Education in cardiopulmonary resuscitation in Sweden and its clinical consequences

Aim

To describe the use of cardiopulmonary resuscitation (CPR) training programmes in Sweden for 25 years and relate those to changes in the percentage of patients with out of hospital cardiac arrest (OHCA) who receive bystander CPR.

Methods

Information was gathered from (a) the Swedish CPR training registry established in 1983 and includes most Swedish education programmes in CPR and (b) the Swedish Cardiac Arrest Register (SCAR) established in 1990 and currently covers about 70% of ambulance districts in Sweden.

Results

CPR education in Sweden functions according to a cascade principle (instructor-trainers who train instructors who then train rescuers in CPR). Since 1989, 5000 instructor-trainers have taught more than 50,000 instructors who have taught nearly 2 million of Sweden's 9 million inhabitants adult CPR. This is equivalent to one new rescuer per 100 inhabitants every year in Sweden. In addition, since 1989, there are 51,000 new rescuers in Advanced Life Support (ALS), since 1996, 41,000 new Basic Life Support (BLS) rescuers with Automated External Defibrillation (AED) training, and since 1998, there are 93,000 new rescuers in child CPR. As a result of this CPR training the number of bystander CPR attempts for OHCA in Sweden increased from 31% in 1992 to 55% in 2007.

Conclusion

By using a cascade principle for CPR education nearly 2 million rescuers were educated in Sweden (9 million inhabitants) between 1989 and 2007. This resulted in a marked increase in bystander CPR attempts.     

Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A review of the Japanese literature

Aim

Although favourable outcomes in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest have been frequently reported in Japanese journals since the late 1980s, there has been no meta-analysis of ECPR in Japan. This study reviewed and analysed all previous studies in Japan to clarify the survival rate of patients receiving ECPR.

Material and methods

Case reports, case series and abstracts of scientific meetings of ECPR for out-of-hospital cardiac arrest written in Japanese between 1983 and 2008 were collected. The characteristics and outcomes of patients were investigated, and the influence of publication bias of the case-series studies was examined by the funnel-plot method.

Results

There were 1282 out-of-hospital cardiac arrest patients, who received ECPR in 105 reports during the period. The survival rate at discharge given for 516 cases was 26.7 ± 1.4%. The funnel plot presented the relationship between the number of cases of each report and the survival rate at discharge as the reverse-funnel type that centred on the average survival rate. In-depth review of 139 cases found that the rates of good recovery, mild disability, severe disability, vegetative state, death at hospital discharge and non-recorded in all cases were 48.2%, 2.9%, 2.2%, 2.9%, 37.4% and 6.4%, respectively.

Conclusions

Based on the results of previous reports with low publication bias in Japan, ECPR appears to provide a higher survival rate with excellent neurological outcome in patients with out-of-hospital cardiac arrest.     

ICU中心肺复苏结果的五年回顾

目的：了解ICU中心肺复苏病人的复苏成功率,存活率以及基础疾病与复苏成功率之间的关系。方法：对1995年－1999年在我院急救科ICU中经历过心肺复苏（CPR）的病人病史进行回顾性研究。结果：5年中共有153例病人经历过CPR,平均年龄59岁,39例（25．5％）CPR成功,但最终仅有10例（6．5％）存活出院,CPR后存活者与未存活者在年龄和CPR持续时间上有一定差别,在性别和基础疾病上无明显差异,CPR前的基础疾病分别为心脑血管疾病44例（28．8）,感染性疾病26例（17．0％）,胃肠道疾病18例（11．8％）,呼吸系统疾病14例（9．2％）。恶性肿瘤14例（9．2％）等。结论：年龄是影响ICU中心腹复苏成功与否的一项重要因素,心脑血管疾病和感染性疾病是ICU中心跳呼吸停止的主要基础疾病。     

Social attitude and willingness to attend cardiopulmonary resuscitation training and perform resuscitation in the Crimea

BACKGROUND: To promote potentially life-saving bystander cardiopulmonary resuscitation (CPR), the proportion of CPR-trained general public and their attitude toward CPR should be assessed, which is yet to be done in the former Soviet Union countries. As a case study, the survey is aimed to investigate the prevalence of CPR training, CPR knowledge, attitude and willingness to attend training and attempt CPR in the general population of the Crimea.METHODS: A personal interview survey was done from November 2017 to January 2018 with quota sampling reflecting age, gender and territorial distribution of the Crimean population.RESULTS: Out of 384 persons surveyed, 53% were trained in CPR. Of trained, 24% passed training within the last year, 44% attended a single course. Among the non-trained, 51% never thought about the need to attend training. Knowledge of CPR is generally poor. About 52% wish to learn CPR, 79% and 91% are willing to attempt CPR on a stranger or a loved one, respectively. Lack of knowledge is the strongest barrier to attempt CPR. People aged ≥60, those with educational level lower than high school, widowed and retired are mostly untrained and unwilling to learn CPR. Females and unemployed are mostly untrained, but willing to be educated.CONCLUSION: There is a need for increasing CPR training and retraining, and improving awareness and motivation to learn CPR in the Crimean population, targeting the least trained groups. The results could be used as a reference point for future studies in the former USSR countries, utilising the same methodology.     

Cardiopulmonary resuscitation quality and patient survival outcome in cardiac arrest: A systematic review and meta-analysis

AimTo conduct a systematic review and meta-analysis to determine whether cardiopulmonary resuscitation (CPR) quality, as indicated by parameters such as chest compression depth, compression rate and compression fraction, is associated with patient survival from cardiac arrest.MethodsFive databases were searched (MEDLINE, Embase, CINAHL, Scopus and Cochrane) as well as the grey literature (MedNar). To satisfy inclusion criteria, studies had to document human cases of in- or out-of hospital cardiac arrest where CPR quality had been recorded using an automated device and linked to patient survival. Where indicated (I² < 75%), meta-analysis was undertaken to examine the relationship between individual CPR quality parameters and either survival to hospital discharge (STHD) or return of spontaneous circulation (ROSC).ResultsDatabase searching yielded 8,842 unique citations, resulting in the inclusion of 22 relevant articles. Thirteen were included in the meta-analysis. Chest compression depth was significantly associated with STHD (mean difference (MD) between survivors and non-survivors 2.59 mm, 95% CI: 0.71, 4.47); and with ROSC (MD 0.99 mm, 95% CI: 0.04, 1.93). Within the range of approximately 100–120 compressions per minute (cpm), compression rate was significantly associated with STHD; survivors demonstrated a lower mean compression rate than non-survivors (MD −1.17 cpm, 95% CI: −2.21, −0.14). Compression fraction could not be examined by meta-analysis due to high heterogeneity, however a higher fraction appeared to be associated with survival in cases with a shockable initial rhythm.ConclusionsChest compression depth and rate were associated with survival outcomes. More studies with consistent reporting of data are required for other quality parameters.     

iCPR: a new application of high-quality cardiopulmonary resuscitation training

Objectives

The present study evaluates a new CPR feedback application for the iPhone (iCPR) designed to improve chest compression performance tested in a cardiac arrest simulation to evaluate performance and acceptance by healthcare professionals and lay people.

Methods

We built an application specifically dedicated to self-directed CPR training through a tutorial that includes a simple feedback module to guide training in order to improve the quality of chest compressions. We tested it in a sample of 50 users to evaluate the effect of iCPR on performance and it is acceptance. The participants were randomly assigned to one of the study groups and were asked to perform a trial of 2 min of chest compressions (CC), to answer a predefined set of questions and then to perform two more minutes of CC. The first group performing the sequence of CC with iCPR - questions - CC without feedback, and the second the sequence CC without feedback - questions CC with iCPR.

Results

The mean compression rate was 101 ± 2.8 min⁻¹ when CC were performed with iCPR and 107.8 ± 20.5 min⁻¹ when performed without iCPR (p < 0.01). Overall, the participants considered iCPR useful to maintain CC at the desired rate of 100 compressions per minute.

Conclusions

The iCPR feedback tool was able to significantly improve the performance of chest compressions in terms of the compression rate in a simulated cardiac arrest scenario. The participants also believed that iCPR helped them to achieve the correct chest compression rate and most users found this device easy to use.     

Videographic assessment of cardiopulmonary resuscitation quality in the pediatric emergency department

ObjectiveTo describe the adherence to guidelines for CPR in a tertiary pediatric emergency department (ED) where resuscitations are reviewed by videorecording.MethodsResuscitations in a tertiary pediatric ED are videorecorded as part of a quality improvement project. Patients receiving CPR under videorecorded conditions were eligible for inclusion. CPR parameters were quantified by retrospective review. Data were described by 30-s epoch (compression rate, ventilation rate, compression:ventilation ratio), by segment (duration of single providers’ compressions) and by overall event (compression fraction). Duration of interruptions in compressions was measured; tasks completed during pauses were tabulated.Results33 children received CPR under videorecorded conditions. A total of 650 min of CPR were analyzed. Chest compressions were performed at <100/min in 90/714 (13%) of epochs; 100–120/min in 309/714 (43%); >120/min in 315/714 (44%). Ventilations were 6–12 breaths/min in 201/708 (23%) of epochs and >12/min in 489/708 (70%). During CPR without an artificial airway, compression:ventilation coordination (15:2) was done in 93/234 (40%) of epochs. 178 pauses in CPR occurred; 120 (67%) were <10 s in duration. Of 370 segments of compressions by individual providers, 282/370 (76%) were <2 min in duration. Median compression fraction was 91% (range 88–100%).ConclusionsCPR in a tertiary pediatric ED frequently met recommended parameters for compression rate, pause duration, and compression fraction. Hyperventilation and failure of C:V coordination were very common. Future studies should focus on the impact of training methods on CPR performance as documented by videorecording.     

3796例院内心肺复苏患者的回顾性分析

目的 了解10年来院内心肺复苏（cardiopulmonary resuscitation,CPR）现状,探索如何提高CPR特别是脑复苏水平。方法 对本院1995至2004年记录完整的3796例患者资料进行院内CPR回顾性研究。对病例数量,疾病种类,CPR有关时程、实施地点、肾上腺素用量,心肺复苏成功率及脑复苏成功率等数据进行统计与分析。结果 CPR病例数量逐年上升,21～50岁年龄段构成比增长显著,而10岁以下病例逐年减少;1999年起,创伤后CPR病例数量超过心血管病而跃居首位;心脏停搏时间大于10min者CPR成功率明显低于10min内开始CPR者（P〈0．001）;全部病例CPR成功率为30．4％,24小时生存率3．6％,脑复苏成功率仅1．4％;CPR成功率与心脏停搏时间、肾上腺素用量、初期复苏地点等有关,ICU及手术室内CPR和脑复苏成功率相对较好,普通病房最低。结论 院内CPR成功率较低,脑复苏成功率则极低。主要原因是早期生命支持“生存链”未得到切实应用。普及、加强院前和院内复苏标准化训练,完善急诊医学体系建设和管理,是提高CPR成功率的根本途径。     

Emerging pharmaceutical therapies in cardiopulmonary resuscitation and post-resuscitation syndrome

Objective

The medication used in cardiopulmonary resuscitation (CPR) has by no means yielded the expected prognostic benefit. This review focuses on drugs that are currently under investigation as part of novel therapeutic strategies in CPR and post-resuscitation care.

Data sources

The main categories of drugs under investigation were identified in position papers regarding gaps in scientific knowledge and research priorities in CPR. The electronic bases of Medline via PubMed and the ClinicalTrials.gov registry were searched. Research terms were identified using the MESH database and were combined thereafter. Initial search terms were “cardiac arrest”, “cardiopulmonary resuscitation”, “post-cardiac arrest syndrome” combined with “drugs” and also the names of pharmaceutical categories and related drugs.

Results

Novel pharmaceutical approaches rely on a better understanding of the pathophysiology of cardiac arrest and post-resuscitation syndrome. Some medications are targeted primarily towards enhancing the return of spontaneous circulation and increasing survival rates, while others mostly aim at the attenuation of post-arrest myocardial and neurological impairment. Only a few of these therapies are currently being evaluated for clinical use. Despite the remarkable variability in study quality and success in achieving therapeutic targets, results for most therapies seem encouraging and support the continuation of research.

Conclusion

New pharmaceutical modalities are being investigated for future use in CPR. Currently, none has been unequivocally accepted for clinical use, while only a few of them are undergoing clinical testing. This research is likely to continue, in view of the unsatisfactory results of current pharmaceutical therapies and the encouraging results of preliminary studies.     

Bacteremia following cardiac arrest and cardiopulmonary resuscitation

After but of hospital CPR thirty three resuscitated patients were studied for bacteremic complications. Thirteen patients (39%) had two or more positive blood cultures during the twelve hours following CPR. Source of superinfection was a central venous catheter in one case (staphylococcus). The twelve other bacteremic patients had fetid diarrhea a few hours after admission. The same organism were found in blood and faeces (streptococcus D, Escherichia coli, Pseudomonas aeruginosa, acinetobacter, enterobacter). Mesenteric ischemia caused by a low cardiac output may explain the diarrhea and the intestinal origin of the septicemia. All patients (12 cases) with diarrhoea and bacteremia died. Patients who recovered without neurologic sequelae (4 cases) had never been septic and never had diarrhea.     

溺水儿童非传统顺序心肺复苏成功的原因探讨

目的　探讨溺水儿童院前非传统顺序心肺复苏 (CPR)的可行性。方法　 4 3例因溺水而心搏骤停即行院前CPR的患儿 ,CPR顺序按ABC (开放气道人工呼吸胸外按压 )和CAB (胸外按压开放气道人工呼吸 )分为传统顺序组 (2 1例 )和非传统顺序组 (2 2例 ) ,分析比较两组复苏效果。结果　两组基本情况及初步复苏成功率、复苏无效率、神经系统病残率无明显差异 ,入院初HR、RR、MBP和血气分析基本相似 ;非传统顺序组复苏成功存活及入院初PaCO2 均明显高于传统顺序组 (P <0 0 0 1) ,复苏成功未存活明显少于传统顺序组 (P <0 0 5 )。结论　限于条件 ,儿童溺水院前急救CPR初期 ,先行胸外按压、开放气道 ,人工通气相对延后 ,其方法简单有效 ,值得探索。     

The impact of a step stool on cardiopulmonary resuscitation: a cross-over mannequin study

Objective

Shallow chest compressions and incomplete recoil are common during cardiopulmonary resuscitation (CPR) and negatively affect outcomes. A step stool has the potential to alter these parameters when performing CPR in a bed but the impact has not been quantified.

Methods

We conducted a cross-over design, simulated study of in-hospital cardiac arrest. Rescuers performed a total of four 2-min segments of uninterrupted chest compressions, half of which were on a step stool. Compression characteristics were measured using a CPR-sensing defibrillator and subjective impressions were obtained from rescuer surveys. Paired analyses were performed to measure the impact of the step stool, taking into account rescuer characteristics, including height.

Results

Fifty subjects, of whom 36% were men, with a median height of 169.8 cm (range 148.6–190.5) volunteered to participate. Use of a step stool resulted in an average increase in compression depth of 4 mm (p < 0.001) and 18% increase in incomplete recoil (p < 0.001). However, unlike with incomplete recoil, the effect was more pronounced in rescuers in the lowest height tertile (9 ± 9 mm vs 2 ± 6 mm for those rescuers taller than 167 cm, p = 0.006).

Conclusions

Using a step stool when performing CPR in a bed results in a trade-off between increased compression depth and increased incomplete recoil. Given the nonlinear relationship between the increase in compression depth and rescuer height, the benefit of a step stool may outweigh the risks of incomplete release for rescuers ≤167 cm in height. The benefit is less clear in taller rescuers.     

Rescuer fatigue during actual in-hospital cardiopulmonary resuscitation with audiovisual feedback: A prospective multicenter study

Background

Rescuer fatigue during cardiopulmonary resuscitation (CPR) is a likely contributor to variable CPR quality during clinical resuscitation efforts, yet investigations into fatigue and CPR quality degradation have only been performed in simulated environments, with widely conflicting results.

Objective

We sought to characterize CPR quality decay during actual in-hospital cardiac arrest, with regard to both chest compression (CC) rate and depth during the delivery of CCs by individual rescuers over time.

Methods

Using CPR recording technology to objectively quantify CCs and provide audiovisual feedback, we prospectively collected CPR performance data from arrest events in two hospitals. We identified continuous CPR “blocks” from individual rescuers, assessing CC rate and depth over time.

Results

135 blocks of continuous CPR were identified from 42 cardiac arrests at the two institutions. Median duration of continuous CPR blocks was 112 s (IQR 101–122). CC rate did not change significantly over single rescuer performance, with an initial mean rate of 105 ± 11/min, and a mean rate after 3 min of 106 ± 9/min (p = NS). However, CC depth decayed significantly between 90 s and 2 min, falling from a mean of 48.3 ± 9.6 mm to 46.0 ± 9.0 mm (p = 0.0006) and to 43.7 ± 7.4 mm by 3 min (p = 0.002).

Conclusions

During actual in-hospital CPR with audiovisual feedback, CC depth decay became evident after 90 s of CPR, but CC rate did not change. These data provide clinical evidence for rescuer fatigue during actual resuscitations and support current guideline recommendations to rotate rescuers during CC delivery.     

Effect of cardiopulmonary resuscitation on restoration of myocardial ATP in prolonged ventricular fibrillation

Background

There has been controversy over whether a short period of cardiopulmonary resuscitation (CPR) prior to defibrillation improves survival in patients who experienced a sudden cardiac arrest. However, there have been no reports about whether CPR restores the myocardial energy source during prolonged ventricular fibrillation (VF). The aim of this study is to investigate the effect of CPR in restoring myocardial high energy phosphates during prolonged VF.

Methods and results

Seventy-two adult male Sprague-Dawley rats were used in this study. Baseline adenosine triphosphate (ATP) and adenosine diphosphate (ADP) prior to induction of VF were measured in nine rats, the No-VF group. Sixty-three rats were subjected to 4 min of untreated VF. Animals were then randomized into two groups: No-CPR (n = 37) and CPR (n = 26). In the No-CPR group, ATPs and ADPs were measured at 4 min (No-CPR4), 6 min (No-CPR6), 8 min (No-CPR8) or 10 min (No-CPR10) after the induction of VF. The CPR group received 2 min (CPR2), 4 min (CPR4) or 6 min (CPR6) of mechanical chest compressions before ATP was measured.Myocardial ATP (nmol/mg protein) was decreased as VF duration was prolonged (No-VF: 5.49 ± 1.71, No-CPR4: 4.27 ± 1.58, No-CPR6: 4.13 ± 1.31, No-CPR8: 3.77 ± 1.42, No-CPR10: 3.52 ± 0.90, p < 0.05 between each of No-CPRs vs. No-VF). Two minutes of CPR restored myocardial ATP to the level of No-VF group (5.27 ± 1.67 nmol/mg protein in CPR2, p > 0.05 vs. No-VF group). However, myocardial ATP (nmol/mg protein) decreased if the duration of CPR was longer than 2 min (CPR4: 3.77 ± 1.05, CPR6: 3.49 ± 1.08, p < 0.05 between CPR4 and CPR6 vs. No-VF).

Conclusions

CPR for 2 min helps to maintain myocardial ATP after prolonged VF.     

急诊心肺复苏140例临床分析

目的分析因心跳骤停（CA）来院急救的140例患者行心肺复苏后的结果及影响心肺复苏的相关因素,为有效的心肺复苏提供临床参考资料。方法选择2009年1月至2010年1月四川省人民医院城东病区急救的140例心跳骤停患者,分析患者复苏的方式、急救时间及复苏的结果等,为临床心肺复苏提供有价值的参考材料。结果复苏失败122例,成功18例,其中3例痊愈出院。复苏的方式、时间等对心肺复苏结果有重要影响。结论心跳骤停是急诊医学中的常见情况,急诊工作者要在尽可能短的时间内进行正确的心肺复苏才能提高患者的存活率。     

A survey of ventilation strategies during cardiopulmonary resuscitation

BACKGROUND: Many controversies still exist regarding ventilator parameters during cardiopulmonary resuscitation (CPR). This study aimed to investigate the CPR ventilation strategies currently being used among physicians in Chinese tertiary hospitals.METHODS: A survey was conducted among the cardiac arrest team physicians of 500 tertiary hospitals in China in August, 2018. Surveyed data included physician and hospital information, and preferred ventilation strategy during CPR.RESULTS: A total of 438 (88%) hospitals completed the survey, including hospitals from all 31 Chinese mainland provinces. About 41.1% of respondents chose delayed or no ventilation during CPR, with delayed ventilations all starting within 12 minutes. Of all the respondents who provided ventilation, 83.0% chose to strictly follow the 30:2 strategy, while 17.0% chose ventilations concurrently with uninterrupted compressions. Only 38.3% respondents chose to intubate after initiating CPR, while 61.7% chose to intubate immediately when resuscitation began. During bag-valve-mask ventilation, only 51.4% of respondents delivered a frequency of 10 breaths per minute. In terms of ventilator settings, the majority of respondents chose volume control (VC) mode (75.2%), tidal volume of 6-7 mL/kg (72.1%), PEEP of 0-5 cmH₂O (69.9%), and an FiO₂ of 100% (66.9%). However, 62.0% of respondents had mistriggers after setting the ventilator, and 51.8% had high pressure alarms.CONCLUSION: There is a great amount of variability in CPR ventilation strategies among cardiac arrest team physicians in Chinese tertiary hospitals. Guidelines are needed with specific recommendations on ventilation during CPR.     

241例心跳骤停与心肺脑复苏的回顾性分析

目的 探讨心跳骤停患者的临床特点及救治经验,以提高心肺脑复苏成功率。方法 回顾性分析我科1990年10月至2002年10月十二年间院内及院外急救的241例心跳骤停患者的临床资料,初步分析治疗与预后的关系。结果 241例心跳骤停患者中,初步复苏成功10例,最终复苏成功(心肺脑均复苏)仅4例,复苏率分别为4．62％、1．82％。1990至1998年间复苏成功率较低,初步复苏成功率1．38％,最终复苏成功率0。1999至2002年间复苏成功率明显提高,初步复苏成功率8．24％,最终复苏成功率4．12％。自1998年我科开展院外急救以来,尚无一例院外心跳骤停者复苏成功。结论 心跳骤停患者抢救成功与否与抢救人员专业水平、抢救开始时间、抢救措施正确与否、对室颤患者能否早期除颤及患者原发病是否可逆等因素密切相关。