROSC), and the secondary was the change of spontaneous respiration and hemodynamics after ROSC. RESULTS Rates of ROSC were 9 of 10, 8 of 10, 7 of 10, and 1 of 10 in the low-dose, medium-dose, and high-dose epinephrine groups and saline group, respectively. The rates of withdrawal from the ventilator within 60 minutes in the low-dose (7 of 9) and medium-dose epinephrine groups (7 of 8) were higher than in the high-dose epinephrine group (1 of 7, P < .05). Mean arterial pressures were comparable, but the heart rate in the high-dose epinephrine group was the lowest among epinephrine groups after ROSC. These differences in part of time points reached statistical significance (P < .05). CONCLUSION Different doses of epinephrine produced the similar rate of ROSC, but high-dose epinephrine inhibited the recovery of spontaneous ventilation and caused relative bradycardia after CPR in an asphyxial rat model. Therefore, low and medium doses of epinephrine were more optimal for CPR in a rat asphyxial cardiac arrest model.
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Affiliation(s)
- Meng-Hua Chen
- Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University, Nanning, PR China.
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Wyllie J, Niermeyer S. The role of resuscitation drugs and placental transfusion in the delivery room management of newborn infants. Semin Fetal Neonatal Med 2008; 13:416-23. [PMID: 18508418 DOI: 10.1016/j.siny.2008.04.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Medications are used rarely in newborn resuscitations and are probably justifiable in less than 0.1% of births. Doses used are mainly extrapolated from animal and adult data. Despite this, the drugs used, their order and route of administration have all been sources of controversy for many years. There have been polarised views, often focusing upon adrenaline and sodium bicarbonate and more recently new drugs such as vasopressin have been suggested, once again extrapolating from adult experience. This article examines the sparse data behind the use of any medication at birth and the poor outcome data available. The appropriate decline in the indiscriminate use of volume expansion is considered and balanced by the increasing evidence in favour of delayed clamping of the umbilical cord. Focusing on the basic steps of resuscitation, improving the quality of their application and avoiding relative hypovolaemia, must improve the quality of outcome data. The place of medications in newborn resuscitation should be regarded as experimental and still requires evidence to justify their use especially in premature babies.
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Mally S, Jelatancev A, Grmec S. Effects of epinephrine and vasopressin on end-tidal carbon dioxide tension and mean arterial blood pressure in out-of-hospital cardiopulmonary resuscitation: an observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:R39. [PMID: 17376225 PMCID: PMC2206459 DOI: 10.1186/cc5726] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/17/2006] [Revised: 02/28/2007] [Accepted: 03/21/2007] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Clinical data considering vasopressin as an equivalent option to epinephrine in cardiopulmonary resuscitation (CPR) are limited. The aim of this prehospital study was to assess whether the use of vasopressin during CPR contributes to higher end-tidal carbon dioxide and mean arterial blood pressure (MAP) levels and thus improves the survival rate and neurological outcome. METHODS Two treatment groups of resuscitated patients in cardiac arrest were compared: in the epinephrine group, patients received 1 mg of epinephrine intravenously every three minutes only; in the vasopressin/epinephrine group, patients received 40 units of arginine vasopressin intravenously only or followed by 1 mg of epinephrine every three minutes during CPR. Values of end-tidal carbon dioxide and MAP were recorded, and data were collected according to the Utstein style. RESULTS Five hundred and ninety-eight patients were included with no significant demographic or clinical differences between compared groups. Final end-tidal carbon dioxide values and average values of MAP in patients with restoration of pulse were significantly higher in the vasopressin/epinephrine group (p < 0.01). Initial (odds ratio [OR]: 18.65), average (OR: 2.86), and final (OR: 2.26) end-tidal carbon dioxide values as well as MAP at admission to the hospital (OR: 1.79) were associated with survival at 24 hours. Initial (OR: 1.61), average (OR: 1.47), and final (OR: 2.67) end-tidal carbon dioxide values as well as MAP (OR: 1.39) were associated with improved hospital discharge. In the vasopressin group, significantly more pulse restorations and a better rate of survival at 24 hours were observed (p < 0.05). Subgroup analysis of patients with initial asystole revealed a higher hospital discharge rate when vasopressin was used (p = 0.04). Neurological outcome in discharged patients was better in the vasopressin group (p = 0.04). CONCLUSION End-tidal carbon dioxide and MAP are strong prognostic factors for the outcome of out-of-hospital cardiac arrest. Resuscitated patients treated with vasopressin alone or followed by epinephrine have higher average and final end-tidal carbon dioxide values as well as a higher MAP on admission to the hospital than patients treated with epinephrine only. This combination vasopressor therapy improves restoration of spontaneous circulation, short-term survival, and neurological outcome. In the subgroup of patients with initial asystole, it improves the hospital discharge rate.
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Affiliation(s)
- Stefan Mally
- Centre for Emergency Medicine Maribor, Ljubljanska 5, 2000 Maribor, Slovenia
| | - Alina Jelatancev
- Centre for Emergency Medicine Maribor, Ljubljanska 5, 2000 Maribor, Slovenia
| | - Stefek Grmec
- Centre for Emergency Medicine Maribor, Ljubljanska 5, 2000 Maribor, Slovenia
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Electrocardiogram waveforms for monitoring effectiveness of chest compression during cardiopulmonary resuscitation. Crit Care Med 2008; 36:211-5. [PMID: 18090357 DOI: 10.1097/01.ccm.0000295594.93345.a2] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Newer guidelines address the importance of effective chest compressions, citing evidence that this primary intervention is usually suboptimally performed during cardiopulmonary resuscitation. We therefore sought a readily available option for monitoring the effectiveness of chest compressions, specifically using the electrocardiogram. METHODS AND RESULTS Ventricular fibrillation was induced by coronary artery occlusion and untreated for 5 mins. Male domestic pigs weighing 40 +/- 2 kg were randomized to optimal or suboptimal chest compressions after onset of ventricular fibrillation. Optimal depth of mechanical compression in six animals was defined as a decrease of 25% in anterior posterior diameter of the chest during compression. Suboptimal compression, also in six animals, was defined as a decrease of 17.5% in anterior posterior diameter. For each group, the chest compressions were maintained at a rate of 100 per min. After 3 mins of chest compression, defibrillation was attempted with a 150-J biphasic shock. All animals had return of spontaneous circulation after optimal compressions. This contrasted with suboptimal compressions, after which none of the animals had return of spontaneous circulation. Amplitude spectrum area values, representing the electrocardiographic amplitude frequency spectral area computed from conventional precordial leads, like coronary perfusion pressure and end tidal PCO2, were predictive of outcomes. CONCLUSION The effectiveness of chest compressions was reflected in the amplitude spectrum area values. Accordingly, the amplitude spectrum area predictor may be incorporated in current automated external defibrillators to monitor and prompt the effectiveness of chest compression during cardiopulmonary resuscitation.
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Combination of cardiac pacing and epinephrine does not always improve outcome of cardiopulmonary resuscitation. Am J Emerg Med 2007; 25:1032-9. [DOI: 10.1016/j.ajem.2007.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2006] [Revised: 01/27/2007] [Accepted: 03/08/2007] [Indexed: 12/27/2022] Open
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Chen MH, Liu TW, Xie L, Song FQ, He T. A comparison of transoesophageal cardiac pacing and epinephrine for cardiopulmonary resuscitation. Am J Emerg Med 2006; 24:545-52. [PMID: 16938592 DOI: 10.1016/j.ajem.2006.01.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2006] [Revised: 01/26/2006] [Accepted: 01/26/2006] [Indexed: 10/24/2022] Open
Abstract
The use of cardiac pacing to deal with bradycardia is well established. There is debate as to the benefits during cardiopulmonary resuscitation (CPR). This study was performed to compare the effects of transoesophageal cardiac pacing and high-dose epinephrine on the benefits of cardiopulmonary resuscitation after asphyxial cardiac arrest in rats. Thirty Sprague-Dawley rats of both sexes were randomly selected to a saline group (Sal-gro, treated with normal saline 1 mL IV, n = 10), an epinephrine group (Epi-gro, treated with epinephrine 0.4 mg/kg IV, n = 10), or a pacing group (Pac-gro, treated with normal saline 1 mL IV combined with transoesophageal cardiac pacing, n = 10) in a blinded fashion during resuscitation after 10 minutes of asphyxial cardiac arrest. Manual chest compression was in all cases performed using the same methodology by the same personnel who was blinded to hemodynamic monitor tracings. The rate of restoration of spontaneous circulation was 1 (10%), 7 (70%), and 8 (80%) of 10 in Sal-gro, Epi-gro, and Pac-gro, respectively. The rate of ventilator withdrawal within 60 minutes after resuscitation in Pac-gro was higher than that of Epi-gro (8/8 vs 1/7, respectively; P = .001); the survival rate after 2 hours in Pac-gro was significantly higher than that in Epi-gro (7/8 vs 1/7, respectively; P = .01). The data demonstrate that both epinephrine and transoesophageal cardiac pacing are effective within 10 minutes of asphyxia in rats. It is worth noting that transoesophageal cardiac pacing produced a better outcome with respiration and longer survival time compared with epinephrine after restoration of spontaneous circulation.
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Affiliation(s)
- Meng-Hua Chen
- Institute of Cardiovascular Diseases, First Affiliated Hospital of Guangxi Medical University, Nanning 530027, PR China.
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Wyckoff MH, Perlman JM. Use of high-dose epinephrine and sodium bicarbonate during neonatal resuscitation: is there proven benefit? Clin Perinatol 2006; 33:141-51, viii-ix. [PMID: 16533640 DOI: 10.1016/j.clp.2005.11.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
For adults and pediatric age patients, high-dose intravenous epinephrine was recommended if standard-dose epinephrine failed to achieve return of spontaneous circulation. More recent trials suggest that high-dose epinephrine is not beneficial and may result in increased harm. There are no randomized clinical studies of high-dose versus standard-dose intravenous epinephrine in neonates. Routine use of high-dose epinephrine during neonatal resuscitation cannot be recommended. Although sodium bicarbonate has been used during neonatal resuscitation, the only randomized controlled trial of its use during brief neonatal resuscitation showed no benefit. Sodium bicarbonate infusion during neonatal cardiopulmonary resuscitation (CPR) has several known and potential side effects. The use of sodium bicarbonate infusion should be discouraged during brief CPR. Whether sodium bicarbonate is beneficial for infants who require prolonged CPR despite adequate ventilation is unknown.
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Affiliation(s)
- Myra H Wyckoff
- Department of Pediatrics, Division of Neonatal/Perinatal Medicine, University of Texas, Southwestern Medical Center, Dallas, TX 75390-9063, USA.
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Affiliation(s)
- Gordon A Ewy
- University of Arizona Sarver Heart Center, University of Arizona, Tucson, Ariz 85724, USA.
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Winning J. Adrenalingabe zur Reanimation von Kindern. Anaesthesist 2004; 53:1241-2. [PMID: 15597165 DOI: 10.1007/s00101-004-0761-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- J Winning
- Klinik für Anaesthesiologie und Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar.
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Vasquez A, Kern KB, Hilwig RW, Heidenreich J, Berg RA, Ewy GA. Optimal dosing of dobutamine for treating post-resuscitation left ventricular dysfunction. Resuscitation 2004; 61:199-207. [PMID: 15135197 DOI: 10.1016/j.resuscitation.2004.01.002] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study was designed to determine the optimal dose of dobutamine in the treatment of post-resuscitation left ventricular dysfunction. BACKGROUND Global left ventricular dysfunction following successful resuscitation from prolonged, ventricular fibrillation cardiac arrest, negatively impacts long-term survival. Dobutamine can overcome this global myocardial stunning. Previous data indicate a dose of 10 mcg/kgmin improves systolic and diastolic function, but markedly increases the heart rate. METHODS Twenty swine (24 +/- 0.4 kg) were randomized to one of four doses (0, 2, 5, and 7.5 mcg/kgmin) of dobutamine for the treatment of post-resuscitation myocardial dysfunction following 12.5 min of untreated ventricular fibrillation cardiac arrest. Cardiac function was measured at pre-arrest baseline and serially for 6 h post-resuscitation. Left ventricular function was evaluated by contrast ventriculograms, left ventricular pressures, +dP/dt, Tau, -dP/dt, and cardiac output. Myocardial oxygen consumption and myocardial blood flow were measured to assess the functional significance of any dobutamine-mediated heart rate responses. RESULTS Left ventricular dysfunction was evident at 25 min and peaked 4 h post-resuscitation. Significant (P < 0.05) improvements in ventricular systolic (EF, CO) and diastolic (LVEDP, Tau) function were evident within minutes of dobutamine initiation and persisted at 6h for the 5 and 7.5 mcg/kgmin groups. Tachycardia manifested with all dobutamine doses, but only affected myocardial oxygen consumption significantly (P < 0.05) at the highest dose (7.5 mcg/kgmin). CONCLUSIONS Dobutamine at 5 mcg/kgmin appears optimal for restoring systolic and diastolic function post-resuscitation without adversely affecting myocardial oxygen consumption.
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Affiliation(s)
- Alejandro Vasquez
- Section of Cardiology, Department of Medicine, Sarver Heart Center, University of Arizona College of Medicine, 1501 N. Campbell Avenue, Tucson, AZ 85724, USA
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Perondi MBM, Reis AG, Paiva EF, Nadkarni VM, Berg RA. A comparison of high-dose and standard-dose epinephrine in children with cardiac arrest. N Engl J Med 2004; 350:1722-30. [PMID: 15102998 DOI: 10.1056/nejmoa032440] [Citation(s) in RCA: 182] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND When efforts to resuscitate a child after cardiac arrest are unsuccessful despite the administration of an initial dose of epinephrine, it is unclear whether the next dose of epinephrine (i.e., the rescue dose) should be the same (standard) dose or a higher dose. METHODS We performed a prospective, randomized, double-blind trial to compare high-dose epinephrine (0.1 mg per kilogram of body weight) with standard-dose epinephrine (0.01 mg per kilogram) as rescue therapy for in-hospital cardiac arrest in children after failure of an initial, standard dose of epinephrine. The trial included 68 children, and Utstein-style reporting guidelines were used. The primary outcome measure was survival 24 hours after the arrest. RESULTS The rate of survival at 24 hours was lower in the group assigned to a high dose of epinephrine as rescue therapy than in the group assigned to a standard dose: 1 of the 34 patients in the high-dose group survived for 24 hours, as compared with 7 of the 34 patients in the standard-dose group (unadjusted odds ratio for death with the high dose, 8.6; 97.5 percent confidence interval, 1.0 to 397.0; P=0.05). After adjustment by multiple logistic-regression analysis for differences in the groups at the time of arrest, the high-dose group tended to have a lower 24-hour survival rate (odds ratio for death, 7.9; 97.5 percent confidence interval, 0.9 to 72.5; P=0.08). The two treatment groups did not differ significantly in terms of the rate of return of spontaneous circulation (which occurred in 20 patients in the high-dose group and 21 of those in the standard-dose group; odds ratio, 1.1; 97.5 percent confidence interval, 0.4 to 3.0). None of the patients in the high-dose group, as compared with four of those in the standard-dose group, survived to hospital discharge. Among the 30 patients whose cardiac arrest was precipitated by asphyxia, none of the 12 who were assigned to high-dose epinephrine were alive at 24 hours, as compared with 7 of the 18 who were assigned to a standard dose (P=0.02). CONCLUSIONS We did not find any benefit of high-dose epinephrine rescue therapy for in-hospital cardiac arrest in children after failure of an initial standard dose of epinephrine. The data suggest that high-dose therapy may be worse than standard-dose therapy.
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Klouche K, Weil MH, Sun S, Tang W, Povoas H, Bisera J. Stroke volumes generated by precordial compression during cardiac resuscitation. Crit Care Med 2002; 30:2626-31. [PMID: 12483049 DOI: 10.1097/00003246-200212000-00002] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To quantitate stroke volumes generated by precordial compression during cardiopulmonary resuscitation and to determine their relationship to coronary perfusion pressure and the success of resuscitation. DESIGN Prospective, observational animal study. SETTING Medical research laboratory in a university-affiliated research and educational foundation. SUBJECTS Domestic pigs. INTERVENTIONS Ventricular fibrillation was electrically induced in 25 anesthetized male domestic pigs. After an interval of 7 mins, electrical defibrillation was attempted. Failing to reverse ventricular fibrillation in each instance, precordial compression was begun coincident with mechanical ventilation. MEASUREMENTS AND MAIN RESULTS Stroke volumes were computed from differences between diastolic and systolic areas of the left ventricle by utilizing transesophageal echocardiography. Both stroke volumes and coronary perfusion pressure were consistently greater in successfully resuscitated animals. Progressive decreases in stroke volumes during precordial compression were predictive of unsuccessful resuscitation. A linear correlation between stroke volume and coronary perfusion pressure (r =.70) was documented. CONCLUSION These observations support the concept that stroke volumes generated by precordial compression are quantitatively related to the coronary perfusion pressure and to the success of cardiopulmonary resuscitation.
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Affiliation(s)
- Kada Klouche
- Institute of Critical Care Medicine, Palm Springs, CA, USA
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Klouche K, Weil MH, Tang W, Povoas H, Kamohara T, Bisera J. A selective alpha(2)-adrenergic agonist for cardiac resuscitation. THE JOURNAL OF LABORATORY AND CLINICAL MEDICINE 2002; 140:27-34. [PMID: 12080325 DOI: 10.1067/mlc.2002.125177] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The effects of selective alpha(2)-adrenergic agonist alpha-methylnorepinephrine on the initial success of resuscitation and postresuscitation myocardial function were compared with nonselective alpha- and beta-adrenergic epinephrine in a swine model of cardiac arrest. Epinephrine, the primary pharmacological intervention in the treatment of cardiac arrest, improves immediate outcome. However, epinephrine increases the severity of myocardial dysfunction after cardiac resuscitation. Both inotropic and chronotropic actions provoke disproportionate increases in myocardial oxygen consumption by the ischemic heart, prompting this study, in which we hypothesized that a selective alpha(2)-adrenergic agonist, alpha-methylnorepinephrine (alpha-MNE), would moderate these adverse effects of epinephrine and minimize postresuscitation myocardial dysfunction. After 7 minutes of untreated ventricular fibrillation (VF) in 14 anesthetized male domestic pigs, precordial compression at a fixed rate of 80 compressions/min was begun, along with mechanical ventilation. Either alpha-MNE (100 microg/kg) or epinephrine (20 microg/kg) was administered as a bolus after 2 minutes of precordial compression. After an additional 4 minutes of precordial compression, defibrillation was attempted. Left ventricular systolic and diastolic function was quantitated with the use of transesophageal echo-Doppler imaging. Comparable increases in coronary perfusion pressure to 15 mm Hg were observed after the administration of both drugs. All animals were successfully resuscitated; epinephrine and alpha-MNE were equally quick in restoring spontaneous circulation after 7 minutes of untreated VF. Ejection fraction was reduced by 35% and 14% by epinephrine and alpha-MNE, respectively, after resuscitation. Epinephrine and alpha-MNE increased postresuscitation heart rate by 38% and 15%, respectively. Accordingly, significantly less postresuscitation impairment followed the administration of alpha-MNE. alpha-MNE, a selective alpha-adrenergic agonist, was as effective as epinephrine in restoring spontaneous circulation after 7 minutes of untreated VF in a porcine model for CPR and demonstrated lesser postresuscitation myocardial injury.
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Affiliation(s)
- Kada Klouche
- Institute of Critical Care Medicine, Palm Springs, CA 92262-5309, USA.
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Hamprecht FA, Achleitner U, Krismer AC, Lindner KH, Wenzel V, Strohmenger HU, Thiel W, van Gunsteren WF, Amann A. Fibrillation power, an alternative method of ECG spectral analysis for prediction of countershock success in a porcine model of ventricular fibrillation. Resuscitation 2001; 50:287-96. [PMID: 11719158 DOI: 10.1016/s0300-9572(01)00359-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Noninvasive prediction of defibrillation success after cardiac arrest and cardiopulmonary resuscitation (CPR) may help in determining the optimal time for a countershock, and thus increase the chance for survival. METHODS In a porcine model (n=25) of prolonged cardiac arrest, advanced cardiac life support was provided by administration of two or three doses of either vasopressin or epinephrine after 3 or 8 min of basic life support. After 4 min of ventricular fibrillation and 18 min of life support, defibrillation was attempted. The denoised power spectral density of 10 s intervals of the ventricular fibrillation electrocardiogram (ECG) was estimated from averaged and smoothed Fourier transforms. We have eliminated the spectral contribution of artifacts from manual chest compressions and provide a definition for the contribution of ventricular fibrillation to the power spectral density. This contribution is quantified and termed "fibrillation power". RESULTS We tested fibrillation power and two established methods in their discrimination of survivors (n=16) vs. non-survivors (n=9) in the last minute before the countershock. A fibrillation power > or =79 dB predicted successful defibrillation with sensitivity, specificity, positive predictive value and negative predictive value of 98%, 98%, 99% and 97% while a mean fibrillation frequency > or =7.7 Hz was predictive with 85%, 83%, 90% and 77% and a mean amplitude > or =0.49 mV was predictive with 95%, 90%, 94% and 91%. CONCLUSIONS We suggest that fibrillation power is an alternative source of information on the status of a fibrillating heart and that it may match the established mean frequency and amplitude analysis of ECG in predicting successful countershock during CPR.
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Affiliation(s)
- F A Hamprecht
- Laboratory of Physical Chemistry, Swiss Federal Institute of Technology, ETH Zentrum, 8092 Zurich, Switzerland.
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Gedeborg R, Silander HC, Rubertsson S, Wiklund L. Cerebral ischaemia in experimental cardiopulmonary resuscitation--comparison of epinephrine and aortic occlusion. Resuscitation 2001; 50:319-29. [PMID: 11719162 DOI: 10.1016/s0300-9572(01)00350-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The apparent inability of epinephrine to improve outcome after cardiopulmonary resuscitation (CPR) could be caused by direct negative effects on the cerebral circulation. Constant aortic occlusion with a balloon catheter could be an alternative way to improve coronary and cerebral perfusion during CPR. The objective of the present study was to compare the effects of standard-dose epinephrine with balloon occlusion of the descending aorta on cortical cerebral blood flow augmentation during CPR. Ventricular fibrillation was induced in 24 anaesthetised piglets. A non-intervention interval of 9 min was followed by open-chest CPR. The animals were randomised to receive repeated intravenous bolus doses of epinephrine 20 microg/kg or balloon occlusion of the descending aorta. Focal cortical cerebral blood flow was measured continuously using laser-Doppler flowmetry. Balloon occlusion of the aorta resulted in a significantly higher mean cortical cerebral blood flow and a lower cerebral oxygen extraction ratio than epinephrine during CPR. After restoration of spontaneous circulation the cerebral perfusion appeared compromised to the same extent in both groups, with lower blood flow compared to baseline, high cerebral oxygen extraction and cerebral tissue acidosis. No difference in cerebral cortical vascular resistance between the two groups could be detected. It is concluded that aortic balloon occlusion was superior to epinephrine in cerebral blood flow augmentation during resuscitation and did not generate adverse effects on cerebral blood flow, oxygenation or tissue pH after restoration of spontaneous circulation. No evidence of cerebral vasoconstriction induced by standard-dose epinephrine was found.
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Affiliation(s)
- R Gedeborg
- Department of Anaesthesiology & Intensive Care, Uppsala University Hospital, S-751 85 Uppsala, Sweden.
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Amann A, Achleitner U, Antretter H, Bonatti JO, Krismer AC, Lindner KH, Rieder J, Wenzel V, Voelckel WG, Strohmenger HU. Analysing ventricular fibrillation ECG-signals and predicting defibrillation success during cardiopulmonary resuscitation employing N(alpha)-histograms. Resuscitation 2001; 50:77-85. [PMID: 11719133 DOI: 10.1016/s0300-9572(01)00322-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mean fibrillation frequency may predict defibrillation success during cardiopulmonary resuscitation (CPR). N(alpha)-histogram analysis should be investigated as an alternative. After 4 min of cardiac arrest, and 3 versus 8 min of CPR, 25 pigs received either vasopressin or epinephrine (0.4, 0.4, and 0.8 U/kg vasopressin versus 45, 45, and 200 microg/kg epinephrine) every 5 min with defibrillation at 22 min. Before defibrillation, the N(alpha)-parameter histogramstart/histogramwidth and the mean fibrillation frequency in resuscitated versus non-resuscitated pigs were 2.9+/-0.4 versus 1.7+/-0.5 (P=0.0000005); and 9.5+/-1.7 versus 6.9+/-0.7 (P=0.0003). During the last minute prior to defibrillation, histogramstart/histogramwidth of > or =2.3 versus mean fibrillation frequency > or =8 Hz predicted successful defibrillation with subsequent return of a spontaneous circulation for more than 60 min with sensitivity, specificity, positive predictive value and negative predictive value of 94 versus 82%, 96 versus 89%, 98 versus 93% and 90 versus 74%, respectively. We conclude, that N(alpha)-analysis was superior to mean fibrillation frequency analysis during CPR in predicting defibrillation success, and distinction between vasopressin versus epinephrine effects.
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Affiliation(s)
- A Amann
- Department of Anesthesiology and Critical Care, The Leopold-Franzens University, Anichstrasse 35, 6020, Innsbruck, Austria
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Eftestøl T, Sunde K, Aase SO, Husøy JH, Steen PA. "Probability of successful defibrillation" as a monitor during CPR in out-of-hospital cardiac arrested patients. Resuscitation 2001; 48:245-54. [PMID: 11278090 DOI: 10.1016/s0300-9572(00)00266-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The frequency spectrum of the ECG in ventricular fibrillation (VF) correlates with myocardial perfusion and might predict defibrillation success defined as return of spontaneous circulation (ROSC). The predictive power increases when more spectral variables are combined, but the complex information can be difficult to handle during the intensity of CPR. We therefore developed a method for expressing this multidimensional information in a single reproducible variable reflecting the probability of defibrillation success. This is based on the highest performing predictor for ROSC after 883 shocks given to 156 patients with VF. This was a combination of two decorrelated spectral features based on a principal component analysis of an original feature set with information on centroid frequency, peak power frequency, spectral flatness and energy. The function "Probability of defibrillation success" (P(ROSC)(v)) was developed by a 2-dimensional histogram technique. P(ROSC)(v) discriminated between shocks followed by ROSC and No-ROSC (P<0.0001). The present methodology indicates a possible way to develop a CPR monitor.
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Affiliation(s)
- T Eftestøl
- Stavanger University College, Department of Electrical and Computer Engineering, P.O. Box 2557, Ullandhaug, N-4091, Stavanger Norway.
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Voelckel WG, Lurie KG, McKnite S, Zielinski T, Lindstrom P, Peterson C, Krismer AC, Lindner KH, Wenzel V. Comparison of epinephrine and vasopressin in a pediatric porcine model of asphyxial cardiac arrest. Crit Care Med 2000; 28:3777-83. [PMID: 11153614 DOI: 10.1097/00003246-200012000-00001] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This study was designed to compare the effects of vasopressin vs. epinephrine vs. the combination of epinephrine with vasopressin on vital organ blood flow and return of spontaneous circulation in a pediatric porcine model of asphyxial arrest. DESIGN Prospective, randomized laboratory investigation using an established porcine model for measurement of hemodynamic variables, organ blood flow, blood gases, and return of spontaneous circulation. SETTING University hospital laboratory. SUBJECTS Eighteen piglets weighing 8-11 kg. INTERVENTIONS Asphyxial cardiac arrest was induced by clamping the endotracheal tube. After 8 mins of cardiac arrest and 8 mins of cardiopulmonary resuscitation, a bolus dose of either 0.8 units/kg vasopressin (n = 6), 200 microg/kg epinephrine (n = 6), or a combination of 45 microg/kg epinephrine with 0.8 units/kg vasopressin (n = 6) was administered in a randomized manner. Defibrillation was attempted 6 mins after drug administration. MEASUREMENTS AND MAIN RESULTS Mean +/- SEM coronary perfusion pressure, before and 2 mins after drug administration, was 13 +/- 2 and 23 +/- 6 mm Hg in the vasopressin group; 14 +/- 2 and 31 +/- 4 mm Hg in the epinephrine group; and 13 +/- 1 and 33 +/- 6 mm Hg in the epinephrine-vasopressin group, respectively (p = NS). At the same time points, mean +/- SEM left ventricular myocardial blood flow was 44 +/- 31 and 44 +/- 25 mL x min-(1) x 100 g(-1) in the vasopressin group; 30 +/- 18 and 233 +/- 61 mL x min(-1) x 100 g(-1) in the epinephrine group; and 36 +/- 10 and 142 +/- 57 mL x min(-1) x 100 g(-1) in the epinephrine-vasopressin group (p < .01 epinephrine vs. vasopressin; p < .02 epinephrine-vasopressin vs. vasopressin). Total cerebral blood flow trended toward higher values after epinephrine-vasopressin (60 +/- 19 mL x min(-1) x 100 g(-1)) than after vasopressin (36 +/- 17 mL x min(-1) x 100 g(-1)) or epinephrine alone (31 +/- 7 mL x min(-1) x 100 g(-1); p = .07, respectively). One of six vasopressin, six of six epinephrine, and four of six epinephrine-vasopressin-treated animals had return of spontaneous circulation (p < .01, vasopressin vs. epinephrine). CONCLUSIONS Administration of epinephrine, either alone or in combination with vasopressin, significantly improved left ventricular myocardial blood flow during cardiopulmonary resuscitation. Return of spontaneous circulation was significantly more likely in epinephrine-treated pigs than in animals resuscitated with vasopressin alone.
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Affiliation(s)
- W G Voelckel
- Cardiac Arrhythmia Center, Department of Medicine, University of Minnesota 55455, USA
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42
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Kern KB. Coronary perfusion pressure during cardiopulmonary resuscitation. Best Pract Res Clin Anaesthesiol 2000. [DOI: 10.1053/bean.2000.0109] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Hilwig RW, Berg RA, Kern KB, Ewy GA. Endothelin-1 vasoconstriction during swine cardiopulmonary resuscitation improves coronary perfusion pressures but worsens postresuscitation outcome. Circulation 2000; 101:2097-102. [PMID: 10790353 DOI: 10.1161/01.cir.101.17.2097] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Vasoconstriction during cardiopulmonary resuscitation (CPR) improves coronary perfusion pressure (CPP) and thereby outcome. The combination of endothelin-1 (ET-1) plus epinephrine improved CPP during CPR compared with epinephrine alone in a canine cardiac arrest model. The effect of the combination on outcome variables, such as successful resuscitation and survival, has not been investigated. METHODS AND RESULTS Twenty-seven swine were randomly provided with 1 mg epinephrine (Epi group) or 1 mg epinephrine plus 0.1 mg ET-1 (ET-1 group) during a prolonged ventricular fibrillatory cardiac arrest. ET-1 resulted in substantially superior aortic relaxation pressure and CPP during CPR. These hemodynamic improvements tended to increase initial rates of restoration of spontaneous circulation (8 of 10 versus 8 of 17, P=0.12). However, continued intense vasoconstriction from ET-1 led to higher aortic diastolic pressure and very narrow pulse pressure after resuscitation. The mean pulse pressure 1 hour after resuscitation was 7+/-8 mm Hg with ET-1 versus 24+/-1 mm Hg with Epi, P<0.01. Most importantly, the postresuscitation mortality was dramatically higher in the ET-1 group (6 of 8 versus 0 of 8 in the Epi group, P<0.01). CONCLUSIONS These data establish that administration of ET-1 during CPR can result in worse postresuscitation outcome. The intense vasoconstriction from ET-1 improved CPP during CPR but had detrimental effects in the postresuscitation period.
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Affiliation(s)
- R W Hilwig
- University of Arizona Department of Medicine, Tucson, AZ, USA
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Gedeborg R, Silander HC, Ronne-Engström E, Rubertsson S, Wiklund L. Adverse effects of high-dose epinephrine on cerebral blood flow during experimental cardiopulmonary resuscitation. Crit Care Med 2000; 28:1423-30. [PMID: 10834690 DOI: 10.1097/00003246-200005000-00028] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To study the effects of high-dose epinephrine, compared with standard-dose epinephrine, on the dynamics of superficial cortical cerebral blood flow as well as global cerebral oxygenation during experimental cardiopulmonary resuscitation. We hypothesized that high-dose epinephrine might be unable to improve cerebral blood flow during cardiopulmonary resuscitation as compared with standard-dose epinephrine. DESIGN Randomized controlled study. SETTING University hospital research laboratory. SUBJECTS A total of 20 male anesthetized piglets. INTERVENTIONS Ventricular fibrillation was induced. A nonintervention interval of 8 mins was followed by open-chest cardiopulmonary resuscitation. The animals were randomized to receive repeated bolus injections of either 20 microg/kg (standard-dose group, n = 10) or 200 microg/kg (high-dose group, n = 10) of epinephrine. MEASUREMENTS AND MAIN RESULTS Focal cortical cerebral blood flow was measured continuously by using laser Doppler flowmetry. The duration of blood flow increase was significantly shorter in the high-dose group after the second dose of epinephrine. In the high-dose group there was also a consistent tendency for lower peak levels and shorter duration of flow increase in response to repeated bolus doses of epinephrine. Cerebral oxygen extraction ratio was significantly lower in the high-dose group after administration of epinephrine. CONCLUSIONS Repeated bolus doses of epinephrine 200 microg/kg, as compared with 20 microg/kg, do not improve superficial cortical cerebral blood flow during experimental open-chest cardiopulmonary resuscitation. High-dose epinephrine appears to induce vasoconstriction of cortical cerebral blood vessels resulting in redistribution of blood flow from superficial cortex. This might be one explanation for the failure of high-dose epinephrine to improve overall outcome in clinical trials.
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Affiliation(s)
- R Gedeborg
- Department of Surgical Sciences, Anesthesiology & Intensive Care, Uppsala University Hospital, Sweden.
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45
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Bar-Joseph G, Weinberger T, Ben-Haim S. Response to repeated equal doses of epinephrine during cardiopulmonary resuscitation in dogs. Ann Emerg Med 2000; 35:3-10. [PMID: 10613934 DOI: 10.1016/s0196-0644(00)70098-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE Advanced cardiac life support (ACLS) guidelines recommend a 3- to 5-minute interval between repeated doses of epinephrine. This recommendation does not take into account the dose of epinephrine used, and only very limited data exist regarding the hemodynamic responses to repeated "high" doses of epinephrine. The objective of this study was to analyze the hemodynamic responses to repeated, equal, high doses of epinephrine administered during cardiopulmonary resuscitation (CPR) in a canine model of ventricular fibrillation (VF). METHODS This study used a secondary analysis of data collected in a prospective, randomized study, primarily designed to assess the effects of acid buffers in a canine model of cardiac arrest. VF was electrically induced. After 10 minutes, CPR was initiated, including ventilation with FIO(2)=1.0, external chest compressions, administration of epinephrine (0.1 mg/kg repeated every 5 minutes) and defibrillation. Animals were randomized to receive either NaHCO(3), Carbicarb, tromethamine (THAM), or NaCl. The hemodynamic variables were sampled from each experiment's paper chart at 1-minute intervals, and the responses to the first 4 doses of epinephrine were compared. RESULTS Thirty-six animals (9 in each buffer group) were included in this analysis. Systolic, diastolic, and coronary perfusion pressures increased steeply (by 100%, 130%, and 190%, respectively) only after the first epinephrine dose. These pressures peaked at 2 to 3 minutes and decreased only slightly and insignificantly during the rest of the 5-minute interval, until the next epinephrine dose. No further significant increases in arterial pressures were observed in response to the next 3 doses of epinephrine, administered 5 minutes apart. CONCLUSION The hemodynamic effects of high-dose epinephrine (0.1 mg/kg) during CPR appear to last longer than 5 minutes. Therefore, longer intervals between doses may be justified with high doses of epinephrine.
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Affiliation(s)
- G Bar-Joseph
- Pediatric Intensive Care Unit, Rambam Medical Center, and the Department of Physiology, the Bruce Rappaport Faculty of Medicine and the Rappaport Institute for Research in the Medical Sciences, Haifa, Israel.
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46
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Herlitz J, Bahr J, Fischer M, Kuisma M, Lexow K, Thorgeirsson G. Resuscitation in Europe: a tale of five European regions. Resuscitation 1999; 41:121-31. [PMID: 10488934 DOI: 10.1016/s0300-9572(99)00045-3] [Citation(s) in RCA: 137] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
AIM To describe cardiac arrest data from five emergency medical services (EMS) systems in Europe with regard to survival from an out-of-hospital cardiac arrest. METHODS Based on recommendations from various countries in Europe EMS systems were approached with regard to survival from out-of-hospital cardiac arrest. Five EMS systems were asked to report their cardiac arrest data according to the Utstein style. RESULTS The five selected EMS systems were: Bonn (Germany), Göttingen (Germany), Helsinki (Finland), Reykjavik (Iceland) and Stavanger (Norway). For patients with a bystander witnessed arrest of cardiac aetiology the percentage of patients being discharged alive from hospital in these regions were: 21, 33, 23, 23 and 35. The corresponding percentages for patients fulfilling criteria as above and being found in ventricular fibrillation were: 32, 42, 32, 27 and 55. CONCLUSIONS Many EMS systems in Europe show extremely good results in terms of survival after an out-of-hospital cardiac arrest. Some of the results should be interpreted with caution since they were based on relatively small sample sizes. Furthermore, the results from one of the regions (Stavanger) was unit based and not community based.
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Affiliation(s)
- J Herlitz
- Division of Cardiology, Sahlgrenska University Hospital, Göteborg, Sweden
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Babar SI, Berg RA, Hilwig RW, Kern KB, Ewy GA. Vasopressin versus epinephrine during cardiopulmonary resuscitation: a randomized swine outcome study. Resuscitation 1999; 41:185-92. [PMID: 10488942 DOI: 10.1016/s0300-9572(99)00071-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In animal models, vasopressin improves short-term outcome after cardiopulmonary resuscitation (CPR) for ventricular fibrillation compared to placebo, and improves myocardial and cerebral hemodynamics during CPR compared to epinephrine. This study was designed to test the hypothesis that vasopressin would improve 24-h neurologically intact survival compared to epinephrine. After a 2-min untreated ventricular fibrillation interval followed by 6 min of simulated bystander CPR, 35 domestic swine (weight, 25+/-1 kg) were randomly provided with a single dose of vasopressin (20 U or approximately 0.8 U kg(-1) intravenously) or with epinephrine (0.02 mg kg(-1) intravenously every 5 min). Ten minutes after initial medication administration (18 min after induction of ventricular fibrillation), standard advanced life support was provided, starting with defibrillation. Animals that were successfully resuscitated received 1 h of intensive care support and were observed for 24 h. Coronary perfusion pressures were higher in the vasopressin group 2 and 4 min after vasopressin administration (28+/-2 versus 18+/-1 mm Hg, P<0.01, and 26+/-3 versus 18+/-2 mm Hg, P<0.05, respectively). The vasopressin group tended to be successfully defibrillated on the first attempt more frequently (8/18 versus 3/17, P = 0.15). Return of spontaneous circulation (ROSC) was attained in 12/18 (67%) vasopressin-treated pigs versus 8/17 (47%) epinephrine-treated pigs, P = 0.24. Twenty-four hour neurologically normal survival occurred in 11/18 (61%) versus 7/17 (41%), respectively, P = 0.24. In conclusion, vasopressin administration during CPR improved coronary perfusion pressure, but did not result in statistically significant outcome improvement.
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Affiliation(s)
- S I Babar
- Sarver Heart Center, The University of Arizona, Pediatrics/3302, Department of Medicine, The University of Arizona College of Medicine, Tuscon, AZ 85724-5073, USA
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Morimoto Y, Kemmotsu O, Morimoto Y, Gando S. End-tidal carbon dioxide and resuscitation. Curr Opin Anaesthesiol 1999; 12:173-7. [PMID: 17013310 DOI: 10.1097/00001503-199904000-00011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In this review, we attempted to summarize the effectiveness and the limitation of end-tidal carbon dioxide monitoring during cardiopulmonary resuscitation. End-tidal carbon dioxide can be an indicator of the real return of spontaneous circulation and can also be an indicator of the effectiveness of cardiac massage. We cannot, however, estimate the prognosis of cardiopulmonary resuscitation from the end-tidal carbon dioxide value. We concluded that cardiopulmonary resuscitation should never be abandoned for the sole reason that the end-tidal carbon dioxide value is low.
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Affiliation(s)
- Y Morimoto
- Department of Anesthesiology and Intensive Care, Hokkaido University School of Medicine, Sapporo, Japan.
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49
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Ward KR, Yealy DM. End-tidal carbon dioxide monitoring in emergency medicine, Part 2: Clinical applications. Acad Emerg Med 1998; 5:637-46. [PMID: 9660293 DOI: 10.1111/j.1553-2712.1998.tb02474.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
End-tidal carbon dioxide (PetCO2) monitoring is becoming more common in both the ED and the out-of-hospital setting. Its main use has been as an aid when confirming endotracheal intubation. Other uses in the ED include monitoring CPR efforts and monitoring the ventilatory and hemodynamic status of intubated and nonintubated patients. In addition, future uses may include using PetCO2 as an adjunct when monitoring the status of asthma treatment, when making the diagnosis of pulmonary embolism, and when measuring cardiac output noninvasively. This article reviews these specific uses of PetCO2 monitoring in emergency medicine.
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Affiliation(s)
- K R Ward
- Department of Emergency Medicine, Case Western Reserve University-Henry Ford Health Sciences Center, Henry Ford Hospital, Detroit, MI 48202, USA.
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50
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Blumenthal SR, Voorhees WD. The relationship of carbon dioxide excretion during cardiopulmonary resuscitation to regional blood flow and survival. Resuscitation 1997; 35:135-43. [PMID: 9316197 DOI: 10.1016/s0300-9572(97)00039-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Currently, there are no practical means of prospectively determining cardiopulmonary resuscitation (CPR) adequacy in the field. Airway CO2 excretion can be noninvasively and stably measured under changing environmental conditions. We investigated the relationships between the volume of airway CO2 excreted (CO2EX) during CPR to regional blood flow (RBF) and survival. A total of 21 dogs were randomly divided into four CO2EX groups (< 5, 5-6, > 6-7 and > 7 ml CO2/min per kg), anesthetized, instrumented and ventilated with an in-line infrared airway CO2 sensor. Anesthesia was reduced and baseline measurements made. Ventricular fibrillation (VF) was initiated and resuscitation withheld for 3 min, followed by 17 min of CPR. Compression force alone was adjusted to maintain predetermined CO2EX. Animals were resuscitated, monitored for 2 h and observed for an additional 22 h. RBF was determined at baseline, 16 min post-VF and 60 min post-resuscitation. Mean CO2EX during CPR was significantly higher in survivors than nonsurvivors. The probability of survival increased as CO2EX increased. The highest CO2EX group had the highest rate of survival (86%), but did not always have significantly higher cardiac output (CO), myocardial or cerebral blood flows (MBF, CBF) than the lowest CO2EX group with a 0% survival rate. These data suggest survival is tracked better by CO2EX than by CO, MBF or CBF. Therefore, CO2EX appears to provide a practical reliable noninvasive method of determining CPR efficacy in the field.
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Affiliation(s)
- S R Blumenthal
- Department of Comparative Medicine, Carolinas Medical Center, Charlotte NC 28232-2861, USA.
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