A Simple Audio-visual Prompt Device Can Improve CPR Performance

Background

An adjunct to assist cardiopulmonary resuscitation (CPR) might improve the quality of CPR performance.

Study Objectives

This study was conducted to evaluate whether a simple audio-visual prompt device improves CPR performance by emergency medical technicians (EMTs).

Methods

From June 2008 to October 2008, 55 EMTs (39 men, mean age 34.9 ± 4.8 years) participated in this study. A simple audio-visual prompt device was developed. The device generates continuous metronomic sounds for chest compression at a rate of 100 beats/min with a distinct 30^th sound followed by two respiration sounds, each for 1 second. All EMTs were asked to perform a 2-min CPR series on a manikin without the device, and one 2-min CPR series with the device.

Results

The average rate of chest compressions was more accurate when the device was used than when the device was not used (101.4 ± 12.7 vs. 109.0 ± 17.4/min, respectively, p = 0.012; 95% confidence interval [CI] 97.2–103.8 vs. 104.5–113.5/min, respectively), and hands-off time during CPR was shorter when the device was used than when the device was not used (5.4 ± 0.9 vs. 9.2 ± 3.9 s, respectively, p < 0.001; 95% CI 5.2–5.7 vs. 8.3–10.3 s, respectively). The mean tidal volume during CPR with the device was lower than without the device, resulting in the prevention of hyperventilation (477.6 ± 60.0 vs. 636.6 ± 153.4 mL, respectively, p < 0.001; 95% CI 463.5–496.2 vs. 607.3–688.9 mL, respectively).

Conclusion

A simple audio-visual prompt device can improve CPR performance by emergency medical technicians.     

Pushing harder,pushing faster,minimizing interruptions… But falling short of 2010 cardiopulmonary resuscitation targets during in-hospital pediatric and adolescent resuscitation

Aim

The objective of this study was to evaluate the effect of instituting the 2010 Basic Life Support Guidelines on in-hospital pediatric and adolescent cardiopulmonary resuscitation (CPR) quality. We hypothesized that quality would improve, but that targets for chest compression (CC) depth would be difficult to achieve.

Methods

Prospective in-hospital observational study comparing CPR quality 24 months before and after release of the 2010 Guidelines. CPR recording/feedback-enabled defibrillators collected CPR data (rate (CC/min), depth (mm), CC fraction (CCF, %), leaning (% > 2.5 kg)). Audiovisual feedback for depth was: 2005, ≥38 mm; 2010, ≥50 mm; for rate: 2005, ≥90 and ≤120 CC/min; 2010, ≥100 and ≤120 CC/min. The primary outcome was average event depth compared with Student's t-test.

Results

45 CPR events (25 before; 20 after) occurred, resulting in 1336 thirty-second epochs (909 before; 427 after). Compared to 2005, average event depth (50 ± 13 mm vs. 43 ± 9 mm; p = 0.047), rate (113 ± 11 CC/min vs. 104 ± 8 CC/min; p < 0.01), and CCF (0.94 [0.93, 0.96] vs. 0.9 [0.85, 0.94]; p = 0.013) increased during 2010. CPR epochs during the 2010 period more likely to meet Guidelines for CCF (OR 1.7; CI95: 1.2–2.4; p < 0.01), but less likely for rate (OR 0.23; CI95: 0.12–0.44; p < 0.01), and depth (OR 0.31; CI95: 0.12–0.86; p = 0.024).

Conclusions

Institution of the 2010 Guidelines was associated with increased CC depth, rate, and CC fraction; yet, achieving 2010 targets for rate and depth was difficult.     

The impact of airway management on quality of cardiopulmonary resuscitation: An observational study in patients during cardiac arrest

Background

Minimising interruptions in chest compressions is associated with improved survival from cardiac arrest. Current in-hospital guidelines recommend continuous chest compressions after the airway is secured on the premise that this will reduce no flow time. The aim of this study was to determine the effect of advanced airway use on the no flow ratio and other measures of CPR quality.

Methods

Consecutive adult patients who sustained an in-hospital cardiac arrest were enrolled in this prospective observational study. The quality of CPR was measured using the Q-CPR device (Phillips, UK) before and after an advanced airway device (endotracheal tube [ET] or laryngeal mask airway [LMA]) was inserted. Patients receiving only bag-mask ventilation were used as the control cohort. The primary outcome was no flow ratio (NFR). Secondary outcomes were chest compression rate, depth, compressions too shallow, compressions with leaning, ventilation rate, inflation time, change in impedance and time required to successfully insert airway device.

Results

One hundred patients were enrolled in the study (2008–2011). Endotracheal tube and LMA placement took similar durations (median 15.8 s (IQR 6.8–19.4) vs LMA median 8.0 s (IQR 5.5–15.9), p = 0.1). The use of an advanced airway was associated with improved no flow ratios (endotracheal tube placement (n = 50) improved NFR from baseline median 0.24 IQR 0.17–0.40) to 0.15 to (IQR 0.09–0.28), p = 0.012; LMA (n = 25) from median 0.28 (IQR 0.23–0.40) to 0.13 (IQR 0.11– 0.19), p = 0.0001). There was no change in NFR in patients managed solely with bag valve mask (BVM) (n = 25) (median 0.29 (IQR 0.18–0.59) vs median 0.26 (IQR 0.12–0.37), p = 0.888). There was no significant difference in time taken to successfully insert the airway device between the two groups.

Conclusion

The use of an advanced airway (ETT or LMA) during in-hospital cardiac arrest was associated with improved no flow ratio. Further studies are required to determine the effect of airway devices on overall patient outcomes.     

Ability of code leaders to recall CPR quality errors during the resuscitation of older children and adolescents

Aim

Performance of high quality CPR is associated with improved resuscitation outcomes. This study investigates code leader ability to recall CPR error during post-event interviews when CPR recording/audiovisual feedback-enabled defibrillators are deployed.

Patients and methods

Physician code leaders were interviewed within 24 h of 44 in-hospital pediatric cardiac arrests to assess their ability to recall if CPR error occurred during the event. Actual CPR quality was assessed using quantitative recording/feedback-enabled defibrillators. CPR error was defined as an overall average event chest compression (CC) rate <95/min, depth <38 mm, ventilation rate >10/min, or any interruptions in CPR >10 s. We hypothesized that code leaders would recall error when it actually occurred ≥75% of the time when assisted by audiovisual alerts from a CPR recording feedback-enabled defibrillators (analysis by χ²).

Results

810 min from 44 cardiac arrest events yielded 40 complete data sets (actual and interview); ventilation data was available in 24. Actual CPR error was present in 3/40 events for rate, 4/40 for depth, 32/40 for interruptions >10 s, and 17/24 for ventilation frequency. In post-event interviews, code leaders recalled these errors in 0/3 (0%) for rate, 0/4 (0%) for depth, and 19/32 (59%) for interruptions >10 s. Code leaders recalled these CPR quality errors less than 75% of the time for rate (p = 0.06), for depth (p < 0.01), and for CPR interruption (p = 0.04). Quantification of errors not recalled: missed rate error median = 94 CC/min (IQR 93–95), missed depth error median = 36 mm (IQR 35.5–36.5), missed CPR interruption >10 s median = 18 s (IQR 14.4–28.9). Code leaders did recall the presence of excessive ventilation in 16/17 (94%) of events (p = 0.07).

Conclusion

Despite assistance by CPR recording/feedback-enabled defibrillators, pediatric code leaders fail to recall important CPR quality errors for CC rate, depth, and interruptions during post-cardiac arrest interviews.     

Myocardial infarction is a frequent cause of exercise-related resuscitated out-of-hospital cardiac arrest in a general non-athletic population

Background

Performing exercise is shown to prevent cardiovascular disease, but the risk of an out-of-hospital cardiac arrest (OHCA) is temporarily increased during strenuous activity. We examined the etiology and outcome after successfully resuscitated OHCA during exercise in a general non-athletic population.

Methods

Consecutive patients with OHCA were admitted with return of spontaneous circulation (ROSC) or on-going resuscitation at hospital arrival (2002–2011). Patient charts were reviewed for post-resuscitation data. Exercise was defined as moderate/vigorous physical activity.

Results

A total of 1393 OHCA-patients were included with 91(7%) arrests occurring during exercise. Exercise-related OHCA-patients were younger (60 ± 13 vs. 65 ± 15, p < 0.001) and predominantly male (96% vs. 69%, p < 0.001). The arrest was more frequently witnessed (94% vs. 86%, p = 0.02), bystander CPR was more often performed (88% vs. 54%, p < 0.001), time to ROSC was shorter (12 min (IQR: 5–19) vs. 15 (9–22), p = 0.007) and the primary rhythm was more frequently shock-able (91% vs. 49%, p < 0.001) compared to non-exercise patients. Cardiac etiology was the predominant cause of OHCA in both exercise and non-exercise patients (97% vs. 80%, p < 0.001) and acute coronary syndrome was more frequent among exercise patients (59% vs. 38%, p < 0.001). One-year mortality was 25% vs. 65% (p < 0.001), and exercise was even after adjustment associated with a significantly lower mortality (HR = 0.40 (95%CI: 0.23–0.72), p = 0.002).

Conclusions

OHCA occurring during exercise was associated with a significantly lower mortality in successfully resuscitated patients even after adjusting for confounding factors. Acute coronary syndrome was more common among exercise-related cardiac arrest patients.     

A 5-year experience with cardiopulmonary resuscitation using extracorporeal life support in non-postcardiotomy patients with cardiac arrest

Background

Cardiopulmonary resuscitation (CPR) using extracorporeal life support (ECLS) system has been successfully used to support patients with in- and out-of-hospital cardiac arrest (IHCA, OHCA) when conventional measures have failed. The purpose of the current study is to report on our experience with extracorporeal CPR in non-postcardiotomy patients.

Methods

We retrospectively analysed a total of 85 consecutive adult patients, who have been treated with ECLS between January 2007 and January 2012.

Results

The mean CPR duration was 40 min (20–70 min). The mean ECLS support duration was 49 h (12–92 h). Twenty-eight patients (33%) had ECLS related complications. Forty patients (47%) were successfully weaned and 29 patients (34%) survived to hospital discharge. Among survivors, 93% were without severe neurologic deficit. Duration of CPR was shorter for survivors than for non-survivors [(25: 20–50 min) vs. (50: 25–86 min); p = 0.003]. Immediately after ECLS start, the mean blood lactate level was lower (p = 0.003), and the mean pH value was higher in the survivors’ group (p < 0.0001) compared to the non-survivors’ group. The CPR duration for the IHCA group (25: 20–50 min) was shorter compared to the OHCA group (70: 55–110 min; p < 0.0001). The survival rate in this group was higher compared to the OHCA group (42% vs. 15%; p < 0.02).

Conclusions

CPR using modern miniaturized ECLS systems should be established in the treatment of prolonged cardiac arrest and unsuccessful conventional CPR in selected patients. CPR with ECLS for OHCA has worse outcomes compared to IHCA. Duration of CPR was independent risk factor for mortality after extracorporeal CPR.     

Compliance with barrier precautions during paediatric trauma resuscitations

Purpose

Barrier precautions protect patients and providers from blood-borne pathogens. Although barrier precaution compliance has been shown to be low among adult trauma teams, it has not been evaluated during paediatric resuscitations in which perceived risk of disease transmission may be low. The purpose of this study was to identify factors associated with compliance with barrier precautions during paediatric trauma resuscitations.

Methods

Video recordings of resuscitations performed on injured children (<18 years old) were reviewed to determine compliance with an established policy requiring gowns and gloves. Depending on activation level, trauma team members included up to six physicians, four nurses, and a respiratory therapist. Multivariate logistic regression was used to determine the effect of team role, resuscitation factors, and injury mechanism on barrier precaution compliance.

Results

Over twelve weeks, 1138 trauma team members participated in 128 resuscitations (4.7% penetrating injuries, 9.4% highest level activations). Compliance with barrier precautions was 81.3%, with higher compliance seen among roles primarily at the bedside compared to positions not primarily at the bedside (90.7% vs. 65.1%, p < 0.001). Bedside residents (98.4%) and surgical fellows (97.6%) had the highest compliance, while surgical attendings (20.8%) had the lowest (p < 0.001). Controlling for role, increased compliance was observed during resuscitations of patients with penetrating injuries (OR = 3.97 [95% CI: 1.35–11.70], p = 0.01), during resuscitations triaged to the highest activation level (OR = 2.61 [95% CI: 1.34–5.10], p = 0.005), and among team members present before patient arrival (OR = 4.14 [95% CI: 2.29–7.39], p < 0.001).

Conclusions

Compliance with barrier precautions varies by trauma team role. Team members have higher compliance when treating children with penetrating and high acuity injuries and when arriving before the patient. Interventions integrating barrier precautions into the workflow of team members are needed to reduce this variability and improve compliance with universal precautions during paediatric trauma resuscitations.     

Emergency department factors associated with survival after sudden cardiac arrest

Background

Sudden cardiac arrest (SCA) is a leading cause of death in the US. Recent innovations in post-arrest care have been demonstrated to increase survival. However, little is known about the impact of emergency department (ED) and hospital characteristics on survival to hospital admission and ultimate outcome.

Objective

We sought to describe the incidence of SCA presenting to the ED and to identify ED and hospital characteristics associated with survival to hospital admission.

Methods

We identified patients with diagnoses of atraumatic cardiac arrest or ventricular fibrillation (ICD-9 427.5 or 427.41) in the 2007 Nationwide Emergency Department Sample (NEDS), a nationally representative estimate of all ED admissions in the United States. We defined SCA as cardiac arrest in the out-of-hospital or ED settings. We used the NEDS sample design to generate nationally representative estimates of the incidence of SCA that presents to EDs. We performed unadjusted and adjusted analyses to examine the relation between patient, ED, and hospital characteristics and outcome using logistic regression. Our primary outcome was survival to hospital admission. Survival to hospital discharge was a secondary outcome. Data are presented as odds ratios (OR) with 95% confidence intervals (CI).

Results

Of the 966 hospitals in the NEDS, 933 (96.6%) reported at least one SCA and were included in the analysis. We identified 38,593 cases of cardiac arrest representing an estimated 174,982 cases nationally. Overall ED SCA survival to hospital admission was 26.2% and survival to discharge was 15.7%. Greater survival to admission was seen in teaching hospitals (OR 1.3 95% CI 1.1–1.5, p = 0.001), hospitals with ≥20,000 annual ED visits (OR 1.3 95% CI 1.1–1.6, p = 0.003), and hospitals with percutaneous coronary intervention capability (OR 1.6 95% CI 1.4–1.8, p < 0.001). Higher SCA volume (>40 annually) was associated with lower survival overall (OR 0.7 95% 0.6–0.9, p = 0.010), but not when transferred patients were excluded from the analysis (OR 0.8 95% CI 0.6–1.1, p = 0.116).

Conclusions

An estimated 175,000 cases of SCA present to or occur in US EDs each year. Percutaneous coronary intervention capability, ED volume, and teaching status were associated with higher survival to hospital admission. Emergency departments with higher annual SCA volume had lower survival rates, possibly because they transfer fewer patients. An improved understanding of the contribution of ED care to survival following SCA may be useful in advancing our understanding of how best to organize a system of care to ensure optimal outcomes for patients with SCA.     

The impact of partial resuscitation attempts on the reported outcomes of out-of-hospital cardiac arrest in Victoria,Australia: Implications for Utstein-style outcome reports

Background

Success rates from cardiopulmonary resuscitation (CPR) are often quantified by Utstein-style outcome reports in populations who receive an attempted resuscitation. In some cases, evidence of futility is ascertained after a partial resuscitation attempt has been administered, and these cases reduce the overall effectiveness of CPR. We examine the impact of partial resuscitation attempts on the reported outcomes of out-of-hospital cardiac arrest (OHCA) in Victoria, Australia.

Methods

Between 2002 and 2012, 34,849 adult OHCA cases of presumed cardiac aetiology were included from the Victorian Ambulance Cardiac Arrest Registry. Resuscitation attempts lasting ≤10 min in cases which died on scene were defined as a partial resuscitation. We used logistic regression to identify factors associated with a partial resuscitation attempt in the emergency medical service (EMS) treated population. Survival outcomes with and without partial resuscitations were compared across included years.

Results

The proportion of partial resuscitations in the overall EMS treated population increased significantly from 8.6% in 2002 to 18.8% in 2012 (p for trend < 0.001), and were largely supported by documented evidence of irreversible death. Partial resuscitations were independently associated with older age, female gender, initial non-shockable rhythm, prolonged downtime, and lower skill level of EMS personnel. Selectively excluding partial resuscitations increased event survival by 7.6% (95% CI 4.1–11.2%), and survival to hospital discharge increased by 3.1% (95% CI 0.5–5.7%) in 2012 (p < 0.001 for both).

Conclusion

In our EMS system, evidence of futility was often identified after the commencement of a partial resuscitation attempt. Excluding these events from OHCA outcome reports may better reflect the overall effectiveness of CPR.     

A clinical observational study analysing the factors associated with hyperventilation during actual cardiopulmonary resuscitation in the emergency department

Aim

This is the first study to identify the factors associated with hyperventilation during actual cardiopulmonary resuscitation (CPR) in the emergency department (ED).

Methods

All CPR events in the ED were recorded by video from April 2011 to December 2011. The following variables were analysed using review of the recorded CPR data: ventilation rate (VR) during each minute and its associated factors including provider factors (experience, advanced cardiovascular life support (ACLS) certification), clinical factors (auscultation to confirm successful intubation, suctioning, and comments by the team leader) and time factors (time or day of CPR).

Results

Fifty-five adult CPR cases including a total of 673 min sectors were analysed. The higher rates of hyperventilation (VR > 10/min) were delivered by inexperienced (53.3% versus 14.2%) or uncertified ACLS provider (52.2% versus 10.8%), during night time (61.0 versus 34.5%) or weekend CPR (53.1% versus 35.6%) and when auscultation to confirm successful intubation was performed (93.5% versus 52.8%) than not (all p < 0.0001). However, experienced (25.3% versus 29.7%; p = 0.448) or certified ACLS provider (20.6% versus 31.3%; p < 0.0001) could not deliver high rate of proper ventilation (VR 8–10/min). Comment by the team leader was most strongly associated with the proper ventilation (odds ratio 7.035, 95% confidence interval 4.512–10.967).

Conclusions

Hyperventilation during CPR was associated with inexperienced or uncertified ACLS provider, auscultation to confirm intubation, and night time or weekend CPR. And to deliver proper ventilation, comments by the team leader should be given regardless of providers’ expert level.     

Survival following witnessed pediatric out-of-hospital cardiac arrests during nights and weekends

Background

The relationship between survival rate following pediatric out-of-hospital cardiac arrests (OHCAs) and time of day or day of week is unknown.

Methods

A nationwide, prospective, population-based observational investigation of consecutive witnessed pediatric OHCAs (<18 years) with resuscitation attempts was conducted from January 2005 to December 2011. Days were defined as 9:00 am to 4:59 pm, nights as 5:00 pm to 8:59 am, weekdays as Mondays to Fridays, and weekends as Saturdays, Sundays, and national holidays. Primary outcome was one-month survival and secondary outcome was survival with favorable neurologic outcome, defined as cerebral performance category 1 or 2.

Results

A total of 3278 bystander-witnessed pediatric OHCAs were registered. One month survival rate was significantly lower during nights than days (15.5% [95% CI: 13.8–17.2%] versus 23.3% [95% CI: 21.1–25.6%]; P < 0.001 and during weekends/holidays (15.7% [95% CI: 13.6–18.0%] than weekdays (20.4% [95% CI: 18.7–22.2%]; P = 0.001. Survival rate with favorable neurologic outcome was substantially lower during nights 7.5% [95% CI: 6.3–8.8%] than days (12.2% [95% CI: 10.6–14.1%]; P < 0.001), and during weekends/holidays (7.7% [95% CI: 6.2–9.5%] than weekdays (10.4% [95% CI: 9.2–11.8%]; P = 0.012). After adjusting for potential confounding factors, one-month survival rate remained significantly lower during nights compared to days (odds ratio 0.68; 95% CI: 0.56–0.82), and during weekends/holidays compared to weekdays (odds ratio 0.79; 95% CI, 0.65–0.97).

Conclusions

One-month survival rate following bystander-witnessed pediatric OHCAs was lower during nights and weekends/holidays than days and weekdays, even when adjusted for potentially confounding factors.     

Proactive rounding by the rapid response team reduces inpatient cardiac arrests

Objective

Rapid response teams (RRTs) are frequently employed to respond to deteriorating inpatients. Proactive rounding (PR) consists of the RRT nurse rounding through the inpatient wards identifying high risk patients and intervening preemptively. At our institution, PR began in July of 2007. Our objective was to determine the effect of PR by the RRT at our institution on non-ICU cardiac arrests, code deaths, RRT interventions, and transfers to a higher level of care. Also, to report ICU transfer survival and survival to discharge rates after the start of PR.

Design

Retrospective review of a prospectively collected database.

Setting

A tertiary, academic, level 1 trauma center with 696 beds and a rapid response system.

Patients

1253 Non-ICU cardiac arrests from 2005 through June of 2012.

Interventions

None.

Measurements and main results

The total study period included 223,267 inpatient admissions (70,129 pre-PR and 153,138 post-PR) and 1,250,814 patient days (391,088 pre-PR and 859,726 post-PR). The quarterly code rate before PR was 66 and the code rate after the institution of PR was 30 (difference = 36.8, 95% CI 25.6–48.0, p < .001). Quarterly code deaths decreased from 29 to 7 (difference = 21.95, 95% CI 16.3–27.6, p < .001). This decrease in floor codes and code deaths was still present after adjusting for inpatient admission and inpatient days. Average quarterly RRT interventions increased from 141 in the pre-PR period to 690 in the post-PR period (difference = 549, 95% CI 360–738, p < .001). Average quarterly transfers to HLC went up from 38 pre-PR to 164 post-PR (difference = 126, 95% CI 79–172, p < .001).

Conclusions

The institution of proactive rounding at a tertiary care, academic, level 1 trauma center results in reduced floor codes and code deaths as well as increased RRT interventions and transfers to a higher level of care.     

The approach to delayed resuscitation in paediatric cardiac arrest: A survey of paediatric intensivists in Canada

Aim

To determine how long a period of having had no cardiopulmonary-resuscitation (CPR) (delay time) is considered to result in subsequent futile efforts at resuscitation.

Methods

In 2007 a survey was mailed to all 77 paediatric intensivists in Canada. Three scenarios of witnessed cardiac arrest were presented: out-of-hospital, in-hospital, and in-hospital with extracorporeal-CPR (E-CPR). Each scenario asked what delay time would make attempts at resuscitation futile for survival to hospital discharge, and for survival to hospital discharge in a better than vegetative state. Comparisons of median [inter-quartile range] used Wilcoxon-signed-rank or Friedman tests with Bonferroni corrections.

Results

The response rate was 49/77 (64%). The delay time was significantly different between rhythms within all scenarios (p < .001); and was significantly shorter for survival than for better than vegetative survival (p < .006) except when E-CPR was to be used. The delay time was not significantly different between the in-hospital and out-of-hospital scenario with the same rhythms (p > .01). The delay time was significantly shorter in scenarios with asystole versus pulseless electrical activity with (p = .010) or without (p < .001) an arterial line with absent pulsation. In out-of-hospital arrest, the delay time for survival varied from 15 [10–20] min for asystole to 20 [15–20] min for pulseless electrical activity. In in-hospital scenarios, the delay time for survival varied from 10 [10–20] min for asystole, to 15 [10–20] min for most other rhythms.

Conclusion

A delay time of 15 [10–20] (range 5–30) min was considered futile for survival. This has implications for pronouncing death in donation after cardiac death.     

Post-resuscitation electrocardiograms,acute coronary findings and in-hospital prognosis of survivors of out-of-hospital cardiac arrest

Background

Identification of acute coronary lesions amenable to urgent intervention in survivors of out-of-hospital cardiac arrest is crucial. We aimed to compare the clinical and electrocardiographic characteristics to urgent coronary findings, and to analyze in-hospital prognosis of these patients.

Methods

From January 2005 to December 2012 we retrospectively identified consecutive patients resuscitated from out-of-hospital cardiac arrest, and analyzed the clinical characteristics, post-resuscitation electrocardiogram and coronary angiogram of those who underwent emergent angiography. Mortality and neurologic status at discharge were also assessed.

Results

Patients with ST-elevation more frequently had obstructive coronary artery disease (89% vs. 51%, p < 0.001) or acute coronary occlusions (83% vs. 8%, p < 0.001) than patients without ST-elevation. Independent predictors of an acute coronary occlusion were chest pain before arrest (OR 0.16, 95% CI 0.04–0.7, p = 0.01), a shockable initial rhythm (OR 0.16, 95% CI 0.03–0.9, p = 0.03), and ST-elevation on the post-resuscitation electrocardiogram (OR 0.02, 95% CI 0.004–0.13, p < 0.001). Survival with favorable neurologic recovery at discharge was 59%. Independent predictors of mortality or unfavorable neurological outcome at discharge were absence of basic life support (OR 0.2, 95% CI 0.06–0.9, p = 0.04), prolonged resuscitation time (OR 0.9, 95% CI 0.8–0.9, p = 0.01), and necessity of vasopressors (OR 14.8, 95% CI 3.3–65.4, p = 0.001).

Conclusions

Most patients with ST-elevation on the post-resuscitation electrocardiogram had an acute coronary occlusion, as opposed to patients without ST-elevation. Absence of basic life support, prolonged resuscitation time and use of vasopressors were independent predictors of worse in-hospital outcome.     

Rapid response team calls to patients with a pre-existing not for resuscitation order

Objective

Compare and contrast rapid response team (RRT) calls to patients with, and those without, a pre-existing not for resuscitation (NFR) order.

Methods

Retrospective medical record and database review of adult inpatients with a hospital stay greater than 24 h.

Results

198 (15.7%) of 1258 patients with a RRT call, had a pre-existing NFR order. Patients with, compared to those without a pre-existing NFR, were older (median years, 81 vs 70, p < 0.01), similar gender (males, 56.6% vs 54.3%, p = 0.55), the trigger be the worried criterion (48.5% vs 33.9%, p < 0.01) and have had a prior RRT call (30.8% vs 18.0%, p < 0.01).At time of RRT attendance, NFR patients had a higher respiratory rate (24 vs 20, p < 0.01), lower SaO2 (93% vs 97%, p = 0.02) and just as likely to receive a critical care (24.2% vs 25.8%, p = 0.63) or ward type (88.9% vs 90.1%, p = 0.61) intervention. NFR patients were less likely to be admitted to an ICU (2.0% vs 9.4%, p < 0.01), more likely to be left on the ward (92.4% vs 80.3%, p < 0.01), and be documented not for further RRT calls (2.5% vs 0.9%, p = 0.06), but have a similar mortality (5.6% vs 3.5%, p = 0.16), at time of RRT call.

Conclusions

RRT calls to patients with pre-existing NFR orders are not uncommon. The worried criterion is more often the trigger, they have abnormal respiratory observations at time of call, a similar level of intervention, less likely to be admitted to the ICU and more likely to be documented not for further RRT calls.     

Schoolchildren as life savers: At what age do they become strong enough?

Objective

It is not clear when schoolchildren become enough strong to perform good quality chest compressions (CC). Our purpose was to assess CC quality in schoolchildren.

Methods

721 children, 10–15 years old (YO) participated in 1 h hands-on training session. Subjects were tested during performing 2 min of continuous CC by means of Laerdal Resusci Anne^® with Skillreporter^®, without feedback.

Results

Mean compression depth (MCD) increased with age, from 30.7 mm in 10YO to 42.9 mm in 15YO (p < 0.05) and was related to height, weight, and BMI. Boys delivered significantly deeper CC than girls in the 10, 13, 14 and 15YO groups (p < 0.001). The percentage of children who achieved the MCD goal (50–60 mm), increased with age, from 0.0% at 10 years to 26.5% at 15 years (p < 0.001). Mean compression rate (MCR) ranged from 121 min^–1 in 15YO to 134 min^–1 in 12YO. The percentage of children who achieved a CC rate inside the goal (100–120 min^–1), ranged from 20.3% in 11YO to 31.0% in 15YO. Correct CC fraction was low and ranged from 2% in the 10YO to 22% in the 15YO (p < 0.05). Children older than 13YO obtained better results than younger ones for all analyzed variables (p < 0.001). Performance decreased with time: 12% of children achieved >50% of correct CC fraction in first minute, while only 5% did it in second minute (p < 0.001).

Conclusions

In schoolchildren, age, sex and anthropometry are significant CPR quality factors. Although quality increases with age, their global performance is poor. Thirteen years is the minimum age to be able to achieve a minimum CPR quality similar to the one adult possess. CPR performance in schoolchildren significantly deteriorates within 60 s.     

Virtual arterial blood pressure feedback improves chest compression quality during simulated resuscitation

Introduction

Quality chest compressions (CC) are the most important factor in successful cardiopulmonary resuscitation. Adjustment of CC based upon an invasive arterial blood pressure (ABP) display would be theoretically beneficial. Additionally, having one compressor present for longer than a 2-min cycle with an ABP display may allow for a learning process to further maximize CC. Accordingly, we tested the hypothesis that CC can be improved with a real-time display of invasively measured blood pressure and with an unchanged, physically fit compressor.

Methods

A manikin was attached to an ABP display derived from a hemodynamic model responding to parameters of CC rate, depth, and compression-decompression ratio. The area under the blood pressure curve over time (AUC) was used for data analysis. Each participant (N = 20) performed 4 CPR sessions: (1) No ABP display, exchange of compressor every 2 min; (2) ABP display, exchange of compressor every 2 min; (3) no ABP display, no exchange of the compressor; (4) ABP display, no exchange of the compressor. Data were analyzed by ANOVA. Significance was set at a p-value < 0.05.

Results

The average AUC for cycles without ABP display was 5201 mmHg s (95% confidence interval (CI) of 4804–5597 mmHg s), and for cycles with ABP display 6110 mmHg s (95% CI of 5715–6507 mmHg s) (p < 0.0001). The average AUC increase with ABP display for each participant was 20.2 ± 17.4% 95 CI (p < 0.0001).

Conclusions

Our study confirms the hypothesis that a real-time display of simulated ABP during CPR that responds to participant performance improves achieved and sustained ABP. However, without any real-time visual feedback, even fit compressors demonstrated degradation of CC quality.     

Evaluation of pre-arrest morbidity score and prognosis after resuscitation score and other clinical variables associated with in-hospital cardiac arrest in southern Sweden

Objective

To evaluate pre-arrest morbidity score (PAM), prognosis after resuscitation score (PAR) and to identify additional clinical variables associated with survival after in-hospital cardiac arrest (IHCA) treated with cardiopulmonary resuscitation (CPR).

Methods

A retrospective observational study involving all cases of IHCA at Skåne University Hospital Malmö 2007–2010.

Results

Two-hundred-eighty-seven cases of IHCA were identified (61.3% male; mean age 70 years) of whom 20.2% survived until discharge. The odds ratio (95% confidence interval) for death prior to discharge was 6.49 (1.50–28.19) (p = 0.013) for PAM > 6 and 3.88 (1.95–7.73) (p < 0.001) for PAR > 4. At PAM- and PAR-scores >5, specificity exceeded 90%, while sensitivity was only 20–30%. The odds ratio for in-hospital mortality was 0.38 (0.20–0.72) (p = 0.003) for patients with cardiac monitoring, 9.86 (5.08–19.12) (p < 0.001) for non-shockable vs shockable rhythm, 0.32 (0.15–0.69) (p = 0.004) for presence of ST-elevation myocardial infarction (STEMI), 0.27 (0.09–0.78) (p = 0.016) for patients with independent Activities of Daily Life (ADL) and 13.86 (1.86–103.46) (p = 0.010) for patients with malignancies. Heart rate (HR) on admission (per bpm) [1.024 (1.009–1.040) (p = 0.002)] and sodium plasma concentration on admission (per mmol l⁻¹) [0.92 (0.85–0.99) (p = 0.023)] were significantly associated with in-hospital mortality.

Conclusion

PAM- and PAR-scores do not sufficiently discriminate between in-hospital death and survival after IHCA to be used as clinical tools guiding CPR decisions. We confirm that malignancy is associated with increased in-hospital mortality, and cardiac monitoring, shockable rhythm, STEMI and independent ADL, with decreased in-hospital mortality. Interestingly, our results suggest that HR and plasma sodium concentration upon admission may represent new tools for risk stratification.     

Chest compression-only cardiopulmonary resuscitation performed by lay rescuers for adult out-of-hospital cardiac arrest due to non-cardiac aetiologies

Objective

Bystander CPR improves survival in patients with out-of-hospital cardiac arrest (OHCA). For adult sudden collapse, bystander chest compression-only CPR (COCPR) is recommended in some circumstances by the American Heart Association and European Resuscitation Council. However, adults who arrest from non-cardiac causes may also receive COCPR. Because rescue breathing may be more important for individuals suffering OHCA secondary to non-cardiac causes, COCPR is not recommended for these cases. We evaluated the relationship of lay rescuer COCPR and survival after OHCA from non-cardiac causes.

Methods

Analysis of a statewide Utstein-style registry of adult OHCA, during a large scale campaign endorsing COCPR for OHCA from presumed cardiac cause. The relationship between lay rescuer CPR (both conventional CPR and COCPR) and survival to hospital discharge was evaluated.

Results

Presumed non-cardiac aetiologies of OHCA accounted for 15% of all cases, and lay rescuer CPR was provided in 29% of these cases. Survival to hospital discharge occurred in 3.8% after conventional CPR, 2.7% after COCPR, and 4.0% after no CPR (p = 0.85). The proportion of patients receiving COCPR was much lower in the cohort of OHCA from respiratory causes (8.3%) than for those with presumed cardiac OHCA (18.0%; p < 0.001).

Conclusions

In the setting of a campaign endorsing lay rescuer COCPR for cardiac OHCA, bystanders were less likely to perform COCPR on OHCA victims who might benefit from rescue breathing.     

American Heart Association cardiopulmonary resuscitation quality targets are associated with improved arterial blood pressure during pediatric cardiac arrest

Aim

To evaluate the association between cardiopulmonary resuscitation (CPR) quality and hemodynamic measurements during in-hospital pediatric cardiac arrest. We hypothesized that AHA recommended CPR rate and depth targets would be associated with systolic blood pressures ≥ 80 mmHg and diastolic blood pressures ≥ 30 mmHg.

Methods

In children and adolescents <18 years of age who suffered a cardiac arrest with an invasive arterial catheter in place, a CPR monitoring defibrillator collected CPR data which was synchronized to arterial blood pressure (BP) tracings. Chest compression (CC) depths were corrected for mattress deflection. Generalized least squares regression estimated the association between BP and CPR quality, treated as continuous variables. Mixed-effects logistic regression estimated the association between systolic BP ≥ 80 mmHg/diastolic BP ≥ 30 mmHg and the AHA targets of depth ≥ 38 mm and/or rate ≥ 100/min.

Results

Nine arrests resulted in 4156 CCs. The median mattress corrected depth was 32 mm (IQR 28–38); median rate was 111 CC/min (IQR 103–120). AHA depth was achieved in 1090/4156 (26.2%) CCs; rate in 3441 (83.7%). Systolic BP ≥ 80 mmHg was attained in 2516/4156 (60.5%) compressions; diastolic ≥ 30 mmHg in 2561/4156 (61.6%). A rate ≥ 100/min was associated with systolic BP ≥ 80 mmHg (OR 1.32; CI⁹⁵ 1.04, 1.66; p = 0.02) and diastolic BP ≥ 30 mmHg (OR 2.15; CI⁹⁵ 1.65, 2.80; p < 0.001). Exceeding both (rate ≥ 100/min and depth ≥ 38 mm) was associated with systolic BP ≥ 80 mmHg (OR 2.02; CI⁹⁵ 1.45, 2.82; p < 0.001) and diastolic BP ≥ 30 mmHg (OR 1.48; CI⁹⁵ 1.01, 2.15; p = 0.042).

Conclusions

AHA quality targets (rate ≥ 100/min and depth ≥ 38 mm) were associated with systolic BPs ≥ 80 mmHg and diastolic BPs ≥ 30 mmHg during CPR in children.