Factors associated with CPR quality in out-of-hospital cardiac arrest.

Background: Previous studies have demonstrated significant associations between cardiopulmonary resuscitation (CPR) quality metrics and survival to hospital discharge following out-of- hospital cardiac arrest (OHCA). No large study has explored the relationship between location of resuscitation (scene vs. transport) and CPR quality. Objective: We sought to determine the impact of CPR location on CPR quality metrics during OHCA. Methods: We performed a retrospective cohort study of prospectively collected data from the Toronto RescuNET Epistry- cardiac arrest database. We analyzed CPR quality data from all treated adult OHCA occurring over a 39 month period beginning January 1, 2013. We included OHCA patients who underwent resuscitation by emergency medical services and had CPR quality metric data for both scene and transport phases of the resuscitation. Based on 2010 American Heart Association guidelines, high quality CPR was defined as chest compression fraction (CCF)> 0.70, compression rate >100/min and compression depth > 5.0 cm. Scene and transport CPR quality metrics were compared for each patient using a Wilcoxon rank-sum paired-samples test . The proportion of patients who received high quality CPR (defined as meeting all 3 CPR quality benchmarks) was compared between resuscitation locations using a chi-square statistic. Results: Amongst 842 included patients (69.5% male, mean (SD) age 66.8±17.0), median compression rate was statistically higher on scene compared to transport (105.8 vs. 102.0 ; Δ 3.8; 95% CI: 2.5, 4.0), while median compression depth (5.56 vs. 5.33; Δ 0.23; 95% CI: 0.12, 0.26) and median CCF (0.95 vs. 0.87; Δ 0.08; 95% CI: 0.07, 0.08) were statistically higher during the transport phase. The proportion of patients with high quality CPR was similar on scene compared to during transport (45.8% vs. 42.5%; Δ 3.3; 95% CI: -1.4, 8.1). Conclusions: High quality CPR metrics were identified in both (scene and transport) locations of resuscitation and exceeded current CPR quality benchmarks. These results suggest that high quality, manual compressions can be performed by well-trained EMS systems regardless of location. Further study is required to determine whether these metrics can be replicated in other EMS jurisdictions.

Sudden cardiac arrest (SCA) is a leading cause of death in the United States and Canada. In the United States, each year ≈330 000 people die of coronary heart disease out of the hospital or in emergency departments. Of these, >150 000 SCAs occur out of the hospital.1,2 Despite the development of electrical defibrillation and the more recent implementation of lay rescuer defibrillation programs, the vast majority of these victims do not leave the hospital alive. In studies over the past 15 years, only 1.4% of patients with out-of-hospital arrest in Los Angeles, Calif, survived to hospital discharge3; in Chicago, Ill, the number was 2%,4 and in Detroit, Mich, it was <1%.5 Conversely, a few municipalities such as Seattle, Wash, report much higher survival rates from SCA—more than 15% in 1 study6—which suggests that survival rates need not remain so low. Recent work in Europe and elsewhere has confirmed that a higher survival-to-hospital discharge rate is indeed a realistic goal, with survival rates as high as 9% reported in Amsterdam7 and 21% in Maribor, Slovenia.8 The American Heart Association (AHA) uses 4 links in the “chain of survival” to illustrate the time-sensitive actions required for victims of SCA: (1) early recognition of the emergency and activation of emergency medical services (EMS), (2) early bystander cardiopulmonary resuscitation (CPR), (3) early delivery of shock(s) from a defibrillator if indicated, and (4) early advanced life support and postresuscitation care. Immediate bystander recognition of the emergency and EMS activation are critical. In many communities, however, these actions may be followed by significant delays, because the time interval from activation of EMS to arrival of these medical personnel may be 7 to 8 minutes or longer.4 Therefore, initial care in the first critical minutes after …

As with other Parts of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC), Part 5 is based on the International Liaison Committee on Resuscitation (ILCOR) 2015 international evidence review process. ILCOR Basic Life Support (BLS) Task Force members identified and prioritized topics and questions with the newest or most controversial evidence, or those that were thought to be most important for resuscitation. This 2015 Guidelines Update is based on the systematic reviews and recommendations of the 2015 International Consensus on CPR and ECC Science With Treatment Recommendations , “Part 3: Adult Basic Life Support and Automated External Defibrillation.”1,2 In the online version of this document, live links are provided so the reader can connect directly to the systematic reviews on the ILCOR Scientific Evidence Evaluation and Review System (SEERS) website. These links are indicated by a combination of letters and numbers (eg, BLS 740). We encourage readers to use the links and review the evidence and appendix. As with all AHA Guidelines, each 2015 recommendation is labeled with a Class of Recommendation (COR) and a Level of Evidence (LOE). The 2015 Guidelines Update uses the newest AHA COR and LOE classification system, which contains modifications of the Class III recommendation and introduces LOE B-R (randomized studies) and B-NR (nonrandomized studies) as well as LOE C-LD (based on limited data) and LOE C-EO (consensus of expert opinion). The AHA process for identification and management of potential conflicts of interest was used, and potential conflicts for writing group members are listed at the end of each Part of the 2015 Guidelines Update. For additional information about the systematic review process or management of potential conflicts of interest, see “Part 2: Evidence Evaluation and Management of Conflicts of Interest” in this …

Analysis of bystander CPR quality during out-of-hospital cardiac arrest using data derived from automated external defibrillators

Introduction: Although high quality cardiopulmonary resuscitation (CPR) has been associated with improvements in survival from cardiac arrest, little is known about the arrest factors that influence CPR performance. This study examined the association between CPR performance and patient and arrest factors in out-of-hospital cardiac arrest (OHCA). Methods: A retrospective observational study using data from a statewide cardiac arrest registry in Victoria, Australia. The study included 2,408 adult, medical OHCA patients who arrested between 11 February 2019 and 10 February 2021. Fractional and logistic regression models were used to analyse factors associated with CPR performance outcomes, including the proportion of compressions at target depth and target rate and a compression fraction ≥90%. Results: The median proportion of compressions at target depth and target rate were 80% (interquartile range [IQR] 58, 92.5) and 62% (IQR 40, 79), respectively, and 70% achieved a compression fraction ≥90%. After multivariable adjustment, achieving a compression depth in the target range was associated with female sex (OR 1.14 [95% CI: 1.02, 1.28]), patient weight (per 10 kg increase, OR 1.08 [95% CI: 1.05, 1.12]), aged care facility location (OR 0.74 [95% CI: 0.58, 0.94]), fire-fighter presence (OR 1.29 [95% CI: 1.14, 1.46]), resuscitation duration (per 5 min increase, OR 1.08 [95% CI: 1.06, 1.10]) and number of rescuers (per 1 person increase, OR 1.06 [95% CI: 1.03, 1.09]). Achieving compressions within target rate were associated with public location (OR 0.81 [95% CI: 0.72, 0.91]) and fire-fighter presence (OR 1.12 [95% CI: 1.02, 1.24]). Achieving a compression fraction ≥90% was associated with female sex (OR 0.75 [95% CI: 0.62, 0.91]), arrests witnessed by emergency services (OR 0.44 [95% CI: 0.32, 0.61]), initial shockable rhythms (OR 0.66 [95% CI: 0.53, 0.81]), fire-fighter presence (OR 1.24 [95% CI: 1.01, 1.54]) and resuscitation duration (per 5 min increase, OR 1.05 [95% CI: 1.02, 1.08]). Conclusion: This study demonstrates that several prehospital factors that are associated with CPR performance which may help inform operational strategies to improve OHCA outcomes.

Introduction: International Guidelines recommend measurement of end-tidal carbon dioxide (EtCO2) to enhance cardiopulmonary resuscitation (CPR) quality and optimize blood flow during CPR. Numerous factors impact EtCO2 (e.g., ventilation, metabolism, cardiac output), yet few clinical studies have correlated CPR quality and EtCO2 during actual out-of-hospital cardiac arrest (OHCA) resuscitations. The purpose of this study was to describe the association between EtCO2 and CPR quality variables during OHCA. Methods: This is an observational study of prospectively collected CPR quality and capnography data from two EMS agencies participating in a statewide resuscitation quality improvement program. CPR quality and capnography data from adult (≥18 years) cardiac resuscitation attempts (10/2008–06/2013) were collected and analyzed on a minute-by-minute basis using RescueNet™ Code Review. Linear mixed effect models were used to evaluate the association between (log-transformed) EtCO2 level and CPR variables: chest compression (CC) depth, CC rate, CC release velocity (CCRV), ventilation rate. Results: Among the 1217 adult OHCA cases of presumed cardiac etiology, 925 (76.0%) had a monitor-defibrillator file with CPR quality data, of which 296 (32.0%) cases had >1 minute of capnography data during CPR. After capnography quality review, 66 of these cases (22.3%) were excluded due to uninterpretable capnography, resulting in a final study sample of 230 subjects (mean age 68 years; 69.1% male), with a total of 1581 minutes of data. After adjustment for other CPR variables, a 10 mm increase in CC depth was associated with a 4.0% increase in EtCO2 (p < 0.0001), a 10 compression/minute increase in CC rate with a 1.7% increase in EtCO2 (p = 0.02), a 10 mm/second increase in CCRV with a 2.8% increase in EtCO2 (p = 0.03), and a 10 breath/minute increase in ventilation rate with a 17.4% decrease in EtCO2 (p < 0.0001). Conclusion: When controlling for known CPR quality variables, increases in CC depth, CC rate and CCRV were each associated with a statistically significant but clinically modest increase in EtCO2. Given the small effect sizes, the clinical utility of using EtCO2 to guide CPR performance is unclear. Further research is needed to determine the practicality and impact of using real-time EtCO2 to guide CPR delivery in the prehospital environment.

Resuscitation highlights in 2013: Part 2

The emergency cardiovascular care (ECC) scientists involved in the 2005 evidence evaluation process and the revision of the 2005 AHA Guidelines for CPR and ECC began and ended the process aware of the limitations of the resuscitation scientific evidence, optimistic about emerging data that documents the benefits of high-quality cardiopulmonary resuscitation (CPR), and determined to make recommendations that would increase survival from cardiac arrest and life-threatening emergencies. This editorial summarizes the factors that contributed to the tipping point, the point at which information and discussion either triggered support for major changes in the guidelines or reaffirmed existing recommendations. The scientists critically reviewed the sequence and priorities of the steps of CPR to identify those factors with the greatest potential impact on survival. They then developed recommendations to support those interventions that should be performed frequently and well. There was unanimous support for increased emphasis on ensuring that rescuers deliver high-quality CPR: rescuers need to provide an adequate number and depth of compressions, allow complete chest recoil after each compression, and minimize interruptions in chest compressions. The 2005 AHA Guidelines for CPR and ECC are based on the most comprehensive review of resuscitation literature ever published.1 The evidence evaluation process incorporated the input of 281 international resuscitation experts who evaluated research, topics, and hypotheses over a 36-month period before the 2005 Consensus Conference. The process included structured evidence evaluation, analysis, and documentation of the literature.2 It also included rigorous disclosure and management of potential conflicts of interest, a process summarized in two editorials.3,4 Cardiopulmonary resuscitation and emergency cardiovascular care is a relatively new field. The epidemiologic data is incomplete, and high-level evidence is insufficient to support many recommendations. Although sudden cardiac arrest (SCA) is responsible for an estimated 250 000 deaths out of the hospital in the United …

Publication of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) marks 49 years since the first CPR guidelines were published in 1966 by an Ad Hoc Committee on Cardiopulmonary Resuscitation established by the National Academy of Sciences of the National Research Council.1 Since that time, periodic revisions to the Guidelines have been published by the AHA in 1974,2 1980,3 1986,4 1992,5 2000,6 2005,7 2010,8 and now 2015. The 2010 AHA Guidelines for CPR and ECC provided a comprehensive review of evidence-based recommendations for resuscitation, ECC, and first aid. The 2015 AHA Guidelines Update for CPR and ECC focuses on topics with significant new science or ongoing controversy, and so serves as an update to the 2010 AHA Guidelines for CPR and ECC rather than a complete revision of the Guidelines. The purpose of this Executive Summary is to provide an overview of the new or revised recommendations contained in the 2015 Guidelines Update. This document does not contain extensive reference citations; the reader is referred to Parts 3 through 9 for more detailed review of the scientific evidence and the recommendations on which they are based. There have been several changes to the organization of the 2015 Guidelines Update compared with 2010. “Part 4: Systems of Care and Continuous Quality Improvement” is an important new Part that focuses on the integrated structures and processes that are necessary to create systems of care for both in-hospital and out-of-hospital resuscitation capable of measuring and improving quality and patient outcomes. This Part replaces the “CPR Overview” Part of the 2010 Guidelines. Another new Part of the 2015 Guidelines Update is “Part 14: Education,” which focuses on evidence-based recommendations to facilitate widespread, consistent, efficient and effective implementation …

Cardiac arrest is a common and treatable cause of death and disability. Each year ≈424 000 people experience emergency medical services (EMS)-assessed out-of-hospital cardiac arrest (OHCA) in the United States.1 The actual burden of OHCA is likely significantly higher because a substantial number go unassessed. In a prospective analysis of deaths in a US county, 5.6% of annual mortality was attributable to cardiac arrest.2 Many patients who suffer OHCA do not receive prompt cardiopulmonary resuscitation (CPR). Among those who receive CPR, a large number do not survive because of an inability to restore spontaneous circulation, or anoxic cerebral injury even after restoration of circulation. Nevertheless, when timely interventions are provided, a small proportion of patients (10.4% of all EMS-treated OHCA) recover to resume normal lives. The key therapeutic interventions that make the difference between life and death, metaphorically characterized as the 5 links in a chain of survival by the American Heart Association, include: (1) immediate recognition of cardiac arrest and activation of the EMS, (2) early CPR with emphasis on chest compression, (3) rapid defibrillation, (4) effective advanced life support, and (5) integrated postcardiac arrest care.3 Resuscitation science has undergone major advances since the origins of modern CPR >50 years ago.4 The field continues to be dynamic with emergence of new therapies such as therapeutic hypothermia5 and improvements in systems of care. However, many questions remain on issues such as optimum compression rate, efficacy of chest compression only CPR (CCCPR), dispatcher-assisted CPR, and benefits of postresuscitation measures such as hypothermia. A critical challenge also lies in the translation of resuscitation science into practice. To improve outcomes, each of the links in the chain of survival needs to be executed promptly and effectively. There remain several lacunae, which need to be overcome to develop an …

AimsAnnual CPR training is recommended for healthcare professionals. Evidence suggests that this is not sufficient to maintain skill proficiency and that three monthly training could be optimum.1 More frequent training...

Introduction: Although quality of cardiopulmonary resuscitation (CPR) is a key to increase survival after out-of-hospital cardiac arrest (OHCA), little is known about the quality of bystander CPR and its association with survival outcomes after OHCA. Objective: To evaluate the association of quality of bystander CPR and patient outcomes after OHCA. Methods: Designs: Population-based cohort study. Cases: All OHCA cases treated by emergency medical services (EMS) personnel in Toyonaka city between September 2011 and August 2013. Data collection and analyses: EMS personnel assessed bystanders’ CPR quality including hand position, depth, and tempo of chest compressions using a specific data form at the scene. Fleiss’ Kappa statistics was used to assess the evaluation reliability among EMS personnel and the Kappa value was 0.81 before the study. The primary outcome was patient one-month survival with favorable neurological outcome and it was compared between the good-quality CPR group and the poor-quality CPR group. Results: Among 877 cases, bystander CPR was attempted in 429 (48.9%). Data on quality of CPR was applicable in 272 (63.4%) of them. In the good-quality CPR group, bystanders were younger, more likely to be health care provider, and have experience of CPR training than in the poor-quality of CPR group. The proportion of patients with neurologically favorable one-month survival was somewhat greater in the good-quality of CPR group (4.6% versus 3.0%), although it was statistically insignificant. Conclusions: Better quality of bystander chest compressions might increase OHCA patient survival. Further efforts to improve quality of CPR by general public are needed.

Extracorporeal Cardiopulmonary Resuscitation: Prehospital or In-Hospital Cannulation?

Cardiac arrest, acute myocardial infarction (AMI), and stroke affect millions of people in the United States annually.1 Despite significant advances in medical treatments for these conditions, they remain a major public health problem and a leading cause of morbidity and mortality.1 A critical common element in optimizing care and outcomes for these conditions is the timely recognition of symptoms and initiation of treatment. For example, rapid initiation of cardiopulmonary resuscitation (CPR) is associated with improved survival from cardiac arrest.2 Similarly, early recognition and presentation after onset of symptoms of AMI and ischemic stroke enable implementation of critical therapies such as primary angioplasty and thrombolysis, which are known to improve outcomes.1 Indeed, the “Chain of Survival” for emergency cardiovascular and cerebrovascular care (ECCC) starts with prompt identification of the condition and early activation of the healthcare system to rapidly initiate care.3 Unfortunately, despite national efforts that include public education initiatives and clinical practice guideline recommendations from entities such as the American Heart Association (AHA), major gaps remain in the timely identification of symptoms and initiation of ECCC.4–6 As one example, studies of out-of-hospital cardiac arrest (OHCA) have consistently noted delays in the initiation of bystander CPR.7 For AMI, there have been advances in the provision of timely primary angioplasty for ST-segment elevation myocardial infarction (STEMI), as reflected by significant improvements in door-to-balloon times.8 However, the time from patient symptom onset to seeking care for possible myocardial infarction has not improved significantly.9,10 Similarly, for stroke, there continue to be advances in door-to-needle times, but stroke symptom recognition and seeking of treatment by patients and their families remain a major barrier to timely stroke care.11–16 Public and clinician education efforts alone are not sufficient to reduce gaps …

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