Mechanische Reanimationshilfen

In Germany 100,000–160,000 people suffer from out-of-hospital cardiac arrest (OHCA) annually. The incidence of cardiopulmonary resuscitation (CPR) after OHCA varies between emergency ambulance services but is in the range of 30–90 CPR attempts per 100,000 inhabitants per year. Basic life support (BLS) involving chest compressions and ventilation is the key measure of resuscitation. Rapid initiation and quality of BLS are the most critical factors for CPR success. Even healthcare professionals are not always able to ensure the quality of CPR measures. Consequently in recent years mechanical resuscitation devices have been developed to optimize chest compression and the resulting circulation. In this article the mechanical resuscitation devices currently available in Germany are discussed and evaluated scientifically in context with available literature. The ANIMAX CPR device should not be used outside controlled trials as no clinical results have so far been published. The same applies to the new device Corpuls CPR which will be available on the market in early 2014. Based on the current published data a general recommendation for the routine use of LUCAS? and AutoPulse® CPR cannot be given. The preliminary data of the CIRC trial and the published data of the LINC trial revealed that mechanical CPR is apparently equivalent to good manual CPR. For the final assessment further publications of large randomized studies must be analyzed (e.g. the CIRC and PaRAMeDIC trials). However, case control studies, case series and small studies have already shown that in special situations and in some cases patients will benefit from the automatic mechanical resuscitation devices (LUCAS?, AutoPulse®). This applies especially to emergency services where standard CPR quality is far below average and for patients who require prolonged CPR under difficult circumstances. This might be true in cases of resuscitation due to hypothermia, intoxication and pulmonary embolism as well as for patients requiring transport or coronary intervention when cardiac arrest persists. Three prospective randomized studies and the resulting meta-analysis are available for active compression-decompression resuscitation (ACD-CPR) in combination with an impedance threshold device (ITD). These studies compared ACD-ITD-CPR to standard CPR and clearly demonstrated that ACD-ITD-CPR is superior to standard CPR concerning short and long-term survival with good neurological recovery after OHCA.     

In-hospital resuscitation

A recent world expert conference on resuscitation and emergency cardiac care led to evidence-based international guidelines for cardiopulmonary resuscitation (CPR). Several changes to CPR interventions were recommended, and will have to be implemented into clinical practice. The poor prognosis of patients who suffer in-hospital cardiac arrest may be improved with developments in CPR interventions. In the present review the most important changes recommended by the new CPR guidelines and the latest promising CPR investigations are described, focusing on their impact on in-hospital resuscitation.     

Cardiopulmonary resuscitation and dialysis: outcome and patients' views

Cardiopulmonary resuscitation (CPR) was initially described as an intervention to be used in otherwise healthy individuals suffering acute cardiorespiratory arrest. Over the years, CPR has been extended to all hospitalized patients unless specific orders not to resuscitate have been written with the informed consent of the patient and/or surrogate. The 14-15% survival to hospital discharge reported for in-hospital CPR has not changed over the past three decades. Compared with other diseases, chronic kidney disease reduces long-term survival (more than 6 months) following CPR, and the functional status of the few who survive is often quite poor. Nevertheless, most dialysis patients want to be resuscitated. Unfortunately television shows portraying resuscitation imply that survival after CPR is much more common than it really is. Such misinformation contributes to the overwhelming choice for CPR despite the dismal prognosis. Dialysis unit staff need to educate patients and families about the expected success and complications of CPR as part of the advance care planning process that should now be routine.     

Überkopfreanimation

Many German paramedic schools are teaching a so-called “over head CPR” for the management of cardiac arrest with two healthcare providers on the scene. One person performs resuscitation and chest compressions at the head of the patient, while the other one prepares the equipment. In contrast, standard CPR consists of resuscitation and preparation of the equipment (during chest compressions) administered by the person at the head of the patient and chest compressions performed by the second rescuer at the side of the patient. A study conducted in Mainz proved that during over head CPR significantly fewer chest compressions were performed than during standard CPR. New studies now emphasize the major importance of chest compressions. After prolonged ventricular fibrillation, it seems to be better to perform chest compressions before defibrillation instead of immediate defibrillation.Over head CPR cannot be recommended in general, but it might be a method for special situations.     

In-hospital cardiopulmonary resuscitation: organization, management and training in hospitals of different levels of care

BACKGROUND: : During recent years in-hospital cardiopulmonary resuscitation (CPR) management has received much attention. This can be attributed to the Utstein model for in-hospital CPR developed in 1997. The present status of in-hospital resuscitation management in Finnish hospitals is not known. Therefore, a study was designed to describe the organization of training and clinical management of CPR in Finnish hospitals of different levels of care. METHODS: : In the summer of 2000, we performed a cross-sectional mail survey throughout Finland, including all district, central and university hospitals. The questionnaire outlined in detail in-hospital resuscitation management and training. For analysis the hospitals were divided into primary, secondary and tertiary groups, depending on levels of care. RESULTS: : Most hospitals (72%) reported having a physician or a nurse in charge of resuscitation management and training. Training in advanced life support was more common among nurses (80%) than among physicians (53%). Surprisingly, a majority of respondents (75%) reported that they felt training in CPR was insufficient. On the general wards and on wards treating cardiac patients, defibrillation was in most cases performed by a physician (91% and 51%, respectively), and less often by a nurse (16% and 31%, respectively). In the secondary and tertiary hospitals cardiac arrest was managed by a cardiac arrest team (53% and 62%, respectively) and in the primary hospitals by the ward physician (56%), anesthesiologist or emergency physician on call (44%). Most hospitals used do-not-resuscitate orders (83%) but only 33% of the hospitals had a unified style of notation. Systematic data collection was practised in 55% of hospitals, predominantly by using a model of their own. Only a few hospitals (11%) used the in-hospital Utstein model. CONCLUSION: : Our study showed that more attention needs to be paid to CPR management in Finnish hospitals. At present, 25% of hospitals do not have an appointed physician or nurse in charge of organizing CPR management. The study also revealed a lack of regular organized training in resuscitation for physicians. Fifty-five per cent of hospitals practise systematic data collection, but only 11% according to the Utstein template; and without which further quality assurance is difficult.     

ERC 2010 guidelines for adult and pediatric resuscitation: summary of major changes

The new European Resuscitation Council (ERC) guidelines for cardiopulmonary resuscitation (CPR) published on October 18th, 2010, replace those published in 2005 and are based on the latest International Consensus on CPR Science with Treatment Recommendations (CoSTR). For both adult and pediatric resuscitation, the most important general changes include: the introduction of chest compression-only CPR in primary cardiac arrest as an option for rescuers who are unable or unwilling to perform expired-air ventilation; increased emphasis on uninterrupted, good-quality CPR and minimisation of both pre- and post-shock pauses during defibrillation. For adult resuscitation, the recommended chest compression depth and rate are 5-6 cm and 100-120 compressions per minute, respectively. Both a specific period of CPR before defibrillation during out-of-hospital resuscitation and use of endotracheal route for drug delivery during advanced life support are no longer recommended. During postresuscitation care, inspired oxygen should be titrated to obtain an arterial oxygen saturation of 94-98%, to avoid possible damage from hyperoxemia. In pediatric resuscitation, the role of pulse palpation for the diagnosis of cardiac arrest has been de-emphasised. The compression-to-ventilation ratio depends on the number of rescuers available, and a 30:2 ratio is acceptable even for rescuers with a duty to respond if they are alone. Chest compression depth should be at least 1/3 of the anterior-posterior chest diameter. The use of automated external defibrillators for children under one year of age should be considered.     

Reanimation im Neugeborenen- und Kindesalter

In comparison to cardiopulmonary resuscitation (CPR) in adults, emergency situations in babies and children which eventually end in cardiopulmonary resuscitation measures constitute a particular challenge for the emergency physician. Paediatric emergencies are always a mental challenge, in particular, if the physician lacks a sufficient paediatric case load during his daily routine working schedule. Especially in CPR situations it has to be emphasised rather than being ignored that children are not “small adults”. In spring 2000, major international resuscitation organisations (International Liaison Committee on Resuscitation, ILCOR) developed clear cut algorithms and guidelines for basic and advanced life support in babies and children and for resuscitation of babies at birth which are presented and discussed.     

Emergency medicine -- new concepts and therapies improve outcome from cardiac arrest

According to scientific articles focusing on emergency medicine published in international journals in the past few months, early defibrillation by lay persons, thrombolysis during cardiopulmonary resuscitation (CPR) and treatment with mild therapeutic hypothermia have been identified as relevant, new and clinically important treatment options to improve outcome following cardiac arrest. Early defibrillation using automated external defibrillators by lay persons reduces the time interval between collapse and first attempts at defibrillation and thus improves outcome after prehospital cardiac arrest. Thrombolysis during CPR -- for which the results regarding safety and efficacy are available from nonrandomized trials -- can also be safely performed in case of pulseless electrical activity. Thrombolysis during cardiopulmonary resuscitation has, however, no significant effect in this subgroup of patients with pulseless electrical activity in whom outcome is poor if the drug is administered at the end of conventional CPR procedures. Mild therapeutic hypothermia, i. e., cooling of cardiac arrest victims to 32-34 degrees C central body temperature for 12-24 h following out-of-hospital cardiac arrest, markedly improves survival rate and neurological outcome. Since this has now been clearly documented in two randomized clinical trials, it can be assumed that this kind of intervention will be recommended and translated into clinical practice soon. In conclusion, new and clinically relevant methods to improve outcome following cardiac arrest are available and can now be widely used clinically.     

Kardiopulmonale Reanimation „oben ohne“

A decade after the onset of a discussion whether ventilation could be omitted from bystander basic life support (BLS) algorithms, the state of the evidence is reevaluated. Initial animal studies and a prospective randomized patient trial had suggested that omission of ventilation during the first minutes of lay cardiopulmonary resuscitation (CPR) did not impair patient outcomes. More recent studies demonstrate, however, that this may hold true only in very specific scenarios, and that the chest compression-only technique was never superior to standard BLS. Instead of calling basics of BLS training and practice into question, more and better training of lay persons and professionals appears mandatory, and targeted use of dispatcher-guided telephone CPR should be evaluated and, if it improves outcome, it should be encouraged. Future studies should focus much less on the omission but on the optimization of ventilation under the specific conditions of CPR.     

Can video mobile phones improve CPR quality when used for dispatcher assistance during simulated cardiac arrest?

Background: Because mobile telephones may support video calls, emergency medical dispatchers may now connect visually with bystanders during pre-hospital cardio-pulmonary resuscitation (CPR). We studied the quality of simulated dispatcher-assisted CPR when guidance was delivered to rescuers by video calls or audio calls from mobile phones.
Methods: One hundred and eighty high school students were randomly assigned in groups of three to communicate via video calls or audio calls with experienced nurse dispatchers at a Hospital Emergency Medical Dispatch Center. CPR was performed on a recording resuscitation manikin during simulated cardiac arrest. Quality of CPR and time factors were compared depending on the type of communication used.
Results: The median CPR time without chest compression ('hands-off time') was shorter in the video-call group vs. the audio-call group (303 vs. 331 s; P =0.048), but the median time to first compression was not shorter (104 vs. 102 s; P =0.29). The median time to first ventilation was insignificantly shorter in the video-call group (176 vs. 205 s; P =0.16). This group also had a slightly higher proportion of ventiliations without error (0.11 vs. 0.06; P =0.30).
Conclusion: Video communication is unlikely to improve telephone CPR (t-CPR) significantly without proper training of dispatchers and when using dispatch protocols written for audio-only calls. Improved dispatch procedures and training for handling video calls require further investigation.     

Decisions not to resuscitate in a Swedish university hospital

Background : Cardiopulmonary resuscitation (CPR) has the potential to save many lives. Used indiscriminately though, it may be harmful and not in the best interest of the patient. An advance directive to refrain from resuscitation in selected patients is probably not uncommon in Sweden, but guidelines ruling this are still generally lacking. This study was performed to evaluate the use and documentation of do–not–resuscitate orders in a Swedish university hospital.
Methods : Adult inpatients at 7 medical, 3 surgical and 2 neurological wards, a total of 220, were investigated on one specific day by interviewing the physicians and nurses responsible for their care.
Results : We found a discrepancy in doctors' and nurses' perception concerning the appropriateness of CPR in selected patients. CPR was judged by doctors to be inappropriate for 45 patients (20%). Out of these 45 patients, only 24 had a written do–not resuscitate order in their medical record, in most cases noted as a code word or sign only. Rarely were the patient or his/her relatives involved in the decision–making process.
Conclusion : We conclude that a decision to refrain from resuscitation is often not made, even when considered medically and ethically justifiable. Also, the use of coded information as a sole indicator for a patient not to be resuscitated is still common practice. The patient or his/her relatives are rarely involved in this decision.     

Cardio‐pulmonary resuscitation of brain‐dead organ donors: a literature review and suggestions for practice

“Organ preserving cardiopulmonary resuscitation (OP‐CPR)” is defined as the use of CPR in cases of cardiac arrest to preserve organs for transplantation, rather than to revive the patient. Is it ethical to provide OP‐CPR in a brain‐dead organ donor to save organs that would otherwise be lost? To answer this question, we review the literature on brain‐dead organ donors, conduct an ethical analysis, and make recommendations. We conclude that OP‐CPR can benefit patients and families by fulfilling the wish to donate. However, it is an aggressive procedure that can cause physical damage to patients, and risks psychological harm to families and healthcare professionals. In a brain‐dead organ donor, OP‐CPR is acceptable without specific informed consent to OP‐CPR, although advance discussion with next of kin regarding this possibility is strongly advised. In a patient where brain death is yet to be determined, but there is known wish for organ donation, OP‐CPR would only be acceptable with a specific informed consent from the next of kin. When futility of treatment has not been established or it is as yet unknown if the patient wished to be an organ donor then OP‐CPR should be prohibited, in order to avoid any conflict of interest.     

Coronary perfusion pressure during cardiopulmonary resuscitation

Coronary perfusion pressure (CPP) generated during cardiopulmonary resuscitation (CPR) is a key component for successful resuscitation. Defined as the pressure gradient between the aorta and the right atrium during the ‘diastolic’ or decompression portion of chest compression-decompression, this gradient has been correlated with both myocardial blood flow generated with CPR and ultimately with resuscitation outcome. Several unique features of cardiac arrest physiology, specifically the loss of vascular auto-regulation, make this pressure gradient even more important and the principal determinant of myocardial blood flow during CPR. Additionally, the loss of the ability to selectively vasoconstrict and vasodilate before and after an intra-coronary lesion results in increased significance of any coronary obstruction (even lesions less than 50%) with profound compromising effects on distal flow. Although CPP has been measured in patients undergoing CPR it remains difficult to acquire, secondary to the time needed to insert the pressure-measuring catheters. Alternative non-invasive measures of coronary perfusion are needed. Expired end-tidal carbon dioxide has been one suggested possibility.     

“Kids save lives” – School resuscitation programs worldwide and WHO initiative for this

Survival-rates and neurological outcome after out-of-hospital cardiac arrest significantly depends on the period of time until initiation of cardiopulmonary resuscitation (CPR). Considering that the emergency medical arrives 8–12 min after collapse, a desperate need of lay-persons able to perform CPR exists. However, bystander CPR-rates in Europe are alarmingly low. The “Kid-save-lives” initiative is a global call to train youngsters CPR in school to sustainably improve bystander CPR-rates. Thus, a large part of the lay population could be trained in CPR over time, which could save thousands of lives every year. This article provides a brief overview of the scientific knowledge in school resuscitation programs and outlines educational and pedagogical aspects in training of schoolchildren in CPR.     

Pro cardiopulmonary resuscitation before defibrillation

Background

The medical dogma has always been to defibrillate a patient discovered to be in ventricular fibrillation (VF), and automatic electric defibrillators (AED) drove this standard into widespread cardiopulmonary resuscitation (CPR) guidelines. Slow AED operation and three stacked shocks added several minutes of not providing blood flow generated by chest compressions. Investigators questioned the practice of providing defibrillation first for patients with longer down time compared to providing chest compressions prior to defibrillation. Human and experimental literature in addition to the interplay between chest compression, defibrillation, and saving lives are discussed.

Materials and methods

The experimental and human literature published regarding chest compression prior to defibrillation is reviewed, the importance of providing chest compressions that generate adequate blood flow to vital organs is highlighted, and the scientific evidence for CPR before defibrillation was performed is explored.

Results

Our review documented that in experimental animal studies of cardiac arrest there is a pooling of blood on the venous side of the heart during VF and that chest compression before defibrillation serve two purposes: (1) high quality chest compressions preserve brain function and (2) perfusing the heart with blood,“primes it” for successful restoration of spontaneous circulation. In clinical practice, the time interval of CPR before defibrillation is unknown. One randomized trial of 3?min of CPR before defibrillation found a significant increase in survival for those who were reached more than 5?min after cardiac arrest, and this was supported by a study based on historic controls. Other studies have not found any benefit but we may speculate that this was due to the quality of the CPR. Delaying defibrillation attempts is meaningless, if quality of chest compressions is suboptimal.

Conclusion

High quality CPR before defibrillation is the treatment of choice for those patients who will not receive a defibrillation attempt shortly after VF started. Regarding survival, it has not been documented that CPR first is inferior to defibrillation first. CPR first is safe and effective for most prehospital cardiac arrest patients.     

Cardiac arrest in the left lateral decubitus position and extracorporeal cardiopulmonary resuscitation during neurosurgery: a case report

Cardiopulmonary resuscitation (CPR) in the lateral position during noncardiac surgery has been described in only a few reports in the past. Here, we report a case of cardiac arrest in a 61-year-old man undergoing microvascular decompression surgery for trigeminal neuralgia in the left lateral decubitus position. During the initial 5 min of CPR, chest compression was performed in this position by two rescuers; one from the chest and the other from the back, pushing simultaneously. Because ventricular arrhythmia was refractory to conventional CPR even after placing the patient back to the supine position, extracorporeal life support was introduced in the operating room by using the femoro–femoral approach (right atrio-femoral veno-arterial bypass). This alternative CPR markedly decreased the frequency of ventricular arrhythmia. Subsequent coronary angiogram detected 99% stenosis of the right coronary artery. Ventricular arrhythmia ceased after coronary revascularization, and the patient was successfully weaned from the extracorporeal bypass circuit. The patient was discharged alive with minimal neurological impairment. We suggest that chest compression in the lateral position by two rescuers is an efficient resuscitation maneuver, and if an electrical storm is refractory to conventional CPR, extracorporeal life support should be considered in the operating-room setting.     

Quality of clinical care provided during simulated pediatric cardiac arrest: a simulation-based study

We sought to assess compliance to resuscitation guidelines during pediatric simulated cardiac arrests in a pediatric intensive care unit (PICU) and to identify performance gaps to target with future training. In a prospective observational study in a PICU, ten cardiac arrest scenarios were developed for resuscitation training and video recorded. The video recordings were examined for times to start cardiopulmonary resuscitation (CPR), delivery of first shock, CPR quality (rate, depth), length of pauses, chest compression fraction (CCF), ventilation, pulse/rhythm assessment, compressors’ rotation, and leader’s behaviours. The primary outcome was percentage of events compliant to Pediatric Advance Life Support guidelines. Compliance to guidelines was poor in the 23 simulation events studied. The median [interquartile range] time to start CPR was 29 [16–76] sec and 320 [245–421] sec to deliver the first shock. A total of 306 30-sec epochs of CPR were analyzed; excellent CPR (≥ 90% compressions in target for rate and depth) was achieved in 22 (7%) epochs. More than a quarter of the CPR pauses lasted > 10 seconds (33/127, 26%) with just one task performed in most of them; CCF was ≥ 80% in 19/23 (82.6%) events. Ventilation rate for intubated patients was greater than 10 breaths·min−1 in 15/27 (56%) of one-minute epochs observed. Review of simulated resuscitation events found suboptimal compliance with resuscitation guidelines, particularly the times to starting CPR and delivering the first shock, as well as compression rate and depth.     

Systemic oxygen uptake during experimental closed-chest cardiopulmonary resuscitation using air or pure oxygen ventilation

Background : Although clinical cardiopulmonary resuscitation always includes ventilation with pure oxygen, this kind of ventilation has been reported to be associated with worse neurological outcome than ventilation with air in experimental cardiopulmonary resuscitation (CPR). The aim of the present investigation was to compare the systemic oxygen uptake during experimental closed-chest CPR including ventilation with pure oxygen or ambient air and, furthermore, to elucidate possible mechanisms of action in the regulation of pulmonary gas exchange.
Methods : In 24 anesthetized piglets, 2 min of induced ventricular fibrillation and no ventilation was followed by 10 min of closed-chest CPR including i.v. administration of 0.5 mg adrenaline (at 8 min), and in one of the experimental groups alkaline buffer (at 5 min). The piglets were randomly divided into 3 groups: air ventilation during the entire CPR period with saline administration (n=8), air ventilation during the entire CPR period plus tris buffer mixture (n=8), and air ventilation for 3 min followed by 100% oxygen with saline administration (n= 8).
Results : In the group ventilated with air and treated with tris buffer mixture, cardiac output was significantly greater than in the group ventilated with pure oxygen. The arterial-mixed venous oxygen content difference was approximately 25% greater with pure oxygen than with air ventilation; however, there was no difference in systemic oxygen uptake. Systemic oxygen uptake increased after administration of tris buffer mixture in the group ventilated with air.
Conclusions : Pulmonary hypoxic vasoconstriction appeared to be abolished during CPR including pure oxygen ventilation. Blood flow, not ventilation or pulmonary gas exchange, is the limiting factor during experimental closed-chest CPR.     

Recent advances in active compression-decompression cardiopulmonary resuscitation

In an attempt to improve upon the currently poor outcomes for patients in cardiac arrest, new methods and devices have been developed to enhance the efficiency and efficacy of standard cardiopulmonary resuscitation (CPR). One new approach, active compression-decompression (ACD) CPR was developed to lower the intrathoracic pressure during the decompression phase of CPR, thereby enhancing venous blood return to the thorax. Over the past decade the ACD CPR device has been extensively evaluated in animals and humans. ACD CPR is the only new approach for improving CPR efficacy with a mechanical device that has achieved clinical relevance. More recently, an inspiratory impedance threshold valve (ITV^™) has been developed that causes a further reduction in intrathoracic pressures, augmenting the efficiency of both standard and ACD CPR. Consequently, ACD CPR and the impedance valve were recently recommended by the American Heart Association. Clinical trials are underway to determine the long-term, potential value of these new technologies.     

Over-the-head cardiopulmonary resuscitation improves efficacy in basic life support performed by professional medical personnel with a single rescuer: a simulation study

Two-rescuer cardiopulmonary resuscitation (CPR) is considered the best method for professional basic life support (BLS). However, in many prehospital cardiac arrest situations, one rescuer has to begin CPR alone while the other performs additional tasks. In theory, over-the-head CPR is a suitable alternative in this situation, with the added benefit of allowing the single rescuer to use a self-inflating bag for ventilation. In this trial, we compared standard single-rescuer CPR with over-the-head CPR in manikins. We planned this study using a crossover study design where each participant administered both CPR techniques in a randomized order. Ventilation and chest compression data were collected with analysis software during a 2-min CPR test for each technique. Sixty-seven emergency medical technician students participated in this trial. Over-the-head CPR allowed for superior ventilation compared to standard CPR (number of correct ventilations: 330 of 760 versus 279 of 779; P = 0.002). The quality of delivered chest compressions did not differ between the two groups (correct chest compressions: 4293 of 6304 versus 4313 of 6395; P = 0.44). In conclusion, our study has shown that over-the-head CPR may be an effective alternative BLS technique when a single professional rescuer has to perform CPR, likely offering superior ventilation and comparable chest compression quality compared with standard BLS.