The role of bicarbonate and fluid loading in improving resuscitation from prolonged cardiac arrest with rapid manual chest compression CPR

Rapid manual chest compression (120 compressions/min) CPR has been shown to improve hemodynamics and survival when compared with standard CPR (60 compressions/min) in a canine model of prolonged cardiac arrest. The study showing improved survival with rapid manual CPR empirically included treatment with bicarbonate and initial fluid loading. To determine the role of bicarbonate and fluid loading in the success of rapid manual chest compression CPR, 31 mongrel dogs were studied. After instrumentation with micromanometer-tipped catheters to measure aortic and right atrial pressures, the animals were assigned sequentially to three treatment groups. Group A underwent rapid manual chest compressions at 120 compressions/min, bicarbonate treatment, and initial fluid loading. Group B underwent rapid manual compressions at 120 compressions/min without bicarbonate or fluid loading. Group C underwent standard CPR at 80 compressions/min with bicarbonate and fluid loading. After 30 minutes of ventricular fibrillation, defibrillation was attempted. Seven of 11 dogs in group A survived 24 hours. None of the animals in group B resuscitated or survived. Three of the ten dogs in group C survived 24 hours. Survival with rapid manual CPR without bicarbonate and initial fluid loading was significantly less than when these interventions were used (P less than .01). To examine the separate contribution of bicarbonate and fluid therapy, two additional groups of animals were studied. Fourteen animals (group D) received rapid manual CPR with bicarbonate therapy, and 12 (group E) received rapid manual CPR with fluid loading only.(ABSTRACT TRUNCATED AT 250 WORDS)     

Thumper型CPR机对心脏复苏的疗效分析

目的探讨Thumper型CPR机对心脏停搏患者心肺复苏(CPR)的临床效果。方法将我院急诊科重症监护病房中发生心脏停搏的患者107例随机分为两组,对照组52例采用徒手胸外心脏按压,两人交替,CPR机组55例采用Thumper型CPR机进行胸外心脏按压,两组均按照《2005年国际CPR和心血管急救指南》进行急救,比较两组患者心脏复苏成功率,复苏成功时间,有创动脉血压,动脉血氧饱和度,动脉血氧分压,肋骨骨折发生率。结果 CPR机组心脏复苏成功率,有创动脉血压,血氧饱和度,动脉血氧分压明显优于对照组,差异具有统计学意义(P<0.05);CPR成功时间,肋骨骨折发生率明显低于对照组,两组差异具有统计学意义(P<0.05)。结论心脏停搏患者早期采用Thumper型CPR机进行心脏复苏,能显著提高CPR成功率,降低并发症的发生。     

Survival and neurologic outcome after cardiopulmonary resuscitation with four different chest compression-ventilation ratios

STUDY OBJECTIVE: The optimal ratio of chest compressions to ventilations during cardiopulmonary resuscitation (CPR) is unknown. We determine 24-hour survival and neurologic outcome, comparing 4 different chest compression-ventilation CPR ratios in a porcine model of prolonged cardiac arrest and bystander CPR. METHODS: Forty swine were instrumented and subjected to 3 minutes of ventricular fibrillation followed by 12 minutes of CPR by using 1 of 4 models of chest compression-ventilation ratios as follows: (1) standard CPR with a ratio of 15:2; (2) CC-CPR, chest compressions only with no ventilations for 12 minutes; (3) 50:5-CPR, CPR with a ratio of 50:5 compressions to ventilations, as advocated by authorities in Great Britain; and (4) 100:2-CPR, 4 minutes of chest compressions only followed by CPR with a ratio of 100:2 compressions to ventilations. CPR was followed by standard advanced cardiac life support, 1 hour of critical care, and 24 hours of observation, followed by a neurologic evaluation. RESULTS: There were no statistically significant differences in 24-hour survival among the 4 groups (standard CPR, 7/10; CC-CPR, 7/10; 50:5-CPR, 8/10; 100:2-CPR, 9/10). There were significant differences in 24-hour neurologic function, as evaluated by using the swine cerebral performance category scale. The animals receiving 100:2-CPR had significantly better neurologic function at 24 hours than the standard CPR group with a 15:2 ratio (1.5 versus 2.5; P =.007). The 100:2-CPR group also had better neurologic function than the CC-CPR group, which received chest compressions with no ventilations (1.5 versus 2.3; P =.027). Coronary perfusion pressures, aortic pressures, and myocardial and kidney blood flows were not significantly different among the groups. Coronary perfusion pressure as an integrated area under the curve was significantly better in the CC-CPR group than in the standard CPR group (P =.04). Minute ventilation and PaO (2) were significantly lower in the CC-CPR group. CONCLUSION: In this experimental model of bystander CPR, the group receiving compressions only for 4 minutes followed by a compression-ventilation ratio of 100:2 achieved better neurologic outcome than the group receiving standard CPR and CC-CPR. Consideration of alternative chest compression-ventilation ratios might be appropriate.     

Update in cardiopulmonary resuscitation

Despite the passage of 50 years since the introduction of closed chest compression and mouth-to-mouth rescue breathing as the techniques of modern cardiopulmonary resuscitation (CPR), the simple techniques remain the backbone of successful resuscitation of victims of cardiac arrest. In particular, the importance of high quality chest compressions is increasingly clear. Current evidence demonstrates chest compressions should be provided at a rate of 100 compressions a minute to a depth of 4 to 5 cm (1.5 to 2 inches) with full chest recoil between compressions. Additionally, all efforts should be made to minimize interruptions in chest compressions, including single shock defibrillation and elimination of pulse check postdefibrillation in favor of continued chest compressions immediately postshock. The emphasis on high quality chest compressions is echoed in the most recent CPR guidelines of the American Heart Association and the International Liaison Committee on Resuscitation. The role of rescue breathing is currently debated; however, it is likely important in prolonged arrests or those of non-cardiac etiology. Current recommendations encourage inclusion of rescue breaths by trained responders, but allow for elimination of rescue breathing and emphasis on chest compressions for responders untrained or unconfident in rescue breathing. Early defibrillation is a key component to successful resuscitation of ventricular tachycardia and ventricular fibrillation arrest; however, implementation of defibrillation should be coordinated with CPR to minimize interruptions in chest compressions. Aside from early defibrillation, there are no clear adjuncts to CPR that improve survival. However, postresuscitation therapies such as therapeutic hypothermia may become an important part of early resuscitation management as tools to provide hypothermia become increasingly portable and capable of rapid cooling.     

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.     

CPR training in the community

To provide a profile of potential rescuers of cardiac arrest victims, 1,271 randomly selected subjects were interviewed by telephone. Thirty-nine percent had formal instruction in cardiopulmonary resuscitation (CPR), 90% knew the emergency telephone number (911), and 5% had performed CPR. Subjects with training were significantly younger than those without (36 vs 48 years old) (P less than .001), and they had a lower incidence of known heart disease in family members (7% vs 15%) (P less than .001). More men than women were trained in CPR (44% vs 37%) (P less than .015). We recommend that efforts be undertaken to reach target groups of middle-age and older women for CPR training, and that physicians assume an active role in encouraging families of cardiac patients to learn this procedure.     

Determinants of elevated creatine kinase activity and creatine kinase MB-fraction following cardiopulmonary resuscitation.

OBJECTIVE: We undertook this study to determine the occurrence and the determinants of elevation of serum creatine kinase (CK) levels and CK MB-fraction following cardiopulmonary resuscitation (CPR). DESIGN: Four hundred twenty consecutive adult admissions to the Long Island Jewish Medical Center from January 1989 through December 1990 with a diagnosis of cardiac arrest were reviewed. SETTING: The Long Island Jewish Medical Center, New Hyde Park, NY, the Long Island Campus for the Albert Einstein College of Medicine, Bronx, NY. PATIENTS: Sixty-three patients survived for at least 12 h following cardiac arrest for evaluation of post-CPR CK levels and were included into the study. MEASUREMENTS: Clinical features, biochemical profiles, and administered drug profiles were studied in these patients. The clinical and biochemical features of the patients with (CK greater than 224 IU/L [3.7 mu kat/L]) and without rhabdomyolysis were also compared. MAIN RESULTS: Two major determinants responsible for elevated CK levels emerged, including physical injury (number of chest compressions during CPR) and electrical injury (cumulative number of joules administered during defibrillation). Post-CPR CK levels showed positive correlations with both the number of chest compressions given (p less than 0.001) and the number of joules administered during defibrillation (p less than 0.001). Post-CPR CK-MB levels also showed a positive correlation with the number of joules administered (p less than 0.005) and the number of chest compressions (p less than 0.02). Forty-three (68.3 percent) of the 63 patients developed rhabdomyolysis. Serum CK levels were higher (p less than 0.005) in the patients who received electrical countershock therapy as well as chest compressions when compared with patients who received chest compressions alone. There were no significant differences in electrolyte levels between patients with and without rhabdomyolysis. Thirty patients had a history of coronary artery disease (CAD) and 18 (60.0 percent) of these had a positive MB-fraction post-CPR while only ten of the 33 patients without known CAD had a positive MB-fraction post-CPR (30.3 percent, p less than 0.05). Patients with no known CAD but positive CK-MB fraction had significantly higher total CK levels, physical injury, and electrical injury compared with patients with negative CK-MB fraction. Twenty patients survived CPR and were discharged from the hospital without significant neurologic sequelae. The remaining 43 either died or suffered severe neurologic injury. The patients who survived CPR had a significantly shorter duration of CPR (p less than 0.01) compared with those who did not. Patients who did not have long-term survival following CPR were more likely to have elevated serum potassium, phosphate, and creatinine values. CONCLUSIONS: CK elevation is a common finding following successful CPR after cardiac arrest and this elevation of post-CPR CK levels is related to both physical as well as electrical injury sustained during CPR. Elevation of post-CPR CK-MB fraction seems to be only a crude indicator of preexisting CAD; however, a positive CK-MB fraction in patients without CAD is related to severity of physical injury and electrical injury during CPR. Patients who survive CPR without neurologic impairment appear to be those with a shorter duration of CPR. Elevated serum potassium, phosphate, and creatinine values may be related to an adverse effect on long-term survival.     

Out‐of‐hospital cardiac arrest: 10 years of progress in research and treatment

Cardiac disease is the most common cause of mortality in Western countries, with most deaths due to out‐of‐hospital cardiac arrest (OHCA). In Sweden, 5000–10 000 OHCAs occur annually. During the last decade, the time from cardiac arrest to start of cardiopulmonary resuscitation (CPR) and defibrillation has increased, whereas survival has remained unchanged or even increased. Resuscitation of OHCA patients is based on the ‘chain‐of‐survival’ concept, including early (i) access, (ii) CPR, (iii) defibrillation, (iv) advanced cardiac life support and (v) post‐resuscitation care. Regarding early access, agonal breathing, telephone‐guided CPR and the use of ‘track and trigger systems’ to detect deterioration in patients' condition prior to an arrest are all important. The use of compression‐only CPR by bystanders as an alternative to standard CPR in OHCA has been debated. Based on recent findings, guidelines recommend telephone‐guided chest compression‐only CPR for untrained rescuers, but trained personnel are still advised to give standard CPR with both compressions and ventilation, and the method of choice for this large group remains unclear and demands for a randomized study. Data have shown the benefit of public access defibrillation for dispatched rescuers (e.g. police and fire fighters) but data are not as strong for the use of automated defibrillators (AEDs) by trained or untrained rescuers. Postresuscitation, use of therapeutic hypothermia, the importance of specific prognostic survival factors in the intensive care unit and the widespread use of percutaneous coronary intervention have all been considered. Despite progress in research and improved treatment regimens, most patients do not survive OHCA. Particular areas of interest for improving survival include (i) identification of high‐risk patients prior to their arrest (e.g. early warning symptoms and genes); (ii) increased use of bystander CPR training (e.g. in schools) and simplified CPR techniques; (iii) better identification of high‐incidence sites and better recruitment of AEDs (via mobile phone solutions?); (iv) improved understanding of the use of therapeutic hypothermia; (v) determining which patients should undergo immediate coronary angiography on hospital admission; and (vi) clarifying the importance of extracorporeal membrane oxygenation during CPR.     

Quality of cardiopulmonary resuscitation among highly trained staff in an emergency department setting

BACKGROUND: Recent reports have highlighted the poor standard of cardiopulmonary resuscitation (CPR) achieved by health care professionals in diverse situations. We explored what can be achieved in an emergency department by highly trained permanent staff. METHODS: In a prospective observational study conducted from June 1, 2002, to August 31, 2005, 80 of 213 patients requiring CPR and admitted to the emergency department of a tertiary care hospital were eligible for study participation. Owing to several logistic problems with CPR, 133 patients could not be studied. The CPR team consisted of emergency- and critical care-trained physicians with more than 10 years of acute care experience, most of whom were instructors of European Resuscitation Council courses in basic and advanced life support. A specially designed defibrillator was used to assess the quality of CPR. RESULTS: For 80 patients, 95 data sets were available for analysis, yielding a total of 1065 minutes of cardiac arrest time. Chest compressions were performed at a rate of 114 (95% confidence interval [CI], 112-116) per minute, resulting in a mean of 96 (95% CI, 93-99) delivered chest compressions per minute. We further observed a mean hands-off ratio of 12.7% (95% CI, 12.3%-13.1%), and the hands-off ratio was linearly associated with the duration of CPR (R(2) = 0.95; mean, 4.3% increments per 5-10 minutes; P<.001). Patients were hyperventilated with a median of 18 (interquartile range, 14-24) ventilations per minute. CONCLUSIONS: Highly trained professionals in an emergency department can achieve appropriate chest compression rates during CPR with a low hands-off ratio. Increased attention must be paid in all situations to the avoidance of hyperventilation.     

An insidious and deadly complication of mechanical chest compressions in a patient on anticoagulation and the subtle echocardiographic findings that enabled timely diagnosis

Good‐quality chest compressions improve outcomes in cardiac arrest. While manual chest compressions are suboptimal in this regard, the LUCAS device has been shown to improve the effectiveness of chest compressions during cardiopulmonary resuscitation (CPR). The complication rate associated with mechanical CPR, however, has not been adequately studied. Limited evidence suggests no difference in internal injury between manual and mechanical CPR. We report the case of a patient on anticoagulation who developed a mediastinal hematoma post mechanical CPR and on whom subtle findings on initial echocardiography could have alerted the clinician to this complication early during the clinical course. This case further suggests that there may be special populations of patients in whom we may need to be more vigilant in the use of mechanical 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.     

Simple CPR: A randomized, controlled trial of video self-instructional cardiopulmonary resuscitation training in an African American church congregation

STUDY OBJECTIVE: Despite the proven efficacy of cardiopulmonary resuscitation (CPR), only a small fraction of the population knows how to perform it. As a result, rates of bystander CPR and rates of survival from cardiac arrest are low. Bystander CPR is particularly uncommon in the African American community. Successful development of a simplified approach to CPR training could boost rates of bystander CPR and save lives. We conducted the following randomized, controlled study to determine whether video self-instruction (VSI) in CPR results in comparable or better performance than traditional CPR training. METHODS: This randomized, controlled trial was conducted among congregational volunteers in an African American church in Atlanta, GA. Subjects were randomly assigned to receive either 34 minutes of VSI or the 4-hour American Heart Association "Heartsaver" CPR course. Two months after training, blinded observers used explicit criteria to assess CPR performance in a simulated cardiac arrest setting. A recording manikin was used to measure ventilation and chest compression characteristics. Participants also completed a written test of CPR-related knowledge and attitudes. RESULTS: VSI trainees displayed a comparable level of performance to that achieved by traditional trainees. Observers scored 40% of VSI trainees competent or better in performing CPR, compared with only 16% of traditional trainees (absolute difference 24%, 95% confidence interval 8% to 40%). Data from the recording manikin confirmed these observations. VSI trainees and traditional trainees achieved comparable scores on tests of CPR-related knowledge and attitudes. CONCLUSION: Thirty-four minutes of VSI can produce CPR of comparable quality to that achieved by traditional training methods. VSI provides a simple, quick, consistent, and inexpensive alternative to traditional CPR instruction, and may be used to extend CPR training to historically underserved populations.     

Out-of-hospital cardiac arrest: recent advances in resuscitation and effects on outcome

Successful treatment of out-of-hospital cardiac arrest remains an unmet health need. Key elements of treatment comprise early recognition of cardiac arrest, prompt and effective cardiopulmonary resuscitation (CPR), effective defibrillation strategies and organised post-resuscitation care. The initiation of bystander CPR followed by a prompt emergency response that delivers high quality CPR is critical to outcomes. The integration of additional tasks such as defibrillation, airway management, vascular access and drug administration should avoid interruptions in chest compressions. Evidence for the routine use of CPR prompt/feedback devices, mechanical chest compression devices and pharmacological therapy is limited.     

Bilateral internal mammary artery laceration after cardiac pulmonary resuscitation

Cardiopulmonary resuscitation (CPR) is essential for the survival of cardiac arrest patients. High‐quality chest compressions are critical for survival, but energetic resuscitation efforts can lead to chest injuries. Internal mammary artery (IMA) injury is a rare complication of CPR, but can lead to life‐threatening intrathoracic hemorrhage. Early detection of IMA injury should be considered in all post cardiac arrest syndrome (PCAS) with anemia refractory to transfusion. To the best of our knowledge, no cases of CPR‐associated bilateral IMA laceration have ever been reported. We report a unique CPR complication resulting in anterior mediastinal hemorrhage that was detected by ECHO, verified by computed tomography angiography, and treated with endovascular intervention.     

Cardiopulmonary resuscitation with a novel chest compression device in a porcine model of cardiac arrest: improved hemodynamics and mechanisms

OBJECTIVES: The goal of this study was to determine the magnitude and mechanisms of hemodynamic improvement of an automated, load-distributing band device (AutoPulse, Revivant Corp., Sunnyvale, California) compared with conventional cardiopulmonary resuscitation (C-CPR). BACKGROUND: Improved blood flow during cardiopulmonary resuscitation (CPR) enhances survival from cardiac arrest. METHODS: AutoPulse CPR (A-CPR) and C-CPR were performed on 30 pigs (16 +/- 4 kg) 1 min after induction of ventricular fibrillation. Aortic and right atrial pressures were measured with micromanometers. Regional flows were measured with microspheres; A-CPR and C-CPR were performed with 20% anterior-posterior chest compression, with (n = 10) and without (n = 10) epinephrine. A pressure transducer was advanced down the airways during chest compressions (n = 10), and magnetic resonance imaging (MRI) was performed. RESULTS: AutoPulse CPR improved coronary perfusion pressure (CPP) (aortic - right atrial pressure) without epinephrine (A-CPR 21 +/- 8 mm Hg vs. C-CPR 14 +/- 6 mm Hg, mean +/- SD, p < 0.0001) and with epinephrine (A-CPR 45 +/- 11 mm Hg vs. C-CPR 17 +/- 6 mm Hg, p < 0.0001). AutoPulse CPR improved myocardial flow without epinephrine and cerebral and myocardial flow with epinephrine (p < 0.05). AutoPulse CPR also produced greater myocardial flow at every CPP (p < 0.01). With A-CPR, high airway pressure was noted distal to the carina, which corresponded to an area of airway collapse on MRI, and which was not present with C-CPR. CONCLUSIONS: AutoPulse CPR improved hemodynamics over C-CPR in this pig model. AutoPulse CPR with epinephrine can produce pre-arrest levels of myocardial and cerebral flow. The improved hemodynamics with A-CPR appear to be mediated through airway collapse, which likely impedes airflow and helps maintain higher levels of intrathoracic pressure.     

Cardiac arrest and cardiopulmonary resuscitation in “hostile” environments: Using automated compression devices to minimize the rescuers’ danger

Mechanical automated compression devices are being used in cardiopulmonary resuscitation instead of manual, “hands-on”, rescuer-delivered chest compressions. The -theoretical- advantages include high-quality non-stop compressions, thus freeing the rescuer performing the compressions and additionally the ability of the rescuer to stand reasonably away from a potentially “hazardous” victim, or from hazardous and/or difficult resuscitation conditions. Such circumstances involve cardiopulmonary resuscitation (CPR) in the Cardiac Catheterization Laboratory, especially directly under the fluoroscopy panel, where radiation is well known to cause detrimental effects to the rescuer, and CPR during/after land or air transportation of cardiac arrest victims. Lastly, CPR in a coronavirus disease 2019 patient/ward, where the danger of contamination and further serious illness of the health provider is very existent. The scope of this review is to review and present literature and current guidelines regarding the use of mechanical compressions in these “hostile” and dangerous settings, while comparing them to manual compressions.     

Basic life support cardiopulmonary resuscitation

CPR represents the primary intervention used during cardiac arrest for maintaining perfusion and extending the potential resuscitation period. Effective CPR, however, requires careful attention to detail by the resuscitation team, including (1) effective control of the airway using manual maneuvers or airway adjuncts, (2) delivery of effective ventilation that assures adequate oxygenation, while reducing the chance for gastric inflation, and (3) chest compressions delivered at the appropriate depth and rate using a duty cycle of 50% compression and 50% release. During the resuscitation effort team leaders should closely monitor the performance of CPR, rotate rescuers frequently to avoid fatigue, and provide continuous feedback based upon direct (transmitted pulse, chest rise) and indirect (end-tidal CO2) measures of effectiveness. A careful and measured approach to CPR performance, combined with a strong chain of survival, provides victims of cardiac arrest the best chance for survival.     

Lower threshold for adenosine-induced chest pain in patients with angina and normal coronary angiograms.

OBJECTIVE--To investigate whether patients with angina-like chest pain and normal coronary angiograms are more sensitive to adenosine as an inducer of chest pain. DESIGN--Increasing doses of adenosine were given in a single blind study as intravenous bolus injections. Chest pain and the electrocardiographic findings were noted. PATIENTS--Eight patients with angina-like chest pain but no coronary stenoses (group A), nine patients with angina and coronary stenoses (group B), and 16 healthy volunteers (group C). RESULTS--In the absence of ischaemic signs on the electrocardiogram adenosine provoked angina-like pain in all patients in groups A and B. The pain was located in the chest, and its quality and location were described as being no different from the patient's habitual angina. In group C, 14 of 16 subjects reported chest pain. The lowest dose resulting in chest pain was lower in group A (0.9 (0.6) mg) than in group B (3.1 (1.5)mg) (p < 0.005) and in group C (6.2 (3.7) mg) (p < 0.005). The maximum tolerable dose was lower in group A (4.7 (2.1) mg) than in group B (9.2 (3.8) mg) (p < 0.05) and in group C (12.0 (4.1) mg) (p < 0.005). CONCLUSIONS--Patients with angina-like chest pain and normal coronary angiograms have a low pain threshold and low tolerance to pain induced by adenosine.     

Dispatcher-assisted telephone CPR: common delays and time standards for delivery

STUDY OBJECTIVES: To determine the rate of bystander CPR before and after implementation of a telephone CPR program in King County; to determine the reasons for dispatcher delays in identifying patients in cardiac arrest in delivering CPR instructions over the telephone; and to suggest time standards for delivery of the telephone CPR message. DESIGN: An ongoing cardiac arrest surveillance system to calculate the annual bystander CPR rates from 1976 through 1988. Two hundred sixty-seven taped recordings of calls reporting cardiac arrests to nine emergency dispatch centers during 1988 were reviewed and timed. SETTING: King County, Washington, excluding the city of Seattle. PARTICIPANTS: Two hundred sixty-seven persons with out-of-hospital cardiac arrests receiving emergency medical services. Arrests in doctors' offices, clinics, or nursing homes were excluded. INTERVENTIONS: Dispatcher-assisted telephone CPR. MEASUREMENTS AND MAIN RESULTS: The rate of bystander CPR increased from 32% (1976 through 1981) to 54% (1982 through 1988) after implementation of the dispatcher-assisted telephone CPR program, although an increase in survival could not be demonstrated. The median time for dispatchers to identify the problem was 75 seconds; to deliver the early protocols, 19 seconds; to deliver the ventilation instructions, 25 seconds; and to deliver compression instructions, 30 seconds. The total time to deliver the entire CPR message was 2.3 minutes. The most frequent cause for delay was unnecessary questions (57%) with questions about patient age asked most frequently (32%). Other causes included the caller not being near the patient (29%) and deviations from protocol (22%). CONCLUSION: In a metropolitan emergency medical services system, a dispatcher-assisted telephone CPR program was associated with an increase in bystander CPR. Delays in proper delivery of telephone CPR can be minimized through training.     

Neue Leitlinien des European Resuscitation Council zur Reanimation

In 2010 the European Resuscitation Council (ERC) revised the guidelines on cardiopulmonary resuscitation (CPR). Important changes include an emphasis on continuous high-quality chest compressions as well as aspects of defibrillation, pharmacotherapy, airway and ventilation management, and post-CPR strategies. In addition, specific aspects of in-hospital and preclinical CPR are discussed. This article outlines the resulting differences between preclinical and in-hospital patient management considering points such as prevention of circulatory arrest, the organization of CPR, initial management of collapsed patients and execution of CPR itself. In summary, differences particularly regarding a higher potential to prevent in-hospital cardiac arrest are revealed.