Strategy analysis of cardiopulmonary resuscitation training in the community

Bystander cardiopulmonary resuscitation (CPR) is a crucial therapy for sudden cardiac arrest. This appreciation produced immense efforts by professional organizations to train laypeople for CPR skills. However, the rate of CPR training is low and varies widely across communities. Several strategies are used in order to improve the rate of CPR training and are performed in some advanced countries. The Chinese CPR training in communities could gain enlightenment from them.     

Ionized calcium during CPR in the canine model

The purpose of our study was to determine ionized calcium levels during cardiopulmonary resuscitation (CPR). Following placement of ascending aortic catheters in 15 adult mongrel dogs, ventricular fibrillation was induced electrically. After five minutes without therapy, mechanical external CPR was instituted. Animals received either standard CPR (S-CPR, n = 8) or simultaneous compression and ventilation CPR (SCV-CPR, n = 7) for 30 minutes. Ionized calcium levels were obtained prior to fibrillation and every five minutes during CPR. Mean ionized calcium levels during CPR (1.27 +/- 0.06 mmol/L) did not differ significantly from prearrest levels (1.27 +/- 0.07 mmol/L) at any point during CPR. This was true when the dogs were analyzed together (P = 0.1293) and when the animals receiving S-CPR (P = 0.4465) and SCV-CPR (P = 0.5470) were analyzed by groups. Defibrillation was attempted in all animals and resulted in electromechanical dissociation in three. None of these dogs was hypocalcemic either prior to arrest or during CPR, and none developed an effective rhythm with the administration of calcium. Furthermore, three of the four animals receiving calcium developed markedly elevated ionized calcium levels. Hypocalcemia apparently does not occur during CPR. The beneficial effect of calcium in reported cases cannot be explained routinely by correction of hypocalcemia. Further studies are needed to define the role of calcium administration, if any, in CPR.     

Guidelines for discontinuing prehospital CPR in the emergency department--a review

We provide information that we believe should allow the establishment of rational guidelines for discontinuing, with physician supervision, unsuccessful prehospital CPR. Goldberg has advocated that CPR be terminated only after evidence of brain or cardiac death has persisted for more than one hour of adequately applied advanced CPR. This recommendation was made for inhospital resuscitation and does not reflect the limited capabilities of basic and advanced CPR techniques to sustain life outside the hospital. In addition, White and associates have demonstrated that after resuscitation from prolonged cardiac arrest, cerebral cortical blood flow is reduced severely. This state of hypoperfusion may last up to 18 hours. Because this condition can result in extensive neurologic damage, it may explain the poor survival rates after prolonged resuscitation. We propose that CPR be terminated in the ED when, despite adequate rescue attempts (intubation, defibrillation, IV medications, CCCM en route) by those responding at the scene of cardiac arrest, intrinsic cardiac activity has not been achieved in patients brought to the hospital with asystole or bradyarrhythmia. Additionally patients who have had advanced prehospital CPR for more than 45 minutes without generation of any intrinsic cardiac activity are not resuscitatable by current standard techniques, and CPR may be discontinued. These criteria must not be used for victims of hypothermia before a core temperature of 35 C to 36.1 C is achieved by active core rewarming during CPR. The available data suggest that if these criteria are implemented, many unproductive hospital-based resuscitative efforts can be eliminated without jeopardizing potential survivors.(ABSTRACT TRUNCATED AT 250 WORDS)     

Lactic acidosis during closed-chest CPR in dogs

Survival after out-of-hospital cardiac arrest is intimately related to the time from cardiovascular collapse to the initiation of CPR, or downtime. Furthermore, the reperfusion technique that optimizes coronary and cerebral blood flow after cardiac arrest may also be dependent on downtime. Peak blood lactate levels have been shown to be unchanged throughout resuscitation and predictive of downtime in dogs subjected to cardiopulmonary arrest and open cardiac massage. The purpose of this study was to determine the course of arterial lactate levels in dogs subjected to a fibrillatory cardiopulmonary arrest and conventional closed-chest CPR (CCPR). Fourteen dogs were subjected to five minutes of cardiopulmonary arrest and 30 minutes of CCPR. Resuscitation was performed according to a standardized protocol. Arterial lactic acid samples were collected at timed intervals throughout the experiment. Mean arterial lactic acid levels increased significantly with each sampling interval during 30 minutes of CCPR (overall P less than .05). In nine dogs successfully resuscitated, there were no significant differences in mean arterial lactic acid levels after the return of spontaneous circulation (ROSC). Open-chest resuscitation after five minutes of ventricular fibrillation in dogs results in peak lactic acid levels that do not change significantly once internal cardiac massage is initiated. In contrast, CCPR in similarly arrested dogs does not appear to provide adequate tissue oxygenation and/or perfusion to prevent continuous lactic acid accumulation.     

Ventilation during CPR: two-rescuer standards reappraised

Current American Heart Association standards for ventilation during two-rescuer CPR recommend that a 0.8- to 1.2-L breath be delivered in 0.5 second after every fifth chest compression. Delivering a high-volume breath over a brief inspiratory time (TI) may lead to hypoventilation and gastric insufflation in victims with an unprotected airway. We reasoned that lengthening TI would lower peak inspiratory pressure and peak inspiratory flow rate, and thus improve lung inflation. To study this possibility, a mechanical model of the airway and upper gastrointestinal tract was designed. A ventilator delivering a sinusoidal wave form was used to simulate artificial ventilation. A 0.8-L breath was delivered at 0.5, 1.0, or 1.5 seconds at three lung compliances (CLs). Also, the effect of lengthening TI was studied with increased airway resistance. Lengthening TI improved lung inflation and decreased gastric insufflation at all CLs, but more so with normal CL than with decreased CL. This study demonstrates the need for evaluating alternative ventilatory patterns with longer TI during CPR.     

Insulin and glucose levels during CPR in the canine model

Cardiopulmonary arrest and resuscitation produces tremendous physiological stress with resultant biochemical derangements. We undertook this study to determine insulin and glucose levels during cardiopulmonary arrest in the canine model. Baseline insulin and glucose levels were obtained from an ascending aortic arch catheter in six mongrel dogs. Ventricular fibrillation was induced by an electrical stimulus and ventilation was terminated. After five minutes of fibrillation, cardiopulmonary resuscitation (CPR) was initiated using external, mechanical CPR and a continuous epinephrine infusion at 5 micrograms/kg/min. Serum insulin and glucose levels were repeated 15 minutes after beginning CPR. Mean blood glucose 15 minutes after initiation of resuscitation (379 +/- 114 mg/dL) was significantly increased from prearrest levels (124 +/- 29 mg/dL, P less than .01). Mean serum insulin 15 minutes after initiation of resuscitation (11.3 +/- 3.3 microU/mL) was significantly decreased compared to prearrest levels (16.2 +/- 6.0 microU/mL, P less than .05). During ischemia, the myocardium becomes dependent primarily on glucose as a source of energy. Inappropriately low insulin levels during CPR may adversely affect an already compromised myocardial glucose metabolism. Further investigation is needed to determine the utility of insulin infusion during CPR.     

CPR skills retention of lay basic rescuers

In 1979-1980, 950 telephone company personnel were trained and tested at the basic rescuer level on recording manikins. In October 1981, a random group of 40 were retested without warning on the recording manikin. Skills retention was measured by comparing the tapes from training and retesting. Sixteen (40%) of those retested were able to perform effective ventilations and compressions of the manikin with 60% to 70% average retention compared to their training scores. The remaining 24 (60%) had ineffective ventilations or compressions or both. The two groups did not differ in the performance level achieved during training, or in the time interval between training and retesting. Eleven individuals retested at 13 to 14 months did not perform better than those retested later, suggesting the maximum skills deterioration had occurred within the first year. However, the effective performance group on the average were younger, and the majority had first aid training in addition to their CPR training. Only one had CPR retraining. This study supports the following recommendations: 1) lay basic rescuers should be retrained within the first year; 2) further studies of the factors influencing retention are advisable; 3) the younger age groups should be the first priority for citizen CPR training; and 4) because first aid training appears to improve CPR retention, training in both should be encouraged.     

Severe burns in a patient after out-of-hospital CPR

We present a case of a patient after prolonged cardio-pulmonary resuscitation on hot asphalt, who suffered from first and second degree burns which worsened during hospitalization. The patient was treated with therapeutic hypothermia. Possible effect of therapeutic hypothermia on the course of burns is discussed.     

Comparison of clinical CPR studies in Milwaukee and elsewhere in the United States

As we mark the 25th anniversary of the clinical application of closed-chest cardiopulmonary resuscitation (SCPR), it is time to look back and analyze the progress we have made in the resuscitation of sudden death syndrome. Recent studies of SCPR's effectiveness have yielded mixed results, in comparison to early studies that were universally favorable. The continued toll of neurologic injury following SCPR resuscitation, and reinforcement of the importance of defibrillation in resuscitation, stimulate us to find improved forms of SCPR and improved methods of resuscitation delivery in emergency medical systems.     

Chest Compression Force of Trained and Untrained CPR Rescuers

The objective of this study was to measure the force exerted by 83 trained CPR rescuers and 104 untrained adult laypersons (college students and staff). A bathroom scale was used to measure the force exerted by these subjects with their hands on the bathroom scale in the CPR position. The weight range for both groups was the same. Of the trained rescuers, 60% pressed with more than 125 lbs, whereas only 37% of the laypersons pressed with more than 125 lbs. In view of the American Heart Association (AHA) guidelines (2000) to depress the chest 1.5 to 2 inches, which requires 100–125 lbs, it would appear that most laypersons do not exert enough force for effective CPR.     

Manual vs. mechanical ventilation in patients with advanced airway during CPR

Early chest compressions and rapid defibrillation are important components of cardiopulmonary resuscitation (CPR). American heart association (AHA) recommends two breaths to be delivered for every 30 compressions for an adult cardiac arrest victim. Patient with an advanced airway like endotracheal tube (ETT) should be given one breath every 6 s without interruptions in chest compression (10 breaths per minute). All of the modern mechanical ventilators have option to generate spontaneous breaths by the patient if the patient has spontaneous respiratory efforts. During CPR, the mechanical ventilator is fallaciously sensing the chest compressions as patient's spontaneous trigger and thereby it delivers higher respiratory rates. Avoiding excessive ventilation is one of the components of high quality CPR as excessive ventilation decreases venous return thereby decreasing the cardiac output and also it affects intra-thoracic pressure thereby adversely affects intra-arterial pressure. As modern ventilators have trigger for spontaneous breaths and they will be erroneously triggered by chest compressions, it would be prudent to use volume marked resuscitation bags or manual breathing devices (manual self-inflating resuscitation bag, Bain's circuit) for delivering breaths which can be synchronised with compression phase of CPR at RR of 10 breaths per min with advanced airway in place. If any patient who is on mechanical ventilation develops cardiac arrest, patient should be disconnected from the mechanical ventilator and should be ventilated manually. Manual ventilation with aforementioned breathing devices should be used in a patient without and with advanced airway devices during CPR.     

CPR Degradation Diagram

During untreated ventricular fibrillation (VF), before CPR is applied, different bodily systems deteriorate at different rates. This paper describes the times when the EEG disappears, when respiratory arrest occurs, and when PD-PEA occurs. It also describes the frequency of VF waves over a 7-min period and how the frequency increases with good CPR.     

Circulation time during standard and modified manual CPR determined by retinal photoangiography

We used retinal fluorescein photoangiography to determine the circulation time (CTv-a) from the inferior vena cava (IVC) to the retinal artery in anesthetized, intubated, paralyzed, and fibrillated dogs. Animals received either standard CPR (SCPR) (n = 11) or modified CPR (MCPR) (n = 11) manually at 60 compressions per minute in both groups. MCPR consisted of simultaneous ventilation-compression with abdominal binding to 40 mm Hg. SCPR or MCPR was begun immediately after inducing ventricular fibrillation and was performed for an average of 4.5 minutes prior to bolus injection of fluorescein dye (0.7 mL, 25% solution). To compare CTv-a in the two groups, dye was injected through a catheter into the IVC (below the diaphragm) and timed, rapid, sequential retinal photoangiography was begun. The time to first appearance of dye in the retinal vasculature initially was determined visually by the camera operator and later was substantiated photographically. The camera simultaneously photographed the retinal vasculature and the built-in timer, thus displaying the elapsed time from injection on each frame. Our results showed a significantly shorter CTv-a in the MCPR group (58.9 seconds +/- 18.6) when compared to the SCPR group (112.6 seconds +/- 47.4; P less than .01). In addition, we have documented retinal blood flow during CPR.     

综合医院心肺复苏培训模式及其应用效果研究

目的 研究煤炭总医院自2012年以来心肺复苏培训的模式及效果,为提高培训效果,继而提高继续教育管理水平提供参考依据。方法 收集煤炭总医院2012～2014年3年间全部心肺复苏培训及考核记录,运用管理学、统计学、教育学等相关理论进行分析。结果 煤炭总医院开展的心肺复苏培训的主要模式有学术讲座、技能操作培训、技能考试、分层培训等。采用分层培训方式后,2014年煤炭总医院医务人员心肺复苏基本知识知晓率已经达到74.9%（χ2=31.3,P<0.0001）,操作技能合格率已经达到92.5%（χ2=6.3,P=0.012）,较2012年相比有明显提高。结论 分层培训是综合医院开展心肺复苏培训的一种有效模式,有助于提高继续教育培训效果和管理水平。     

Human C-peptide immunoreactivity (CPR) in blood and urine — Evaluation of a radioimmunoassay method and its clinical applications

Summary A double-antibody radioimmunoassay method, using synthetic human connecting peptide as an immunizing antigen and standard, was evaluated for clinical assay of blood and urine samples. Normal fasting blood connecting peptide immunoreacivity (CPR) was 2.45±0.96 ng/ml, increasing promptly after a 50 g oral glucose load, but somewhat slower than insulin. Molar concentration of CPR exceeded that of insulin. CPR responses to glucose were subnormal in diabetics, very low in juvenile-type cases, and often poor in patients on insulin treatment. Fasting CPR levels were elevated in patients on corticosteroid treatment and with uraemia. A patient with insulin auto-antibod had high serum CPR. A considerable amount of CPR appeared in urine. Normal daily excretion of CPR was 1.52±0.55 g/kg or 55.1±18.2 ng/mg creatinine. Urine CPR was very low in juvenile-type diabetics, and elevated in patients on corticosteroid treatment. The results confirm that blood and urine CPR are useful measures of the endocrine pancreatic function.     

Support workers can develop the skills to work with complexity in community aged care: An Australian study of training provided across aged care community services

ABSTRACT

Enhancing support workers’ (SW) role is timely given increasing demands on human and financial health care resources. This article presents outcomes of a program, delivered to 140 participants from five community aged care providers in Australia, designed to enhance knowledge, skills, and confidence of community aged care SWs, building their practical skills in understanding, recognizing, and responding to complexity. Evaluation training modules on communication, complexity, behavior change, and chronic condition self-management support involved pre/post surveys with SWs and their supervisors. SWs reported greater awareness, skills, and confidence in working with complexity, reinforcing the value of their existing practices and skills. Coordinators reported greater appreciation of SWs’ skills, and greater awareness of gaps in SWs’ support and supervision needs. Educators, policy makers, and services should account for these contributions, given growing fiscal restraint and focus on reablement and consumer-directed care.     

急诊科心肺复苏术成功率影响因素分析

目的探讨急诊科心肺复苏成功率的影响因素,以利提高急诊科救治水平。方法回顾性分析326例患者实行心肺复苏救治的过程。结果患者性别和肾上腺素使用方法与心肺复苏的成功率无关;有无目击者及是否及时除颤与心肺复苏的成功率有关（P〈0．05）;有无目击者、是否专业急救人员、是否启动EMSS、是否5min内心肺复苏与心肺复苏的成功率有关（P〈0．01）。结论普及心肺复苏急救知识,提高公众急救意识,加强急诊科建设及专业素质培养,可提高抢救成功率。     

Comparison of central venous and arterial pH and PCO2 during open-chest CPR in the canine model

Arterial blood gases are difficult to obtain during cardiopulmonary resuscitation (CPR) in human beings, and the possibility of venous sampling is raised frequently. The reliability of central venous gases as a substitute for arterial blood gases in assessing acid base status, however, has not been investigated adequately under conditions of CPR. Therefore, femoral arterial and central venous catheters were placed in 24 mongrel dogs, and ventricular fibrillation was electrically induced. After varying predetermined downtimes from five to 60 minutes, open-chest CPR was begun, and arterial and central venous blood gases were simultaneously drawn every five minutes during a 30-minute period. Arterial pH (pHa) was consistently higher than central venous pH (pHcv) by an average of .048 units. A significant correlation existed between the pHa and pHcv at all times during CPR, with an overall r = .9771 (P less than .0001). The difference between central venous PCO2 (PcvCO2) and arterial PCO2 (PaCO2) was 5.17 mm Hg prior to cardiac arrest, but it increased 300% to a mean of 15.51 mm Hg during CPR. Correction of pHcv using conventional methods to account for this respiratory component decreased the correlation between pHa and pHcv to r = .6905. The ability of pHcv to substitute for pHa was assessed, and showed a sensitivity of 100% when pHa of 7.2 was used as a criterion for treatment. In this model, pHcv is a sensitive indicator of pHa and it may be used to guide bicarbonate therapy. The increased PcvCO2 during CPR probably results from the marked tissue lactic acid production and subsequent shift of the bicarbonate buffer into free carbon dioxide.     

社区医师中风病康复培训的研究与思考

目的对社区康复医师进行中风病康复知识培训,观察培训后的效果,总结社区康复人才的培养策略。方法对北京10家社区卫生服务中心的17家社区卫生服务站的康复工作人员共20名进行摸底、培训、现场指导、考核。调研这20名康复医师的学历、职称、工作经验、从事的科室、康复知识的掌握情况,通过培训后,进行4次考核,比较这些康复医师康复知识水平的变化。结果社区康复医师在培训前后对中风病康复知识的掌握情况,第2次与第1次比较、第4次与第2次比较,P<0.05,差异有统计学意义。结合正确回答人数情况,说明社区康复医师在康复培训后对康复知识掌握情况明显提高。结论社区康复医师在康复培训后对康复知识掌握情况明显提高。