Physiology-Guided CPR.

Following current cardiopulmonary resuscitation (CPR) guidelines, which recommend chest compressions at "the center of the chest," ~50% of patients experiencing out-of-hospital cardiac arrest (OHCA) undergo aortic valve (AV) compression, obstructing blood flow. We used resuscitative transesophageal echocardiography (TEE) to elucidate the impact of uncompressed vs. compressed AV on outcomes of adult patients experiencing OHCA. Prospective observational cohort study. Single center. This study included adult OHCA patients undergoing resuscitative TEE in the emergency department. Patients were categorized into AV uncompressed or AV compressed groups based on TEE findings. None. The primary outcome was sustained return of spontaneous circulation (ROSC). The secondary outcomes included end-tidal co2 (Et co2 ) during CPR, any ROSC, survival to ICU and hospital discharge, post-resuscitation withdrawal, and favorable neurologic outcomes at discharge. Additional analyses on intra-arrest arterial blood pressure (ABP) were also conducted. The sample size was pre-estimated at 37 patients/group. From October 2020 to January 2023, 76 patients were enrolled, 39 and 37 in the AV uncompressed and AV compressed groups, respectively. Intergroup baseline characteristics were similar. Compared with the AV compressed group, the AV uncompressed group had a higher probability of sustained ROSC (53.8% vs. 24.3%; adjusted odds ratio [aOR], 4.72; p = 0.010), any ROSC (56.4% vs. 32.4%; aOR, 3.30; p = 0.033), and survival to ICU (33.3% vs. 8.1%; aOR, 6.74; p = 0.010), and recorded higher initial diastolic ABP (33.4 vs. 11.5 mm Hg; p = 0.002) and a larger proportion achieving diastolic ABP greater than 20 mm Hg during CPR (93.8% vs. 33.3%; p < 0.001). The Et co2 , post-resuscitation withdrawal, and survival to discharge revealed no significant intergroup differences. No patients were discharged with favorable neurologic outcomes. Uncompressed AV seemed critical for sustained ROSC across all subgroups. Absence of AV compression during OHCA resuscitation is associated with an increased chance of ROSC and survival to ICU. However, its effect on long-term outcomes remains unclear.

BackgroundPodiatrists in New Zealand have a duty of care to assist patients in an emergency, and current cardiopulmonary resuscitation (CPR) certification is a requirement for registration. However, it is unknown how competent and confident podiatrists are in administering CPR and how they would respond in an emergency. Having a health professional who has a competent knowledge of CPR and skills in basic life support, can improve survival rates from sudden cardiac arrest. Therefore, the aim of this study was to survey New Zealand podiatrists to determine their CPR knowledge and qualifications; beliefs about the application of CPR; and perceptions of their competency in CPR.MethodsThis cross-sectional study used a web-based survey. Participants were New Zealand registered podiatrists with a current annual practising certificate. The 31-item survey included questions to elicit demographic information, CPR practice and attitudes, and CPR knowledge. Responses were collected between March and August 2020.Results171 podiatrists responded to the survey. 16 % of the podiatrists (n = 28) had performed CPR in an emergency, with a 50 % success rate. Participants were predominantly female (n = 127, 74 %) and working in private practice (n = 140,82 %). Nearly half of respondents were younger than 40 years (n = 75,44 %) and had less than 10 years of clinical experience (n = 73, 43 %). Nearly all (n = 169,97 %) participants had received formal CPR training in the past two years, with 60 % (n = 105) receiving training in the past 12 months. Most respondents (n = 167,98 %) self-estimated their CPR ability as being effective, very effective, or extremely effective. Participants’ knowledge of CPR was variable, with the percentage of correct answers for CPR protocol statements ranging between 20 and 90 %.ConclusionsThis study provides the first insight into New Zealand podiatrists’ CPR knowledge and perceptions. Podiatrists were found to have high levels of CPR confidence but demonstrated gaps in CPR knowledge. Currently, New Zealand registered podiatrists require biennial CPR re-certification. However, resuscitation authorities in New Zealand and overseas recommend an annual update of CPR skills. Based on this study’s findings, and in line with Australia and the United Kingdom, the authors recommend a change from biennial to annual CPR re-certification for podiatrists in New Zealand.Trial registrationThe study was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12620001144909).

Background: Current cardiopulmonary resuscitation (CPR) guidelines recommend chest compressions at "the center of the chest." However, studies have shown that over half of patients with out-of-hospital cardiac arrest (OHCA) experience aortic valve (AV) compression following this recommendation, which may worsen outcomes. We hypothesized that using transesophageal echocardiography (TEE) to guide chest compressions in adult OHCA patients, avoiding AV compression and targeting the left ventricle (LV), would improve outcomes compared to the conventional site. Methods: The EXECT-CPR trial was a single-center cluster randomized clinical trial enrolling adults (≥20 years old) with non-traumatic OHCA presenting to the emergency department (ED). Exclusion criteria included return of spontaneous circulation (ROSC) before ED arrival, extracorporeal CPR, pre-existing contraindications for TEE, do-not-resuscitate orders, or obvious signs of death. Patients were assigned to the TEE-guided or conventional group using biweekly cluster randomization. Both groups received standard advanced life support, except the intervention group's compression site, which was initially conventional then rapidly adjusted by TEE. The primary outcome was sustained ROSC (≥20 mins). Secondary outcomes included survival to ICU and discharge with favorable neurological outcomes. The sample size was estimated at 66/group. Analyses were performed on intention-to-treat (ITT) and per-protocol (PP) basis. Results: From June 26 to November 15, 2023, a total of 262 OHCA patients were sent to the ED, and 132 were enrolled in the final analysis (mean age 65 years, 66% male), with 66 in each group. In the TEE-guided group, TEE was successfully imaged in 53 patients (5.3 mins after arrival at the ED). Due to clinical situations, only 46 patients completed the assigned TEE-guided interventions. Of these, 35 patients, who were initially not compressed at the LV, had their compression sites successfully adjusted (9.2 mins after arrival at ED). In ITT analysis, the primary outcome was 29/66(43.9%) in the TEE-guided group and 26/66(39.4%) in the conventional group (odds ratio[OR] 1.21, P=0.60), while in PP analysis it was 20/46(43.5%) and 26/66(39.4%) (OR 1.18, P=0.67; adjusted OR 1.63, P=0.28). Secondary outcomes showed no significant differences. Conclusion: Among adults with non-traumatic OHCA, TEE-guided CPR with an adjusted compression site in the ED did not result in different outcomes compared to conventional CPR.

BackgroundInternational literature suggests current Cardiopulmonary Resuscitation (CPR) policy and practice is highly variable and often ad-hoc in aged care settings. At present, there is no comparable published research on CPR...

Funding Acknowledgements Japan Society for the Promotion of Science (KAKENHI Grant No. 18K09999) Background For out-of-hospital cardiac arrest (OHCA), current cardiopulmonary resuscitation (CPR) guidelines recommend chest compression-only bystander CPR (C- BCPR) for both untrained and trained bystanders unwilling to perform rescue breaths before emergency medical services personnel arrival. However, during 3 consecutive guideline periods, changes in type of BCPR and neurologically intact survival rate are unclear in paediatric OHCA cases. Purpose We aimed to determine the change in the rate and type of BCPR in correlation to the 1-month neurologically intact survival and causes of OHCA. Methods We reviewed 5461 children with bystander witnessed OHCA included in the All-Japan Utstein-style registry from 2005 to 2017. Patients were divided into 3 groups according to the type of BCPR: no BCPR (NO-BCPR), standard BCPR with rescue breaths (S-BCPR), and C-BCPR. Guideline periods 2005 to 2010 (pre-G2010), 2011 to 2015 (G2010), and 2016 to 2017 (G2015) were used for comparison over time. The study endpoint was 1-month neurologically intact survival (Cerebral Performance Category [CPC] scale 1 or 2; CPC 1–2). Results The rates of patients receiving any BCPR and 1-month CPC 1–2 by year significantly increased from 46.2% and 9.4% in 2005 to 61.3% and 15.7% in 2017 (all P for trend &amp;lt;0.0001), respectively. The rates of patients receiving C-BCPR in the pre-G2010 period significantly increased from 21.6% to 35.5% in the G2010 period, and to 40.4% in the G2015 period (P for trend &amp;lt;0.0001); the overall proportion of cases with 1-month CPC 1–2 increased from 9.1% to 10.8% and 14.7%, respectively (P for trend &amp;lt;0.0001). Particularly, in patients receiving C-BCPR, CPC 1–2 rate significantly increased from 9.5% in the pre-G2010 period to 19.0% in the G2015 period (P for trend &amp;lt;0.0001). For all time periods, 1-month CPC 1–2 rate in the S-BCPR (17.2%) cohort was significantly higher than those in the C-BCPR (12.5%) and NO-BCPR (6.4%) cohorts (adjusted odds ratio [aOR] of S-BCPR compared with C-BCPR, 1.59; 95% confidence interval [CI], 1.25–2.01; P &amp;lt; 0.0001; compared with NO-BCPR, aOR 2.31; 95% CI, 1.82–2.94; P &amp;lt; 0.0001). No significant difference between S-BCPR and C-BCPR was found in 1-month CPC 1–2 rate for patients with non-traumatic origin (17.7% vs. 16.3%; aOR, 1.23, 95% CI, 0.95–1.59, all P &amp;gt;0.05). However, in patients with traumatic origin, S-BCPR was superior to C-BCPR (15.1% vs. 3.4%; aOR, 4.53, 95% CI, 2.39–8.61, all P &amp;lt;0.0001). During the 3 guidelines periods, the CPC 1–2 rate in patients with non-traumatic origin significantly increased from 11.8% to 19.7% (P for trend &amp;lt; 0.0001), but not in patients with traumatic origin (from 4.9% to 4.1%, P for trend = 0.29). Conclusions During the 3 guidelines periods, the rate of C-BCPR and 1-month CPC 1–2 increased by approximately 2-fold each over time. C-BCPR was associated with increased odds of 1-month CPC 1–2 similar to S-BCPR for children with non-traumatic origin but not in those with traumatic origin.

Cardiopulmonary arrest is an emergency situation which can present to any veterinary clinic at any time. The RECOVER guidelines (2012) are an evidence-based consensus for current cardiopulmonary resuscitation (CPR) recommendations for veterinary patients. Basic life support (BLS) includes circulation, airway and breathing. Advanced life support measures involve the administration of emergency drug therapy and cardiorespiratory monitoring. Alternative drug therapies may be beneficial such as electrolyte supplementation or drug antagonist administration. Both electrocardiogram (ECG) and end tidal carbon dioxide (ETCO2) monitoring are recommended during CPR efforts and the veterinary nurse will play a vital role in ensuring that trends are observed. Debriefing is an important part of any CPR event so that the team can critique one another and improve performance in the future.

BackgroundEffective paediatric basic life support improves survival and outcomes. Current cardiopulmonary resuscitation (CPR) training involves 4-yearly courses plus annual updates. Skills degrade by 3–6 months. No method has been described...

Current cardiopulmonary resuscitation (CPR) guidelines emphasize continuous compressions with minimal interruptions. The focus has been on minimizing

Predicting a pulse: Can monitoring heart rate and end-tidal carbon dioxide minimize compression pauses and impact outcomes in out-of-hospital cardiac arrest?

Introduction: Pediatric cardiopulmonary resuscitation (CPR) guidelines provide primitive ventilation guidance (observe chest rise, target a ventilation rate). Calculated from capnography waveforms, airway opening index (AOI) is a metric recently described in adults to infer airway patency during CPR. AOI has not yet been associated with survival nor described in pediatric patients. Aims: 1) To quantitatively describe AOI during pediatric CPR and 2) to evaluate the association of AOI with intra-/post-arrest physiology and outcomes. Methods: This was a prospective multicenter observational cohort study. Children (≤18 years) with invasive airways and end-tidal carbon dioxide (ETCO 2 ) / arterial blood pressure (BP) data were included. AOI was calculated as the average of ((delta CO 2 )/max CO 2 ) associated with each chest compression during a ventilation (range 0 [closed] to 1 [open/patent]). Cubic splines / receiver operating characteristic curves were used to identify an AOI target for evaluation in modified Poisson regression models ( a priori covariates: age; cause of arrest; P ediatric RIS k of M ortality score). A sensitivity analysis excluded extracorporeal CPR patients (E-CPR). The primary outcome was survival to hospital discharge (SHD). Secondary / exploratory outcomes included: other patient outcomes (e.g., favorable neurological outcome [Pediatric Cerebral Performance Category Score 1-3 or no change]) and intra- and post-arrest (6 hours after return of circulation [ROC]) physiology. Results: Among 99 included events (median age: 0.34 [0.04, 3.26] yrs), median AOI was 0.38 (survivors: 0.45 [0.28, 0.61]; non-survivors: 0.30 [0.24, 0.48]; p=0.02). A target AOI of ≥0.35 was identified, which was associated with improved SHD (aRR 1.53 [CI95 1.03, 2.28], p=0.04) and favorable neurological outcome (aRR 1.56 [CI95 1.01, 2.41], p=0.04) compared to an AOI &lt;0.35. During CPR, intra-arrest ETCO 2 was lower (-5.82 mmHg [CI95 -9.72, -1.91], p&lt;0.01) in events with AOI ≥0.35. Findings were robust when excluding E-CPR patients. In the 6 hours after ROC, events with AOI ≥0.35 had lower peak arterial lactates (6.1 [3.2, 13.1] vs. 11.4 [5.4, 16.1] mmol/L, p=0.043), despite similar CPR durations (≥0.35: 9 [3, 36] vs. &lt;0.35: 8.5 [3, 21] min, p=0.64). Conclusions: In this multicenter study, an AOI ≥0.35 was associated with improved survival and favorable neurological outcome. Among events with AOI ≥0.35, there was evidence of improved immediate post-arrest physiology (lower lactates).

Postconditioning in cardiopulmonary resuscitation: A better protocol for cardiopulmonary resuscitation

Background: Published survival rates after out-of-hospital cardiac arrests (OHCA) are lower than in-hospital cardiac arrest (IHCA). Current estimates for the incidence and rate of survival for maternal cardiac arrest are published only for IHCA. There are no studies that report the incidence and outcomes of maternal OHCA. Current cardiopulmonary resuscitation guidelines contain specific maternal recommendations, although compliance with recommended benchmarks has not been reported. The objective of this study was to report maternal OHCA incidence, outcomes, and compliance with resuscitation and maternal specific guidelines. Methods: This was a population-based cohort study of consecutive maternal OHCA between May 2010 and April 2014. The denominator was estimated from the total regional population of all women of childbearing age obtained from census and age-specific pregnancy rates provided by regional health authorities. Resuscitation performance was measured against the 2010 AHA Guidelines. Results: A total of 6 maternal OHCA occurred amongst 1,085 OHCA occurring in females of child bearing age (15-49) over 4yrs; Incidence-1.85:100,000 (95% CI 1.76 to 1.95) vs. 19.4 per 100,000 (95% CI, 19.37 to 19.43). Maternal and neonatal survival to discharge was 16.7% and 33.3%, respectively. Compliance with CPR quality metrics averaged 83% with a range from 75% to 100%. Compliance with maternal-specific resuscitation guidelines averaged 46.9%, with a range from 0% to 100%. The only performance metrics with 100% compliance was intravenous line insertion above the diaphragm and prehospital activation of the maternal cardiac arrest team. Uterine displacement compliance was low at 0%. Conclusion: The incidence of maternal OHCA was 1.85:100,000, which is lower than the published estimate for maternal IHCA. Survival after OHCA for mother and for child was higher than OHCA occurring in non-pregnant adult females of child bearing age; however, the number of survivors was small (&lt;5). Compliance rates with recommended resuscitation guidelines were high, yet compliance with maternal-specific guidelines were low suggesting targeted training and implementation optimization at the point of care is required to prepare for this rare event involving two lives.

Antiarrhythmics in Cardiac Arrest: A Systematic Review and Meta-Analysis

Cardiac arrest outcomes before and after the 2005 resuscitation guidelines implementation: Evidence of improvement?

xisting American Heart Association cardiopulmonary resuscitation (CPR) guidelines do not address the challenges of providing resuscitation in the setting of the coronavirus disease 2019 (COVID-19) global pandemic, wherein rescuers must continuously balance the immediate needs of the patients with their own safety.To address this gap, the American Heart Association, in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists, and with the support of the American Association of Critical Care Nurses and National Association of EMS Physicians, has compiled interim guidance to help rescuers treat individuals with cardiac arrest with suspected or confirmed COVID-19.Over the past 2 decades, there has been a steady improvement in survival after cardiac arrest occurring both inside and outside the hospital. 1That success has relied on initiating proven resuscitation interventions such as high-quality chest compressions and defibrillation within seconds to minutes.The evolving and expanding outbreak of severe acute respiratory syndrome coronavirus 2 infections has created important challenges to such resuscitation efforts and requires potential modifications of established processes and practices.The challenge is to ensure that patients with or without COVID-19 who experience cardiac arrest get the best possible chance of survival without compromising the safety of rescuers, who will be needed to care for future patients.Complicating the emergency response to both out-of-hospital and in-hospital cardiac arrest is that COVID-19 is highly transmissible, particularly during resuscitation, and carries a high morbidity and mortality.3][4] Hypoxemic respiratory failure secondary to acute respiratory distress syndrome, myocardial injury, ventricular arrhythmias, and shock are common among critically ill patients and predispose them to cardiac arrest, [5][6][7][8] as do some of the proposed treatments such as hydroxychloroquine and azithromycin, which can prolong the QT. 9 With infections currently growing exponentially in the United States and internationally, the percentage of patients with cardiac arrests and COVID-19 is likely to increase.Healthcare workers are already the highest-risk profession for contracting the disease. 10This risk is compounded by worldwide shortages of personal protective equipment (PPE).Resuscitations carry added risk to healthcare workers for many reasons.First, the administration of CPR involves performing numerous aerosol-generating procedures, including chest compressions, positive-pressure ventilation, and establishment of an advanced airway.During those procedures, viral particles can remain suspended in the air with a half-life of ≈1 hour and