Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Implementation of a Smart Teaching and Assessment System for High-Quality Cardiopulmonary Resuscitation

The purpose of this study is to develop a smart training and assessment system called SmartCPR, for teaching and training cardiopulmonary resuscitation (CPR), based on human posture estimation techniques. In this system, trainees can automatically recognize and evaluate whether chest compressions during CPR meet the standard of high-quality CPR by simply using a device such as a smart phone. Through the system, trainees are able to obtain real-time feedback on the quality of compressions so that they can adjust the cycle, depth, frequency, and posture of compressions to meet the standard of high-quality CPR. In addition, the SmartCPR system is convenient for CPR trainers. Trainers can instantly and accurately assess whether the trainee's compressions meet the standard of high-quality CPR, which reduces the risk of manual assessment errors and also reduces the trainer's teaching pressures. Therefore, the SmartCPR system developed in this study can be an important tool for CPR teaching and training for physicians, which can provide training and guidance for high-quality CPR maneuvers and enable trainees to become more proficient in CPR and self-training.

Performance of the Medical Priority Dispatch System® in Identifying Patients Requiring Chest Compressions at Overdose Prevention Services: A Retrospective Cohort Study

BACKGROUND AND AIMS

The Medical Priority Dispatch System (MPDS)® is used to triage 9-1-1 calls according to acuity, with certain coding receiving telecommunicator cardiopulmonary resuscitation (T-CPR) for suspected out-of-hospital cardiac arrest (OHCA). However, this may be challenging for those with drug poisoning emergencies, who may resemble OHCA. We sought to examine the performance of the system to correctly identify cases requiring T-CPR, specifically at overdose prevention services (OPS).

METHODS

This retrospective cohort study included patients attended by the provincial emergency medical system (EMS) (May 1, 2019-January 31, 2023). We calculated the diagnostic performance of MPDS® assessment of whether the case required T-CPR instructions against the gold standard of whether the patient was found pulseless on EMS clinician arrival. We compared performance among subgroups, specifically OPS vs other locations and drug poisoning-classified cases vs other case classifications.

RESULTS

Comparing OPS to other locations, the sensitivity of MPDS® was similar (66.7% vs 62.4%, p = 0.4), with lower specificity (87.3% vs 98.1%, p < 0.01) and positive predictive value (0.3% vs 35.7%, p < 0.01) and higher negative predictive value (99.9% vs 99.4%, p < 0.01). The negative likelihood ratio of MPDS® was 0.381 at OPS locations, compared with 0.383 at other locations, while the positive likelihood ratio was 5.24, compared with 32.36. In patients with drug poisoning emergencies, compared with other 9-1-1 events, MPDS® had higher sensitivity (83.6% vs 60.6%, p < 0.01) but lower specificity (77.6% vs 98.9%, p < 0.01) and positive predictive value (10.5% vs 48.5%, p < 0.01), and similar negative predictive value (99.33% vs 99.35%, p = 0.03). The negative likelihood ratio of MPDS® was 0.212 in drug poisoning emergencies compared with 0.398 for all other presentations, and the positive likelihood ratio was 3.73 compared with 57.88.

DISCUSSION AND CONCLUSIONS

The ability of MPDS® to correctly identify patients needing telecommunicator cardiopulmonary resuscitation instructions differed between OPS settings and other locations, frequently recommending T-CPR for patients not suffering OHCA at an OPS. Different strategies developed in collaboration with people who use substances are required to better tailor dispatch instructions prior to EMS arrival to avoid delays in life-saving interventions.

The approach to extracorporeal cardiopulmonary resuscitation (ECPR) in children. A narrative review by the paediatric ECPR working group of EuroELSO

Extracorporeal Cardiopulmonary Resuscitation (ECPR) has potential benefits compared to conventional Cardiopulmonary Resuscitation (CCPR) in children. Although no randomised trials for paediatric ECPR have been conducted, there is extensive literature on survival, neurological outcome and risk factors for survival. Based on current literature and guidelines, we suggest recommendations for deployment of paediatric ECPR emphasising the requirement for protocols, training, and timely intervention to enhance patient outcomes. Factors related to outcomes of paediatric ECPR include initial underlying rhythm, CCPR duration, quality of CCPR, medications during CCPR, cannulation site, acidosis and renal dysfunction. Based on current evidence and experience, we provide an approach to patient selection, ECMO initiation and management in ECPR regarding blood and sweep flow settings, unloading of the left ventricle, diagnostics whilst on ECMO, temperature targets, neuromonitoring as well as suggested weaning and decannulation strategies.

Real-world comparison between mechanical and manual cardiopulmonary resuscitation during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has posed significant challenges to healthcare systems worldwide, including an increase in out-of-hospital cardiac arrests (OHCA). Healthcare providers are now required to use personal protective equipment (PPE) during cardiopulmonary resuscitation (CPR). Additionally, mechanical CPR devices have been introduced to reduce the number of personnel required for resuscitation. This study aimed to compare the outcomes of CPR performed with a mechanical device and the outcomes of manual CPR performed by personnel wearing PPE.

METHODS

This multicenter observational study utilized data from the Korean Cardiac Arrest Research Consortium registry. The study population consisted of OHCA patients who underwent CPR in emergency departments (EDs) between March 2020 and June 2021. Patients were divided into two equal propensity score matched groups: mechanical CPR group (n = 421) and PPE-equipped manual CPR group (n = 421). Primary outcomes included survival rates and favorable neurological outcomes at discharge. Total CPR duration in the ED was also assessed.

RESULTS

There were no significant between-group differences with respect to survival rate at discharge (mechanical CPR: 7.4% vs PPE-equipped manual CPR: 8.3%) or favorable neurological outcomes (3.3% vs. 3.8%, respectively). However, the mechanical CPR group had a longer duration of CPR in the ED compared to the manual CPR group.

CONCLUSION

This study found no significant differences in survival rates and neurological outcomes between mechanical CPR and PPE-equipped manual CPR in the ED setting. However, a longer total CPR duration was observed in the mechanical CPR group. Further research is required to explore the impact of PPE on healthcare providers' performance and fatigue during CPR in the context of the pandemic and beyond.

Analysis of Out-of-Hospital First Aid for Recovery of Spontaneous Circulation after Cardiac Arrest in Korea

The characteristics of an individual patient experiencing out-of-hospital cardiac arrest who recovered spontaneous circulation with the assistance of witnesses and paramedics were examined. The analysis of bystander cardiopulmonary resuscitation (CPR) and the professional first aid efforts of paramedics in the pre-hospital environment is pivotal to enhancing the survival rate of out-of-hospital cardiac arrest patients. The data used in this study were extracted from the Korea Centers for Disease Control and Prevention (KCDC) nationally recognized statistics, Acute Heart Failure big data survey. Out-of-hospital cardiac arrest (OHCA) customer data were collected from the Gangwon Fire Headquarters public information database as social management data. The data were analyzed using SPSS 24. The study's results emphasized the significance of offering basic CPR training to the public. This is evident from the fact that 90.5% of the first witnesses in the study performed CPR on OHCA patients, resulting in the recovery of spontaneous circulation (ROSC). The majority of patients with ROSC were male, with the highest age group being 41-50 years. Heart disease, hypertension, and diabetes were common medical conditions. The rate of witnessing cardiac arrest was high. Among the first witnesses, about 78.4% were of cardiac arrest incidents involving family members, co-workers, or acquaintances; 12.2% were on-duty medical healthcare personnel; and 9.5% were off-duty healthcare personnel. Cardiac arrest was treated in 83.8% of cases, with 90% of witnesses performing CPR. The percentage of witnesses that used an automated external defibrillator (AED) was 13.5%. In this study, the rates of ECG monitoring, CPR performance, and defibrillation performed by paramedics were high, but intravascular access and drug administration had a lower rate of performance. The time elapsed depended on the patient's physical fitness. The study found that paramedics had the highest CPC restoration rate in patients with cardiac arrest, followed by EMTs and nurses. Significant differences were observed in cerebral performance scores after care by these paramedics and nurses. To increase the performance of AEDs, more AEDs should be installed in public spaces so that the public can access them conveniently in cases of emergency. In addition, it is necessary to improve the quality of professional first aid physical activity services performed by first-class paramedics.

Association Between Advanced Airway Management With Adrenaline Injection and Prognosis in Adult Patients With Asystole Asphyxia Out-of-hospital Cardiac Arrest

BACKGROUND

The neurological prognosis of asphyxia is poor and the effect of advanced airway management (AAM) in the prehospital setting remains unclear. This study aimed to evaluate the association between AAM with adrenaline injection and prognosis in adult patients with asystole asphyxia out-of-hospital cardiac arrest (OHCA).

METHODS

This study assessed all-Japan Utstein cohort registry data between January 1, 2013 and December 31, 2019. We used propensity score matching analyses before logistic regression analysis to evaluate the effect of AAM on favorable neurological outcome.

RESULTS

There were 879,057 OHCA cases, including 70,299 cases of asphyxia OHCAs. We extracted the data of 13,642 cases provided with adrenaline injection by emergency medical service. We divided 7,945 asphyxia OHCA cases in asystole into 5,592 and 2,353 with and without AAM, respectively. After 1:1 propensity score matching, 2,338 asphyxia OHCA cases with AAM were matched with 2,338 cases without AAM. Favorable neurological outcome was not significantly different between the AAM and no AAM groups (adjusted odds ratio [OR] 1.1; 95% confidence interval [CI], 0.5-2.5). However, the return of spontaneous circulation (ROSC) (adjusted OR 1.7; 95% CI, 1.5-1.9) and 1-month survival (adjusted OR 1.5; 95% CI, 1.1-1.9) were improved in the AAM group.

CONCLUSION

AAM with adrenaline injection for patients with asphyxia OHCA in asystole was associated with improved ROSC and 1-month survival rate but showed no differences in neurologically favorable outcome. Further prospective studies may comprehensively evaluate the effect of AAM for patients with asphyxia.

Clinical Implications of the Lung Ultrasound Score in Patients after Cardiopulmonary Resuscitation

Background

Lung ultrasound score (LUS) is a clinical index used to measure lung injury, but its clinical value in patients after cardiopulmonary resuscitation (CPR) remains relatively unknown. The purpose of this study was to investigate the clinical value of LUS in patients after CPR.

Methods

This retrospective study included a total of 34 patients older than 18 years with a nontraumatic cause of in-hospital cardiac arrest, who received standard resuscitation and achieved return of spontaneous circulation (ROSC). All patients underwent bedside lung ultrasound examination within half an hour once ROSC was achieved, and LUSs were calculated. The study included patient death as the endpoint event.

Results

Compared with the group with lower LUSs, the patients with higher LUSs had a lower oxygenation index, longer duration of CPR, and lower 72 h survival rate. The initial LUS had good clinical value in predicting the secondary outcomes of CPR (adjusted odds ratio (aOR): 1.353, 95% confidence interval (CI): 1.018-1.797, and P = 0.037) and 72 h survival rate of patients who underwent CPR (aOR: 1.145, 95% CI: 1.014-1.294, and P = 0.029).

Conclusions

LUS was shown to be helpful and had a prognostic value in patients after CPR.

Automated external defibrillators and the link to first responder systems

PURPOSE OF REVIEW

Automated external defibrillators are a very effective treatment to convert ventricular fibrillation (VF) in out-of-hospital cardiac arrest. The purpose of this paper is to review recent publications related to automated external defibrillators (AEDs).

RECENT FINDINGS

Much of the recent research focus on ways to utilize publicly available AEDs included in different national/regional registers. More and more research present positive associations between engaging volunteers to increase the use of AEDs. There are only a few recent studies focusing on professional first responders such as fire fighters/police with mixed results. The use of unmanned aerial vehicles (drones) lacks clinical data and is therefore difficult to evaluate. On-site use of AED shows high survival rates but suffers from low incidence of out-of-hospital cardiac arrest (OHCA).

SUMMARY

The use of public AEDs in OHCA are still low. Systems focusing on engaging volunteers in the cardiac arrest response have shown to be associated with higher AED usage. Dispatching drones equipped with AEDs is promising, but research lacks clinical data. On-site defibrillation is associated with high survival rates but is not available for most cardiac arrests.

Chest compression quality and patient outcomes with the use of a CPR feedback device: A retrospective study

Feedback devices were developed to guide resuscitations as targets recommended by various guidelines are difficult to achieve. Yet, there is limited evidence to support their use for in-hospital cardiac arrests (IHCA), and they did not correlate with patient outcomes. Therefore, this study has investigated the compression quality and patient outcomes in IHCA with the use of a feedback device via a retrospective study of inpatient code blue activations in a Singapore hospital over one year. The primary outcome was compression quality and secondary outcomes were survival, downtime and neurological status. 64 of 110 (58.2%) cases were included. Most resuscitations (71.9%) met the recommended chest compression fraction (CCF, defined as the proportion of time spent on compressions during resuscitation) despite overall quality being suboptimal. Greater survival to discharge and better neurological status in resuscitated patients respectively correlated with higher median CCF (p = 0.040 and 0.026 respectively) and shorter downtime (p < 0.001 and 0.001 respectively); independently, a higher CCF correlated with a shorter downtime (p = 0.014). Overall, this study demonstrated that reducing interruptions is crucial for good outcomes in IHCA. However, compression quality remained suboptimal despite feedback device implementation, possibly requiring further simulation training and coaching. Future multicentre studies incorporating these measures should be explored.

2023 HRS expert consensus statement on the management of arrhythmias during pregnancy

This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.

Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival

Delays in treatment of in-hospital cardiac arrests (IHCAs) are associated with worsened survival. We sought to assess the impact of a bundled intervention on IHCA survival in patients on centralised telemetry. A retrospective quality improvement study was performed of a bundled intervention which incorporated (1) a telemetry hotline for telemetry technicians to reach nursing staff; (2) empowerment of telemetry technicians to directly activate the IHCA response team and (3) a standardised escalation system for automated critical alerts within the nursing mobile phone system. In the 4-year study period, there were 75 IHCAs, including 20 preintervention and 55 postintervention. Cox proportional hazard regression predicts postintervention individuals have a 74% reduced the risk of death (HR 0.26, 95% CI 0.08 to 0.84) during a code and a 55% reduced risk of death (HR 0.45, 95% CI 0.23 to 0.89) prior to hospital discharge. Overall code survival improved from 60.0% to 83.6% (p=0.031) with an improvement in ventricular tachycardia/ventricular fibrillation (VT/VF) code survival from 50.0% to 100.0% (p=0.035). There was no difference in non-telemetry code survival preintervention and postintervention (71.4% vs 71.3%, p=0.999). The bundled intervention, including improved communication between telemetry technicians and nurses as well as empowerment of telemetry technicians to directly activate the IHCA response team, may improve IHCA survival, specifically for VT/VF arrests.

Delayed arrival of advanced life support adversely affects the neurological outcome in a multi-tier emergency response system

AIM

Prehospital management of out-of-hospital cardiac arrest (OHCA) is based on basic life support, with the addition of advanced life support (ALS) if possible. This study aimed to investigate the effect of delayed arrival of ALS on neurological outcomes of patients with OHCA at hospital discharge.

METHODS

This was a retrospective study of a registry of patients with OHCA. A multi-tier emergency response system was established in the study area. ALS was initiated when the second-arrival team arrived at the scene. A restricted cubic spline curve was used to investigate the relationship between the response time interval of the second-arrival team and neurological outcomes at hospital discharge. Multivariable logistic regression analysis was performed to assess the independent association between the response time interval of the second-arrival team and neurological outcomes of patients at hospital discharge.

RESULTS

A total of 3186 adult OHCA patients who received ALS at the scene were included in the final analysis. A restricted cubic spline curve showed that a long response time interval of the second-arrival team was correlated with a high likelihood of poor neurological outcomes. Meanwhile, multivariable logistic regression analysis showed that a long response time interval of the second-arrival team was independently associated with poor neurological outcomes (odds ratio, 1.10; 95% confidence interval, 1.03-1.17).

CONCLUSION

In a multi-tiered prehospital emergency response system, the delayed arrival of ALS was associated with poor neurological outcomes at hospital discharge.

Focused Ultrasonography in Cardiac Arrest

Rapid diagnostic tools available to the emergency physician caring for cardiac arrest patients are limited. Focused ultrasound (US), and in particular, focused echocardiography, is a useful tool in the evaluation of patients in cardiac arrest. It can help identify possible causes of cardiac arrest like tamponade and pulmonary embolism, which can guide therapy. US can also yield prognostic information, with lack of cardiac activity being highly specific for failure to achieve return of spontaneous circulation. US may also be used to aid in procedural guidance. Recently, focused transesophageal echocardiography has been used in the emergency department setting.

A Cross-Sectional Study Investigating the Knowledge and Attitude of Health Professions Students in Saudi Arabia: Are They Ready for Cardiopulmonary Resuscitation?

INTRODUCTION

Cardiopulmonary resuscitation (CPR) training is important for students of health professions to learn and be prepared to perform. Colleges have a responsibility to provide adequate training for their students to ensure that they are ready and confident to deal with life-threatening situations. However, studies have shown that some graduates and practitioners lack sufficient knowledge in performing CPR. The aim of this study is to assess the knowledge of health professions students in the Kingdom of Saudi Arabia (KSA) who have started clinical practice.  Methodology: This cross-sectional study was conducted in February 2022 and included health professions students in all academic years, including interns and residents, across colleges of King Saud bin Abdulaziz University for Health Sciences, Riyadh, KSA. The study questionnaire consisted of three sections: attitudes, knowledge, and demographics. The attitudes section included 11 questions, while the knowledge section included 10. The demographic section included university level, Grade Point Average (GPA), CPR training status, willingness to learn CPR, witnessing CPR, and family history of cardiac disease. Statistical analysis was conducted using chi-squared tests, t-tests, two-sample proportion tests, ANOVA, and bivariate correlation analyses.

RESULTS

The mean age of the participants was 21.2 (±1.9) years. Participants had a mean knowledge score of 5.1 (±1.8) out of 10 potential points. Also, the participants had a total attitude score of 42.7 (±6.2) out of 55 potential points.

CONCLUSION

The study highlights the importance of CPR training for healthcare providers and the need for ongoing training to maintain knowledge and skills. The results suggest that attitudes towards providing CPR may be influenced by cultural beliefs and fear of liability or disease transmission. Higher participant GPA and positive attitudes towards chest compressions and CPR training were found to be associated with increased knowledge.

Manual Chest Compression versus Automated Chest Compression Device during Day-Time and Night-Time Resuscitation Following Out-of-Hospital Cardiac Arrest: A Retrospective Historical Control Study

OBJECTIVE

We assessed the effectiveness of automated chest compression devices depending on the time of admission based on the frequency of iatrogenic chest injuries, the duration of in-hospital resuscitation efforts, and clinical outcomes among out-of-hospital cardiac arrest (OHCA) patients.

METHODS

We conducted a retrospective historical control study of OHCA patients in Japan between 2015-2022. The patients were divided according to time of admission, where day-time was considered 07:00-22:59 and night-time 23:00-06:59. These patients were then divided into two categories based on the in-hospital cardiopulmonary resuscitation (IHCPR) device: manual chest compression (mCC) group and automatic chest compression devices (ACCD) group. We used univariate and multivariate ordered logistic regression models adjusted for pre-hospital confounders to evaluate the impact of ACCD use during IHCPR on outcomes (IHCPR duration, CPR-related chest injuries, and clinical outcomes) in the day-time and night-time groups.

RESULTS

Among 1101 patients with OHCA (day-time, 809; night-time, 292), including 215 patients who underwent ACCD during IHCPR in day-time (26.6%) and 104 patients in night-time group (35.6%), the multivariate model showed a significant association of ACCD use with the outcomes of in-hospital resuscitation and higher rates of return in spontaneous circulation, lower incidence of CPR-related chest injuries, longer in-hospital resuscitation durations, greater survival to Emergency Department and hospital discharge, and greater survival with good neurological outcome to hospital discharge, though only in the night-time group.

CONCLUSIONS

Patients who underwent ACCD during in-hospital resuscitation at night had a significantly longer duration of in-hospital resuscitation, a lower incidence of CPR-related chest injuries, and better outcomes.

Impact of Care Interventions on the Survival of Patients with Cardiac Chest Pain

BACKGROUND

Chest pain is considered the second most frequent complaint among patients seeking emergency services. However, there is limited information in the literature about how the care provided to patients with chest pain, when being attended to in the emergency room, influences their clinical outcomes.

AIMS

To assess the relationship between care interventions performed on patients with cardiac chest pain and their immediate and late clinical outcomes and to identify which care interventions were essential to survival.

METHODS

In this retrospective study. We analyzed 153 medical records of patients presenting with chest pain at an emergency service center, São Paulo, Brazil. Participants were divided into two groups: (G1) remained hospitalized for a maximum of 24 h and (G2) remained hospitalized for between 25 h and 30 days.

RESULTS

Most of the participants were male 99 (64.7%), with a mean age of 63.2 years. The interventions central venous catheter, non-invasive blood pressure monitoring, pulse oximetry, and monitoring peripheral perfusion were commonly associated with survival at 24 h and 30 days. Advanced cardiovascular life support and basic support life (p = 0.0145; OR = 8053; 95% CI = 1385-46,833), blood transfusion (p < 0.0077; OR = 34,367; 95% CI = 6489-182,106), central venous catheter (p < 0.0001; OR = 7.69: 95% CI 1853-31,905), and monitoring peripheral perfusion (p < 0.0001; OR = 6835; 95% CI 1349-34,634) were independently associated with survival at 30 days by Cox Regression.

CONCLUSIONS

Even though there have been many technological advances over the past decades, this study demonstrated that immediate and long-term survival depended on interventions received in an emergency room for many patients.

Comparison of carotid artery ultrasound and manual method for pulse check in cardiopulmonary resuscitation

OBJECTIVES

The success of the manual pulse check method frequently employed during cardiopulmonary resuscitation (CPR) is controversial due to its subjective, patient- and operator-dependent, and time-consuming nature. Carotid ultrasound (c-USG) has recently emerged as an alternative, although there are still insufficient studies on the subject. The purpose of the present study was to compare the success of the manual and c-USG pulse check methods during CPR.

METHODS

This prospective observational study was conducted in the critical care area of a university hospital emergency medicine clinic. Pulse checks in patients with non-traumatic cardiopulmonary arrest (CPA) undergoing CPR were performed using the c-USG method from one carotid artery and the manual method from the other. The gold standard in the decision regarding return of spontaneous circulation (ROSC) was the clinical judgment made using the rhythm on the monitor, manual femoral pulse check, end tidal carbon dioxide (ETCO₂), and cardiac USG instruments. The success in predicting ROSC and measurement times of the manual and c-USG methods were compared. The success of both methods was calculated as sensitivity and specificity, and the clinical significance of the difference between the methods' sensitivity and specificity was evaluated Newcombe's method.

RESULTS

A total of 568 pulse measurements were performed on 49 CPA cases using both c-USG and the manual method. The manual method exhibited 80% sensitivity and 91% specificity in predicting ROSC (+PV: 35%, -PV: 64%), while c-USG exhibited 100% sensitivity and 98% specificity (+PV: 84%, -PV: 100%). The difference in sensitivities between the c-USG and manual methods was -0.0704 (95% CI: -0.0965; -0.0466), and the difference between their specificities was 0.0106 (95% CI: 0.0006; 0.0222). The difference between the specificities and sensitivities was statistically significant at analysis performed adopting the clinical judgment of the team leader using multiple instruments as the gold standard. The manual method yielded an ROSC decision in 3 ± 0.17 s and c-USG in 2.8 ± 0.15 s, the difference being statistically significant.

CONCLUSION

According to the results of this study, the pulse check method with c-USG may be superior to the manual method in terms of fast and accurate decision making in CPR.

COVID-19-specific adult basic life support guideline strategies for chiropractors and other healthcare providers to maximize the safety and efficacy of resuscitation: a commentary

BACKGROUND

The emergence of an unprecedented novel severe acute respiratory syndrome coronavirus-2 (SARS-C0V-2), which causes the coronavirus disease 2019 (COVID-19) pandemic, has created new scenarios in basic life support (BLS) management. According to current evidence, SARS-CoV-2 can be transmitted airborne in aerosol particles during resuscitation. Research evidence found an alarming global increase in out-of-hospital cardiac arrests during the COVID-19 pandemic. Healthcare providers are legally obliged to respond to cardiac arrest as soon as possible. Chiropractors will likely encounter potential exercise-related and non-exercise-related cardiac emergencies at some point in their professional lives. They have a duty of care to respond to emergencies such as cardiac arrest. Chiropractors are increasingly involved in providing care, including emergency care, for athletes and spectators at sporting events. Also, exercise-related cardiac arrest in adult patients may occur during exercise testing or rehabilitation with exercise prescriptions in chiropractic and other healthcare settings. Little is known about the COVID-19 BLS guidelines for chiropractors. Knowledge of the current COVID-19-specific adult BLS guidelines is essential to developing an emergency response plan for the on-field and sideline management of exercise-related cardiac arrest and non-athletic, non-exercise-related cardiac arrest.

MAIN TEXT

Seven peer-reviewed articles on the COVID-19-specific BLS guidelines, including two updates, were reviewed for this commentary. Responding to the COVID-19 pandemic, the national and international resuscitation organizations recommended interim COVID-19-specific BLS guidelines with precaution, resuscitation, and education strategies. BLS safety is paramount. A precautionary approach with the bare minimum of appropriate personal protective equipment for resuscitation is recommended. There was disagreement among the COVID-19 BLS guidelines on the level of personal protective equipment. All healthcare professionals should also undergo self-directed BLS e-learning and virtual skill e-training. The summarized COVID-19-specific adult BLS guideline strategies and protocols are tabled, respectively.

CONCLUSIONS

This commentary provides a practical overview and highlights current evidence-based intervention strategies of the COVID-19-specific adult BLS guidelines that may help chiropractors and other healthcare providers reduce BLS-related exposures to SARS-CoV-2 and the risks of SARS-CoV-2 transmission and maximize the efficacy of resuscitation. This study is relevant to and impacts future COVID-19-related research in areas such as infection prevention and control.

The timing of booster sessions may not improve resuscitation skill retention among healthcare providers: a randomized controlled trial

Introduction

Booster sessions can improve cardiopulmonary resuscitation (CPR) skill retention among healthcare providers; however, the optimal timing of these sessions is unknown. This study aimed to explore differences in skill retention based on booster session timing.

Methods

After ethics approval, healthcare providers who completed an initial CPR training course were randomly assigned to either an early booster, late booster, or no booster group. Participants' mean resuscitation scores, time to initiate compressions, and time to successfully provide defibrillation were assessed immediately post-course and four months later using linear mixed models.

Results

Seventy-three healthcare professionals were included in the analysis. There were no significant differences by randomization in the immediate post-test (9.7, 9.2, 8.9) or retention test (10.2, 9.8, and 9.5) resuscitation scores. No significant effects were observed for time to compression. Post-test time to defibrillation (mean ± SE: 112.8 ± 3.0 sec) was significantly faster compared to retention (mean ± SE: 120.4 ± 2.7 sec) (p = 0.04); however, the effect did not vary by randomization.

Conclusion

No difference was observed in resuscitation skill retention between the early, late, and no booster groups. More research is needed to determine the aspects of a booster session beyond timing that contribute to skill retention.

Content validation of the HeartRunner questionnaire to volunteer responders dispatched to out-of-hospital cardiac arrests: A qualitative study

Aim

To increase survival after out-of-hospital cardiac arrest (OHCA) in Denmark, volunteer responders are activated through a smartphone application (HeartRunner app) to quickly locate an automated external defibrillator (AED) and assist with cardiopulmonary resuscitation (CPR). All dispatched volunteer responders who have been activated by the app receive a follow-up questionnaire to evaluate their participation in the programme. The content of the questionnaire has never been thoroughly evaluated. We therefore aimed to validate the content of the questionnaire.

Methods

Content validity was evaluated qualitatively. It was based on individual interviews with three experts, along with three focus group interviews and five individual interviews using cognitive interview technique, with a total of 19 volunteer responders. The interviews were also used to inform refinements of the questionnaire to reach improvements in content validity.

Results

The initial questionnaire consisted of 23 items. After the content validation process, the questionnaire consisted of 32 items; with the addition of 9 new items. Specifically, some original items were merged into one item or divided into separate items. Moreover, we revised the order of items, some sentences were rephrased or reworded, an introduction and headlines to different sections were added, and skip logic were incorporated to hide non-relevant items.

Conclusion

Our findings support the importance of validating questionnaires to ensure accuracy of survey instruments. Validation led to modifications of the questionnaire, and we propose a new version of the HeartRunner questionnaire. Our findings support the content validity of the final HeartRunner questionnaire. The questionnaire may allow the collection of quality data to evaluate and improve volunteer responder programmes.

Under pressure: What individual characteristics lead to performance of high-quality chest compressions during CPR practice sessions?

Aim

Despite well-established protocols for cardiopulmonary resuscitation training, performance during real-life cardiac arrests can be suboptimal. Understanding personal characteristics which could influence performance of high-quality chest compressions could provide insight into the practice-performance gap. This study examined chest compression performance, while employing feedback and introducing code team sounds as an anxiety-inducing factor in registered nurses using a cardiopulmonary resuscitation training manikin.

Methods

Participants included 120 registered nurses with basic life support certification randomized to one of the following groups: no feedback and no code team sounds, feedback without code team sounds, or feedback with code team sounds. Chest compression sessions occurred at baseline, 30-days and 60-days. Demographic variables and anxiety level were also collected. The primary outcome was chest compression performance, defined as average percent of time with correct rate and percent with correct depth as captured by the defibrillator. Statistical analysis included linear mixed effects analysis.

Results

The effect of feedback on chest compression performance depended on the value of other parameters. The benefit of feedback on the primary outcome depended on: age, with feedback less beneficial among older participants (p = 0.0413); and time, with feedback more beneficial with repetition (p = 0.011). These interactions also affected the outcome percent of time with correct compression depth. Increased anxiety was associated with decreased percent correct compression depth (p < 0.001).

Conclusion

Feedback emerged as important in determining chest compression performance. Chest compression quality was limited by the performer's age and anxiety level. Future research should focus on identifying factors related to individual characteristics which may influence chest compression performance.

Using real-time device-based visual feedback in CPR recertification programs: A prospective randomised controlled study

BACKGROUND

Receiving regular training to maintain CPR skills is critical for in-service health-care professionals, especially because motor skills diminish over time.

OBJECTIVES

To compare the effects of real-time device-based visual feedback and conventional instructor-based feedback on the chest compression skills and self-efficacy of nurses receiving a CPR recertification program.

DESIGN

A prospective randomised controlled study with repeated measurements was conducted according to the CONSORT 2010 guidelines.

METHODS

A total of 109 nurses were recruited, and 98 nurses were eligible for random allocation. The control group (CG, n = 49) was advised by instructors for skill correction, and the experimental group (EG, n = 49) adjusted their skills according to on-screen real-time feedback data. The study outcomes were CPR performance metrics and self-efficacy that were assessed immediately after the training session (T1) and retested after 12 weeks (T2).

RESULTS

In the EG, the percentage of the appropriate rate, depth, and chest recoil at T1 significantly improved by 24.47 % (P < .001), 19.63 % (P < .001), and 11.52 % (P = .001), respectively. The EG exhibited significantly higher chest compression total scores at T1, and the difference remained significant at T2 (P < 0.001). Moreover, the self-efficacy in the EG significantly improved at T1 (2.76; P < .001) and T2 (2.58; P < .001).

CONCLUSION

Compared with instructor-based feedback, real-time device-based visual feedback improved chest compression quality and CPR self-efficacy.

Association between the number of prehospital defibrillation attempts and a sustained return of spontaneous circulation: a retrospective, multicentre, registry-based study

BACKGROUND

Currently, there is no consensus on the number of defibrillation attempts that should be made before transfer to a hospital in patients with out-of-hospital cardiac arrest (OHCA). This study aimed to evaluate the association between the number of defibrillations and a sustained prehospital return of spontaneous circulation (ROSC).

METHODS

A retrospective analysis of a multicentre, prospectively collected, registry-based study in Republic of Korea was conducted for OHCA patients with prehospital defibrillation. The primary outcome was sustained prehospital ROSC, and the secondary outcome was a good neurological outcome at hospital discharge, defined as Cerebral Performance Category score 1 or 2. Cumulative incidence of sustained prehospital ROSC and good neurological outcome according to number of defibrillations were examined. Multivariable logistic regression analysis was used to examine whether the number of defibrillations was independently associated with the outcomes.

RESULTS

Excluding 172 patients with missing data, a total of 1983 OHCA patients who received prehospital defibrillation were included. The median time from arrest to first defibrillation was 10 (IQR 7-15) min. The numbers of patients with sustained prehospital ROSC and good neurological outcome were 738 (37%) and 549 (28%), respectively. Sustained ROSC rates decreased as the number of defibrillation attempts increased from the first to the sixth (16%, 9%, 5%, 3%, 2% and 1%, respectively). The cumulative sustained ROSC rate, and good neurological outcome rate from initial defibrillation to sixth defibrillation were 16%, 25%, 30%, 34%, 36%, 36% and 11%, 18%, 22%, 25%, 26%, 27%, respectively. With adjustment for clinical characteristics and time to defibrillation, a higher number of defibrillations was independently associated with a lower chance of a sustained ROSC (OR 0.81, 95% CI 0.76 to 0.86) and a lower chance of good neurological outcome (OR 0.86, 95% CI 0.80 to 0.92).

CONCLUSIONS

We observed no significant increase in ROSC after five defibrillations, and no absolute increase in ROSC after seven defibrillations. These data provide a starting point for determination of the optimal defibrillation strategy prior to consideration for prehospital extracorporeal cardiopulmonary resuscitation (ECPR) or conveyance to a hospital with an ECPR capability.

TRIAL REGISTRATION NUMBER

NCT03222999.

Impact of Ultrasonography on Chest Compression Fraction and Survival in Patients with Out-of-hospital Cardiac Arrest

INTRODUCTION

Whether ultrasonography (US) contributes to delays in chest compressions and hence a negative impact on survival is uncertain. In this study we aimed to investigate the impact of US on chest compression fraction (CCF) and patient survival.

METHODS

We retrospectively analyzed video recordings of the resuscitation process in a convenience sample of adult patients with non-traumatic, out-of-hospital cardiac arrest. Patients receiving US once or more during resuscitation were categorized as the US group, while the patients who did not receive US were categorized as the non-US group. The primary outcome was CCF, and the secondary outcomes were the rates of return of spontaneous circulation (ROSC), survival to admission and discharge, and survival to discharge with a favorable neurological outcome between the two groups. We also evaluated the individual pause duration and the percentage of prolonged pauses associated with US.

RESULTS

A total of 236 patients with 3,386 pauses were included. Of these patients, 190 received US and 284 pauses were related to US. Longer resuscitation duration was observed in the US group (median, 30.3 vs 9.7 minutes, P<.001). The US group had comparable CCF (93.0% vs 94.3%, P=0.29) with the non-US group. Although the non-US group had a better rate of ROSC (36% vs 52%, P=0.04), the rates of survival to admission (36% vs 48%, P=0.13), survival to discharge (11% vs 15%, P=0.37), and survival with favorable neurological outcome (5% vs 9%, P=0.23) did not differ between the two groups. The pause duration of pulse checks with US was longer than pulse checks alone (median, 8 vs 6 seconds, P=0.02). The percentage of prolonged pauses was similar between the two groups (16% vs 14%, P=0.49).

CONCLUSION

When compared to the non-ultrasound group, patients receiving US had comparable chest compression fractions and rates of survival to admission and discharge, and survival to discharge with a favorable neurological outcome. The individual pause was lengthened related to US. However, patients without US had a shorter resuscitation duration and a better rate of ROSC. The trend toward poorer results in the US group was possibly due to confounding variables and nonprobability sampling. It should be better investigated in further randomized studies.

Cardiac arrest and cardiopulmonary resuscitation in “hostile” environments: Using automated compression devices to minimize the rescuers’ danger

Mechanical automated compression devices are being used in cardiopulmonary resuscitation instead of manual, “hands-on”, rescuer-delivered chest compressions. The -theoretical- advantages include high-quality non-stop compressions, thus freeing the rescuer performing the compressions and additionally the ability of the rescuer to stand reasonably away from a potentially “hazardous” victim, or from hazardous and/or difficult resuscitation conditions. Such circumstances involve cardiopulmonary resuscitation (CPR) in the Cardiac Catheterization Laboratory, especially directly under the fluoroscopy panel, where radiation is well known to cause detrimental effects to the rescuer, and CPR during/after land or air transportation of cardiac arrest victims. Lastly, CPR in a coronavirus disease 2019 patient/ward, where the danger of contamination and further serious illness of the health provider is very existent. The scope of this review is to review and present literature and current guidelines regarding the use of mechanical compressions in these “hostile” and dangerous settings, while comparing them to manual compressions.

The association of the post-resuscitation on-scene interval and patient outcomes after out-of-hospital cardiac arrest

BACKGROUND

After resuscitation from out-of-hospital cardiac arrest (OHCA) by Emergency Medical Services (EMS), the amount of time that should be dedicated to pre-transport stabilization is unclear. We examined whether the time spent on-scene after return of spontaneous circulation (ROSC) was associated with patient outcomes.

METHODS

We examined consecutive adult EMS-treated OHCAs from the British Columbia Cardiac Arrest registry (January 1/2019-June 1/2021) that had on-scene ROSC (sustained to scene departure). The primary outcome was favourable neurological outcome (Cerebral Performance Category ≤ 2) at hospital discharge; secondary outcomes were re-arrest during transport and hospital-discharge survival. Using adjusted logistic regression models, we estimated the association between the post-resuscitation on-scene interval (divided into quartiles) and outcomes.

RESULTS

Of 1653 cases, 611 (37%) survived to hospital discharge, and 523 (32%) had favourable neurological outcomes. The median post-resuscitation on-scene interval was 18.8 minutes (IQR:13.0-25.5). Compared to the first post-resuscitation on-scene interval quartile, neither the second (adjusted odds ratio [AOR] 1.19; 95% CI 0.72-1.98), third (AOR 1.10; 95% CI 0.67-1.81), nor fourth (AOR 1.54; 95% CI 0.93-2.56) quartiles were associated with favourable neurological outcomes; however, the fourth quartile was associated with a greater odds of hospital-discharge survival (AOR 1.73; 95% CI 1.05-2.85), and both the third (AOR 0.40; 95% CI 0.22-0.72) and fourth (AOR 0.44;95% CI 0.24-0.81) quartiles were associated with a lower odds of intra-transport re-arrest.

CONCLUSION

Among resuscitated OHCAs, increased post-resuscitation on-scene time was not associated with improved neurological outcomes, but was associated with improved survival to hospital discharge and decreased intra-transport re-arrest.

Dedicated chest compressor team: A quality improvement initiative to improve chest compression performance at in-hospital cardiac arrest events through quarterly training

Background

High-quality cardiopulmonary resuscitation (CPR) is foundational to all resuscitative efforts. Spaced practice improves learners' skill retention. We evaluated the implementation of a quarterly CPR curriculum and skills training program for a dedicated chest compressor team to improve the quality of CPR performed during in-hospital cardiac arrest (IHCA) events and its impact on patient survival of event.

Methods

Baseline observations on CPR performance within the hospital were collected in October 2018. The CPR quarterly training program was implemented in November 2018. Training included use of high-fidelity simulation manikins and team members received real-time feedback scores related to compression rate, depth and recoil. High-quality CPR scores were set at ≥ 70%. Yearly IHCA event survival data was examined in relation to the implementation of training.

Results

Quarterly CPR training of the team led to retention of CPR skills (chest compression rate, depth, and recoil). The team's initial CPR training performance average score was 49.1%, increasing to 80.3%, with 95% (n = 37) of participants achieving a higher score after feedback during their initial training. A two-sample t-test was used for numerical data and chi-square was used for proportional data analysis. The survival of event prior to this training was 61.0% January-October 2018. Post -training, event survival rose to 73.5% (p-value 0.03) in 2019.

Conclusion

Implementation of a team that attends quarterly CPR training with a high-fidelity simulation manikin is attainable. This training resulted in improved CPR quality and benefited IHCA event survival.

Feasibility of electroacupuncture at Baihui (GV20) and Zusanli (ST36) on survival with a favorable neurological outcome in patients with postcardiac arrest syndrome after in-hospital cardiac arrest: study protocol for a pilot randomized controlled trial

BACKGROUND

At present, even the first-line medication epinephrine still shows no evidence of a favourable neurological outcome in patients with sudden cardiac arrest (SCA). The high mortality of patients with postcardiac arrest syndrome (PCAS) can be attributed to brain injury, myocardial dysfunction, systemic ischaemia/reperfusion response, and persistent precipitating pathology. Targeted temperature management, the only clinically proven method in the treatment of PCAS, is still associated with a series of problems that have not been completely resolved. Acupuncture is a crucial therapy in traditional Chinese medicine. On the basis of the results of previous studies, we hypothesize that electroacupuncture (EA) might provide therapeutic benefits in the treatment of PCAS. This study will explore the feasibility of EA on SCA patients.

METHODS

This is a prospective pilot, randomized controlled clinical trial. Eligible patients with PCAS after in-hospital cardiac arrest (IHCA) admitted to our department will be randomly allocated to the control group or the EA group. Both groups will receive standard therapy according to American Heart Association guidelines for cardiopulmonary resuscitation. However, the EA group will also receive acupuncture at the Baihui acupoint (GV20) and Zusanli acupoint (ST36) with EA stimulation for 30 min using a dense-dispersed wave at frequencies of 20 and 100 Hz, a current intensity of less than 10 mA, and a pulse width of 0.5 ms. EA treatment will be administered for up to 14 days (until either discharge or death). The primary endpoint is survival with a favourable neurological outcome. The secondary endpoints are neurological scores, cardiac function parameters, and other clinical parameters, including Sequential Organ Failure Assessment (SOFA) scores and Acute Physiology and Chronic Health Evaluation (APACHE) II scores, on days 0 to 28.

DISCUSSION

This study will provide crucial clinical evidence on the efficacy of EA in PCAS when used as an adjunctive treatment with AHA standard therapy.

TRIAL REGISTRATION

chictr.org.cn : ChiCTR2000040040. Registered on 19 November 2020. Retrospectively registered. http://www.chictr.org.cn/ .

Improved simulated ventilation with a novel tidal volume and peak inspiratory pressure controlling bag valve mask: A pilot study

Introduction

The dangers of hyperventilation during resuscitation are well known. Traditional bag valve mask (BVM) devices rely on end users to control tidal volume (V_t), rate, and peak inspiratory pressures (PIP) of ventilation. The Butterfly BVM (BBVM) is a novel device intending to give greater control over these parameters. The objective of this pilot study was to compare the BBVM against a traditional device in simulated resuscitations.

Methods

Senior emergency medicine residents and fellows participated in a three-phase simulation study. First, participants used the Ambu Spur II BVM in adult and pediatric resuscitations. V_t, PIP, and rate were recorded. Second, participants repeated the resuscitations after a brief introduction to the BBVM. Third, participants were given a longer introduction to the BBVM and were tested on their ability to adjust its various settings.

Results

Nineteen participants were included in the adult arm of the study, and 16 in the pediatric arm. The BBVM restricted V_t delivered to a range of 4-8 ml/kg vs 9 ml/kg and 13 ml/kg (Ambu adult and Ambu pediatric respectively). The BBVM never exceeded target minute ventilations while the Ambu BVMs exceeded target minute ventilation in 2 of 4 tests. The BBVM failed to reliably reach higher PIP targets in one test, while the pediatric Ambu device had 76 failures of excessive PIP compared to 2 failures by the BBVM.

Conclusion

The BBVM exceeded the Ambu Spur II in delivering appropriate V_ts and in keeping PIPs below target maximums to simulated adult and pediatric patients in this pilot study.

Effect of a low-cost instruction card for automated external defibrillator operation in lay rescuers: a randomized simulation study

BACKGROUND

To evaluate whether a simplified self-instruction card can help potential rescue providers use automated external defibrillators (AEDs) more accurately and quickly.

METHODS

From June 1, 2018, to November 30, 2019, a prospective longitudinal randomized controlled simulation study was conducted among 165 laypeople (18-65 years old) without prior AED training. A self-instruction card was designed to illuminate key AED operation procedures. Subjects were randomly divided into the card (n=83) and control (n=82) groups with age stratification. They were then individually evaluated in the same simulated scenario to use AED with (card group) or without the self-instruction card (control group) at baseline, post-training, and at the 3-month follow-up.

RESULTS

At baseline, the card group reached a significantly higher proportion of successful defibrillation (31.1% vs. 15.9%, P=0.03), fully baring the chest (88.9% vs. 63.4%, P<0.001), correct electrode placement (32.5% vs. 17.1%, P=0.03), and resuming cardiopulmonary resuscitation (CPR) (72.3% vs. 9.8%, P<0.001). At post-training and follow-up, there were no significant differences in key behaviors, except for resuming CPR. Time to shock and time to resume CPR were shorter in the card group, while time to power-on AED was not different in each phase of tests. In the 55-65 years group, the card group achieved more skill improvements over the control group compared to the other age groups.

CONCLUSION

The self-instruction card could serve as a direction for first-time AED users and as a reminder for trained subjects. This could be a practical, cost-effective way to improve the AED skills of potential rescue providers among different age groups, including seniors.

Analyzing willingness for extracorporeal cardiopulmonary resuscitation in refractory ventricular fibrillation

Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory ventricular fibrillation/ventricular tachycardia in out-of-hospital cardiac arrest has recently been recommended for selected patients with favorable prognostic features. We aimed to identify factors affecting the willingness of emergency physicians to implement extracorporeal cardiopulmonary resuscitation (ECPR). We conducted a factorial survey with nine experimental vignettes by combining three different scene time intervals and transportation time intervals. Emergency physicians reported willingness to implement ECPR (1-100 points). Respondent characteristics that could affect the willingness were studied. Multilevel analysis of vignettes and respondent factors was conducted using a mixed-effects regression model. We obtained 486 vignette responses from 54 emergency physicians. In the case of longer scene time intervals, there was a significant difference in the willingness scores at 9 and 12 min transportation time intervals. When the pre-hospital time interval was > 40 min, emergency physicians demonstrated lower willingness to implement ECPR. Clinical experience of 15-19 years showed a significant favorable effect on willingness to implement extracorporeal membrane oxygenation (ECMO). However, the mean willingness scores of EPs for ECMO implementation were more than 75 across all vignettes. In ECPR, the prehospital time interval is an important factor, and the willingness of emergency physicians to implement ECMO could be mutually affected by scene time intervals, transportation time intervals, and total prehospital time.

The impact of alcohol use on the quality of cardiopulmonary resuscitation among festival attendees: A prespecified analysis of a randomised trial

BACKGROUND

Cardiac arrests often occur in public places, but despite the undisputed impact of bystander CPR, it is debated whether one should act as a rescuer after alcohol consumption due to the perceived adverse effects. We provide the first objective data on the impact of alcohol levels on CPR-skills.

METHODS

Pre-specified analysis of a randomised study at the Lowlands music festival (August 2019, the Netherlands) on virtual reality vs face-to-face CPR-training. Participants with an alcohol level ≥ 0.5‰ (WHO-endorsed cut-off for traffic participation) were eligible provided they successfully completed a tandem gait test. We studied alcohol levels (AL, ‰) in relation to CPR-quality (compression depth and rate) and CPR-scenario performance.

RESULTS

Median age of the 352 participants was 26 (22-31) years, 56% were female, with n = 214 in Group 1 (AL = 0‰), n = 85 in Group 2 (AL = 0-0.5‰) and n = 53 in Group 3 (AL ≥ 0.5‰). There were no significant differences in CPR-quality (depth: 57 [49-59] vs 57 [51-60] vs 55 mm [47-59], p = 0.16; rate: 115 [104-121] vs 114 [106-122] vs 111 min^-1 [95-120], p = 0.19). There were no significant correlations between alcohol level and compression depth (Spearman's rho -0.113, p = 0.19) or rate (Spearman's rho -0.073, p = 0.39). CPR-scenario performance scores (maximum 13) were not different between groups (12 (9-13) vs 12 (9-13) vs 11 (9-13), p = 0.80).

CONCLUSION

In this study on festival attendees, we found no association between alcohol levels and CPR-quality or scenario performance shortly after training.

TRIAL REGISTRATION

Lowlands Saves Lives is registered on https://www.

CLINICALTRIALS

gov (NCT04013633).

Comparison of Sustained Return of Spontaneous Circulation Rate Between Manual and Mechanical Chest Compression in Adult Cardiac Arrest

Objective

This study aimed to compare the rates of sustained return of spontaneous circulation (ROSC) between manual and mechanical chest compression in adult non-traumatic cardiac arrest.

Methods

A retrospective cohort study was conducted from 2017 to 2019. The medical records were reviewed in 227 cardiac arrest patients aged ≥18 years who experienced out-of-hospital cardiac arrest or cardiac arrest while visiting the emergency department (ED). The patients were divided into manual chest compression and mechanical chest compression groups. The two groups were compared in terms of baseline characteristics, time to arrive at the ED, time to basic life support, initial rhythm, time to defibrillation in the shockable group, time to the first dose of adrenaline, and possible cause of arrest. A multivariate logistic regression model was used to determine the factors associated with ROSC.

Results

A total of 227 patients met the inclusion criteria:193 patients in the manual chest compression group and 34 patients in the mechanical chest compression group. The rate of sustained ROSC in the manual chest compression group was higher (43% vs 8.8%; P < 0.001). The significant factors associated with ROSC were witnessed cardiac arrest (odds ratio (OR) = 3.41; 95% confidence interval (CI) 0.94–12.4), ED arrival by basic ambulance service (OR = 1.93; 95% CI 0.86–4.35), cardiac arrest at the ED (OR = 3.69; 95% CI 1.73–7.88), and cardiac arrest from hypoxia (OR = 2.01; 95% CI 1.02–3.97).

Conclusion

Mechanical chest compression was not associated with sustained ROSC and tended to be selectively used in patients with a prolonged duration of cardiac arrest.

Exposure to incivility does not hinder speaking up: a randomised controlled high-fidelity simulation-based study

BACKGROUND

Speaking up with concerns is critical for patient safety. We studied whether witnessing a civil (i.e. polite, respectful) response to speaking up would increase the occurrence of further speaking up by hospital staff members as compared with witnessing a pseudo-civil (i.e. vague and slightly dismissive) or rude response.

METHODS

In this RCT in a single, large academic teaching hospital, a single simulated basic life support scenario was designed to elicit standardised opportunities to speak up. Participants in teams of two or three were randomly assigned to one of three experimental conditions in which the degree of civility in reacting to speaking up was manipulated by an embedded simulated person. Speaking up behaviour was assessed by behaviour coding of the video recordings of the team interactions by applying 10 codes using The Observer XT 14.1. Data were analysed using multilevel modelling.

RESULTS

The sample included 125 interprofessional hospital staff members (82 [66%] women, 43 [34%] men). Participants were more likely to speak up when they felt psychologically safe (γ=0.47; standard error [se]=0.19; 95% confidence interval [CI], 0.09-0.85; P=0.017). Participants were more likely to speak up in the rude condition than in the other conditions (γ=0.28; se=0.12; 95% CI, 0.05-0.52; P=0.019). Across conditions, participants spoke up most frequently by structuring inquiry (n=289, 31.52%), proactive (n=240, 26.17%), and reactive (n=148, 16.14%) instruction statements, and gestures (n=139, 15.16%).

CONCLUSION

Our study challenges current assumptions about the interplay of civility and speaking up behaviour in healthcare.

Association of multiple rib fractures with the frequency of pneumonia in the post-resuscitation period

Purpose

Successful cardiopulmonary resuscitation is associated with a high incidence of chest wall injuries. However, few studies have examined chest wall injury as a risk factor for respiratory complications after cardiopulmonary resuscitation. Therefore, herein, we investigated the association of multiple rib fractures on the incidence of post-resuscitation pneumonia.

Methods

This single-centre retrospective cohort study enrolled adult, nontraumatic, out-of-hospital cardiac arrest patients who maintained circulation for more than 48 h between June 2015 and May 2019. Rib fractures were evaluated by computed tomography on the day of hospital admission. The association with newly developed pneumonia within 7 days of hospitalisation was analysed using a Fine-Gray proportional hazards regression model adjusted for the propensity score of multiple rib fractures estimated from age, sex, presence of witnessed status, bystander CPR, initial rhythm, and total CPR time and for previously reported risk factors for pneumonia (therapeutic hypothermia and prophylactic antibiotics).

Results

Overall, 683 patients with out-of-hospital cardiac arrest were treated; 87 eligible cases were enrolled for analysis. Thirty-two (36.8%) patients had multiple rib fractures identified on computed tomography, and 35 (40.2%) patients developed pneumonia. The presence of multiple rib fractures was significantly associated with a higher incidence of pneumonia, consistently both with and without adjustment for background factors (unadjusted hazard ratio 4.63, 95% confidence interval: 2.35–9.13, p < 0.001; adjusted hazard ratio 4.03, 95% confidence interval: 2.08–7.82, p < 0.001).

Conclusions

Multiple rib fractures are independently associated with the development of pneumonia after successful resuscitation.

Manual and Mechanical Induced Peri-Resuscitation Injuries-Post-Mortem and Clinical Findings

(1) Background: Injuries related to resuscitation are not usually systematically recorded and documented. By evaluating this data, conclusions could be drawn about the quality of the resuscitation, with the aim of improving patient care and safety. (2) Methods: We are planning to conduct a multicentric, retrospective 3-phased study consisting of (1) a worldwide literature review (scoping review), (2) an analysis of anatomical pathological findings from local institutions in North Rhine-Westphalia, Germany to assess the transferability of the review data to the German healthcare system, and (3) depending on the results, possibly establishing potential prospective indicators for resuscitation-related injuries as part of quality assurance measures. (3) Conclusions: From the comparison of literature and local data, the picture of resuscitation-related injuries will be focused on and quality indicators will be derived.

Manual versus Mechanical Delivery of High-Quality Cardiopulmonary Resuscitation on a River-Based Fire Rescue Boat

Objectives:

Studies have demonstrated the efficacy of mechanical devices at delivering high-quality cardiopulmonary resuscitation (HQ-CPR) in various transport settings. Herein, this study investigates the efficacy of manual and mechanical HQ-CPR delivery on a fire rescue boat.

Methods:

A total of 15 active firefighter-paramedics were recruited for a prospective manikin-based trial. Each paramedic performed two minutes manual compression-only CPR while navigating on a river-based fire rescue boat. The boat was piloted in either a stable linear manner or dynamic S-turn manner to simulate obstacle avoidance. For each session of manual HQ-CPR, a session of mechanical HQ-CPR was also performed with a LUCAS 3 (Stryker; Kalamazoo, Michigan USA). A total of 60 sessions were completed. Parameters recorded included compression fraction (CF) and the percentage of compressions with correct depth >5cm (D%), correct rate 100-120 (R%), full release (FR%), and correct hand position (HP%). A composite HQ-CPR score was calculated as follows: ((D% + R% + FR% + HP%)/4) * CF%). Differences in magnitude of change seen in stable versus dynamic navigation within study conditions were evaluated with a Z-score calculation. Difficulty of HQ-CPR delivery was assessed utilizing the Borg Rating of Perceived Exertion Scale.

Results:

Participants were mostly male and had a median experience of 20 years. Manual HQ-CPR delivered during stable navigation out-performed manual HQ-CPR delivered during dynamic navigation for composite score and trended towards superiority for FR% and R%. There was no difference seen for any measured variable when comparing mechanical HQ-CPR delivered during stable navigation versus dynamic navigation. Mechanical HQ-CPR out-performed manual HQ-CPR during both stable and dynamic navigation in terms of composite score, FR%, and R%. Z-score calculation demonstrated that manual HQ-CPR delivery was significantly more affected by drive style than mechanical HQ-CPR delivery in terms of composite HQ-CPR score and trended towards significance for FR% and R%. Borg Rating of Perceived Exertion was higher for manual CPR delivered during dynamic sessions than for stable sessions.

Conclusion:

Mechanical HQ-CPR delivery is superior to manual HQ-CPR delivery during both stable and dynamic riverine navigation. Whereas manual HQ-CPR delivery was worse during dynamic transportation conditions compared to stable transport conditions, mechanical HQ-CPR delivery was unaffected by drive style. This suggests the utility of routine use of mechanical HQ-CPR devices in the riverine patient transport setting.

Compromised cardiopulmonary resuscitation quality due to regurgitation during endotracheal intubation: a randomised crossover manikin simulation study

Background

Regurgitation is a complication common during cardiopulmonary resuscitation (CPR). This manikin study evaluated the effect of regurgitation during endotracheal intubation on CPR quality.

Methods

An airway-CPR manikin was modified to regurgitate simulated gastric contents into the oropharynx during chest compression during CPR. In total, 54 emergency medical technician-paramedics were assigned to either an oropharyngeal regurgitation or clean airway scenario and then switched to the other scenario after finishing the first. The primary outcomes were CPR quality metrics, including chest compression fraction (CCF), chest compression depth, chest compression rate, and longest interruption time. The secondary outcomes were intubation success rate and intubation time.

Results

During the first CPR–intubation sequence, the oropharyngeal regurgitation scenario was associated with a significantly lower CCF (79.6% vs. 85.1%, P < 0.001), compression depth (5.2 vs. 5.4 cm, P < 0.001), and first-pass success rate (35.2% vs. 79.6%, P < 0.001) and greater longest interruption duration (4.0 vs. 3.0 s, P < 0.001) than the clean airway scenario. During the second and third sequences, no significant difference was observed in the CPR quality metrics between the two scenarios. In the oropharyngeal regurgitation scenario, successful intubation was independently and significantly associated with compression depth (hazard ratio = 0.47, 95% confidence interval, 0.24–0.91), whereas none of the CPR quality metrics were related to successful intubation in the clean airway scenario.

Conclusion

Regurgitation during endotracheal intubation significantly reduces CPR quality.

Trial registration

ClinicalTrials.gov, NCT05278923, March 14, 2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00662-0.

Lack of Early Etiologic Investigations in Young Sudden Cardiac Death

BACKGROUND

Since majority of sudden cardiac arrest (SCA) victims die in the intensive care unit (ICU), early etiologic investigations may improve understanding of SCA and targeted prevention.

METHODS

In this prospective, population-based registry all SCA admitted alive across the 48 hospitals of the Paris area were enrolled. We investigated the extent of early etiologic work-up among young SCD cases (<45 years) eventually dying within the ICU.

RESULTS

From May 2011 to May 2018, 4,314 SCA patients were admitted alive. Among them, 3,044 died in ICU, including 484 (15.9%) young patients. SCA etiology was established in 233 (48.1%) and remained unexplained in 251 (51.9%). Among unexplained (compared to explained) cases, coronary angiography (17.9 vs. 49.4%, P<0.001), computed tomography scan (24.7 vs. 46.8%, P<0.001) and trans-thoracic echocardiography (31.1 vs. 56.7%, P<0.001) were less frequently performed. Only 22 (8.8%) patients with unexplained SCD underwent all three investigations. SCDs with unexplained status decreased significantly over the 7 years of the study period (from 62.9 to 35.2%, P=0.005). While specialized TTE and CT scan performances have increased significantly, performance of early coronary angiography did not change. Autopsy, genetic analysis and family screening were performed in only 48 (9.9%), 5 (1.0%) and 14 cases (2.9%) respectively.

CONCLUSIONS

More than half of young SCD dying in ICU remained etiologically unexplained; this was associated with a lack of early investigations. Improving early diagnosis may enhance both SCA understanding and prevention, including for relatives. Failure to identify familial conditions may result in other preventable deaths within these families.

A New Immersive Virtual Reality Station for Cardiopulmonary Resuscitation Objective Structured Clinical Exam Evaluation

The Objective Structured Clinical Exam (OSCE) is an assessment tool used as a reliable method for clinical competence evaluation of students. This paper presents an investigation focused on the chain of survival, its related exploration, management, and technical skills, and how Virtual Reality (VR) can be used for the creation of immersive environments capable of evaluating students' performance while applying the correct protocols. In particular, the Cardiopulmonary Resuscitation (CPR) procedure is studied as an essential step in the development of the chain of survival. The paper also aims to highlight the limitations of traditional methods using mechanical mannequins and the benefits of the new approaches that involve the students in virtual, immersive, and dynamic environments. Furthermore, an immersive VR station is presented as a new technique for assessing CPR performance through objective data collection and posterior evaluation. A usability test was carried out with 33 clinicians and OSCE evaluators to test the viability of the presented scenario, reproducing conditions of a real examination. Results suggest that the environment is intuitive, quick, and easy to learn and could be used in clinical practice to improve CPR performance and OSCE evaluation.

Influence of pretesting and a near peer sharing real life experiences on CPR training outcomes in first year medical students: a non-randomized quasi-experimental study

BACKGROUND

Existing literature on cardiopulmonary resuscitation (CPR) training focuses on the knowledge and skill components while the attitudinal component is rarely addressed. There is a need to explore how peer interaction, learning atmosphere, and communication influence learning effectiveness during CPR training. Therefore, this study's objective was to evaluate how a senior student (near peer) sharing their real-life experience of performing CPR would influence medical students' learning and readiness to perform CPR.

METHODS

The present study involved 250 newly enrolled undergraduate medical students. The Solomon's four-group study design was used to evaluate the influence of both pretesting and peer interaction. Students belonging to two groups initially completed a pre-training knowledge test (pretest) and a questionnaire on readiness to perform CPR. Students from all four groups then participated in instructor-led hands-on skills training, after which the two intervention groups interacted with their senior, who shared their life experiences of performing CPR. Finally, all four groups underwent skills evaluation, immediate and delayed post-tests, and completed a questionnaire to assess readiness to perform CPR. The students also provided their feedback on the experience of interacting with a peer during the training.

RESULTS

Post-test scores were significantly higher than pretest scores (Kruskal-Wallis test, p < 0.05). Scores were significantly higher in pretested intervention groups than in the non-pretested non-intervention group (p < 0.05). Delayed post-test scores were slightly but not significantly lower than the immediate post-test scores with no significant difference observed in the scores among the groups. The pretested groups showed more readiness to perform CPR and the pretested intervention group were least concerned about acquiring infection during CPR. Students in all groups were confident of performing chest compressions correctly, and found it inspiring and motivating listening to and discussing real-life experiences with a near peer.

CONCLUSIONS

Hearing from peers about real-life CPR experience during CPR training sessions significantly impacted learning, enhanced student motivation to learn and may be an effective strategy to consider in routine CPR training. However, the positive effects of pretesting and peer interaction on knowledge were not sustained, highlighting a need for repeat training.

A comparison of the effectiveness of QCPR and conventional CPR training in final-year medical students at a South African university

INTRODUCTION

High-quality cardiopulmonary resuscitation (CPR) saves lives. Training on basic first aid manikins allows students to practice manoeuvres and provides realistic resistance to chest compressions. Conventional CPR has no real-time feedback to observe the quality of CPR. Quality cardiopulmonary resuscitation (QCPR) is technology using wireless sensors embedded in the manikin to measure the effectiveness of core CPR components. This study compared the effectiveness of CPR training of final-year undergraduate medical students using electronic-feedback QCPR adult manikins and conventional adult manikins. The effectiveness of compressions was compared and return on investment was investigated.

METHODS

In an experimental study, 53 students were divided into two groups using simple random sampling. The QCPR group practised CPR on the QCPR manikins. The CPR group practised on conventional CPR manikins. Both groups were allowed to practice for approximately 10 minutes. After the training session, both groups were tested using the QCPR manikin. Only chest compression performance in adult-sized manikins were measured, recorded and compared.

RESULTS

The median flow fraction for the QCPR group was 78.0% (interquartile range (IQR) 63-89%) and for the CPR group 80.0% (IQR 74-85%). The median number of compressions for the QCPR group was 104 (IQR 101-109) and for the CPR group 107 (IQR 79-124). Both groups achieved a 100% compression rate with adequate depth. The maximum total effectiveness of both groups was 99%. No statistically significant difference was seen for the overall percentage of compression effectiveness between the groups.

CONCLUSION

Participants achieved acceptable scores on most CPR compression metrics and complied with CPR guidelines in most cases. Efficacy of CPR training on conventional and QCPR manikins was comparable. CPR training in low resource settings can be just as effective on conventional manikins. Immediate feedback technology adds value to the training experience, allowing for individuals to adjust for deviations to set standards.

Public knowledge and attitudes toward automated external defibrillators use among first aid eLearning course participants: a survey

Objective

Survival from out-of-hospital cardiac arrest (OHCA) often depends on the effective and immediate use of automated external defibrillators (AEDs). Given that there have been few studies about AED use in China, the purpose of this study is to investigate the knowledge and attitudes regarding AED use among the Chinese public, then provide an effective suggestion for AED education strategies and legislation.

Method

The online survey was conducted among Chinese participants of the First Aid eLearning courses in June 2020.

Result

A total of 2565 (95.00%) surveys were completed, only 23.46% of respondents with non-medical related respondents reported having attended previous AED training courses. Regarding the basic knowledge of AEDs, few respondents (12.28%, n = 315) could answer all four questions correctly. 95.67% (n = 2454) were willing to learn AED use. Even if without the precondition of being skilled in AEDs, the female was more likely to rescue OHCA patients than the male (p = 0.003). Almost all respondents (96.65%) showed a strong willingness to rescue OHCA patients with training in using AEDs. The top four barriers to rescuing OHCA patients were lack of practical performing ability (60.47%), fear of hurting patients (59.30%), inadequate knowledge of resuscitation techniques (44.19%), and worry about taking legal responsibility (26.74%).

Conclusion

Our study reflects a deficiency of AED knowledge among the general public in China. However, positive attitudes towards rescuing OHCA patients and learning AED use were observed, which indicates that measures need to be taken to disseminate knowledge and use of AEDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01863-1.

Are Pediatric Manual Resuscitators Only Fit For Pediatric Use? A Comparison of Ventilation Volumes in a Moving Ambulance

BACKGROUND

The manual resuscitator device is the most common method of ventilating patients with respiratory failure, either with a facemask, or with an advanced airway such as an ETT. Barotrauma and gastric inflation from excessive ventilation volumes or pressure are concerning complications. Ventilating adult patients with pediatric manual resuscitator may provide more lung-protective tidal volumes based on stationary patient simulations. However, use of a pediatric manual resuscitator in mobile simulations contradictorily generates inadequate tidal volumes.

METHODS

Sixty-two EMS clinicians in a moving ambulance ventilated a manikin using pediatric and adult manual resuscitators in conjunction with oral-pharyngeal airway, i-gel, King LTS-D, or an endotracheal tube.

RESULTS

Oral-pharyngeal airway data were discarded due to EMS clinician inability to produce measurable tidal volumes. Mean ventilation volumes using the pediatric manual resuscitator were inadequate compared to those with the adult manual resuscitator on all other airway devices. In addition, i-gel, King LTS-D, and endotracheal tube volumes were statistically comparable. Paramedics ventilated larger volumes than emergency medical technicians.

CONCLUSIONS

Using a pediatric manual resuscitator on adult patients is not supported by our findings.

Impact of family presence during cardiopulmonary resuscitation on team performance and perceived task load: a prospective randomised simulator-based trial

OBJECTIVES

Guidelines recommend family presence to be offered during cardiopulmonary resuscitation (CPR). Data on the effects of family presence on the quality of CPR and rescuers' workload and stress levels are sparse and conflicting. This randomised trial investigated the effects of family presence on quality of CPR, and rescuers' perceived stress.

DESIGN

Prospective randomised single-blind trial.

SETTING

Voluntary workshops of educational courses.

PARTICIPANTS

1085 physicians (565 men) randomised to 325 teams entered the trial. 318 teams completed the trial without protocol violation.

INTERVENTIONS

Teams were randomised to a family presence group (n=160) or a control group (n=158) and to three versions of leadership: (a) designated at random, (b) designated by the team or (c) left open. Thereafter, teams were confronted with a simulated cardiac arrest which was video-recorded. Trained actors played a family member according a scripted role.

MAIN OUTCOME MEASURES

The primary endpoint was hands-on time. Secondary outcomes included interaction time, rescuers' perceived task load and adherence to CPR algorithms.

RESULTS

Teams interacted with the family member during 24 (17-36) % of the time spent for resuscitation. Family presence had no effect on hands-on time (88% (84%-91%) vs 89% (85%-91%); p=0.18). Family presence increased frustration (60 (30-75) vs 45 (30-70); p<0.001) and perceived temporal (75 (55-85) vs 70 (50-80); p=0.001) and mental demands (75 (60-85) vs 70 (55-80); p=0.009), but had no relevant effect on CPR performance markers. Leadership condition had no effects.

CONCLUSIONS

Interacting with a family member occupied about a quarter of the time spent for CPR. While this additional task was associated with an increase in frustration and perceived temporal and mental demands, family presence had no relevant negative effect on the quality of CPR.

TRIAL REGISTRATION NUMBER

DRKS00024759.

Novel Mode of Near-Infrared Spectroscopy as a Continuous Cerebral Physiological Monitoring Device during Cardiopulmonary Resuscitation: Four Case Reports

Background: NIRO-Pulse is a novel mode of near-infrared spectroscopy that can be used to visually evaluate cerebral perfusion during cardiopulmonary resuscitation (CPR), providing real-time feedback as to the quality of the CPR. The aim of this report was to describe the several representative cases of NIRO-Pulse for physiological monitoring during CPR. Methods: We present several cases from out-of-hospital cardiac arrest (OHCA) patients for whom NIRO-Pulse was attached to the forehead after hospital arrival. Patients were subjected to continuous brain monitoring during CPR using NIRO-Pulse, which allows for the visualisation of ΔHb (Hb pulsation). NIRO-Pulse is capable of simultaneously measuring and displaying cerebral tissue oxygen saturation (SctO2) and Hb pulsation, providing real-time feedback during CPR in the form of physiological indicators, and assessing changes in SctO2 throughout the CPR procedure by post-mortem analysis. Results: We observed several representative cases that provided the following insights: (1) SctO2 increased after a change in the quality of chest compression, (2) SctO2 decreased during the ventilation phase of synchronised CPR, (3) SctO2 decreased during the interruption of chest compressions for the preparation of defibrillation, and (4) SctO2 gradually and continuously increased after return of spontaneous circulation. Conclusion: Displaying Hb pulsation in conjunction with SctO2 during CPR may be helpful for evaluating the quality of and patient responsiveness to CPR. Further studies investigating the association between the use of NIRO-Pulse during CPR and subsequent outcomes should be conducted.