2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 4. Adult advanced life support

Impact of intravenous accessibility and prehospital epinephrine use on survival outcomes of adult nontraumatic out-of-hospital cardiac arrest patients

BACKGROUND

This study compared out-of-hospital cardiac arrest (OHCA) patient outcomes based on intravenous (IV) access and prehospital epinephrine use.

METHODS

A retrospective study in Ulsan, South Korea, from January 2017 to December 2022, analyzed adult nontraumatic OHCA cases. Patients were grouped: Group 1 (no IV attempts), Group 2 (failed IV access), Group 3 (successful IV access without epinephrine), and Group 4 (successful IV access with epinephrine), with comparisons using logistic regression analysis.

RESULTS

Among 2,656 patients, Group 4 had significantly lower survival to hospital discharge (adjusted OR 0.520, 95% CI 0.346-0.782, p = 0.002) and favorable neurological outcomes (adjusted OR 0.292, 95% CI 0.140-0.611, p = 0.001) than Group 1. Groups 2 and 3 showed insignificant survival to hospital discharge (adjusted OR 0.814, 95% CI 0.566-1.171, p = 0.268) and (adjusted OR 1.069, 95% CI 0.810-1.412, p = 0.636) and favorable neurological outcomes (adjusted OR 0.585, 95% CI 0.299-1.144, p = 0.117) and (adjusted OR 1.075, 95% CI 0.689-1.677, p = 0.751). In the shockable rhythm group, Group 3 had better survival to hospital discharge (adjusted OR 1.700, 95% CI 1.044-2.770, p = 0.033).

CONCLUSIONS

Successful IV access with epinephrine showed worse outcomes in both rhythm groups than no IV attempts. Outcomes for failed IV and successful IV access without epinephrine were inconclusive. Importantly, successful IV access without epinephrine showed favorable survival to hospital discharge in the shockable rhythm group, warranting further research into IV access for fluid resuscitation in shockable rhythm OHCA patients.

Effects of team-based mixed reality simulation program in emergency situations

BACKGROUND

This study aimed to demonstrate the effectiveness of a team-based mixed reality simulation program about emergencies.

METHOD

A nonequivalent control group pretest-posttest design was utilized. We recruited 32 nurses for the experimental group and 32 for the control group, resulting in a total of 61 nurses ultimately included as subjects for analysis. This mixed reality program is designed to facilitate responses in cardiopulmonary resuscitation situations simultaneously using four HoloLens. With shared content visible to all four trainees, the participants could engage in simulation while freely communicating. The experimental group engaged in cardiopulmonary resuscitation emergency simulation while wearing the HoloLens, while the control group was provided with written CPR materials.

RESULTS

There were significant increases in the experimental group's critical thinking (p < .001), learning transfer motivation (p = .006), communication confidence (p = .033), and learning immersion (p < .001) compared to the control group.

CONCLUSION

The program developed in this study presents an effective educational strategy that can enhance nurses' emergency competencies and leverage the practicality of mixed reality.

A remote-controlled automatic chest compression device capable of moving compression position during CPR: A pilot study in a mannequin and a swine model of cardiac arrest

BACKGROUND

Recently, we developed a chest compression device that can move the chest compression position without interruption during CPR and be remotely controlled to minimize rescuer exposure to infectious diseases. The purpose of this study was to compare its performance with conventional mechanical CPR device in a mannequin and a swine model of cardiac arrest.

MATERIALS AND METHODS

A prototype of a remote-controlled automatic chest compression device (ROSCER) that can change the chest compression position without interruption during CPR was developed, and its performance was compared with LUCAS 3 in a mannequin and a swine model of cardiac arrest. In a swine model of cardiac arrest, 16 male pigs were randomly assigned into the two groups, ROSCER CPR (n = 8) and LUCAS 3 CPR (n = 8), respectively. During 5 minutes of CPR, hemodynamic parameters including aortic pressure, right atrial pressure, coronary perfusion pressure, common carotid blood flow, and end-tidal carbon dioxide partial pressure were measured.

RESULTS

In the compression performance test using a mannequin, compression depth, compression time, decompression time, and plateau time were almost equal between ROSCER and LUCAS 3. In a swine model of cardiac arrest, coronary perfusion pressure showed no difference between the two groups (p = 0.409). Systolic aortic pressure and carotid blood flow were higher in the LUCAS 3 group than in the ROSCER group during 5 minutes of CPR (p < 0.001, p = 0.008, respectively). End-tidal CO2 level of the ROSCER group was initially lower than that of the LUCAS 3 group, but was higher over time (p = 0.022). A Kaplan-Meier survival analysis for ROSC also showed no difference between the two groups (p = 0.46).

CONCLUSION

The prototype of a remote-controlled automated chest compression device can move the chest compression position without interruption during CPR. In a mannequin and a swine model of cardiac arrest, the device showed no inferior performance to a conventional mechanical CPR device.

Hemodynamic Effect of Repeated Epinephrine Doses Decreases With Cardiopulmonary Resuscitation Cycle Progression

BACKGROUND

Epinephrine is administered to increase coronary perfusion pressure during advanced life support and promote short-term survival. Recent cardiopulmonary resuscitation (CPR) guidelines recommend an epinephrine dosing interval of 3 to 5 minutes during resuscitation; however, scientific evidence supporting this recommendation is lacking. Therefore, we aimed to investigate the hemodynamic effects of repeated epinephrine doses during CPR by monitoring augmented blood pressure after its administration in a swine model of cardiac arrest.

METHODS AND RESULTS

A secondary analysis of data from a published study was performed using a swine cardiac arrest model. The epinephrine dose was fixed at 1 mg, and the first dose of epinephrine was administered after no-flow and low-flow times of 2 minutes and 8 minutes, respectively, and subsequently administered every 4 minutes. Four cycles of dosing intervals were defined because a previous study was terminated 26 minutes after the induction of ventricular fibrillation. Augmented blood pressures and corresponding timelines were determined. Augmented blood pressure trends following cycles and the epinephrine effect duration were also monitored. Among the 140 CPR cycles, the augmented blood pressure after epinephrine administration was the highest during the first cycle of CPR and decreased gradually with further cycle repetitions. The epinephrine effect duration did not differ between repeated cycles. The maximum blood pressure was achieved 78 to 97 seconds after epinephrine administration.

CONCLUSIONS

Hemodynamic augmentation with repeated epinephrine administration during CPR decreased with cycle progression. Further studies are required to develop an epinephrine administration strategy to maintain its hemodynamic effects during prolonged resuscitation.

Association of prehospital advanced airway and epinephrine with survival in patients with out-of-hospital cardiac arrest

Survival benefits of prehospital advanced airway and epinephrine in out-of-hospital cardiac arrest (OHCA) patients are controversial, but few studies evaluated this together. This study evaluated association of prehospital advanced airway and epinephrine with survival outcomes in OHCA patients. This was observational study using a prospective multicentre KoCARC registry. Adult OHCA patients between October 2015 and December 2021 were included. The variables of interest were prehospital managements, which was classified into basic life support (BLS)-only, BLS + advanced airway, and BLS + advanced airway + epinephrine. In total, 8217 patients were included in analysis. Survival to discharge and good neurological outcomes were lowest in the BLS + advanced airway + epinephrine group (22.1% in BLS-only vs 13.2% in BLS + advanced airway vs 7.5% in BLS + advanced airway + epinephrine, P < 0.001 and 17.1% in BLS-only vs 9.2% in BLS + advanced airway vs 4.3% in BLS + advanced airway + epinephrine, P < 0.001, respectively). BLS + advanced airway + epinephrine group was less likely to survive to discharge and have good neurological outcomes (aOR 0.39, 95% CI 0.28-0.55, P < 0.001 and aOR 0.33, 95% CI 0.21-0.51, P < 0.001, respectively) than BLS-only group after adjusting for potential confounders. In prehospital settings with intermediate EMS providers and prehospital advanced airway insertion is performed followed by epinephrine administration, prehospital management with BLS + advanced airway + epinephrine in OHCA patients was associated with lower survival to discharge rate compared to BLS-only.

Efficacy of Cardiopulmonary Resuscitation Using Automatic Compression-Defibrillation Apparatus: An Animal Study and A Manikin-Based Simulation Study

BACKGROUND

Chest compression and defibrillation are essential components of cardiac arrest treatment. Mechanical chest compression devices (MCCD) and automated external defibrillators (AED) are used separately in clinical practice. We developed an automated compression-defibrillation apparatus (ACDA) that performs mechanical chest compression and automated defibrillation. We investigated the performance of cardiopulmonary resuscitation (CPR) with automatic CPR (A-CPR) compared to that with MCCD and AED (conventional CPR: C-CPR).

METHODS

Pigs were randomized into A-CPR or C-CPR groups: The A-CPR group received CPR+ACDA, and the C-CPR group received CPR+MCCD+AED. Hemodynamic parameters, outcomes, and time variables were measured. During a simulation study, healthcare providers performed a basic life support scenario for manikins with an ACDA, MCCD, and AED, and time variables and chest compression parameters were measured.

RESULTS

The animals showed no significant in hemodynamic effects, including aortic pressures, coronary perfusion pressure, carotid blood flow, and end-tidal CO2, and resuscitation outcomes between the two groups. In both animal and simulation studies, the time to defibrillation, time to chest compression, and hands-off time were significantly shorter in the A-CPR group than those in the C-CPR group.

CONCLUSIONS

CPR using ACDA showed similar hemodynamic effects and resuscitation outcomes as CPR using AED and MCCD separately, with the advantages of a reduction in the time to compression, time to defibrillation, and hands-off time.

Saline versus Plasma Solution-A in Initial Resuscitation of Patients with Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial

BACKGROUND

Although saline is commonly used during cardiopulmonary resuscitation (CPR) or post-cardiac arrest care, it has detrimental effects. This trial aimed to evaluate the efficacy of a balanced crystalloid solution (Plasma Solution-A [PS]) in out-of-hospital cardiac arrest (OHCA) patients and compare it with the efficacy of saline.

METHODS

A randomized, unblinded clinical trial was conducted using PS and saline for intravenous fluid administration during CPR and post-cardiac arrest care of non-traumatic OHCA patients admitted to the emergency department of a tertiary university hospital. Patients received saline (saline group) or PS (PS group) within 24 h of hospital arrival. The primary outcomes were changes in arterial pH, bicarbonate, base excess (BE), and chloride levels within 24 h. The secondary outcomes were clinical outcomes including mortality.

RESULTS

Of the 364 patients, data from 27 and 26 patients in the saline and PS groups, respectively, were analyzed. Analysis using a linear mixed model revealed a significant difference in BE change over time between the groups (treatment-by-time p = 0.044). Increase in BE and bicarbonate levels from 30 min to 2 h was significantly greater (p = 0.044 and p = 0.024, respectively) and the incidence of hyperchloremia was lower (p < 0.001) in the PS group than in the saline group. However, there was no difference in clinical outcomes.

CONCLUSION

Use of PS for resuscitation resulted in a faster improvement in BE and bicarbonate, especially in the early phase of post-cardiac arrest care, and lower hyperchloremia incidence than the use of saline, without differences in clinical outcomes, in OHCA patients.

Arterial Blood Gas Analysis for Survival Prediction in Pediatric Patients with Out-of-Hospital Cardiac Arrest

Arterial blood gas analysis (ABGA) is one of the few tests performed during cardiopulmonary resuscitation (CPR). There have been some studies on the prediction of survival outcomes in adult out-of-hospital cardiac arrest (OHCA) patients during CPR using ABGA results. However, in pediatric OHCA patients, the prognosis of survival outcome based on ABGA results during CPR remains unclear. We retrospectively analyzed prospectively collected data from the Korean Cardiac Arrest Resuscitation Consortium (KoCARC) registry, a multicenter OHCA registry of Republic of Korea. We analyzed 108 pediatric (age < 19 years) OHCA patients between October 2015 and June 2022. Using multivariable logistic regression, an adjusted odds ratio (aOR) was obtained to validate the ABGA results of survival to hospital admission and survival to discharge. The variables associated with survival to hospital admission were non-comorbidities (aOR 3.03, 95% confidence interval (CI) 1.22-7.53, p = 0.017) and PaO₂ > 45.750 mmHg (aOR 2.69, 95% CI 1.13-6.42, p = 0.026). There was no variable that was statistically significant association with survival to discharge. PaO₂ > 47.750 mmHg and non-comorbidities may serve as an independent prognostic factor for survival to hospital admission in pediatric OHCA patients. However, the number of cases analyzed in our study was relatively small, and there have been few studies investigating the association between ABGA results during CPR and the survival outcome of pediatric OHCA patients. Therefore, further large-scale studies are needed.

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.

Pre-arrest comorbidity burden and the future risk of out-of-hospital cardiac arrest in Korean adults

OBJECTIVE

To investigate the impact of pre-arrest comorbidities on future out-of-hospital cardiac arrest (OHCA) development using a nationwide dataset.

METHODS

This population-based, matched case-control study used the national health insurance claims data relevant to OHCA in South Korea from January 2009 to December 2018. Case patients were randomly matched to controls by age, sex and date of cardiac arrest. Controls were defined as patients who did not experience OHCA based on claim codes in national health screening data. The comorbidity burden was assessed using the Charlson Comorbidity Index (CCI).

RESULTS

A total of 191 370 OHCA patients were matched to 347 568 controls. The mean CCI in the case group was 3.76, which was significantly higher than that in the control group (1.75, p<0.001). Overall, OHCA was 1.35 (95% CI 1.34 to 1.35) times more likely to occur with every 1 point increase in the CCI. All other comorbidities constituting the CCI were associated with the OHCA risk (p<0.001). Patients with CCI ≥3 presented an OR of 3.71 (95% CI 3.67 to 3.76) for the risk of OHCA occurrence. This association was more pronounced in patients aged <70 years than in those aged ≥70 years (OR (95% CI) 16.07 (15.48 to 16.68) vs 6.50 (6.33 to 6.68)).

CONCLUSION

A high burden of pre-arrest comorbidity was associated with a higher risk of OHCA development, which was more pronounced in patients with less advanced age.

Extracorporeal cardiopulmonary resuscitation for adult out-of-hospital cardiac arrest patients: time-dependent propensity score-sequential matching analysis from a nationwide population-based registry

BACKGROUND

There is inconclusive evidence regarding the effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) patients. We aimed to evaluate the association between ECPR and neurologic recovery in OHCA patients using time-dependent propensity score matching analysis.

METHODS

Using a nationwide OHCA registry, adult medical OHCA patients who underwent CPR at the emergency department between 2013 and 2020 were included. The primary outcome was a good neurological recovery at discharge. Time-dependent propensity score matching was used to match patients who received ECPR to those at risk for ECPR within the same time interval. Risk ratios (RRs) and 95% confidence intervals (CIs) were estimated, and stratified analysis by the timing of ECPR was also performed.

RESULTS

Among 118,391 eligible patients, 484 received ECPR. After 1:4 time-dependent propensity score matching, 458 patients in the ECPR group and 1832 patients in the no ECPR group were included in the matched cohort. In the matched cohort, ECPR was not associated with good neurological recovery (10.3% in ECPR and 6.9% in no ECPR; RR [95% CI] 1.28 [0.85-1.93]). In the stratified analyses according to the timing of matching, ECPR with a pump-on within 45 min after emergency department arrival was associated with favourable neurological outcomes (RR [95% CI] 2.51 [1.33-4.75] in 1-30 min, 1.81 [1.11-2.93] in 31-45 min, 1.07 (0.56-2.04) in 46-60 min, and 0.45 (0.11-1.91) in over 60 min).

CONCLUSIONS

ECPR itself was not associated with good neurological recovery, but early ECPR was positively associated with good neurological recovery. Research on how to perform ECPR at an early stage and clinical trials to evaluate the effect of ECPR is warranted.

Intra-arrest transesophageal echocardiography during cardiopulmonary resuscitation

Determining the cause of cardiac arrest (CA) and the heart status during CA is crucial for its treatment. Transesophageal echocardiography (TEE) is an imaging method that facilitates close observation of the heart without interfering with cardiopulmonary resuscitation (CPR). Intra-arrest TEE is a point-of-care ultrasound technique that is used during CPR. Intra-arrest TEE is performed to diagnose the cause of CA, determine the presence of cardiac contraction, evaluate the quality of CPR, assist with catheter insertion, and explore the mechanism of blood flow during CPR. The common causes of CA diagnosed using intra-arrest TEE include cardiac tamponade, aortic dissection, pulmonary embolism, and intracardiac thrombus, which can be observed on a few simple image planes at the mid-esophageal and upper esophageal positions. To operate an intra-arrest TEE program, it is necessary to secure a physician who is capable of performing TEE, provide appropriate training, establish implementation protocols, and prepare a plan in collaboration with the CPR team.

Augmented-Medication CardioPulmonary Resuscitation (AMCPR) trial: a study protocol for a randomized controlled trial

Objective Clinical trials on demodynamic-directed cardiopulmonary resuscitation have been limited. The aim of this study is to investigate whether Augmented-Medication CardioPulmonary Resuscitation (AMCPR) would improve the odds of return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest. Methods This is a double-blind, single-center, randomized placebo-controlled trial that will be conducted in the emergency department of a tertiary, university-affiliated hospital in Seoul, Korea. A total of 148 adult patients with nontraumatic, nonshockable, out-of-hospital cardiac arrest who have an initial diastolic blood pressure above 20 mmHg will be randomly assigned to two groups of 74 patients (a 1:1 ratio). Patients will receive an intravenous dose of 40 IU of vasopressin with epinephrine, or a placebo with epinephrine. The primary endpoint is a sustained ROSC (over 20 minutes). Secondary endpoints are enhanced diastolic blood pressure, end-tidal carbon dioxide levels, acidosis, and lactate levels during resuscitation. Discussion AMCPR is a trial about tailored medication for select patients during resuscitation. This is the first randomized control trial to identify patients who would benefit from vasopressin for achieving ROSC. This study will provide evidence about the effect of administration of vasopressin with epinephrine to increase ROSC rate. Trial registration ClinicalTrials.gov identifier: NCT03191240. Registered on June 19, 2017.

The use of video laryngoscopy outside the operating room: A systematic review

This study aimed to describe how video laryngoscopy is used outside the operating room within the hospital setting. Specifically, we aimed to summarise the evidence for the use of video laryngoscopy outside the operating room, and detail how it appears in current clinical practice guidelines. A literature search was conducted across two databases (MEDLINE and Embase), and all articles underwent screening for relevance to our aims and pre-determined exclusion criteria. Our results include 14 clinical practice guidelines, 12 interventional studies, 38 observational studies. Our results show that video laryngoscopy is likely to improve glottic view and decrease the incidence of oesophageal intubations; however, it remains unclear as to how this contributes to first-pass success, overall intubation success and clinical outcomes such as mortality outside the operating room. Furthermore, our results indicate that the appearance of video laryngoscopy in clinical practice guidelines has increased in recent years, and particularly through the COVID-19 pandemic. Current COVID-19 airway management guidelines unanimously introduce video laryngoscopy as a first-line (rather than rescue) device.

Effect of corticosteroid administration on cardiac arrest: a systematic review and network meta-analysis of the timing of administration

Corticosteroids may have a beneficial effect on the outcome of cardiac arrest (CA); however, it is not known whether the timing of corticosteroid use affects the outcome. We performed a systematic review and network meta-analysis to compare the efficacy of corticosteroid administration according to the timing. A favorable final outcome, as the primary study outcome, was defined as a combination of survival with good neurologic outcome and survival for 1 year. The secondary outcome was survival to discharge. Nine clinical studies were included. Corticosteroids administered during cardiopulmonary resuscitation (CPR; odds ratio [OR], 1.29; 95% confidence interval [CI], 1.11-1.51) and post-CA (OR, 1.47; 95% CI, 1.30-1.66) had a positive effect on the favorable final outcome compared to the control protocol (no corticosteroid administration), while those used prior to CA had a negative effect. Corticosteroids administered post-CA had a positive effect on survival to discharge compared to the control protocol (OR, 1.82; 95% CI, 1.02-3.27), while those used prior to CA and during CPR had no significant effect. Post-CA was evaluated to be the best administration timing for both outcomes. In conclusion, the timing of corticosteroid administration may be an important factor for the prognosis of CA. Corticosteroids administration post-CA and during CPR may have beneficial effects on CA outcomes.