Use of an automated, load-distributing band chest compression device for out-of-hospital cardiac arrest resuscitation

Context  Only 1% to 8% of adults with out-of-hospital cardiac arrest survive to hospital discharge. Objective  To compare resuscitation outcomes before and after an urban emergency medical services (EMS) system switched from manual cardiopulmonary resuscitation (CPR) to load-distributing band (LDB) CPR. Design, Setting, and Patients  A phased, observational cohort evaluation with intention-to-treat analysis of 783 adults with out-of-hospital, nontraumatic cardiac arrest. A total of 499 patients were included in the manual CPR phase (January 1, 2001, to March 31, 2003) and 284 patients in the LDB-CPR phase (December 20, 2003, to March 31, 2005); of these patients, the LDB device was applied in 210 patients. Intervention  Urban EMS system change from manual CPR to LDB-CPR. Main Outcome Measures  Return of spontaneous circulation (ROSC), with secondary outcome measures of survival to hospital admission and hospital discharge, and neurological outcome at discharge. Results  Patients in the manual CPR and LDB-CPR phases were comparable except for a faster response time interval (mean difference, 26 seconds) and more EMS-witnessed arrests (18.7% vs 12.6%) with LDB. Rates for ROSC and survival were increased with LDB-CPR compared with manual CPR (for ROSC, 34.5%; 95% confidence interval [CI], 29.2%-40.3% vs 20.2%; 95% CI, 16.9%-24.0%; adjusted odds ratio [OR], 1.94; 95% CI, 1.38-2.72; for survival to hospital admission, 20.9%; 95% CI, 16.6%-26.1% vs 11.1%; 95% CI, 8.6%-14.2%; adjusted OR, 1.88; 95% CI, 1.23-2.86; and for survival to hospital discharge, 9.7%; 95% CI, 6.7%-13.8% vs 2.9%; 95% CI, 1.7%-4.8%; adjusted OR, 2.27; 95% CI, 1.11-4.77). In secondary analysis of the 210 patients in whom the LDB device was applied, 38 patients (18.1%) survived to hospital admission (95% CI, 13.4%-23.9%) and 12 patients (5.7%) survived to hospital discharge (95% CI, 3.0%-9.3%). Among patients in the manual CPR and LDB-CPR groups who survived to hospital discharge, there was no significant difference between groups in Cerebral Performance Category (P = .36) or Overall Performance Category (P = .40). The number needed to treat for the adjusted outcome survival to discharge was 15 (95% CI, 9-33). Conclusion  Compared with resuscitation using manual CPR, a resuscitation strategy using LDB-CPR on EMS ambulances is associated with improved survival to hospital discharge in adults with out-of-hospital nontraumatic cardiac arrest.      

Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest

Context  Cardiopulmonary resuscitation (CPR) guidelines recommend target values for compressions, ventilations, and CPR-free intervals allowed for rhythm analysis and defibrillation. There is little information on adherence to these guidelines during advanced cardiac life support in the field. Objective  To measure the quality of out-of-hospital CPR performed by ambulance personnel, as measured by adherence to CPR guidelines. Design and Setting  Case series of 176 adult patients with out-of-hospital cardiac arrest treated by paramedics and nurse anesthetists in Stockholm, Sweden, London, England, and Akershus, Norway, between March 2002 and October 2003. The defibrillators recorded chest compressions via a sternal pad fitted with an accelerometer and ventilations by changes in thoracic impedance between the defibrillator pads, in addition to standard event and electrocardiographic recordings. Main Outcome Measure  Adherence to international guidelines for CPR. Results  Chest compressions were not given 48% (95% CI, 45%-51%) of the time without spontaneous circulation; this percentage was 38% (95% CI, 36%-41%) when subtracting the time necessary for electrocardiographic analysis and defibrillation. Combining these data with a mean compression rate of 121/min (95% CI, 118-124/min) when compressions were given resulted in a mean compression rate of 64/min (95% CI, 61-67/min). Mean compression depth was 34 mm (95% CI, 33-35 mm), 28% (95% CI, 24%-32%) of the compressions had a depth of 38 mm to 51 mm (guidelines recommendation), and the compression part of the duty cycle was 42% (95% CI, 41%-42%). A mean of 11 (95% CI, 11-12) ventilations were given per minute. Sixty-one patients (35%) had return of spontaneous circulation, and 5 of 6 patients discharged alive from the hospital had normal neurological outcomes. Conclusions  In this study of CPR during out-of-hospital cardiac arrest, chest compressions were not delivered half of the time, and most compressions were too shallow. Electrocardiographic analysis and defibrillation accounted for only small parts of intervals without chest compressions.      

绑带式胸廓挤压仪在心跳骤停小型猪心肺复苏中的作用

目的 观察新型绑带式胸廓挤压仪在心跳骤停小型猪心肺复苏(CPR)中的效果,并与传统人工按压的CPR结果进行比较.方法 26只小型猪随机分为机械按压组(n=13)和传统人工按压组(n=13),在电击诱发心室颤动(室颤)致心跳骤停4 min后分别实施机械胸外按压和人工胸外按压.比较两组动物CPR后的存活率;测定并比较两组动物诱导室颤前和恢复自主循环(ROSC)后1 min、5 min和1h时间点的血流动力学指标、主动脉血气参数和乳酸浓度;X线摄片观察CPR成功后动物肋骨的损伤情况.结果 两组动物在ROSC时和CPR后1h的存活率比较差异无统计学意义(P＞0.05).人工按压组在ROSC 1 min时的主动脉收缩压(AOS)、主动脉舒张压(AOD)和平均动脉压(MAP)均显著高于机械按压组(P＜0.05),而各时间点的冠状动脉灌注压(CPP)比较差异均无统计学意义(P＞0.05);机械按压组在ROSC 1 min、15 min及1h时间点的血液乳酸浓度均明显低于人工按压组(P＜0.05).X线胸片显示,机械按压组的肋骨损伤发生率与人工按压组比较差异无统计学意义(33.3％和45.5％)(P＞0.05).结论 绑带式胸廓挤压仪在小型猪CPR中的效果与传统人工按压效果相似,可以作为代替CPR中人工按压的一种方法.     

Cardiopulmonary resuscitation and termination of resuscitation on out-of-hospital cardiac arrest in China

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萨勃心肺复苏机在心脏骤停治疗中的效果分析

目的:观察心肺复苏机对心脏骤停患者胸外心脏按压效果及复苏成功率.方法:65例使用萨勃心肺复苏机的患者为观察组,70例采用人工胸外按压心肺复苏的患者为对照组,比较两组患者的平均动脉压、心跳恢复时间、心肺复苏成功率及患者骨折发生率.结果:萨勃心肺复苏机组临床效果优于人工按压组,复苏成功率较人工按压组高,而骨折发生率较人工按压组低,两组比较有统计学意义(P＜0.05).结论:萨勃心肺复苏机心肺复苏效果和成功率要优于传统人工心肺复苏.     

Prehospital termination of resuscitation in cases of refractory out-of-hospital cardiac arrest

Comilla Sasson, MD, MS; A. J. Hegg, MD; Michelle Macy, MD; Allison Park, MPH; Arthur Kellermann, MD, MPH; Bryan McNally, MD, MPH; for the CARES Surveillance Group

JAMA. 2008;300(12):1432-1438.

Context  Identifying patients in the out-of-hospital setting who have no realistic hope of surviving an out-of-hospital cardiac arrest could enhance utilization of scarce health care resources.

Objective  To validate 2 out-of-hospital termination-of-resuscitation rules developed by the Ontario Prehospital Life Support (OPALS) study group,one for use by responders providing basic life support (BLS) and the other for those providing advanced life support (ALS).

Design, Setting, and Patients  Retrospective cohort study using surveillance data prospectively submitted by emergency medical systems and hospitals in 8 US cities to the Cardiac Arrest Registry to Enhance Survival (CARES) between October 1, 2005, and April 30, 2008. Case patients were 7235 adults with out-of-hospital cardiac arrest; of these, 5505 met inclusion criteria.

Main Outcome Measures  Specificity and positive predictive value of each termination-of-resuscitation rule for identifying patients who likely will not survive to hospital discharge.

Results  The overall rate of survival to hospital discharge was 7.1%(n = 392). Of 2592 patients (47.1%) who met BLS criteria for termination of resuscitation efforts, only 5 (0.2%) patients survived to hospital discharge. Of 1192 patients (21.7%) who met ALS criteria,none survived to hospital discharge. The BLS rule had a specificity of 0.987 (95% confidence interval [CI], 0.970-0.996) and a positive predictive value of 0.998 (95% CI, 0.996-0.999) for predicting lack of survival. The ALS rule had a specificity of 1.000 (95% CI, 0.991-1.000)and positive predictive value of 1.000 (95% CI, 0.997-1.000) for predicting lack of survival.

Conclusion  In this validation study, the BLS and ALS termination-of-resuscitation rules performed well in identifying patients with out-of-hospital cardiac arrest who have little or no chance of survival.

     

Improved survival outcome with continuous chest compressions with ventilation compared to 5:1 compressions-to-ventilations mechanical cardiopulmonary resuscitation in out-of-hospital cardiac arrest

BackgroundFewer pauses and better chest compression quality are thought to improve overall survival following cardiac arrest. This study aimed to measure the outcomes of adult nontraumatic out-of-hospital cardiac arrests (OHCAs) treated with 5:1 compressions-to-ventilations (Thumper 1007) or continuous chest compressions with ventilation (Thumper 1008 CCV) mechanical cardiopulmonary resuscitation (CPR) within a specified period of time.MethodsA retrospective observational cohort study of 515 adults with OHCA was conducted at the emergency department of an urban tertiary hospital. There were 307 patients in the Thumper 1007 phase (January 2008 to December 2009) and 208 patients in the Thumper 1008 CCV phase (January 2010 to May 2011). Return of spontaneous circulation (ROSC) and survival to hospital discharge were the primary outcome measures.ResultsPatients in the Thumper 1007 and Thumper 1008 CCV phases had comparable results with the following exceptions: less hypertension (42.4% vs. 62.0%), cerebrovascular accidents (11.4% vs. 25.0%), and faster emergency medical service response time intervals (mean, 3.7 vs. 4.5 minutes) with the Thumper 1007. The average ambulance transport time was 6.1 minutes in both phases. The rates of ROSC [35.1% vs. 23.5%; adjusted odds ratio (OR), 1.616; 95% confidence interval (CI), 1.073–2.432] and survival to hospital discharge (10.1% vs. 4.2%; adjusted OR 2.431; 95% CI, 1.154–5.120) were significantly higher with the Thumper 1008 CCV than with the Thumper 1007. Favorable neurologic outcome upon discharge, defined as cerebral performance category scores of 1 (good performance) or 2 (moderate disability), was not significantly different between the two phases [1.6% (5/307) vs. 1.9% (4/208); p = 0.802]. The Thumper 1008 CCV provided significantly faster average chest compression rates and shorter no-chest compression intervals than the Thumper 1007 after activation.ConclusionIn an emergency department with short ambulance transport times, continuous chest compressions with ventilation through mechanical CPR showed improved outcomes, including ROSC and survival to hospital discharge, in an adult with OHCA. However, there are a variety of confounding influences that may affect the validity of conclusions that have been drawn.     

Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest

Context  The survival benefit of well-performed cardiopulmonary resuscitation (CPR) is well-documented, but little objective data exist regarding actual CPR quality during cardiac arrest. Recent studies have challenged the notion that CPR is uniformly performed according to established international guidelines. Objectives  To measure multiple parameters of in-hospital CPR quality and to determine compliance with published American Heart Association and international guidelines. Design and Setting  A prospective observational study of 67 patients who experienced in-hospital cardiac arrest at the University of Chicago Hospitals, Chicago, Ill, between December 11, 2002, and April 5, 2004. Using a monitor/defibrillator with novel additional sensing capabilities, the parameters of CPR quality including chest compression rate, compression depth, ventilation rate, and the fraction of arrest time without chest compressions (no-flow fraction) were recorded. Main Outcome Measure  Adherence to American Heart Association and international CPR guidelines. Results  Analysis of the first 5 minutes of each resuscitation by 30-second segments revealed that chest compression rates were less than 90/min in 28.1% of segments. Compression depth was too shallow (defined as <38 mm) for 37.4% of compressions. Ventilation rates were high, with 60.9% of segments containing a rate of more than 20/min. Additionally, the mean (SD) no-flow fraction was 0.24 (0.18). A 10-second pause each minute of arrest would yield a no-flow fraction of 0.17. A total of 27 patients (40.3%) achieved return of spontaneous circulation and 7 (10.4%) were discharged from the hospital. Conclusions  In this study of in-hospital cardiac arrest, the quality of multiple parameters of CPR was inconsistent and often did not meet published guideline recommendations, even when performed by well-trained hospital staff. The importance of high-quality CPR suggests the need for rescuer feedback and monitoring of CPR quality during resuscitation efforts.      

Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial

Context  Defibrillation as soon as possible is standard treatment for patients with ventricular fibrillation. A nonrandomized study indicates that after a few minutes of ventricular fibrillation, delaying defibrillation to give cardiopulmonary resuscitation (CPR) first might improve the outcome. Objective  To determine the effects of CPR before defibrillation on outcome in patients with ventricular fibrillation and with response times either up to or longer than 5 minutes. Design, Setting, and Patients  Randomized trial of 200 patients with out-of-hospital ventricular fibrillation in Oslo, Norway, between June 1998 and May 2001. Patients received either standard care with immediate defibrillation (n = 96) or CPR first with 3 minutes of basic CPR by ambulance personnel prior to defibrillation (n = 104). If initial defibrillation was unsuccessful, the standard group received 1 minute of CPR before additional defibrillation attempts compared with 3 minutes in the CPR first group. Main Outcome Measure  Primary end point was survival to hospital discharge. Secondary end points were hospital admission with return of spontaneous circulation (ROSC), 1-year survival, and neurological outcome. A prespecified analysis examined subgroups with response times either up to or longer than 5 minutes. Results  In the standard group, 14 (15%) of 96 patients survived to hospital discharge vs 23 (22%) of 104 in the CPR first group (P = .17). There were no differences in ROSC rates between the standard group (56% [58/104]) and the CPR first group (46% [44/96]; P = .16); or in 1-year survival (20% [21/104] and 15% [14/96], respectively; P = .30). In subgroup analysis for patients with ambulance response times of either up to 5 minutes or shorter, there were no differences in any outcome variables between the CPR first group (n = 40) and the standard group (n = 41). For patients with response intervals of longer than 5 minutes, more patients achieved ROSC in the CPR first group (58% [37/64]) compared with the standard group (38% [21/55]; odds ratio [OR], 2.22; 95% confidence interval [CI], 1.06-4.63; P = .04); survival to hospital discharge (22% [14/64] vs 4% [2/55]; OR, 7.42; 95% CI, 1.61-34.3; P = .006); and 1-year survival (20% [13/64] vs 4% [2/55]; OR, 6.76; 95% CI, 1.42-31.4; P = .01). Thirty-three (89%) of 37 patients who survived to hospital discharge had no or minor reductions in neurological status with no difference between the groups. Conclusions  Compared with standard care for ventricular fibrillation, CPR first prior to defibrillation offered no advantage in improving outcomes for this entire study population or for patients with ambulance response times shorter than 5 minutes. However, the patients with ventricular fibrillation and ambulance response intervals longer than 5 minutes had better outcomes with CPR first before defibrillation was attempted. These results require confirmation in additional randomized trials.      

A randomized clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest.

OBJECTIVE--To determine the relative efficacy of high- vs standard-dose catecholamines in initial treatment of prehospital cardiac arrest. DESIGN--Randomized, prospective, double-blind clinical trial. SETTING--Prehospital emergency medical system of a major US city. PATIENTS--All adults in nontraumatic cardiac arrest, treated by paramedics, who would receive epinephrine according to American Heart Association advanced cardiac life support guidelines. INTERVENTIONS--High-dose epinephrine (HDE, 15 mg), high-dose norepinephrine bitartrate (NE, 11 mg), or standard-dose epinephrine (SDE, 1 mg) was blindly substituted for advanced cardiac life support doses of epinephrine. MAIN OUTCOME MEASURES--Restoration of spontaneous circulation in the field, admission to hospital, hospital discharge, and Cerebral Performance Category score. RESULTS--Of 2694 patients with cardiac arrests during the study period, resuscitation was attempted on 1062 patients. Of this total, 816 patients met study criteria and were enrolled. In the entire cardiac arrest population, 63% of the survivors were among the 11% of patients who were defibrillated by first responders. The three drug treatment groups were similar for all independent variables. Thirteen percent of patients receiving HDE regained a pulse in the field vs 8% of those receiving SDE (P = .01), and 18% of HDE patients were admitted to the hospital vs 10% of SDE patients who were admitted to the hospital (P = .02). Similar trends for NE were not significant. There were 18 survivors; 1.7% of HDE patients and 2.6% of NE patients were discharged from the hospital compared with 1.2% of SDE patients, but this was not significant (P = .37; beta = .38). There was a nonsignificant trend for Cerebral Performance Category scores to be worse for HDE (3.2) and NE patients (3.7) than for SDE patients (2.3) (P = .10; beta = .31). No significant complications were identified. High-dose epinephrine did not produce longer hospital or critical care unit stays. CONCLUSIONS--High-dose epinephrine significantly improves the rate of return of spontaneous circulation and hospital admission in patients who are in prehospital cardiac arrest without increasing complications. However, the increase in hospital discharge rate is not statistically significant, and no significant trend could be determined for neurological outcome. No benefit of NE compared with HDE was identified. Further study is needed to determine the optimal role of epinephrine in prehospital cardiac arrest.     

Effects of subdiaphragmatic cardiac compression on cardiac arrest during liver transplantation

Cardiac arrest during upper abdominal surgery such as liver transplantation is a rare but very severe complication. Traditional external cardiac compression has been the mainstay of basic life support in general circumstances. Subdiaphragmatic cardiac compression (SDCC), with no incision in the diaphragm, may be a more effective measure. This maneuver can provide more effective and timely cardiac compression via the already open abdomen in surgery and not add extra trauma. This method can provide a quicker and more effective means of circulation support for intraoperative cardiac arrest patients without adding new injuries. Five cases are reported and all the patients had return of spontaneous circulation (ROSC). This is the first report of the SDCC method.

     

Hyperkalemic cardiac arrest successfully reversed by hemodialysis during cardiopulmonary resuscitation: case report

Severe hyperkalemia is a potential life-threatening cardiac emergency especially in the patients who suffer from a defective renal capacity to excrete potassium such as the dialysis patient. Various conventional therapies including intravenous sodium bicarbonate, insulin with glucose and several beta-2 agonists are commonly employed as transient measures to enhance shift of potassium from the extracellular to the intracellular compartment. If the potassium load is massive and situation is critical, emergency hemodialysis may be useful. During cardiopulmonary resuscitation, the external cardiac compression can support adequate blood flow for hemodialysis. We report a case of a 68-year-old woman who developed sudden cardiac arrest secondary to hyperkalemia with renal insufficiency. Despite 100 minutes of cardiopulmonary resuscitation and conventional treatment for hyperkalemia, the cardiac arrest still persisted. Hemodialysis was then initiated during cardiopulmonary resuscitation and the patient restored spontaneous heart beat 20 minutes later. There was no neurologic sequela after her recovery. Hemodialysis should be considered early in the course of cardiopulmonary resuscitation in severe hyperkalemia induced cardiac arrest if conventional therapies were judged to be ineffective.     

Lucas2心肺复苏仪器用于急诊科心脏骤停的临床效果

目的 探讨Lucas2心肺复苏仪器用于急诊科心脏骤停的临床效果.方法 选择2018年7月至2019年7月宝鸡市人民医院急诊科收治的200例心脏骤停患者为研究对象,根据复苏治疗的方式将患者分为观察组和对照组各100例,对照组患者给予徒手心肺复苏治疗,观察组患者采用Lucas2心肺复苏仪器治疗.比较两组患者的生命体征恢复情...