Resuscitation highlights in 2011

Abstract

Following the publication in 2010 of the International Liaison Committee on Resuscitation (ILCOR) Consensus on Cardiopulmonary Resuscitation (CPR) Science with Treatment Recommendations (CoSTR)1Nolan J.P. Hazinski M.F. Billi J.E. et al.Part 1: Executive summary: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.Resuscitation. 2010; 81: e1-e25Abstract Full Text Full Text PDF PubMed Scopus (242) Google Scholar and the European Resuscitation Council (ERC) Guidelines,2Nolan J.P. Soar J. Zideman D.A. et al.European Resuscitation Council Guidelines for Resuscitation 2010. Section 1. Executive summary.Resuscitation. 2010; 81: 1219-1276Abstract Full Text Full Text PDF PubMed Scopus (1021) Google Scholar the Resuscitation editorial team was expecting a relatively quiet 2011. Instead, we are delighted to report a substantial increase in the number and, more importantly, the quality of submissions to the journal. Here we summarise briefly the key papers published in Resuscitation in 2010.1. EpidemiologySeveral recent publications provide important insights into the present and changing epidemiology of cardiac arrest in the community. Vayrynen et al. reported that the internationally-observed decline in the incidence of out-of-hospital ventricular fibrillation (VF) seems to have ended in Helsinki, Finland, where the annual VF incidence has stabilised at 11.6 (95% CI 9.7–13.5) per 100,000 inhabitants.3Vayrynen T. Boyd J. Sorsa M. Maatta T. Kuisma M. Long-term changes in the incidence of out-of-hospital ventricular fibrillation.Resuscitation. 2011; 82: 825-829Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Sasson et al. reported on 1108 out-of-hospital cardiac arrest (OHCA) cases from Fulton County/Atlanta, Georgia, that appeared eligible to receive bystander CPR; only 279 (25%) victims actually received bystander CPR.4Sasson C. Keirns C.C. Smith D.M. et al.Examining the contextual effects of neighborhood on out-of-hospital cardiac arrest and the provision of bystander cardiopulmonary resuscitation.Resuscitation. 2011; 82: 674-679Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar Cardiac arrest patients in highest income areas were much more likely to receive bystander CPR than individuals living in lower income neighbourhoods. Finally, Stromsoe et al. found no significant association between population density and incidence or survival from OHCA in the Swedish Cardiac Arrest Register, although bystander CPR, cardiac aetiology and longer emergency medical services (EMS) response times were more frequent in less populated areas.5Stromsoe A. Svensson L. Claesson A. Lindkvist J. Lundstrom A. Herlitz J. Association between population density and reported incidence, characteristics and outcome after out-of-hospital cardiac arrest in Sweden.Resuscitation. 2011; 82: 1307-1313Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar2. PreventionPrevention of in-hospital cardiac arrest (IHCA) has remained a major topic in this journal ever since readers were alerted to the concept of the medical emergency team (MET) in 2001.6Hillman K. Parr M. Flabouris A. Bishop G. Stewart A. Redefining in-hospital resuscitation: the concept of the medical emergency team.Resuscitation. 2001; 48: 105-110Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar The 2010 CoSTR and ERC guidelines recommended that hospitals should provide a system of care that includes education, regular vital signs monitoring, clear guidance (via calling criteria) in the early detection of patient deterioration, a system to call for assistance, and timely clinical responses.7Deakin C.D. Morrison L.J. Morley P.T. et al.Part 8: Advanced life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations.Resuscitation. 2010; 81: e93-e174Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar, 8Deakin C.D. Nolan J.P. Soar J. et al.European Resuscitation Council Guidelines for Resuscitation 2010. Section 4. Adult advanced life support.Resuscitation. 2010; 81: 1305-1352Abstract Full Text Full Text PDF PubMed Scopus (864) Google ScholarStudying the effects of the MET, rapid response teams (RRT) and critical care outreach services (CCOS) on patient outcomes is difficult but single centre studies continue to report fewer adverse outcomes after implementation of these systems. Moon and colleagues demonstrated significant reductions in the incidence of cardiac arrest calls, patients admitted to the intensive care unit (ICU) after CPR and their in-hospital mortality, in the four years following the introduction of a CCOS and modified early warning scoring (MEWS) charts.9Moon A. Cosgrove J.F. Lea D. Fairs A. Cressey D.M. An eight year audit before and after the introduction of modified early warning score (MEWS) charts, of patients admitted to a tertiary referral intensive care unit after CPR.Resuscitation. 2011; 82: 150-154Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar Implementation of the MET in a regional hospital was also associated with statistically significant reductions in hospital-wide mortality rates, ICU admissions and cardiopulmonary arrests.10Laurens N. Dwyer T. The impact of medical emergency teams on ICU admission rates, cardiopulmonary arrests and mortality in a regional hospital.Resuscitation. 2011; 82: 707-712Abstract Full Text Full Text PDF PubMed Scopus (35) Google ScholarThe impact of afferent limb failure – ward staff not calling for assistance when MET criteria are fulfilled – was studied by Trinkle and co-workers and accompanied by an editorial.11Trinkle R.M. Flabouris A. Documenting rapid response system afferent limb failure and associated patient outcomes.Resuscitation. 2011; 82: 810-814Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 12Sandroni C. Cavallaro F. Failure of the afferent limb: a persistent problem in rapid response systems.Resuscitation. 2011; 82: 797-798Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar Despite 20 years of implementation, afferent limb failure is still a major issue even in mature systems and results in poor outcomes. Strategies to ensure afferent limb activation are needed and suggested by the authors. With reference to the afferent limb, Tarassenko et al. aimed to develop a centile-based EWS system based on the statistical properties of at-risk patients vital signs.13Tarassenko L. Clifton D.A. Pinsky M.R. Hravnak M.T. Woods J.R. Watkinson P.J. Centile-based early warning scores derived from statistical distributions of vital signs.Resuscitation. 2011; 82: 1013-1018Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar They found their system to be comparable to previously published systems but with some differences in scoring of respiratory rate and systolic blood pressure. The system requires validation and in the accompanying editorial, Subbe comments that despite the many reviews of track and trigger criteria, hospitals continue to create their own set of criteria and national and internationally standardization does not exist; this is probably overdue.14Subbe C.P. Centile-based early warning scores derived from statistical distributions of vital signs.Resuscitation. 2011; 82: 969-970Abstract Full Text Full Text PDF PubMed Scopus (6) Google ScholarTwo studies from Australia looked at the epidemiology of common reasons for activation of MET calls: atrial fibrillation (AF) and the need for non-invasive ventilation (NIV).15Schneider A. Calzavacca P. Jones D. Bellomo R. Epidemiology and patient outcome after medical emergency team calls triggered by atrial fibrillation.Resuscitation. 2011; 82: 410-414Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 16Schneider A.G. Calzavacca P. Mercer I. Hart G. Jones D. Bellomo R. The epidemiology and outcome of medical emergency team call patients treated with non-invasive ventilation.Resuscitation. 2011; 82: 1218-1223Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar In the first, they found AF triggers 10% of MET activations and associated mortality is high. Admitting these patients to wards with higher-level care reduced mortality, suggesting that some of these deaths are preventable. In the second study, one in ten MET call patients received NIV, two-thirds were transferred to a higher care area, one in four progressed to intubation, and one in four died. They concluded that NIV use during a MET call identified high-risk patients for whom admission to high-level care should be strongly considered.Micallef et al. showed that a MET system also provides an opportunity to identify patients for whom a do not attempt CPR (DNACPR) order should be considered, thus avoiding unnecessary intervention and costs.17Micallef S. Skrifvars M.B. Parr M.J. Level of agreement on resuscitation decisions among hospital specialists and barriers to documenting do not attempt resuscitation (DNAR) orders in ward patients.Resuscitation. 2011; 82: 815-818Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar3. Quality of CPRThe quality of CPR remains an important theme in resuscitation science.18Koster R.W. Baubin M.A. Bossaert L.L. et al.European Resuscitation Council Guidelines for Resuscitation 2010. Section 2. Adult basic life support and use of automated external defibrillators.Resuscitation. 2010; 81: 1277-1292Abstract Full Text Full Text PDF PubMed Scopus (456) Google Scholar Previous research highlighted the need to avoid interruptions in chest compressions during ventricular fibrillation/tachycardia.19Christenson J. Andrusiek D. Everson-Stewart S. et al.Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation.Circulation. 2009; 120: 1241-1247Crossref PubMed Scopus (574) Google Scholar Vaillancourt et al. extended these findings by confirming that chest compression fraction was independently associated with a trend toward an increased likelihood of return of spontaneous circulation in patients with non-VF/VT initial rhythm.20Vaillancourt C. Everson-Stewart S. Christenson J. et al.The impact of increased chest compression fraction on return of spontaneous circulation for out-of-hospital cardiac arrest patients not in ventricular fibrillation.Resuscitation. 2011; 82: 1483-1489Abstract Full Text Full Text PDF PubMed Scopus (47) Google ScholarSimulation provides a safe opportunity to examine factors which influence CPR process variables and team performance.21Catchpole K. Hadi M. Simulation provides a window on the quality and safety of the system.Resuscitation. 2011; 82: 1375-1376Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Insights from such an observational study identified un-necessary interruptions in CPR 32% of the time.22Tschan F. Vetterli M. Semmer N.K. Hunziker S. Marsch S.C. Activities during interruptions in cardiopulmonary resuscitation: a simulator study.Resuscitation. 2011; 82: 1419-1423Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Analysis of activities during interruptions identified secondary medical activities, particularly observing the monitor (47%) and dealing with the defibrillator (47%) as the predominant cause. There was evidence of loss of situational awareness and poor task distribution as all team members frequently focussed their attention on the same secondary activity. Non-technical skills or the way in which team members / team leaders interact and behave in a crisis impacts technical skill performance. Fernandez Castelao et al. elegantly showed how the inclusion of crew resource management training during advanced life support training was able to reduce no flow duration by increasing the number of team leader verbalisations.23Fernandez Castelao E. Russo S.G. Cremer S. et al.Positive impact of crisis resource management training on no-flow time and team member verbalisations during simulated cardiopulmonary resuscitation: a randomised controlled trial.Resuscitation. 2011; 82: 1338-1343Abstract Full Text Full Text PDF PubMed Scopus (57) Google ScholarAnother recommendation contained in Guidelines 2010 included an increase in chest compression depth to 5–6 cm during adult CPR.18Koster R.W. Baubin M.A. Bossaert L.L. et al.European Resuscitation Council Guidelines for Resuscitation 2010. Section 2. Adult basic life support and use of automated external defibrillators.Resuscitation. 2010; 81: 1277-1292Abstract Full Text Full Text PDF PubMed Scopus (456) Google Scholar The rationale was in part motivated by the observation that the majority of chest compressions delivered by people following the previous guidelines were too shallow. Mpotos et al. investigated the impact of this change on CPR skill retention 6 months after initial training.24Mpotos N. Lemoyne S. Wyler B. et al.Training to deeper compression depth reduces shallow compressions after six months in a manikin model.Resuscitation. 2011; 82: 1323-1327Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Medical student participants (n = 180) were randomised to training with CPR feedback targeting compressions of 40–50 mm vs. >50 mm. At follow-up assessment the proportion of students achieving a depth <40 mm was 29% in the standard group vs. 14% in the deep compression group (P = 0.01). Compressions above 50 mm were achieved by 6% in the standard group compared to 49% in the deep group (P < 0.001). Together these findings support the recommendation to ‘push hard and fast and please do not stop!’25Yannopoulos D. Halperin H.R. During C.P.R. Push hard and fast and please do not stop!.Resuscitation. 2011; 82: 1475-1476Abstract Full Text Full Text PDF PubMed Scopus (5) Google ScholarConcerns have been expressed about the potential for injuries from deeper chest compressions or hand positioning.26Young N. Cook B. Gillies M. New resuscitation guidelines may result in an increased incidence of severe chest wall injury, and lead to prolonged length of stay in the Intensive Care Unit.Resuscitation. 2011; 82: 1355Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 27Yeung J. Butler T. Digby J.W. et al.Basic life support providers’ assessment of centre of the chest and inter-nipple line for hand position and their underlying anatomical structures.Resuscitation. 2011; 82: 190-194Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Similar expressions of concern also frequent the literature in relation to mechanical chest compression devices.28Smekal D. Johansson J. Huzevka T. Rubertsson S. A pilot study of mechanical chest compressions with the LUCAS device in cardiopulmonary resuscitation.Resuscitation. 2011; 82: 702-706Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar, 29Perkins G.D. Brace S. Gates S. Mechanical chest-compression devices: current and future roles.Curr Opin Crit Care. 2010; 16: 203-210Crossref PubMed Scopus (41) Google Scholar Compression injuries in non-survivors are optimally identified by autopsy30Baubin M. Rabl W. How to detect side effects of chest compressions?.Resuscitation. 2011; 82: 1262Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar or non-invasively with CT scanning.31Kim E.Y. Yang H.J. Sung Y.M. et al.Multidetector CT findings of skeletal chest injuries secondary to cardiopulmonary resuscitation.Resuscitation. 2011; 82: 1285-1288Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar However what remains important is the overall impact on patient outcomes as opposed to injury patterns in non-survivors.29Perkins G.D. Brace S. Gates S. Mechanical chest-compression devices: current and future roles.Curr Opin Crit Care. 2010; 16: 203-210Crossref PubMed Scopus (41) Google Scholar We encourage the on-going collection and publication of prospective data linking CPR quality to outcome to enable a complete picture to be drawn linking compression quality to outcome.The now almost universal carriage of mobile phones positions them as a potentially powerful tool to reinforce the chain of survival.32Arntz H.R. Mobile phones—their increasing role in education and implementation of CPR.Resuscitation. 2011; 82: 1479-1480Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 33Bhanji F. Soar J. Do smartphones help deliver high-quality resuscitation care?.Resuscitation. 2011; 82: 1377-1378Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 34Kovic I. Lulic I. Mobile phone in the chain of survival.Resuscitation. 2011; 82: 776-779Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Specific opportunities include as an adjunct to CPR training,35Ahn J.Y. Cho G.C. Shon Y.D. Park S.M. Kang K.H. Effect of a reminder video using a mobile phone on the retention of CPR and AED skills in lay responders.Resuscitation. 2011; 82: 1543-1547Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar dispatcher CPR, activating trained bystanders to the site of an arrest,36Ringh M. Fredman D. Nordberg P. Stark T. Hollenberg J. Mobile phone technology identifies and recruits trained citizens to perform CPR on out-of-hospital cardiac arrest victims prior to ambulance arrival.Resuscitation. 2011; 82: 1514-1518Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar location of automated external defibrillators (AEDs),37Sakai T. Iwami T. Kitamura T. et al.Effectiveness of the new ‘Mobile AED Map’ to find and retrieve an AED: a randomised controlled trial.Resuscitation. 2011; 82: 69-73Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar locating the site of an incident/emergency and providing feedback on CPR performance.38Semeraro F. Taggi F. Tammaro G. Imbriaco G. Marchetti L. Cerchiari E.L. iCPR: a new application of high-quality cardiopulmonary resuscitation training.Resuscitation. 2011; 82: 436-441Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar4. DefibrillationAutomated external defibrillators using biphasic waveforms continue to dominate the resuscitation literature. Hess and colleagues found that shock success (termination of VF within 5 s post-shock) did not differ between initial and recurrent episodes of VF using a rectilinear biphasic waveform.39Hess E.P. Agarwal D. Myers L.A. Atkinson E.J. White R.D. Performance of a rectilinear biphasic waveform in defibrillation of presenting and recurrent ventricular fibrillation: a prospective multicenter study.Resuscitation. 2011; 82: 685-689Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Several papers explored novel methods to increase early defibrillation in the community by laypeople using AEDs. Scholten et al. sent 3227 SMS-text AED-alerts to 2287 laypersons concerning 52 patients suspected of cardiac arrest.40Scholten A.C. van Manen J.G. van der Worp W.E. Ijzerman M.J. Doggen C.J. Early cardiopulmonary resuscitation and use of automated external defibrillators by laypersons in out-of-hospital cardiac arrest using an SMS alert service.Resuscitation. 2011; 82: 1273-1278Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar Action was taken by only 579 of these laypeople. The principal reasons for non-response were because the laypeople were not in the patient's vicinity (41%) or noticed the alert too late (35%). In 298 alerts, laypeople faced problems with retrieving an AED (51%), finding the victim (29%), or traversing traffic (5%). The SMS-text activated laypeople provided aid to 47 patients, arriving before EMS personnel in 21 patients, starting CPR and defibrillating 18, and assisting EMS personnel in 9 patients. In a similar report, Rea et al. document the value of having an AED registry that can alert emergency dispatchers to the presence of a nearby public access AED that a caller can retrieve and use on a victim while awaiting EMS arrival.41Rea T. Blackwood J. Damon S. Phelps R. Eisenberg M. A link between emergency dispatch and public access AEDs: potential implications for early defibrillation.Resuscitation. 2011; 82: 995-998Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar5. Advanced life support5.1 AirwayThe best airway technique for use during cardiac arrest is unknown and likely to depend on several factors. Wang et al. described tracheal intubation success rate using data from the 2008 National Emergency Medical Services Information System (NEMSIS).42Wang H.E. Mann N.C. Mears G. Jacobson K. Yealy D.M. Out-of-hospital airway management in the United States.Resuscitation. 2011; 82: 378-385Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar Among 4,383,768 EMS activations, there were 10,356 tracheal intubations, 2246 alternate airways (Combitube, laryngeal mask airway (LMA), laryngeal tube (LT), Esophageal-Obturator Airway), and 88 cricothyroidotomies. The overall tracheal intubation success rate was 77.0% (95% CI: 76.1–77.9%), and the alternate airway success rate was 87.2%. In a physician-staffed EMS, difficult pre-hospital tracheal intubation occurred in 13% of cases.43Breckwoldt J. Klemstein S. Brunne B. Schnitzer L. Mochmann H.C. Arntz H.R. Difficult prehospital endotracheal intubation – predisposing factors in a physician based EMS.Resuscitation. 2011; 82: 1519-1524Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar Predisposing factors included lack of space around the victim, or victims with a short neck, obesity, or face and neck injuries.A tracheal rapid ultrasound exam (TRUE) performed during emergency intubation with the transducer placed over the suprasternal notch enables accurate identification of correct tube placement.44Chou H.C. Tseng W.P. Wang C.H. et al.Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube placement during emergency intubation.Resuscitation. 2011; 82: 1279-1284Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 45Zechner P.M. Breitkreutz R. Ultrasound instead of capnometry for confirming tracheal tube placement in an emergency?.Resuscitation. 2011; 82: 1259-1261Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar In 112 patients (17 [15.2%] with oesophageal intubation determined by waveform capnography), the overall accuracy of TRUE was 98.2%, with a median time of 9 s, and no differences were observed between cardiac arrest and non-cardiac arrest patients.Numerous alternatives to tracheal intubation are available. Frascone et al. observed that placement success (ventilation to chest rise, no gastric sounds, bilateral lung sounds, and when applicable, quantitative end-tidal CO2 readings) by paramedics was similar for the disposable laryngeal tube with suction port (LTS-D) and tracheal intubation (tracheal intubation 80.2% vs. LTS-D 80.5%; P = 0.97).46Frascone R.J. Russi C. Lick C. et al.Comparison of prehospital insertion success rates and time to insertion between standard endotracheal intubation and a supraglottic airway.Resuscitation. 2011; 82: 1529-1536Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Another study of OHCA patients, observed that first attempt success rates by basic life support (BLS) first responders using the LT-D were higher than tracheal intubation success rates by paramedics (87.8% vs. 57.6%).47Gahan K. Studnek J.R. Vandeventer S. King LT-D use by urban basic life support first responders as the primary airway device for out-of-hospital cardiac arrest.Resuscitation. 2011; 82: 1525-1528Abstract Full Text Full Text PDF PubMed Scopus (45) Google ScholarWhether the findings of manikin studies of airway devices can be extrapolated to real patients is controversial. The i-gel and LMA-Supreme had the highest first attempt insertion success in a randomized manikin study of 267 medical students using four different supraglottic airway devices (i-gel, LMA-Supreme, LMA-Unique, LMA-ProSeal) or a bag-mask.48Fischer H. Hochbrugger E. Fast A. et al.Performance of supraglottic airway devices and 12 month skill retention: a randomized controlled study with manikins.Resuscitation. 2011; 82: 326-331Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar In another manikin study, 40 EMS technicians with no previous advanced airway management experience, performed airway management, after brief training, with six airway devices (tracheal tube, Combitube, EasyTube, LT, LMA, and i-gel) during on-going chest compressions.49Ruetzler K. Gruber C. Nabecker S. et al.Hands-off time during insertion of six airway devices during cardiopulmonary resuscitation: a randomised manikin trial.Resuscitation. 2011; 82: 1060-1063Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Interruptions to CPR were significantly longer with tracheal intubation that the other devices. Only a third of technicians were successful with tracheal intubation whereas all successfully inserted the other devices.A study to assess LMA use in newborn resuscitation showed improved success compared with bag-mask ventilation with a first attempt LMA insertion success rate of 98.5%.50Zhu X.Y. Lin B.C. Zhang Q.S. Ye H.M. Yu R.J. A prospective evaluation of the efficacy of the laryngeal mask airway during neonatal resuscitation.Resuscitation. 2011; 82: 1405-1409Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 51Gupta S. Laryngeal mask airway for babies: uncharted waters.Resuscitation. 2011; 82: 1373-1374Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar A study of pre-term (<32 weeks gestation) newborn resuscitations that required tracheal intubation showed that colorimetric CO2 detectors can fail to change colour in spite of correct tube placement in up to one third of the cases.52Schmolzer G.M. Poulton D.A. Dawson J.A. Kamlin C.O. Morley C.J. Davis P.G. Assessment of flow waves and colorimetric CO2 detector for endotracheal tube placement during neonatal resuscitation.Resuscitation. 2011; 82: 307-312Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar5.2 Mechanical devicesMechanical devices continue to offer theoretical advantages over manual chest compression, but evidence for clinical benefit continues to be elusive. Several studies documented the value of mechanical chest compression devices in minimizing the hands-off time during resuscitation. Fischer and colleagues found that a team of two trained flight attendant rescuers had significantly less ‘absolute hands-off time’ when they performed CPR on a manikin in a simulated aircraft environment using a manually-powered mechanical device compared to performing compressions manually.53Fischer H. Neuhold S. Hochbrugger E. et al.Quality of resuscitation: flight attendants in an airplane simulator use a new mechanical resuscitation device—a randomized simulation study.Resuscitation. 2011; 82: 459-463Abstract Full Text Full Text PDF PubMed Scopus (15) Google ScholarBonnemeier et al. studied 28 pulseless electrical activity (PEA) patients in a university hospital setting and concluded that continuous chest compression with a Lund University Cardiac Assist System (LUCAS) device proved feasible and safe during transport or diagnostic procedures.54Bonnemeier H. Simonis G. Olivecrona G. et al.Continuous mechanical chest compression during in-hospital cardiopulmonary resuscitation of patients with pulseless electrical activity.Resuscitation. 2011; 82: 155-159Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar However, a 149 patient randomised pilot study conducted in two Swedish cities showed no difference in early survival in patients treated with mechanical LUCAS vs. manual chest compressions.28Smekal D. Johansson J. Huzevka T. Rubertsson S. A pilot study of mechanical chest compressions with the LUCAS device in cardiopulmonary resuscitation.Resuscitation. 2011; 82: 702-706Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar5.3 Extracorporeal life supportUse of extracorporeal circulation to treat selected patients who do not respond to conventional resuscitation is becoming increasingly popular, particularly in Japan. An increasing number of case reports document the feasibility and benefit of this strategy.55Arlt M. Philipp A. Voelkel S. Graf B.M. Schmid C. Hilker M. Out-of-hospital extracorporeal life support for cardiac arrest: a case report.Resuscitation. 2011; 82: 1243-1245Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 56Hagiwara S. Yamada T. Furukawa K. et al.Survival after 385 min of cardiopulmonary resuscitation with extracorporeal membrane oxygenation and rewarming with haemodialysis for hypothermic cardiac arrest.Resuscitation. 2011; 82: 790-791Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 57Lebreton G. Pozzi M. Luyt C.E. et al.Out-of-hospital extra-corporeal life support implantation during refractory cardiac arrest in a half-marathon runner.Resuscitation. 2011; 82: 1239-1242Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar Morimura et al. reviewed case reports, case series and abstracts of scientific meetings of 1282 OHCA patients who received extracorporeal support between 1983–2008 and concluded that this strategy can provide a high survival rate with excellent neurological outcome.58Morimura N. Sakamoto T. Nagao K. et al.Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a review of the Japanese literature.Resuscitation. 2011; 82: 10-14Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar5.4 DrugsAdrenaline (epinephrine) has been a mainstay of cardiac arrest guidelines despite limited evidence for its efficacy. A randomised study comparing adrenaline with placebo is therefore welcome. Jacobs and colleagues studied 534 (262 placebo vs. 272 adrenaline) OHCA patients.59Jacobs I.G. Finn J.C. Jelinek G.A. Oxer H.F. Thompson P.L. Effect of adrenaline on survival in out-of-hosp