Outcome of out-of-hospital cardiac arrest over a period of 15 years in comparison to the RACA score in a physician staffed urban emergency medical service in Germany

BackgroundPatient outcome after out of hospital cardiac arrest (OHCA) depends on the cardiopulmonary resuscitation (CPR) performance and might also be influenced by organisation of the emergency medical service (EMS) and implementation of guidelines.AimTo assess the rate of return of spontaneous circulation (ROSC) after cardiac arrest to the predicted rate by the ROSC after cardiac arrest (RACA) score over a 15-year period reflecting three different implemented ALS-guidelines in a physician-staffed EMS.MethodsAll adult patients with non-traumatic OHCA in the EMS of Bonn from 1996 to 2011 were included. Utstein data from three 5-years time periods (1996–2001, 2001–2006, 2006–2011) representing different ALS-guideline implementations were collected. Group comparisons were made in terms of incidence, epidemiology and short-term outcome of CPR with emphasis on changes over time and factors of importance. In each group observed ROSC rate were compared to the predicted ROSC rates (the RACA score).ResultsCPR by the ALS unit was attempted in a total of 1989 patients (735, 666, and 588 patients in the first, second and third period, respectively). Average crude incidence of CPR per 100,000 person-years decreased over time (61.3; 55.5; 49.0/100,000/years) while patients treated were significantly older (65.5 ± 16.5; 67.9 ± 15; 68.9 ± 15.7 (p < 0.001)). Observed ROSC rates were higher than predicted by the RACA score in all time periods, however, admittance to ICU decreased significantly from 50% in the first five-year period to 38% last five-year period (p < 0.001). From first to third period the proportion of arrests with first observed rhythm of VT/VF arrests did not change (29% vs. 27%, p = 0.323) nor there were changes in bystander CPR rates (17% vs. 17%, p = 0.520).ConclusionsIn a 15-years period and in the setting of a physician-staffed EMS the ROSC rates remain higher than predicted by the RACA score but the admittance to the ICU after OHCA declined significantly. This finding was accompanied by a decrease in CPR incidence and an increase in age of patients.     

Effects of mechanical chest compression device with a load-distributing band on post-resuscitation injuries identified by post-mortem computed tomography

ObjectiveTo determine the effects of cardiopulmonary resuscitation (CPR) with AutoPulse™ (LDB-CPR) on post-resuscitation injuries identified by post-mortem computed tomography (PMCT). AutoPulse™ is a novel mechanical chest-compression device with a load-distributing band (LDB) that may affect post-resuscitation injury identified by PMCT.MethodsWe conducted a retrospective cohort study of non-traumatic adult out-of-hospital cardiac arrest patients whose death was confirmed in our emergency department between October 2009 and September 2014. Patients were divided according to whether LDB-CPR (LDB-CPR group) or manual CPR only (manual CPR only group) was performed. The background characteristics and post-resuscitation injuries identified by PMCT were compared between both groups. Logistic regression was used to identify risk factors for posterior rib fracture and abdominal injury.ResultsOverall, 323 patients were evaluated, with 241 (74.6%) in the LDB-CPR group. The total duration of CPR was significantly longer in the LDB-CPR group than in the manual CPR only group. Posterior rib fracture, hemoperitoneum, and retroperitoneal hemorrhage were significantly more frequent in the LDB-CPR group. The frequencies of anterior/lateral rib and sternum fracture were similar in both groups. Pneumothorax tended to be more frequent in the LDB-CPR group, although not significantly. LDB-CPR was an independent risk factor for posterior rib fracture (odds ratio 30.57, 95% confidence interval 4.15–225.49, P = 0.001) and abdominal injury (odds ratio 4.93, 95% confidence interval 1.88–12.95, P = 0.001).ConclusionsLDB-CPR was associated with higher frequencies of posterior rib fracture and abdominal injury identified by PMCT. PMCT findings should be carefully examined after LDB-CPR.     

Visual assessment of CPR quality during pediatric cardiac arrest: Does point of view matter?

AimIn many clinical settings, providers rely on visual assessment when delivering feedback on CPR quality. Little is known about the accuracy of visual assessment of CPR quality. We aimed to determine how accurate pediatric providers are in their visual assessment of CPR quality and to identify the optimal position relative to the patient for accurate CPR assessment.MethodsWe videotaped high-quality CPR (based on 2010 American Heart Association guidelines) and 3 variations of poor quality CPR in a simulated resuscitation, filmed from the foot, head and the side of the manikin. Participants watched 12 videos and completed a questionnaire to assess CPR quality.ResultsOne hundred and twenty-five participants were recruited. The overall accuracy of visual assessment of CPR quality was 65.6%. Accuracy was better from the side (70.8%) and foot (68.8%) of the bed when compared to the head of the bed (57.2%; p < 0.001). The side was the best position for assessing depth (p < 0.001). Rate assessment was equivalent between positions (p = 0.58). The side and foot of the bed were superior to the head when assessing chest recoil (p < 0.001). Factors associated with increased accuracy in visual assessment of CPR quality included recent CPR course completion (p = 0.034) and involvement in more cardiac arrests as a team member (p = 0.003).ConclusionHealthcare providers struggle to accurately assess the quality of CPR using visual assessment. If visual assessment is being used, providers should stand at the side of the bed.     

Prevalence of systemic air-embolism after prolonged cardiopulmonary resuscitation in newborns: A pilot study

BackgroundChest compressions (CC) during cardiopulmonary resuscitation (CPR) are the cornerstone of adult CPR protocols and are meant to restore circulation and improve outcome. Although adverse effects such as air-embolisms have been reported, these are rare and considered to be outweighed by beneficial effect. In newborns, however, the lung tissue is more fragile. Thus, the high intra-thoracic pressures resulting from CC may make the newborns more vulnerable for air-embolisms.ObjectivesWe studied the postmortem prevalence of air-embolism in neonates that have received CPR.MethodsProspective cohort analysis of newborns receiving CC during CPR. CPR was performed by trained staff according to ILCOR guidelines, in a tertiary hospital. Air-embolisms were sought after using CT/MRI and autopsy.ResultsDuring a 61/2 year period (2007–2014), n = 56 newborns received CC. Newborns were resuscitated following severe perinatal hypoxia, or due to complications during NICU treatment. In n = 14 (25.0%) circulation could not be restored (mean CPR duration: 32.7 ± 15.2 min). Post-mortem CT/MRI was performed in n = 9, of whom n = 8 (88.9%) had air-embolisms. Autopsy was performed in n = 9. The air-embolisms could not be retraced on autopsy except for n = 1 patient.In patients with CPR resulting in restored circulation (n = 42), no CT or MRI was performed for comparison due to radiation and/or hemodynamic instability. Cerebral ultrasound could not identify or exclude air-embolisms in this subgroup.ConclusionsPost-mortem CT after prolonged resuscitation showed a high prevalence of intravascular air-embolism. Autopsy was not suited to detect air-embolism. The clinical importance of air-embolisms on the lethal outcome needs further research.     

Simultaneous beat-to-beat assessment of arterial blood pressure and quality of cardiopulmonary resuscitation in out-of-hospital and in-hospital settings

ObjectiveThe current recommendation for depth and rate of chest compression (CC) during cardiopulmonary resuscitation (CPR) is based on limited hemodynamic data recorded during human CPR. We have evaluated the possible association between CC depth and rate and continuously measured arterial blood pressure during adult CPR.MethodsThis prospective study included data from 104 patients resuscitated inside or outside hospital. Adequate data on continuously measured invasive arterial blood pressure (BP) and the quality of CPR from a defibrillator capable recording CPR quality parameters was successful in 39 patients. We used logistic regression and mixed effects modeling to identify CC depths and rates associated with systolic blood pressure (SBP) ≥85 mmHg and diastolic blood pressure (DBP) ≥30 mmHg.ResultsWe analyzed 41,575 compression-BP pairs. The values for blood pressure varied greatly between the patients. SBP varied from 25 to 225 mmHg and DBP from 2 to 59 mmHg. CC rate 100–120/min and CC depth ≥60 mm (without mattress deflection correction) was associated with DBP ≥30 mmHg in both femoral (OR 1.14; 95% CI 1.03, 1.26; p < 0.05) and radial (OR 4.70; 95% CI 3.92, 5.63; p < 0.001) recordings. For any given subject there was a weak upward trend in blood pressure as CC depth increased.ConclusionDeeper CC does not equal higher BP in every patient. The heterogeneity of patients creates a challenge to find the optimal way to resuscitate patients individually.Clinical Trial Registration: Clinicaltrials.gov NCT00951704.     

Oxygen requirement during cardiopulmonary resuscitation (CPR) to effect return of spontaneous circulation

BackgroundRecent scientific evidence has demonstrated the importance of good quality chest compressions without interruption to improve cardiac arrest resuscitation rates, and suggested that a de-emphasis on minute ventilation is needed. However, independent of ventilation, the role of oxygen and the optimal oxygen concentration during CPR is not known. Previous studies have shown that ventilation with high oxygen concentration after CPR is associated with worse neurologic outcome. We tested the hypothesis that initial ventilation during CPR without oxygen improves resuscitation success.MethodsSprague–Dawley rats were anesthetized with ketamine/xylazine (IP), intubated and ventilated with room air. A KCl bolus (0.04 mg/g) was given (IV) to induce asystolic cardiac arrest and ventilation was stopped. At 6 min, CPR was started with an automated chest compressor at a rate of 200–240/min and epinephrine (0.01 mg/kg) was given 1 min later. During CPR, the ventilation rate was 50% of baseline with one of three oxygen concentrations: (1) 0% O₂ (100% N₂), (2) 21% O₂, or (3) 100% O₂. The prescribed oxygen concentration was continued for 2 min after return of spontaneous circulation (ROSC) and then all animals were switched to 100% oxygen for 1 h prior to extubation. Blood gases were measured at baseline, 2 min and 1 h after ROSC. Group comparisons were done using Fisher's exact test and ANOVA.ResultsROSC was achieved in 1/10 (0% O₂), 9/11 (21% O₂) and 10/12 (100% O₂, p < 0.001). ROSC times after starting CPR were 80 s in the 0% O₂, 115 ± 87 s in the 21% O₂ group and 95 ± 33 s in the 100% O₂ group (mean ± SD, p = 0.5). Aortic end-diastolic pressure before ROSC was not different among groups. 100% oxygen ventilation in the first 2 min resulted in higher PaO₂ at ROSC 2 min (109 ± 44 mm Hg vs. 33 ± 8 mm Hg, p < 0.001). Survival to 72 h was 0/1 (0% O₂), 7/9 (21% O₂) and 8/10 (100% O₂) with a low neurologic deficit score in both O₂ groups (NDS range 5–25).ConclusionsIn a mild cardiac arrest model with generally good neurologic recovery, initial CPR ventilation with no O₂ did not allow for ROSC. In contrast, CPR coupled with room air or higher oxygen levels result in a high rate of ROSC with good neurologic recovery. During CPR, the level of oxygenation must be considered, which if too low may preclude initial ROSC.     

Intra-arrest hypothermia: Both cold liquid ventilation with perfluorocarbons and cold intravenous saline rapidly achieve hypothermia,but only cold liquid ventilation improves resumption of spontaneous circulation

BackgroundRapid intra-arrest induction of hypothermia using total liquid ventilation (TLV) with cold perfluorocarbons improves resuscitation outcome from ventricular fibrillation (VF). Cold saline intravenous infusion during cardiopulmonary resuscitation (CPR) is a simpler method of inducing hypothermia. We compared these 2 methods of rapid hypothermia induction for cardiac resuscitation.MethodsThree groups of swine were studied: cold preoxygenated TLV (TLV, n = 8), cold intravenous saline infusion (S, n = 8), and control (C, n = 8). VF was electrically induced. Beginning at 8 min of VF, TLV and S animals received 3 min of cold TLV or rapid cold saline infusion. After 11 min of VF, all groups received standard air ventilation and closed chest massage. Defibrillation was attempted after 3 min of CPR (14 min of VF). The end point was resumption of spontaneous circulation (ROSC).ResultsPulmonary arterial (PA) temperature decreased after 1 min of CPR from 37.2 °C to 32.2 °C in S and from 37.1 °C to 34.8 °C in TLV (S or TLV vs. C p < 0.0001). Coronary perfusion pressure (CPP) was higher in TLV than S animals during the initial 3 min of CPR. Arterial pO₂ was higher in the preoxygenated TLV animals. ROSC was achieved in 7 of 8 TLV, 2 of 8 S, and 1 of 8 C (TLV vs. C, p = 0.03).ConclusionsModerate hypothermia was achieved rapidly during VF and CPR using both cold saline infusion and cold TLV, but ROSC was higher than control only in cold TLV animals, probably due to better CPP and pO₂. The method by which hypothermia is achieved influences ROSC.     

Racial disparities in outcomes following PEA and asystole in-hospital cardiac arrests

AimTo define the racial differences present after PEA and asystolic IHCA and explore factors that could contribute to this disparity.MethodsWe analyzed PEA and asystolic IHCA in the Get-With-The-Guidelines-Resuscitation database. Multilevel conditional fixed effects logistic regression models were used to estimate the relationship between race and survival to discharge and return of spontaneous circulation (ROSC), sequentially controlling for hospital, patient demographics, comorbidities, arrest characteristic, process measures, and interventions in place at time of arrest.ResultsAmong the 561 hospitals, there were 76,835 patients who experienced IHCA with an initial rhythm of PEA or asystole (74.8% white, 25.2% black). Unadjusted ROSC rate was 55.1% for white patients and 54.1% for black patients (unadjusted OR: 0.94 [95% CI, 0.90–0.98], p = 0.016). Survival to discharge was 12.8% for white patients and 10.4% for black patients (unadjusted OR: 0.83 [95% CI, 0.78–0.87], p < 0.001). After adjusting for temporal trends, patient characteristics, hospital, and arrest characteristics, there remained a difference in survival to discharge (OR: 0.85 [95% CI, 0.79–0.92]) and rate of ROSC (OR: 0.88 [95% CI, 0.84–0.92]). Black patients had a worse mental status at discharge after survival. Rates of DNAR placed after survival from were lower in black patients with a rate of 38.3% compared to 44.5% in white patients (p < 0.001).ConclusionBlack patients are less likely to experience ROSC and survival to discharge after PEA or asystole IHCA. Individual patient characteristics, event characteristics, and hospital characteristics don’t fully explain this disparity. It is possible that disease burden and end-of-life preferences contribute to the racial disparity.     

Initial end-tidal carbon dioxide as a prognostic indicator for inpatient PEA arrest

AimInvestigate the relationship of initial PetCO2 values of patients during inpatient pulseless electrical activity (PEA) cardiopulmonary arrest with return of spontaneous circulation (ROSC) and survival to discharge.MethodsThis study was performed in two urban, academic inpatient hospitals. Patients were enrolled from July 2009 to July 2013. A comprehensive database of all inpatient resuscitative events is maintained at these institutions, including demographic, clinical, and outcomes data. Arrests are stratified by primary etiology of arrest using a priori criteria. Inpatients with PEA arrest for whom recorded PetCO2 was available were included in the analysis. Capnography data obtained after ROSC and/or more than 10 min after initiation of CPR were excluded. Multivariable logistic regression was used to explore the association between initial PetCO2 >20 mmHg and both ROSC and survival-to-discharge.ResultsA total of 50 patients with PEA arrest and pre-ROSC capnography were analyzed. CPR continued an average of 11.8 min after initial PetCO2 was recorded confirming absence of ROSC at time of measurement. Initial PetCO2 was higher in patients with versus without eventual ROSC (25.3 ± 14.4 mmHg versus 13.4 ± 6.9 mmHg, P = 0.003). After adjusting for age, gender, and arrest location (ICU versus non-ICU), initial PetCO2 >20 mmHg was associated with increased likelihood of ROSC (adjusted OR 4.8, 95% CI 1.2–19.2, P = 0.028). Initial PetCO2 was not significantly associated with survival-to-discharge (P = 0.251).ConclusionsInitial PetCO2 >20 mmHg during CPR was associated with ROSC but not survival-to-discharge among inpatient PEA arrest victims. This analysis is limited by relatively small sample size.     

Perception of CPR quality: Influence of CPR feedback,Just-in-Time CPR training and provider role

AimMany healthcare providers rely on visual perception to guide cardiopulmonary resuscitation (CPR), but little is known about the accuracy of provider perceptions of CPR quality. We aimed to describe the difference between perceived versus measured CPR quality, and to determine the impact of provider role, real-time visual CPR feedback and Just-in-Time (JIT) CPR training on provider perceptions.MethodsWe conducted secondary analyses of data collected from a prospective, multicenter, randomized trial of 324 healthcare providers who participated in a simulated cardiac arrest scenario between July 2012 and April 2014. Participants were randomized to one of four permutations of: JIT CPR training and real-time visual CPR feedback. We calculated the difference between perceived and measured quality of CPR and reported the proportion of subjects accurately estimating the quality of CPR within each study arm.ResultsParticipants overestimated achieving adequate chest compression depth (mean difference range: 16.1–60.6%) and rate (range: 0.2–51%), and underestimated chest compression fraction (0.2–2.9%) across all arms. Compared to no intervention, the use of real-time feedback and JIT CPR training (alone or in combination) improved perception of depth (p < 0.001). Accurate estimation of CPR quality was poor for chest compression depth (0–13%), rate (5–46%) and chest compression fraction (60–63%). Perception of depth is more accurate in CPR providers versus team leaders (27.8% vs. 7.4%; p = 0.043) when using real-time feedback.ConclusionHealthcare providers’ visual perception of CPR quality is poor. Perceptions of CPR depth are improved by using real-time visual feedback and with prior JIT CPR training.     

Epidemiology and outcomes of in-hospital cardiopulmonary resuscitation in the United States, 2000–2009

AimTo examine temporal trends in the epidemiology and outcomes of in-hospital cardiopulmonary resuscitation (CPR) recipients at a population level.MethodsRetrospective analysis of temporal trends in CPR incidence, survival to discharge, discharge disposition, hospital length of stay, and cost of hospitalization for CPR recipients (age ≥18years) captured in the Nationwide Inpatient Sample (2000–2009) in the United States.ResultsBetween years 2000 and 2009, CPR incidence increased by 33.7%, from 1 case per 453 to 1 case per 339 hospitalized patients (annual percentage increase: 4.3%, 95% CI: 3.4–5.2%, p < 0.001). Compared to CPR recipients in years 2000–2001, those in 2008–2009 were more often younger (age < 65 years: 33.4% vs. 40.0%), non-white (29.3% vs. 36.4%), and higher comorbidity scores (score ≥ 4: 22.2% vs. 27.1%) (all p < 0.001). Rates of neurologic compromise, mechanical ventilator, and feeding tube use increased by 37.7, 28.2, and 58.5%, respectively (all p < 0.001). Adjusted rate of survival to discharge increased by 41.3% (20.6–29.1%, p < 0.001). Compared to survivors in 2000, those discharged in 2009 were more often discharged to hospice (0.4% vs. 7.1%, p < 0.001); a 35% decrease in discharge to home was noted (36.4% vs. 23.8%, p < 0.001). Mean cost of hospitalization per day increased for both survivors ($2742–$3462, p = 0.006) and decedents ($3159–$4212, p < 0.001).ConclusionsThe rate of in-hospital CPR in the U.S. increased, and CPR recipients have become younger and sicker over time. Survival to discharge has improved by 41.3%. Functional outcomes after in-hospital CPR appear to have worsened, with considerable clinical and economic implications.     

Managing cardiac arrest with refractory ventricular fibrillation in the emergency department: Conventional cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation

AimRefractory ventricular fibrillation, resistant to conventional cardiopulmonary resuscitation (CPR), is a life threatening rhythm encountered in the emergency department. Although previous reports suggest the use of extracorporeal CPR can improve the clinical outcomes in patients with prolonged cardiac arrest, the effectiveness of this novel strategy for refractory ventricular fibrillation is not known. We aimed to compare the clinical outcomes of patients with refractory ventricular fibrillation managed with conventional CPR or extracorporeal CPR in our institution.MethodThis is a retrospective chart review study from an emergency department in a tertiary referral medical center. We identified 209 patients presenting with cardiac arrest due to ventricular fibrillation between September 2011 and September 2013. Of these, 60 patients were enrolled with ventricular fibrillation refractory to resuscitation for more than 10 min. The clinical outcome of patients with ventricular fibrillation received either conventional CPR, including defibrillation, chest compression, and resuscitative medication (C-CPR, n = 40) or CPR plus extracorporeal CPR (E-CPR, n = 20) were compared.ResultsThe overall survival rate was 35%, and 18.3% of patients were discharged with good neurological function. The mean duration of CPR was longer in the E-CPR group than in the C-CPR group (69.90 ± 49.6 min vs 34.3 ± 17.7 min, p = 0.0001). Patients receiving E-CPR had significantly higher rates of sustained return of spontaneous circulation (95.0% vs 47.5%, p = 0.0009), and good neurological function at discharge (40.0% vs 7.5%, p = 0.0067). The survival rate in the E-CPR group was higher (50% vs 27.5%, p = 0.1512) at discharge and (50% vs 20%, p = 0. 0998) at 1 year after discharge.ConclusionsThe management of refractory ventricular fibrillation in the emergency department remains challenging, as evidenced by an overall survival rate of 35% in this study. Patients with refractory ventricular fibrillation receiving E-CPR had a trend toward higher survival rates and significantly improved neurological outcomes than those receiving C-CPR.     

The effect of transport on quality of cardiopulmonary resuscitation in out-of-hospital cardiac arrest

IntroductionMost manikin and clinical studies have found decreased quality of CPR during transport to hospital. We wanted to study quality of CPR before and during transport for out-of-hospital cardiac arrest patients and also whether quality of CPR before initiation of transport was different from the quality in patients only receiving CPR on scene.Materials and methodsQuality of CPR was prospectively registered with a modified defibrillator for consecutive cases of out-of-hospital cardiac arrest in three ambulance services during 2002–2005. Ventilations were registered via changes in transthoracic impedance and chest compressions were measured with an extra chest compression pad placed on the patients’ sternum. Paired t-tests were used to analyse quality of CPR before vs. during transport with ongoing CPR. Unpaired t-tests were used to compare CPR quality prior to transport to CPR quality in patients with CPR terminated on site.ResultsQuality of CPR did not deteriorate during transport, but as previously reported overall quality of CPR was substandard. Quality of CPR performed on site was significantly better when transport was not initiated with ongoing CPR compared to episodes with initiation of transport during CPR: fraction of time without chest compressions was 0.45 and 0.53 (p < 0.001), compression depth 37 mm and 34 mm (p = 0.04), and number of chest compressions per minute 61 and 56 (p = 0.01), respectively.ConclusionCPR quality was sub-standard both before and during transport. Early decision to transport might have negatively affected CPR quality from the early stages of resuscitation.     

Changes in treatments and outcomes among elderly patients with out-of-hospital cardiac arrest between 2002 and 2012: A post hoc analysis of the SOS-KANTO 2002 and 2012

BackgroundLittle is known about recent changes in pre- and in-hospital treatments and outcomes for elderly patients with out-of-hospital cardiac arrest (OHCA).MethodsWe compared data collected for the SOS-KANTO study in 2002 and 2012. We included patients aged ≥65 years who experienced OHCA of cardiac aetiology. The primary endpoint was favourable neurological outcomes 1 month after cardiac arrest.ResultsA total of 8,964 (2002 vs. 2012: 3,544 vs. 5,420) patients were eligible for the current analysis. The proportion of pre-hospital return of spontaneous circulation (ROSC) increased significantly (3.8 vs. 5.6%, p < 0.001). Among patients achieving ROSC, the proportion of advanced in-hospital treatments (i.e. extracorporeal membrane oxygenation, therapeutic hypothermia, and/or percutaneous coronary angiogram/intervention) provided increased significantly in 2012 (1.2 vs. 5.5%, p < 0.001; 2.6 vs. 15.1%, p < 0.001; 4.9 vs. 16.5%, p < 0.001; respectively). The proportion of favourable neurological outcomes at 1 month increased significantly in 2012 (1.6 vs. 2.7%, p = 0.001). A logistic regression analysis that did not consider advanced in-hospital treatments showed a significantly higher rate of favourable neurological outcomes in the 2012 group than that in the 2002 group (OR, 2.2; 95% CI, 1.4–3.5). However, this difference was no longer observed in the second regression model that accounted for advanced in-hospital treatments (OR, 1.6; 95% CI, 0.9–2.9).ConclusionThere was an increased proportion of aggressive treatment, both pre- and in-hospital, for elderly patients with cardiogenic OHCA in the Kanto area, Japan. Favourable neurological outcomes improved significantly over 10 years.     

Survey of outcome of CPR in pediatric in-hospital cardiac arrest in a medical center in Taiwan

Purpose of the studyWhile the outcomes of cardiopulmonary resuscitation (CPR) for pediatric in-hospital cardiac arrest (IHCA) are reported for many regions, none is reported for Asian countries. We report the outcomes of CPR for pediatric IHCA in a tertiary medical center in Taiwan and also identify prognostic factors associated with poor outcome.MethodsData were retrieved retrospectively from 2000 to 2003 and prospectively from 2004 to 2006 from our web-based registry system. We evaluated patients younger than 18 years of age who had IHCA and received CPR. The primary outcome was survival to hospital discharge, and the secondary outcomes were sustained return of spontaneous circulation (ROSC), and favorable neurological outcomes as assessed by pediatric cerebral performance categories (PCPC).ResultsWe identified 316 patients and the overall hospital survival was 20.9% and 16.1% had favorable neurological outcomes. Sixty-four patients ever supported with ECMO. We further analyzed 252 patients who underwent conventional CPR only and most had cardiac disease (133/252, 52.8%). The second most common preexisting condition was hematologic or oncologic disease (43/252, 17.1%). Of the 252 patients, 153 (60.7%) achieved sustained ROSC, 50 (19.8%) survived to discharge, and 39 patients (15.5%) had favorable neurological outcomes. CPR during off-work hours resulted in inferior chances of reaching sustained ROSC. Multivariate analysis showed that long CPR duration, hematology/oncology patients, and pre-arrest vasoactive drug infusion were significantly associated with decreased hospital survival (p < 0.05).ConclusionsOutcomes of CPR for pediatric patients with IHCA in Taiwan were comparable to corresponding reports in Western countries, but more hematology/oncology patients were included. Long CPR duration, hematologic or oncologic underlying diseases, and vasoactive agent infusion prior IHCA were associated with poor outcomes. The concept of palliative care should be proposed to families of terminally ill cancer patients in order to avoid unnecessary patient suffering. Also, establishing a balanced duty system in the future might increase chances of sustained ROSC.     

Quality of CPR: An important effect modifier in cardiac arrest clinical outcomes and intervention effectiveness trials

ObjectivesTo determine if the quality of CPR had a significant interaction with the primary study intervention in the NIH PRIMED trial.DesignThe public access database from the NIH PRIMED trial was accessed to determine if there was an interaction between quality of CPR performance, intervention, and outcome (survival to hospital discharge with modified Rankin Score (mRS) ≤3).SettingMulti-centered prehospital care systems across North America.PatientsOf 8719 adult patients enrolled, CPR quality was electronically recorded for compression rate, depth, and fraction in 6199 (71.1%), 3750 (43.0%) and 6204 (71.2%) subjects, respectively. “Acceptable” quality CPR was defined prospectively as simultaneous provision of a compression rate of 100/min (±20%), depth of 5 cm (±20%) and fraction of >50%. Significant interaction was considered as p < 0.05.InterventionStandard CPR with an activated versus sham (inactivated) ITD.Measurements and main resultsOverall, 848 and 827 patients, respectively, in the active and sham-ITD groups had “acceptable” CPR quality performed (n = 1675). There was a significant interaction between the active and sham-ITD and compression rate, depth and fraction as well as their combinations. The strongest interaction was seen with all three parameters combined (unadjusted and adjusted interaction p-value, <0.001). For all presenting rhythms, when “acceptable” quality of CPR was performed, use of an active-ITD increased survival to hospital discharge with mRS ≤3 compared to sham (61/848 [7.2%] versus 34/827 [4.1%], respectively; p = 0.006). The opposite was true for patients that did not receive “acceptable” quality of CPR. In those patients, use of an active – ITD led to significantly worse survival to hospital discharge with mRS ≤3 compared to sham (34/1012 [3.4%] versus 62/1061 [5.8%], p = 0.007).ConclusionsThere was a statistically significant interaction between the quality of CPR provided, intervention, and survival to hospital discharge with mRS ≤3 in the NIH PRIMED trial. Quality of CPR delivered can be an underestimated effect modifier in CPR clinical trials.     

A quality improvement initiative to optimize use of a mechanical chest compression device within a high-performance CPR approach to out-of-hospital cardiac arrest resuscitation

BackgroundMinimizing the chest compression pause associated with application of a mechanical CPR device is a key component of optimal integration into the overall resuscitation process. As part of a multi-agency implementation project, Anchorage Fire Department deployed LUCAS CPR devices on BLS and ALS fire apparatus for initiation early in resuscitation efforts. A 2012 report identified the pause interval for device application as a key opportunity for quality improvement (QI). In early 2013 we began a QI initiative to reduce device application time interval and optimize the overall CPR process. To assess QI initiative effectiveness, we compared key CPR process metrics from before to during and after its implementation.MethodsWe included all cases of EMS-treated out-of-hospital cardiac arrest during 2012 and 2013 in which a mechanical CPR device was used and the defibrillator electronic record was available. Continuous ECG and impedance data were analyzed to measure chest compression fraction, duration of the pause from last manual to first mechanical compression, and duration of the longest overall pause in the resuscitation effort.ResultsCompared to cases from 2012 (n = 61), median duration of the pause prior to first mechanical compression for cases from 2013 (n = 71) decreased from 21 (15, 31) to 7 (4, 12) s (p < 0.001), while median chest compression fraction increased from 0.90 (0.88, 0.93) to 0.95 (0.93, 0.96) (p < 0.001). Median duration of the longest pause decreased from 25 (20, 35) to 13 (10, 20) s (p < 0.001), while the proportion of cases where the longest pause was for mechanical CPR application decreased from 74% to 31% (p < 0.001).ConclusionsOur QI initiative substantially reduced the duration of the pause prior to first mechanical compression. Combined with the simultaneous significant increase in compression fraction and significant decrease in duration of the longest pause, this finding strongly suggests a large improvement in mechanical CPR device application efficiency within an overall high-performance CPR process.     

Cerebral oximetry and return of spontaneous circulation after cardiac arrest: A systematic review and meta-analysis

AimThe prediction of return of spontaneous circulation (ROSC) during resuscitation of patients suffering of cardiac arrest (CA) is particularly challenging. Regional cerebral oxygen saturation (rSO₂) monitoring through near-infrared spectrometry is feasible during CA and could provide guidance during resuscitation.MethodsWe conducted a systematic review and meta-analysis on the value of rSO₂ in predicting ROSC both after in-hospital (IH) or out-of-hospital (OH) CA. Our search included MEDLINE (PubMed) and EMBASE, from inception until April 4th, 2015. We included studies reporting values of rSO₂ at the beginning of and/or during resuscitation, according to the achievement of ROSC.ResultsA total of nine studies with 315 patients (119 achieving ROSC, 37.7%) were included in the meta-analysis. The majority of those patients had an OHCA (n = 225, 71.5%; IHCA: n = 90, 28.5%). There was a significant association between higher values of rSO₂ and ROSC, both in the overall calculation (standardized mean difference, SMD –1.03; 95%CI –1.39,–0.67; p < 0.001), and in the subgroups analyses (rSO₂ at the beginning of resuscitation: SMD –0.79; 95%CI –1.29,–0.30; p = 0.002; averaged rSO₂ value during resuscitation: SMD –1.28; 95%CI –1.74,–0.83; p < 0.001).ConclusionsHigher initial and average regional cerebral oxygen saturation values are both associated with greater chances of achieving ROSC in patients suffering of CA. A note of caution should be made in interpreting these results due to the small number of patients and the heterogeneity in study design: larger studies are needed to clinically validate cut-offs for guiding cardiopulmonary resuscitation.     

No difference in autopsy detected injuries in cardiac arrest patients treated with manual chest compressions compared with mechanical compressions with the LUCAS™ device—A pilot study

AimTo compare the variety and incidence of internal injuries after manual and mechanical chest compressions during CPR.MethodsIn a prospective pilot study conducted in two Swedish cities, 85 patients underwent autopsy after unsuccessful resuscitation attempts with manual or mechanical chest compressions, the latter with the LUCAS? device. Autopsy was performed and the results were evaluated according to a specified protocol.ResultsNo injuries were found in 26/47 patients in the manual group and in 16/38 patients in the LUCAS group (p = 0.28). Sternal fracture was present in 10/47 in the manual group and 11/38 in the LUCAS group (p = 0.46), and there were multiple rib fractures (≥3 fractures) in 13/47 in the manual group and in 17/38 in the LUCAS group (p = 0.12). Bleeding in the ventral mediastinum was noted in 2/47 and 3/38 in the manual and LUCAS groups respectively (p = 0.65), retrosternal bleeding in 1/47 and 3/38 (p = 0.32), epicardial bleeding in 1/47 and 4/38 (p = 0.17), and haemopericardium in 4/47 and 3/38 (p = 1.0) respectively. One patient in the LUCAS group had a small rift in the liver and one patient in the manual group had a rift in the spleen. These injuries were not considered to have contributed to the patient's death.ConclusionMechanical chest compressions with the LUCAS? device appear to be associated with the same variety and incidence of injuries as manual chest compressions.     

Relationships between pre-hospital characteristics and outcome in victims of foreign body airway obstruction during meals

ObjectiveThe purpose of this study is to determine the outcome of foreign body airway obstruction according to the initial actions taken for choking victims during meals.MethodsOur subjects were patients who became unresponsive or unconscious because of foreign body airway obstruction (FBAO) during meals in the presence of bystander witnesses. We investigated the associations between outcome and the following factors: age, gender, type of foreign body, chest compressions after the patient became unresponsive or unconscious, episode of cardiac arrest, efforts by a bystander to remove the foreign body, eating-related activities of daily living, time elapsed from the 119 call to arrival of emergency medical technicians (EMTs), and time elapsed from the 119 call to hospital arrival (primary endpoint).ResultsOf the 138 patients enrolled during the study period, 35 (25.4%) received chest compressions by bystanders after becoming unresponsive or unconscious and 69 (50.0%) suffered cardiac pulmonary arrest. Chest compressions by a bystander after the victim became unresponsive or unconscious (p < 0.0001) and no CPA (p < 0.0001) were significantly related to good outcome. Chest compressions by a bystander were both associated with good neurological outcome (odds ratio, 10.57; 95% CI, 2.472–65.059, p < 0.0001). No CPA after FBAO was another independent predictor (odds ratio, 50.512; 95% CI, 13.45–284.41; p < 0.0001), but efforts to remove the foreign body before the arrival of EMTs did not affect outcome.ConclusionChest compressions by a bystander, a support received by only 25% of the patients, proved to be essential for improved outcome for choking victims who became unresponsive or unconscious. Education for lay-rescuer response to choking might further improve overall outcome.