A technique revisited: hemodynamic comparison of closed- and open-chest cardiac massage during human cardiopulmonary resuscitation

Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy are associated with similar outcomes in traumatic cardiac arrest

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive alternative to resuscitative thoracotomy (RT) for patients with hemorrhagic shock. However, the potential benefits of this approach remain subject of debate. The aim of this study was to compare the outcomes of REBOA and RT for traumatic cardiac arrest.

METHODS

A planned secondary analysis of the United States Department of Defense-funded Emergent Truncal Hemorrhage Control study was performed. Between 2017 and 2018, a prospective observational study of noncompressible torso hemorrhage was conducted at six Level I trauma centers. Patients were dichotomized by REBOA or RT, and baseline characteristics and outcomes were compared between groups.

RESULTS

A total of 454 patients were enrolled in the primary study, of which 72 patients were included in the secondary analysis (26 underwent REBOA and 46 underwent resuscitative thoracotomy). Resuscitative endovascular balloon occlusion of the aorta patients were older, had a greater body mass index, and were less likely to be the victims of penetrating trauma. Resuscitative endovascular balloon occlusion of the aorta patients also had less severe abdominal injuries and more severe extremity injuries, although the overall injury severity scores were similar. There was no difference in mortality between groups (88% vs. 93%, p = 0.767). However, time to aortic occlusion was longer in REBOA patients (7 vs. 4 minutes, p = 0.001) and they required more transfusions of red blood cells (4.5 vs. 2.5 units, p = 0.007) and plasma (3 vs. 1 unit, p = 0.032) in the emergency department. After adjusted analysis, mortality remained similar between groups (RR, 0.89; 95% confidence interval, 0.71-1.12, p = 0.304).

CONCLUSION

Resuscitative endovascular balloon occlusion of the aorta and RT were associated with similar survival after traumatic cardiac arrest, although time to successful aortic occlusion was longer in the REBOA group. Further research is needed to better define the role of REBOA in trauma.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery

INTRODUCTION

Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines.

MATERIAL AND METHODS

The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches.

RESULTS

This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy.

CONCLUSIONS

Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery

INTRODUCTION

Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines.

MATERIAL AND METHODS

The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches.

RESULTS

This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy.

CONCLUSION

Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.

Postoperative Cardiac Arrest in Cardiac Surgery-How to Improve the Outcome?

Background

In the early postoperative period after cardiac surgery the heart may be temporarily dysfunctional and prone to arrhythmias due to the phenomenon of myocardial stunning, vasoplegic syndrome, systemic inflammatory response syndrome (SIRS), electrolyte disturbances, operative trauma and myocardial edema. Most cases of cardiac arrest after cardiac surgery are reversible.

Objective

To analyse the factors that may influence the outcome of cardiac arrest after adult and pediatric cardiac surgery.

Methods

Retrospective analysis that included cardiac surgical procedures (886 adult and 749 pediatric patients) performed during the 18 month period of this study at Queen Alia Heart Institute/ Amman, Jordan. All cardiac arrest events were recorded and analysed. Data was collected on Utstein style templates designed for the purpose of this study. The outcome of cardiac arrest is examined as an early outcome (ROSC or lethal outcome) and late outcome (full recovery, recovery with complications, or in-hospital mortality). Factors that may influence the outcome of cardiac arrest were recorded and statistically analysed. Ethical committee approval obtained.

Results

The overall mortality rate was 3.3%. Cardiac arrest occurred in 114 patients (6.97%). The age of patients ranged from 5 days to 82 years and constituted 66 pediatric and 48 adult patients. Most pediatric cardiac arrests manifested as non-shockable rhythms (77%). Most in-hospital cardiac arrests occurred in the intensive care unit (86.5%). The majority of patients were mechanically ventilated at the time of occurrence of arrest (62.5% and 54.5% in adult and pediatric patients, respectively). Average time of cardiopulmonary resuscitation was 32.24 minutes. Overall, CA survival was 20% higher in the paediatric sub-group (full recovery rate of 51.5%). Neurological injury was slightly lower in pediatric than adult cardiac arrest survivals. (2% vs. 3%).

Conclusion

Shockable rhythms are more common in adult cardiac arrest, while non-shockable rhythms are more frequent in the pediatric sub-population. Hemodynamic monitoring, witnessed-type of cardiac arrest, non-interrupted cardiac massage, and early recognition of cardiac tamponade are the factors associated with higher rates of survival.

Resuscitative thoracotomy

A trauma patient with cardiac tamponade may not survive transfer to the operating theatre for pericardial decompression. This article describes an approach to a resuscitative thoracotomy in the ED, which may be life-saving in these patients when a cardiothoracic surgeon is not immediately available.

Resuscitative Endovascular Balloon Occlusion of the Aorta Improves Cardiac Compression Fraction Versus Resuscitative Thoracotomy in Patients in Traumatic Arrest

STUDY OBJECTIVE

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is emerging as an alternative to resuscitative thoracotomy for proximal aortic control in select patients with exsanguinating hemorrhage below the diaphragm. The purpose of this study is to compare interruptions in closed chest compression or open chest cardiac massage during REBOA versus resuscitative thoracotomy.

METHODS

From May 2014 to December 2016, patients in arrest who received aortic occlusion with REBOA or resuscitative thoracotomy were included. Total cardiac compression time was defined as the total time that closed chest compression was performed for REBOA patients and the total time that closed chest compression (before resuscitative thoracotomy) and open chest cardiac massage (after thoracotomy) were performed for resuscitative thoracotomy patients. Cardiac compression fraction was defined as the time compressions occurred during the entire resuscitation phase. All resuscitations were captured by multiview, time-stamped videography.

RESULTS

Fifty patients with aortic occlusion after arrest were enrolled: 22 REBOA and 28 resuscitative thoracotomy. Most were men (86%) (median age 30.2 years, interquartile range [IQR] 24.9 to 42.3; median Injury Severity Score 27, IQR 16 to 42; neither differed between groups). The median duration of total cardiac compression time was 945 seconds (IQR 697 to 1,357) for REBOA versus 496 seconds (IQR 375 to 933) for resuscitative thoracotomy. During initial resuscitation, compressions occurred 86.5% of the time (SD 9.7%) during resuscitation with REBOA versus 35.7% of the time (SD 16.4%) in patients receiving resuscitative thoracotomy. Cardiac compression fraction improved after open cross clamp in resuscitative thoracotomy patients to 73.2% of the time (SD 18.0%) but remained significantly less than the same period for REBOA (86.7%; SD 9.4%). Mean cardiac compression fraction for REBOA was significantly improved over that for resuscitative thoracotomy (86.2% [SD 9.1%] versus 55.3 [SD 17.1%]; mean difference 31.0%; 95% confidence interval for difference 22.7% to 39.23%; P<.001). Median pause in resuscitation related to procedural tasks was 0 seconds (IQR 0 to 13) for REBOA and 148 seconds (IQR 118 to 223) in resuscitative thoracotomy.

CONCLUSION

Total duration of interruptions of cardiac compressions is shorter for patients receiving REBOA versus resuscitative thoracotomy before and during resuscitation with aortic occlusion. Markers for perfusion during resuscitation must be examined to understand the effects of cardiac compressions and aortic occlusion on patients in arrest because of hemorrhagic shock.

Use of Tandem Perimortem Cesarean Section and Open-Chest Cardiac Massage in the Resuscitation of Peripartum Cardiomyopathy Cardiac Arrest

Cardiac arrest and resuscitation of the pregnant woman at gestational term is rare. Depending on the circumstances of cardiac arrest and its timing, options are limited for allowing successful resuscitation of both mother and neonate. Herein, we describe the use of tandem perimortem cesarean section and thoracotomy for open-chest cardiac massage in a young woman with newly diagnosed peripartum cardiomyopathy. We used goal-directed resuscitation including diagnostic ultrasonography and capnography to assist in decision making and successfully resuscitated both mother and neonate to hospital discharge without discernable long-term complications.

Reanimating Patients After Traumatic Cardiac Arrest: A Practical Approach Informed by Best Evidence

Resuscitation of traumatic cardiac arrest is typically considered futile. Recent evidence suggests that traumatic cardiac arrest is survivable. In this article key principles in managing traumatic cardiac arrest are discussed, including the importance of rapidly seeking prognostic information, such as signs of life and point-of-care ultrasonography evidence of cardiac contractility, to inform the decision to proceed with resuscitative efforts. In addition, a rationale for deprioritizing chest compressions, steps to quickly reverse dysfunctional ventilation, techniques for temporary control of hemorrhage, and the importance of blood resuscitation are discussed. The best available evidence and the authors' collective experience inform this article.

Open chest cardiac massage offers no benefit over closed chest compressions in patients with traumatic cardiac arrest

BACKGROUND

Open chest cardiac massage (OCCM) is a commonly performed procedure after traumatic cardiac arrest (TCA). OCCM has been reported to be superior to closed chest compressions (CCC) in animal models and in non-TCA. The purpose of this study is to prospectively compare OCCM versus CCC in TCA using end-tidal carbon dioxide (ETCO2), the criterion standard for determining the effectiveness of chest compressions and detection of return of spontaneous circulation (ROSC), as the surrogate for cardiac output and marker for adequacy of resuscitation.

METHODS

This prospective observational study enrolled patients over a 9-month period directly presenting to a level 1 trauma center after TCA. Continuous high-resolution ETCO2 measurements were collected every 6 seconds for periods of CCC and OCCM, respectively. Patients receiving CCC only were compared with patients receiving CCC followed by OCCM. Student's t tests were used to compare ETCO2 within and between groups.

RESULTS

Thirty-three patients were enrolled (16 OCCM, 17 CCC-only). Mean time of CCC before OCCM was 66 seconds. Within the OCCM group, final, peak, mean, and median ETCO2 levels significantly increased when comparing the initial CCC period to the OCCM interval. Using a time-matched comparison, significant increases were observed in the final and peak but not mean and median values when comparing the first minute of CCC to the remaining time in the CCC-only group. However, when periods of OCCM were compared with equivalent periods of CCC-only, there were no differences in the initial, final, peak, mean, or median ETCO2 values. Correspondingly, no difference in rates of ROSC was observed between groups (OCCM 23.5% vs. CCC 38.9%; p = 0.53).

CONCLUSION

Although we could not control for confounders, we found no significant improvement in ETCO2 or ROSC with OCCM. With newer endovascular techniques for aortic occlusion, thoracotomy solely for performing OCCM provides no benefit over CCC.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Prolonged Intraoperative Cardiac Resuscitation Complicated by Intracardiac Thrombus in a Patient Undergoing Orthotopic Liver Transplantation

We report the case of successful resuscitation after prolonged cardiac arrest during orthotopic liver transplantation. After reperfusion, the patient developed ventricular tachycardia, complicated by intracardiac clot formation and massive hemorrhage. Transesophageal echocardiography demonstrated stunned and nonfunctioning right and left ventricles, with developing intracardiac clots. Treatment with heparin, massive transfusion and prolonged cardiopulmonary resuscitation ensued for 51 minutes. Serial arterial blood gases demonstrated adequate oxygenation and ventilation during cardiopulmonary resuscitation. Cardiothoracic surgery was consulted for potential use of extracorporeal membrane oxygenation, however, the myocardial function improved and the surgery was completed without further intervention. On postoperative day 6, the patient was extubated without neurologic or cardiac impairment. The patient continues to do well 2 years posttransplant, able to perform independent daily activities of living and his previous job. This case underscores the potential for positive outcomes with profoundly prolonged, effective advanced cardiovascular life support in patients who experience postreperfusion syndrome.

Outcome of patients receiving CPR in the ED of an urban academic hospital

BACKGROUND

The success of Closed Chest Cardiopulmonary Resuscitation (CC-CPR) degrades with prolonged times. Open Chest CPR (OC-CPR) is an alternative that may lead to superior coronary and cerebral perfusion. It is critical to determine when continued CC-CPR is unlikely to be successful to justify initiating OC-CPR as rescue therapy. The purpose of this study is to review CC-CPR outcomes to define a time threshold for attempting OC-CPR.

METHODS

We identified all adult non-trauma patients diagnosed with cardiac arrest, ventricular fibrillation, ventricular tachycardia and asystole from 1/1/10-12/31/14. We collected demographics, cardiac rhythm, resuscitation duration, survival to hospital discharge and neurological outcome. Using time to ROSC after ED arrival and good neurological outcome, we explored various times as triggers for attempting OC-CPR.

RESULTS

Among 242 cases of CPR, 205 cases were out-of-hospital cardiac arrest (OHCA). Mean age was 63.7 (±16.9),woman comprised 29.8% (72/242), and median prehospital CPR time was 30 min (20-44). Patients suffering ED arrest had improved ROSC (54.1% vs. 12.7%, p<0.001) and survival to hospital discharge rates (37.8% vs. 2.9%, p<0.001) compared to OHCA. Patients achieving ROSC had median total CPR duration of 18 minutes (10 minutes of pre-hospital CPR) compared with patients without ROSC who had 45 minutes (30 pre-hospital) respectively. No patient receiving > 10 minutes of CPR in the ED survived to hospital discharge.

CONCLUSION

In patients suffering OHCA and requiring CC-CPR in the ED, overall survival rate to good neurologic function is low. OC-CPR could potentially be attempted after 10 minutes of CC-CPR in the ED.

Perimortem caesarean deliveries

Although cardiac arrest in pregnancy is rare, it is important that all individuals involved in the acute care of pregnant women are suitably trained, because the outcome for both mother and fetus can be affected by the management of the arrest. Perimortem caesarean delivery was first described in 715 BC. Initially the procedure was performed principally for religious or political reasons. Although the potential for fetal survival was proposed, it was rarely successful, probably because the delivery was delayed until maternal death was established. However, in recent decades, case reports have suggested improved maternal as well as fetal survival if perimortem caesarean section was performed rapidly once maternal arrest has occurred. While evidence for this is largely based on case reports, the physiological advantages including removing inferior caval obstruction, and hence improving venous return to the heart, reducing oxygen requirement and improving chest compliance appear compelling. Factors that reduce errors and minimise the delay in performance of caesarean delivery are discussed, in particular the importance of training, organizational factors within a hospital and the use of prompts during an arrest. While evidence is limited, it is probable that both maternal and fetal survival are improved with early delivery by perimortem caesarean delivery. More importantly, no evidence was found from case report reviews that either maternal or fetal survival was worsened. Perimortem caesarean delivery therefore remains a key consideration in the management of maternal arrest from the mid second trimester.

Perimortem caesarean section

This review describes a simple approach to perimortem caesarean section (PMCS) that can be used by a doctor in the resuscitation room or prehospital environment when faced with a mother of more than 20 weeks gestation in cardiac arrest. It explores the indications for and contraindications to the procedure, the physiological rationale behind it, equipment needed, technical aspects of the procedure and reviews recent literature on maternal and fetal outcomes. Like other uncommon procedures such as emergency department thoracotomy, rehearsal and preparation for a PMCS is essential to give both mother and baby the best chance of survival.

Resuscitative thoracotomies and open chest cardiac compressions in non-traumatic cardiac arrest

Since the popularisation of closed chest cardiac compressions in the 1960s, open chest compressions in non-traumatic cardiac arrest have become a largely forgotten art. Today, open chest compressions are only rarely performed outside operating theatres. Early defibrillation and high quality closed chest compressions is the dominating gold standard for the layman on the street as well as for the resuscitation specialist. In this paper we argue that the concept of open chest direct cardiac compressions in non-traumatic cardiac arrest should be revisited and that it might be due for a revival. Numerous studies demonstrate how open chest cardiac compressions are superior to closed chest compressions in regards to physiological parameters and outcomes. Thus, by incorporating resuscitative thoracotomies and open chest compressions in our algorithms for non-traumatic cardiac arrest we may improve outcomes.

The use of emergency department thoracotomy for traumatic cardiopulmonary arrest

Despite the establishment of evidence-based guidelines for the resuscitation of critically injured patients who have sustained cardiopulmonary arrest, rapid decisions regarding patient salvageability in these situations remain difficult even for experienced physicians. Regardless, survival is limited after traumatic cardiopulmonary arrest. One applicable, well-described resuscitative technique is the emergency department thoracotomy-a procedure that, when applied correctly, is effective in saving small but significant numbers of critically injured patients. By understanding the indications, technical details, and predictors of survival along with the inherent risks and costs of emergency department thoracotomy, the physician is better equipped to make rapid futile versus salvageable decisions for this most severely injured subset of patients.

Six-year prospective audit of 'scoop and run' for chest-reopening after cardiac arrest in a cardiac surgical ward setting

OBJECTIVES

The aim of the study was to identify which cardiac surgical ward patients benefit from 'scoop and run' to the operating room for chest reopening.

METHODS

In-hospital arrests in a cardiothoracic hospital were prospectively audited over a 6-year period. The following pieces of information were collected for every patient who was scooped to the operating room following cardiac arrest on the postoperative cardiac surgical wards: type of arrest, time since surgery, patient physiology before arrest, time to chest reopening, location of chest opening, surgical findings on reopening, time to cardiopulmonary bypass (if used) and patient outcomes.

EXCLUSIONS

arrests in intensive care unit (ICU) and operating rooms. The primary outcome measure was survival to discharge from the hospital.

RESULTS

There were 99 confirmed ward arrests in 97 cardiac surgical patients. The overall survival rates to discharge and at 1 year were 53.6% (52 of 97 patients) and 44.3% (43 of 97 patients), respectively. Twenty-one of the 97 (21.6%) patients underwent scoop and run to the operating room or ICU. Five of 12 daytime 'scoop and runs' survived to discharge, whereas none of nine survived where scoop and run was undertaken at night (P < 0.05). There was a trend towards increased survival when 'scoop and run' was undertaken following ventricular fibrillation/pulseless ventricular tachycardia arrests (P = 0.06) and in younger patients (P = 0.12) but neither achieved statistical significance. The median time out from surgery of survivors was 4 days (range 2-14 days). The median time to chest opening in survivors was 22 min. Cardiopulmonary bypass was utilized in four of five survivors. The median ICU and hospital lengths of stay were 176 h (range 34-857) and 28 days (range 13-70), respectively.

CONCLUSIONS

The key determinant of a favourable 'scoop and run' outcome was whether the arrest occurred during daytime or night-time hours (P < 0.05). Despite a median time to chest opening of 22 min, all five survivors were discharged neurologically intact. The median time from surgery in these survivors was 4 days. Because of the risk of hypoxic brain damage, 'scoop and run' should be restricted to patients suffering witnessed arrests. The study has potential implications for resuscitation training and out-of-hours medical staffing in cardiothoracic hospitals.

Outcomes from prehospital cardiac arrest in blunt trauma patients

BACKGROUND

There are few strategies for treating patients who have suffered cardiopulmonary arrest due to blunt trauma (BT-CPA). The aim of this population-based case series observational study was to clarify the outcome of BT-CPA patients treated with a standardized strategy that included an emergency department thoracotomy (EDT) under an emergency medical service (EMS) system with a rapid transportation system.

METHODS

The 477 BT-CPA registry data were augmented by a review of the detailed medical records in our emergency department (ED) and action reports in the prehospital EMS records.

RESULTS

Of those, 76% were witnessed and 20% were CPA after leaving the scene. In all, 18% of the patients went to the intensive care unit (ICU), the transcatheter arterial embolization (TAE) room, or the operating room (OR). Only 3% survived to be discharged. Among the 363 witnessed patients-11 of whom had ventricular fibrillation (VF) as the initial rhythm, 134 exhibiting pulseless electrical activity (PEA), and 221 with asystole-13, 1, and 3%, respectively, survived to discharge. The most common initial rhythm just after collapse was not VF but PEA, and asystole increased over the 7 min after collapse. There were no differences in the interval between arrival at the hospital and the return of spontaneous circulation between the patients that survived to discharge and deceased patients in the ED, OR, TAE room, or ICU. The longest interval was 17 min.

CONCLUSIONS

In BT-CPA patients, a 20-min resuscitation effort and termination of the effort are thought to be relevant. The initial rhythm is not a prognostic indicator. We believe that the decision on whether to undertake aggressive resuscitation efforts should be made on a case-by-case basis.

Part 7: CPR techniques and devices: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

A variety of CPR techniques and devices may improve hemodynamics or short-term survival when used by well-trained providers in selected patients. All of these techniques and devices have the potential to delay chest compressions and defibrillation. In order to prevent delays and maximize efficiency, initial training, ongoing monitoring, and retraining programs should be offered to providers on a frequent and ongoing basis. To date, no adjunct has consistently been shown to be superior to standard conventional (manual) CPR for out-of-hospital basic life support, and no device other than a defibrillator has consistently improved long-term survival from out-of-hospital cardiac arrest.

Randomised comparison of percutaneous left ventricular assist device with open-chest cardiac massage and with surgical assist device during ischaemic cardiac arrest

AIMS

A percutaneous left ventricular assist device can maintain blood flow to vital organs during ventricular fibrillation and may improve outcomes in ischaemic cardiac arrest. We compared haemodynamic and clinical effects of a percutaneous left ventricular assist device with a larger device deployed via endovascular prosthesis and with open-chest cardiac massage during ischaemic cardiac arrest.

METHODS

Eighteen swine were randomised into three groups. After thoracotomy, coronary ischaemia and ventricular fibrillation was induced. Cardiac output was measured with transit-time flowmetry. Tissue perfusion was measured with microspheres. Defibrillation was performed after 20 min.

RESULTS

Cardiac output with cardiac massage was 1129 mL min⁻¹ vs. 1169 mL min⁻¹ with the percutaneous- and 570 mL min⁻¹ with the surgical device (P < 0.05 surgical vs. others). End-tidal CO₂ was 3.3 kPa with cardiac massage vs. 3.2 kPa with the percutaneous- and 2.3 kPa with the surgical device (P < 0.05 surgical vs. others). Subepicardial perfusion was 0.33 mL min⁻¹ g⁻¹ with cardiac massage vs. 0.62 mL min⁻¹ g⁻¹ with both devices (P < 0.05 devices vs. massage), cerebral perfusion was comparable between groups (all reported values after 3 min cardiac arrest, all P<0.05 vs. baseline, all P = NS for 3 min vs. 15 min). Return of spontaneous circulation was achieved in 5/6 subjects with cardiac massage vs. 6/6 with the percutaneous- and 4/6 with the surgical device (P = NS).

CONCLUSION

The percutaneous device improved myocardial perfusion, maintained cerebral perfusion and systemic circulation with similar rates of successful defibrillation vs. cardiac massage. Increased delivery was not obtained with the surgical device during cardiac arrest.

Percutaneous left ventricular assist in ischemic cardiac arrest

BACKGROUND

Ischemic cardiac arrest represents a challenge for optimal emergency revascularization therapy. A percutaneous left ventricular assist device (LVAD) may be beneficial.

OBJECTIVE

To determine the effect of a percutaneous LVAD during cardiac arrest without chest compressions and to assess the effect of fluid loading.

DESIGN

Totally, 16 pigs randomized to either conventional or intensive fluid with LVAD support during ventricular fibrillation (VF).

SETTING

Acute experimental trial with pigs under general anesthesia.

SUBJECTS

Farm pigs of both sexes.

INTERVENTIONS

After randomization for fluid infusion, VF was induced by balloon occlusion of the proximal left anterior descending artery. LVAD and fluid were started after VF had been induced.

MEASUREMENTS

Brain, kidney, myocardial tissue perfusion, and cardiac index were measured with the microsphere injection technique at baseline, 3, and 15 minutes. Additional hemodynamic monitoring continued until 30 minutes.

MAIN RESULTS

At 15 minutes, vital organ perfusion was maintained without significant differences between the two groups. Mean cardiac index at 3 minutes of VF was 1.2 L x min(-1) x m2 (29% of baseline, p < 0.05). Mean perfusion at 3 minutes was 65% in the brain and 74% in the myocardium compared with baseline (p < 0.05), then remained unchanged during the initial 15 minutes. At 30 minutes, LVAD function was sustained in 11 of 16 animals (8 of 8 intensified fluid vs. 3 of 8 conventional fluid) and was associated with intensified fluid loading (p < 0.001).

CONCLUSIONS

During VF, a percutaneous LVAD may sustain vital organ perfusion. A potential clinical role of the device during cardiac arrest has yet to be established.

Emergency department thoracotomy: still useful after abdominal exsanguination?

BACKGROUND

Although literature regarding emergency department thoracotomy (EDT) outcome after abdominal exsanguination is limited, numerous reports have documented poor EDT survival in patients with anatomic injuries other than cardiac wounds. As a result, many trauma surgeons consider prelaparotomy EDT futile for patients dying from intra-abdominal hemorrhage. Our primary study objective was to prove that prelaparotomy EDT is beneficial to patients with exsanguinating abdominal hemorrhage.

METHODS

A retrospective review of 237 consecutive EDTs for penetrating injury (2000-2006) revealed 50 patients who underwent EDT for abdominal exsanguination. Age, gender, injury mechanism and location, field and emergency department (ED) signs of life, prehospital time, initial ED cardiac rhythm, vital signs, Glasgow Coma Score, blood transfusion requirements, predicted mortality, primary abdominal injuries, and the need for temporary abdominal closure were analyzed. The primary study endpoint was neurologically intact hospital survival.

RESULTS

The 50 patients who underwent prelaparotomy EDT for abdominal exsanguination were largely young (mean, 27.3 +/- 8.2 years) males (94%) suffering firearm injuries (98%). Patients presented with field (84%) and ED signs of life (78%) after a mean prehospital time of 21.2 +/- 9.8 minutes. Initial ED cardiac rhythms were variable and Glasgow Coma Score was depressed (mean, 4.2 +/- 3.2). Eight (16%) patients survived hospitalization, neurologically intact. Of these eight, all were in hemorrhagic shock because of major abdominal vascular (75%) or severe liver injuries (25%) and all required massive blood transfusion (mean, 28.6 +/- 17.3 units) and extended intensive care unit length of stay (mean, 36.3 +/- 25.7 days).

CONCLUSIONS

Despite critical injuries, 16% survived hospitalization, neurologically intact, after EDT for abdominal exsanguination. Our results suggest that prelaparotomy EDT provides survival benefit to penetrating trauma victims dying from intra-abdominal hemorrhage.

Open-chest cardiopulmonary resuscitation: past, present and future

Out-of-hospital cardiac arrests account for approximately 1000 sudden cardiac deaths per day in the United States. Since its introduction in 1960 closed-chest cardiac massage (CCCM) often takes place as an attempt at resuscitation, although its survival rates are low. Other resuscitation techniques are available to physicians such as open-chest cardiopulmonary resuscitation (OCCPR). OCCPR has been shown by several scientists to be hemodynamically superior to CCCM as it increases arterial pressures, cardiac output, coronary perfusion pressures, return of spontaneous circulation and cerebral blood flow. Improved neurological and cardiovascular outcome and an increase in survival rate compared to CCCM have been described. Timing is one of the key variables in determining patient outcome when performing OCCPR. The American Heart Association in association with the International Liaison Committee (ILCOR) has specific indications for the use of OCCPR. Some investigators recommend starting OCCPR in out-of-hospital cardiac arrests on arrival at the scene instead of CCCM. Surprisingly, the incidence of infectious complications after thoracotomy in an unprepared chest is low. The vast majority of the patients' families accept OCCPR as a therapeutic choice for cardiac arrests and it has been showed to be economically viable. This paper reviews some of the basic and advanced concepts of this evolving technique.

Open indirect cardiac massage in neonate

Open, direct cardiac massage (OCM), as a technique of resuscitation has not been very inspiring due to its various limitations. We report a case of resuscitation where open 'indirect' cardiac massage was used to resuscitate a neonate successfully. A 24 hr old neonate with multiple gastrointestinal anomalies presented for emergency laparotomy. Intraoperatively she suffered a cardiac arrest. External chest compressions (ECC) failed to produce detectable circulation and surgeons were asked to initiate direct cardiac compressions. They could palpate and successfully compress the heart without the need to split the diaphragm. This 'infra-diaphragmatic' approach resulted in adequate circulation and subsequent uncomplicated recovery.

Open-Chest Cardiopulmonary Resuscitation after Cardiac Arrest in Cases of Blunt Chest or Abdominal Trauma: A Consecutive Series of 38 Cases

BACKGROUND

According to the literature, the overall outcome in a patient population with chest or abdominal injury with initial cardiac arrest has to be rated as poor. In cases of penetrating injuries, open-chest cardiopulmonary resuscitation (CPR) has been recommended as a treatment option to improve the survival rate. The aim of this study was to prove equal outcome for patients with blunt chest or abdominal trauma.

METHODS

During a 5-year period, a consecutive patient series admitted to an urban Level I trauma center was examined. Only patients with blunt trauma and witnessed cardiac arrest, who had a documented, uninterrupted closed-chest CPR (CCCPR) of less than 20 minutes were included in this study (n=38). Exclusion criteria were age over 70 years, penetrating injuries, CCCPR of more than 20 minutes, as well as nonprofessional bystander resuscitation.

RESULTS

Four of 38 patients survived. In comparison with the group of nonsurvivors, both groups showed a similar age and gender ratio (mean age, 28, 32, respectively). The mean Injury Severity Scale was 54 (range, 42-66) in the survivor group and 66 (range, 29-75) in the nonsurvivor group, respectively. The time of CCCPR was on average 13 minutes (range, 11-15 minutes) for the survivors and 16 minutes (range, 1-20 minutes) for the nonsurvivors.

CONCLUSION

Patients with blunt trunk trauma and cardiac arrest after hemorrhagic shock may benefit from open-chest CPR with the same probability as shown for patients with penetrating injuries. This is especially true if the procedure is started as soon as possible, but at the latest within 20 minutes after initial CCCPR.

Thoracotomie transverse de réanimation

The technique of resuscitative transverse thoracotomy is for use in case of circulatory arrest in the trauma patient. This technique, performed after orotracheal intubation, is initiated by a 5th intercostal space thoracostomy in each mid-axillary line. If the circulatory arrest is not caused by a tension pneumothorax, bilateral thoracotomies in the 5th intercostal spaces with transverse transsection of the sternum is performed. Middle vertical incision of the pericardium allows the evacuation of a cardiac tamponade. This wide surgical access has proved simple to perform, even by non experienced operators. It allows digital control of a heart wound, cross-clamping of the thoracic descending aorta or of pulmonary hilum, rapid perfusion of warm fluids through the right auricle and the performance of bimanual internal cardiac massage.

Pediatric cardiopulmonary-cerebral resuscitation: an overview and future directions

The evolving understanding of pathophysiologic events during and after pediatric cardiac arrest has not yet resulted in significantly improved outcome. Exciting breakthroughs in basic and applied science laboratories are, however, on the immediate horizon for study in specific subpopulations of cardiac arrest victims. Strategically focusing therapies to specific phases of cardiac arrest and resuscitation and evolving pathophysiologic events offers great promise that critical care interventions will lead the way to more successful cardiopulmonary and cerebral resuscitation in children.

Alternative cardiopulmonary resuscitation devices

Cardiopulmonary resuscitation (CPR) involving manual external chest compression combined with artificial respiration was first described in 1960 by Kouwenhoven et al. (Kouwenhoven W, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA. 1960; 173:1064-7). In the four decades since then, there have been no widely accepted alternatives for this technique. Even with the subsequent worldwide adoption of CPR and other advanced cardiac life support measures, long-term survival after prehospital cardiac arrest is still typically only 5%, to 10%. The performance of CPR must therefore be improved to increase the rate of long-term survival. Currently under development are new, alternative techniques such as interposed abdominal compression (IAC), active compression-decompression (ACD), pneumatic and nonpneumatic circumferential chest compression, and minimally invasive cardiac massage. Many of these newer techniques, compared with standard manual CPR, appear to provide superior vital organ blood flow and increased blood pressure. To date, only IAC (in-hospital only) and ACD have been shown to improve long-term survival in clinical studies. Circumferential chest compression and minimally invasive cardiac massage, on the other hand, have not yet been adequately tested in large clinical trials. Despite the difficulty and expense in studying these CPR techniques, additional research is necessary to evaluate their effectiveness in improving survival after sudden cardiac arrest.

Defibrillation with a minimally invasive direct cardiac massage device

OBJECTIVE

This study examined (1) the defibrillation efficacy of using a minimally invasive direct cardiac massage (MID-CM) device as one electrode of the defibrillation electrical circuit and (2) the effect on external defibrillation of defibrillating when the MID-CM device is in place and a pneumothorax is present.

METHODS

Part 1: in seven pigs, defibrillation thresholds (DFTs) were determined with a truncated exponential biphasic waveform. DFTs were determined for five electrode configurations: standard transthoracic defibrillation with electrodes on the left and right chest walls (1), with the MID-CM as one of the defibrillation electrodes pressed gently (2) or firmly (3) against the heart with the right chest wall patch as the second electrode, the same as (1) with the MID-CM device in place and the lungs at end-inspiration (4) or at end-expiration (5). Part 2: in six pigs, DFTs were determined with a monophasic damped sinusoidal waveform with external defibrillation electrodes (1) and with the device as one defibrillation electrode and the other electrode on either the anterior (2), lateral (3), or posterior right chest wall (4).

RESULTS

Part 1: the DFTs for (2) or (3) were not different (18.7+/-12.4 vs. 17.0+/-8.3 J), but both DFTs were lower than that for (1) (155+/-45 J). The DFT was elevated for (4) (205+/-69 J) compared with (1). For (5) only one animal could be defibrillated with shocks up to 360 J. Part 2: the DFTs for (2), (3) or (4) were not different (19.5+/-11.0, 25.4+/-9.4, 27.4+/-9.0 J), but all three were lower than the DFT for (1) (198+/-70 J).

CONCLUSIONS

Using the MID-CM device as one electrode of the defibrillation circuit markedly lowers the DFT compared with that for standard transthoracic defibrillation for both a monophasic and biphasic waveform. Defibrillation with the device in place and the chest opened elevates the DFT for external defibrillation much more during end-expiration than during end-inspiration.

[New aspects and perspectives on cardiac arrest]

OBJECTIVES

To analyse the current knowledge based on the experimental and the clinical research studies focused on the main fields of cardiopulmonary resuscitation.

DATA SOURCES

International guidelines and recent review articles. Data collected from the Medline database with the key word: cardiac arrest.

STUDY SELECTION

Research studies published during the last ten years were reviewed. Relevant clinical information was extracted and discussed when it induced changes in guidelines.

DATA SYNTHESIS

Promising improvements on basic and advanced life supports are proposed. Chest compressions prevail over ventilation. Alternatives to classical chest compressions are tested. Ventilatory volume must be reduced from 1000 to approximatively 500 mL for each breath with oxygen. Biphasic waveform defibrillators and automated external defibrillators will be considered as the best devices in the near future. Some non-catecholaminergic vasopressors could reduce the use of epinephrine for advanced cardiac life support. Lidocaine could be replaced by amiodarone as anti-arrhythmic drug of choice. New post-resuscitation therapeutic strategies are evaluated, especially coronary reperfusion when the cause of cardiac arrest is cardiac.

CONCLUSION

Many fields of cardiopulmonary resuscitation are investigated. Some relevant informations are included in the last international guidelines published in 2000, but most of them need complementary studies before other changes could be recommended for routine practice.

Alternative cardiopulmonary resuscitation devices

Cardiac arrest survival rates remain low despite increased access to advanced cardiac life support. Survival from cardiac arrest is, at least in part, related to the perfusion pressures and blood flow achieved during cardiopulmonary resuscitation (CPR). A number of alternative CPR devices have been developed that aim to improve the perfusion pressures and/or blood flow achieved during CPR. Active compression-decompression CPR devices are by far the most studied alternative CPR devices, but the results have been inconsistent and conflicting. A number of other devices, including the inspiratory impedance threshold valve, minimally invasive direct cardiac massage, phased chest and abdominal compression-decompression CPR, and vest CPR, are all capable of improving perfusion pressures and/or blood flow compared with standard external chest compressions. However, no convincing human outcome data has been produced yet for any of these devices. Although an interesting area of research, none of the alternative CPR devices convincingly improve long-term patient outcomes.

Survival to discharge following open chest cardiac compression (OCCC). A 4-year retrospective audit in a cardiothoracic specialist centre--Royal Brompton and Harefield NHS Trust, United Kingdom

OBJECTIVE

To review the use of Open Chest Cardiac Compression (OCCC) techniques in postcardiac surgical patients in one specialist cardiothoracic centre in the UK.

METHODS

A 4-year retrospective audit (April 1995--March 1999) of all cardiac arrest victims and resuscitation practice across two specialist cardiothoracic hospitals. Audit outcomes related to initial survival and survival to discharge, arrest rhythm, reasons for resternotomy, surgical procedure prior to resternotomy and time elapsed from original surgery to resternotomy.

RESULTS

Seventy-two patients (adult and paediatric) suffering cardiac arrest received OCCC following cardiac surgery. Thirty-three patients initially survived (46%) and 12 patients survived to discharge (17%).

DISCUSSION AND RECOMMENDATIONS

In the absence of current European Resuscitation Council guidelines, we adopted recommendations for resternotomy to be performed after 5 min of unsuccessful conventional CPR and OCCC initiated. An adapted ERC algorithm incorporating these recommendations can provide much needed direction in postcardiac surgery cardiac arrest victims.

Functional status and quality of life in long-term survivors of cardiac arrest after cardiac surgery

OBJECTIVE

To assess long-term survival, functional status, and quality of life in patients who experienced cardiac arrest after cardiac surgery.

DESIGN

Prospective, observational study.

SETTING

An 18-bed, adult cardiac surgery intensive care unit in a tertiary teaching center.

PATIENTS

Twenty-nine cardiac surgery patients who suffered an unexpected cardiac arrest in the immediate postoperative period.

INTERVENTIONS

The New York Heart Association classification and a questionnaire based on the Nottingham Health Profile were used to evaluate functional status and quality of life 4 yrs after hospital discharge.

MEASUREMENTS AND MAIN RESULTS

Of the 29 patients who experienced cardiac arrest during the first 24 hrs after cardiac surgery, 27 patients (93%) were successfully resuscitated and 23 patients (79%) survived to hospital discharge. Evaluation 4 yrs postdischarge showed that, of the 29 patients, 16 patients (55%) were still alive (long-term survivors). Functional status assessment of long-term survivors revealed that 12 patients (75%) were grouped in New York Heart Association class I, 3 patients (19%) in class II, and 1 patient (6%) in class III. None of them had a neurologic deficit. They all were living independently at home, without need of any nursing care. No patient reported any abnormal emotional reactions, and six patients (38%) had mild sleep disturbances, such as early awaking. Regarding activities of daily living, 20% returned to work, 94% were able to look after their home, 96% had a social life, 63% were sexually active, 81% were involved in their hobbies, and 75% had gone on holidays.

CONCLUSIONS

Cardiac surgery patients who experience an unexpected cardiac arrest in the immediate postoperative period have a 55% chance of being alive 4 yrs postdischarge. The majority of these long-term survivors has a good outcome with respect to functional status and quality of life.

Minimally invasive direct cardiac massage versus closed-chest cardiopulmonary resuscitation in a porcine model of prolonged ventricular fibrillation cardiac arrest

Open chest cardiac massage has been shown to be superior to closed-chest cardiopulmonary resuscitation for both hemodynamics produced during resuscitation and ultimate resuscitation success. The inexperience of many rescuers with emergency thoracotomy, along with the associated morbidity contributes to the continued reluctance in the use of invasive cardiopulmonary resuscitation techniques. A device has been developed for performing 'minimally invasive' direct cardiac massage. This technique was compared to standard closed-chest CPR for resuscitation results in 20 swine during prolonged ventricular fibrillation cardiac arrest. Minimally invasive direct cardiac massage was superior to closed-chest CPR for return of spontaneous circulation (7/10 vs. 2/10; P<0.02) and coronary perfusion pressure at 30 min of CPR (17+/-9 vs. 6+/-6 mmHg; P<0.05). No significant injuries altering outcome were found with the invasive device. Throughout most of the time course of the study no significant differences in end-tidal expired carbon dioxide levels were noted. Nor were there any differences in 24-h survival. Improvements in assuring proper placement of the device on the epicardium should make this technique a potent advanced cardiac life support adjunct.

Is emergency open chest cardiopulmonary resuscitation accepted by patients' families?

Emergency open chest cardiopulmonary resuscitation (OCCPR) is sometimes performed on patients with cardiopulmonary arrest (CPA), especially those resulting from trauma. Since OCCPR is frequently carried out without the permission of patients' families, we surveyed the opinions of the families. A total of 1058 CPA patients were transferred to our department during the last 15 years. We sent questionnaires individually to the families of these patients to ask their opinions about OCCPR. The questionnaire provided the six questions allowing multiple answers; (1) Do you unconditionally agree with OCCPR? (2) Do you agree with OCCPR in children? (3) Do you agree with OCCPR in elderly patients? (4) Do you agree with OCCPR without permission from patient's families? (5) Do you entrust OCCPR to the doctors in charge? and (6) others. The questionnaire reached 846 families, of which 277 (32.7%) responded. The percentage response to each question was (1) 70.2, (2) 5.8, (3) 21.8, (4) 7.1, (5) 4.2 and (6) 5.0%. The younger the age of the responders the more they agreed with OCCPR. All the responders less than 30 years old agreed with the procedure. Of the 277 families, 95 had CPA patients treated with OCCPR. This group of families responded to six questions at the following rates: (1) 79.5, (2) 6.0, (3) 13.3, (4) 2. 4, (5) 4.8 and (6) 4.8%, suggesting that families with OCCPR patients are more cooperative to our treatment than those with non-OCCPR patients. The results of this study suggest that OCCPR in CPA patients is generally accepted by the patients' families, especially by young generations, although post-OCCPR careful explanation to patients' families is still indispensable.