Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation

The National Registry of Cardiopulmonary Resuscitation (NRCPR) is an American Heart Association (AHA)-sponsored, prospective, multisite, observational study of in-hospital resuscitation. The NRCPR is currently the largest registry of its kind. The purpose of this article is to describe the NRCPR and to provide the first comprehensive, Utstein-based, standardized characterization of in-hospital resuscitation in the United States. All adult (>/=18 years of age) and pediatric (<18 years of age) patients, visitors, employees, and staff within a facility (including ambulatory care areas) who experience a resuscitation event are eligible for inclusion in the NRCPR database. Between January 1, 2000, and June 30, 2002, 14720 cardiac arrests that met inclusion criteria occurred in adults at the 207 participating hospitals. An organized emergency team is available 24 h a day, 7 days a week in 86% of participating institutions. The three most common reasons for cardiac arrest in adults were (1) cardiac arrhythmia, (2) acute respiratory insufficiency, and (3) hypotension. Overall, 44% of adult in-hospital cardiac arrest victims had a return of spontaneous circulation (ROSC); 17% survived to hospital discharge. Despite the fact that a primary arrhythmia was one of the precipitating events in nearly one half of adult cardiac arrests, ventricular fibrillation (VF) was the initial pulseless rhythm in only 16% of in-hospital cardiac arrest victims. ROSC occurred in 58% of VF cases, yielding a survival-to-hospital discharge rate of 34% in this subset of patients. An automated external defibrillator was used to provide initial defibrillation in only 1.4% of patients whose initial cardiac arrest rhythm was VF. Neurological outcome in discharged survivors was generally good. Eighty-six percent of patients with Cerebral Performance Category-1 (CPC-1) at the time of hospital admission had a postarrest CPC-1 at the time of hospital discharge.     

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.     

Cardiac arrest in the Emergency Department: a report from the National Registry of Cardiopulmonary Resuscitation

BACKGROUND: Little is known about cardiac arrests (CA) in the Emergency Department (ED). The objective of this study was to determine the characteristics of ED CAs. METHODS: 60,852 adult, in-patient CA events in the National Registry of Cardiopulmonary Resuscitation were included. Multiple regression analysis compared ED CA with those occurring in the ICU, telemetry, or general floors. Subgroup analysis examined traumatic vs. non-traumatic ED CA and ED CA occurring after a successful pre-hospital resuscitation (recurrent) vs. primary ED event. RESULTS: In multivariate analysis, ED location predicted improved survival to discharge (OR 0.74, 95%CI [0.67-0.82]). ED CAs had higher survival to discharge rates (ED 22.2, ICU 15.5, Tele 19.8, Floor 10.8, p<0.0001), better cerebral performance category scores (ED 1.59, ICU 1.73, Tele 1.96, Floor 1.69, p<0.0001), and shorter post-event length of stays (ED 8.6, ICU 17.5, Tele 16.5, Floor 14.2 days, p<0.0001) than other locations. Recurrent ED CAs were less likely to survive to discharge (10.1% vs. 24.6%, p<0.0001) than primary events. Trauma-related ED CAs had a lower survival to discharge rate (7.5% vs. 23.8%, p<0.0001), were less likely to be caused by an arrhythmia (23.6% vs. 32.5%, p<0.0008), and more likely to be preceded by hypotension or shock (41.6% vs. 29.0%, p<0.0001) than non-trauma ED events. CONCLUSIONS: ED CAs have unique characteristics, and better survival and neurologic outcomes compared to other hospital locations. Primary ED CAs have a better chance of survival to discharge than recurrent events. Traumatic ED CAs have worse outcomes than non-traumatic CA.     

The effects of changes to the ERC resuscitation guidelines on no flow time and cardiopulmonary resuscitation quality: a randomised controlled study on manikins

AIM OF THE STUDY: The European Resuscitation Council (ERC) guidelines changed in 2005. We investigated the impact of these changes on no flow time and on the quality of cardiopulmonary resuscitation (CPR). MATERIALS AND METHODS: Simulated cardiac arrest (CA) scenarios were managed randomly in manikins using ERC 2000 or 2005 guidelines. Pairs of paramedics/paramedic students treated 34 scenarios with 10min of continuous ventricular fibrillation. The rhythm was analysed and defibrillation shocks were delivered with a semi-automatic defibrillator, and breathing was assisted with a bag-valve-mask; no intravenous medication was given. Time factors related to human intervention and time factors related to device, rhythm analysis, charging and defibrillation were analysed for their contribution to no flow time (time without chest compression). Chest compression quality was also analysed. RESULTS: No flow time (mean+/-S.D.) was 66+/-3% of CA time with ERC 2000 and 32+/-4% with ERC 2005 guidelines (P<0.001). Human factor interventions occupied 114+/-4s (ERC 2000) versus 107+/-4s (ERC 2005) during 600-s scenarios (P=0.237). Device factor interventions took longer using ERC 2000 guidelines: 290+/-19s versus 92+/-15s (P<0.001). The total number of chest compressions was higher with ERC 2005 guidelines (808+/-92s versus 458+/-90s, P<0.001), but the quality of CPR did not differ between the groups. CONCLUSIONS: The use of a single shock sequence with guidelines 2005 has decreased the no flow time during CPR when compared with guidelines 2000 with multiple shocks.     

Out-of-hospital cardiopulmonary resuscitation: a population-based Norwegian study of incidence and survival.

The Trondheim region's (315 km2, population 154,000) emergency medical service (EMS) provides advanced cardiac life support (ACLS) with combined paramedic and physician response. This EMS system is commonly employed in Norway, yet no population based study of outcome in cardiac arrest has been published to date. This retrospective study reports incidence and outcome from every attempted out-of-hospital cardiopulmonary resuscitation (CPR) during 1990 through 1994 according to the Utstein template. Information on the patient's pre-morbid conditions and final outcome was obtained from hospital records. The incidence of cardiac arrest and CPR from all causes was 68 per 100,000 per year, with 83% primary cardiac aetiology. The median alarm to patient arrival interval for ambulance and emergency physician was 8 minutes and 11 minutes, respectively. The presenting rhythm was ventricular fibrillation or tachycardia in 51%, asystole in 34%, pulseless electrical activity in 8% and undetermined in 8%. Definite return of spontaneous circulation occurred in 211 patients (40%, 27 per 100,000 per year) and 57 patients (11%, 7.4 per 100,000 per year) survived to discharge. Most patients made a favourable cerebral outcome, although nine were severely disabled. This is the first population-based Norwegian study of outcome from out-of-hospital cardiac arrest in this combined paramedic/physician staffed EMS. Incidence, survival and neurological outcome are comparable with results obtained in other EMS systems.     

The impact of manual defibrillation technique on no-flow time during simulated cardiopulmonary resuscitation

INTRODUCTION: Rapid defibrillation is the most effective strategy for establishing return of spontaneous circulation following cardiac arrest due to ventricular fibrillation. The aim of this study is to measure the delay due to of charging the defibrillator during chest compression in an attempt to reduce the duration of the pre-shock pause in between cessation of chest compressions and shock delivery as advocated by the American Heart Association (AHA) guidelines compared to charging the defibrillator immediately following rhythm analysis without resuming chest compressions as recommended by the European Resuscitation Council (ERC). METHODS: This was a randomised controlled cross over trial comparing pre-shock pause times when defibrillation was performed on a manikin according to the AHA and ERC guidelines using paddles and hands free defibrillation systems. RESULTS: The pre-shock pause between cessation of chest compression and shock delivery was significantly different between techniques (Friedman test, P<0.0001). ERC paddles technique had the greatest pre-shock pause (7.4 s [6.7-11.2]) followed by ERC hands free (7.0 s [6.5-8.5]) and AHA paddles (1.6 s [1.1-2.3]). AHA hands free took the least amount of time (1.5 s [0.8-1.5]). Extrapolating these data to older defibrillators with longer charge times saw pre-shock pause intervals of 9 s (Codemaster XL) and 12 s (Lifepak 20) with the ERC approach. CONCLUSION: This study demonstrated clinically significant delays to defibrillation by analysing and charging the defibrillator without performing concurrent chest compressions. In a simulated scenario, charging the defibrillator whilst performing chest compressions was perceived as safe and significantly reduced the pre-shock pause between cessation of chest compression and shock delivery.     

Reverse CPR: a pilot study of CPR in the prone position

BACKGROUND: Cardiopulmonary resuscitation (CPR), as described in 1960, remains the cornerstone of therapy for cardiopulmonary arrest. Recent case reports have described CPR in the prone position. We hypothesized rhythmic back pressure on a patient in the prone position with sternal counter-pressure (termed reverse CPR here) would increase intra-thoracic pressure and in turn systolic blood pressure (SBP) during cardiac arrest versus standard CPR. METHODS AND RESULTS: Six patients from Columbia Presbyterian Medical Center's Cardiac and Medical Intensive Care Units (CICU and MICU) were enrolled. Eligible patients had suffered circulatory arrest and failed standard CPR for at least 30 min. After enrollment the patients received 15 additional min of standard CPR and then reverse CPR for 15 min. The study's primary endpoint, mean SBP, significantly improved from 48 mmHg during standard CPR to 72 mmHg during reverse CPR (mean improvement=23+/-14 mmHg). Mean calculated mean arterial pressure (MAP) was also improved significantly from 32 mmHg during standard CPR to 46 mmHg during reverse CPR (mean improvement=14+/-11 mmHg). The mean diastolic blood pressure (DBP) improved from 24 mmHg during standard to 34 mmHg during reverse CPR (mean improvement=10+/-12 mmHg). This difference did not meet statistical significance. No patients had return of spontaneous circulation. CONCLUSIONS: Reverse CPR generates higher mean SBP and higher mean MAP during circulatory arrest than standard CPR. These novel findings justify further research into this technique.     

广州东部地区公众徒手心肺复苏术掌握现状调查及培训分析

目的了解广州东部地区公众对徒手心肺复苏术（CPR）掌握现状,探讨对公众进行CPR培训的方法。方法对广州东部地区738人进行CPR培训,培训前后理论和操作考试。结果广州东部地区公众普遍缺乏心肺复苏知识和技能。培训后操作考试合格率从培训前12．0％提高到100．0％。结论广州东部地区公众普遍缺乏心肺复苏基本知识和技能,规范培训能有效提高公众心肺复苏技能。     

Communication and protocol compliance and their relation to the quality of cardiopulmonary resuscitation (CPR): A mixed-methods study of simulated telephone-assisted CPR

BackgroundIn the event of a cardiac arrest, emergency medical dispatchers (EMDs) play a critical role by providing telephone-assisted cardiopulmonary resuscitation (T-CPR) to laypersons. The aim of our investigation was to describe compliance with the T-CPR protocol, the performance of the laypersons in a simulated T-CPR situation, and the communication between laypersons and EMDs during these actions.MethodsWe conducted a retrospective observational study by analysing 20 recorded video and audio files. In a simulation, EMDs provided laypersons with instructions following T-CPR protocols. These were then analysed using a mixed method with convergent parallel design.ResultsIf the EMDs complied with the T-CPR protocol, the laypersons performed the correct procedures in 71% of the actions. The single most challenging instruction of the T-CPR protocol, for both EMDs and laypersons, was airway control. Mean values for compression depth and frequency did not reach established guideline goals for CPR.ConclusionProper application of T-CPR protocols by EMDs resulted in better performance by laypersons in CPR. The most problematic task for EMDs as well for laypersons was airway management. The study results did not establish that the quality of communication between EMDs and laypersons performing CPR in a cardiac arrest situation led to statistically different outcomes, as measured by the quality and effectiveness of the CPR delivered.     

Views of oncology patients, their relatives and oncologists on cardiopulmonary resuscitation (CPR): questionnaire-based study

BACKGROUND: Doctors are justified withholding a treatment, such as cardiopulmonary resuscitation (CPR), if it is unlikely to benefit a patient. The success rates for CPR in patients with cancer is <1%. Guidelines produced in 2001 recommended that CPR should be discussed with patients, even when it is unlikely to be successful. Therefore, should oncologists always discuss resuscitation, even when it is likely to be futile? METHOD: Sixty oncology in-patients and 32 of their relatives were asked their views on CPR, and their views were compared with the oncologist involved in their care. RESULTS: Some 58% of patients wanted to be resuscitated. There was a moderate-strong correlation between patients and their next of kin and the desire for resuscitation. There was also a positive correlation between the doctor's views on suitability for resuscitation, patient's prognostic score, and World Health Organisation (WHO) performance score. CONCLUSION: Most patients wanted to be resuscitated despite being given the likely poor survival rates from CPR. They also wanted to be involved in the decision-making process, and wanted their next of kin involved, even when, medically, the procedure was unlikely to be successful. The findings that patient and next of kin views correlated well shows that relatives' views are a good representation of patient views. In contrast, consultant's decisions were strongly correlated with the patient's performance status and clinical state. No patients were upset by the study, although nine patients declined to participate.     

The impact of the ILCOR 2005 CPR guidelines on a physical fitness assessment: a comparison of old and new protocols

OBJECTIVE: St. John Ambulance Australia has used the performance of CPR for 10 min as a fitness test for its members. Recent changes in international guidelines for cardiopulmonary resuscitation caused concern that the new ILCOR protocol was more strenuous than the previous one. This study compared the two protocols to determine if there were significant differences and to allow an evidence-based decision on the continuation or modification of this practice. MATERIALS AND METHODS: We studied 26 subjects performing single-rescuer cardiopulmonary resuscitation on a manikin. Every subject did 10 min cardiopulmonary resuscitation using each protocol. The study used a randomized cross-over design. The estimated maximum heart rate was calculated for each subject. Compression rate and effective ventilation (number and depth) were enforced by direct feedback. Subjective and objective measures of physical activity were recorded at regular intervals. RESULTS: The maximum percentage of estimated maximum heart rate achieved during 15:2 and 30:2 CPR was 76+/-2% and 79+/-2%, respectively (mean+/-standard error of mean; P<0.001). The rate pressure product at the end of 10 min cardiopulmonary resuscitation was 18,999+/-891 for 15:2 and 19,204+/-757 for 30:2 (ns) while the Borg rating of perceived exertion was 13.7+/-0.5 for 15:2 and 14.8+/-0.5 for 30:2 (P<0.05). CONCLUSION: The new protocol increases both objective and subjective measures of effort. While the absolute differences in workload are small, they are statistically significant. There are significant indicators of this difference in the first 3 min of assessment. Rescuers are more likely to be operating at a high-level of physical activity. To avoid increasing the demands of its mandatory fitness test, St. John should reduce the required performance time from its present 10 min.     

The continuous quality improvement project for telephone-assisted instruction of cardiopulmonary resuscitation increased the incidence of bystander CPR and improved the outcomes of out-of-hospital cardiac arrests

Review

In 2007, the Ishikawa Medical Control Council initiated the continuous quality improvement (CQI) project for telephone-assisted cardiopulmonary resuscitation (telephone-CPR), which included instruction on chest-compression-only CPR, education on how to recognise out-of-hospital cardiac arrests (OHCAs) with agonal breathing, emesis and convulsion, recommendations for on-line or redialling instructions and feedback from emergency physicians. This study aimed to investigate the effect of this project on the incidence of bystander CPR and the outcomes of OHCAs.

Materials and methods

The baseline data were prospectively collected on 4995 resuscitation-attempted OHCAs, which were recognised or witnessed by citizens rather than emergency medical technicians during the period of February 2004 to March 2010. The incidence of telephone-CPR and bystander CPR, as well as the outcomes of the OHCAs, was compared before and after the project.

Results

The incidence of telephone-CPR and bystander CPR significantly increased after the project (from 42% to 62% and from 41% to 56%, respectively). The incidence of failed telephone-CPR due to human factors significantly decreased from 30% to 16%. The outcomes of OHCAs significantly improved after the projects. A multiple logistic regression analysis revealed that the CQI project is one of the independent factors associated with one-year (1-Y) survival with favourable neurological outcomes (odds ratio = 1.81, 95% confidence interval = 1.20–2.76).

Conclusions

The CQI project for telephone-CPR increased the incidence of bystander CPR and improved the outcome of OHCAs. A CQI project appeared to be essential to augment the effects of telephone-CPR.     

Catheter ablation of atrial fibrillation in the young: insights from the German Ablation Registry

Introduction

Catheter ablation of paroxysmal atrial fibrillation (PAF) has been suggested as first-line treatment for selected patients (pts). However, patient characteristics, procedural data, and complication rate in the group of young patients remain undetermined.

Methods

The German Ablation Registry has been designed as a multi-center prospective registry. AF ablation data were collected from 51 German centers between March 2007 to September 2012 and 2 groups were defined (group A: ≤45 years, group B: >45 years). Data were analyzed according to patient characteristics, procedural data, and complications. To calculate differences between both groups CHI₂ or Mann–Whitney–Wilcoxon tests was utilized.

Results

A total of 7243 patients undergoing AF ablation were included (group A: 593, 8.2 %; group B: 6650, 91.8 %). Male gender and PAF were significantly more often present in group A. Patient characteristic revealed decreased co-morbidities in the young. In both groups circumferential pulmonary vein isolation represented the procedural cornerstone, whereas substrate modification was significantly more often performed in group B. Procedure-, and fluoroscopy-time was similar but there was a shorter hospital stay and a favorable complication profile in the young. After 12 months AF recurrence and use of antiarrhythmic drugs were less common in group A.

Conclusion

The young AF ablation patient has typically paroxysmal AF and less comorbidities. In this group, catheter ablation of AF is associated with a lower major complication rate, shorter hospitalization, and a favorable clinical outcome.