The PULSE Study: Paramedic Upgrade and Life Support Evaluation.

The recommendations for electrical therapies described in this section are designed to improve survival from SCA and life-threatening arrhythmias. Whenever defibrillation is attempted, rescuers must coordinate high-quality CPR with defibrillation to minimize interruptions in chest compressions and to ensure immediate resumption of chest compressions after shock delivery. The high first-shock efficacy of newer biphasic defibrillators led to the recommendation of single shocks plus immediate CPR instead of 3-shock sequences that were recommended prior to 2005 to treat VF. Further data are needed to refine recommendations for energy levels for defibrillation and cardioversion using biphasic waveforms.

Part 6: Defibrillation

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 …

ObjectiveSeveral studies have examined the impact of mechanical cardiopulmonary resuscitation (CPR) devices among multi-jurisdictional emergency medical services (EMS) systems; however, the variability across such systems can inject bias and confounding variables. We focused our investigation on the effect of introducing the Lund University Cardiac Assist System 2 (LUCAS-2) into a single basic life support (BLS) fire department first response jurisdiction served by a single private advanced life support (ALS) agency, hypothesizing that the implementation of the device would increase prehospital return of spontaneous circulation (ROSC) rates as compared with manual CPR. MethodsA retrospective observational analysis of adult non-traumatic prehospital cardiac arrest ALS agency records was conducted. Descriptive statistics were computed, and logistic regression was used to assess the impact of CPR method, response time, age, gender, CPR initiator, witnessed status, automated external defibrillator (AED) initiator, and presence of an initial shockable rhythm on ROSC rates. A Chi-square analysis was used to compare ROSC rates among compression modalities both before and after the implementation of LUCAS-2 on July 1, 2011. ResultsFrom an initial dataset of 857 cardiac arrest records, only 264 (74 pre-LUCAS period, 190 LUCAS-2 period) met inclusion criteria for the primary objective. The ROSC rates were 29.7% (22/74) and 29.5% (56/190), respectively, for manual-only and LUCAS-assisted CPR (p=0.9673). Logistic regression revealed a significant association between ROSC and two of the independent variables: arrest witnessed (OR 3.104; 95% CI 1.896-5.081; p<0.0001) and initial rhythm shockable (OR 2.785; 95% CI 1.492-5.199; p<0.0013). ConclusionsAnalyses support the null hypothesis that there is no difference in prehospital ROSC rates among adult non-traumatic cardiac arrest patients when comparing mechanical-assisted and manual-only CPR. These results are consistent with other larger multi-jurisdictional mechanical CPR studies. Systems with limited personnel might consider augmenting their resuscitations with a mechanical CPR device, although cost and system design should be factored into the decision. Secondary analysis of independent variables suggests that prehospital cardiac arrest patients with a witnessed arrest or an initial rhythm that is shockable have a higher likelihood of attaining ROSC. The power of our primary objective was limited by the sample size. Additionally, we were not able to adequately assess the quality of CPR among the two comparison groups with a lack of consistent end-tidal carbon dioxide (EtCO2) data.

IntroductionSudden cardiac arrest is one of the most frequent causes of death in the world. In highly qualified emergency medical service (EMS) systems, including well-trained emergency physicians, spontaneous circulation may be restored in up to 53% of patients at least until admission to hospital. Compared with these highly qualified EMS systems, markedly lower success rates are observed in other systems. These data clearly show that there are considerable differences between EMS systems concerning treatment success following cardiac arrest and resuscitation, although in all systems international guidelines for resuscitation are used. In this study, we investigated the impact of response time reliability (RTR) on cardiopulmonary resuscitation (CPR) incidence and resuscitation success by using the return of spontaneous circulation (ROSC) after cardiac arrest (RACA) scores and data from seven German EMS systems participating in the German Resuscitation Registry.MethodsAnonymised patient data after out-of-hospital cardiac arrest gathered from seven EMS systems in Germany from 2006 to 2009 were analysed with regard to socioeconomic factors (population, area and EMS unit-hours), process quality (RTR, CPR incidence, special CPR measures and prehospital cooling), patient factors (age, gender, cause of cardiac arrest and bystander CPR). End points were defined as ROSC, admission to hospital, 24-hour survival and hospital discharge rate. χ2 tests, odds ratios and the Bonferroni correction were used for statistical analyses.ResultsOur present study comprised 2,330 prehospital CPR patients at seven centres. The incidence of sudden cardiac arrest ranged from 36.0 to 65.1/100,000 inhabitants/year. We identified two EMS systems (RTR < 70%) that reached patients within 8 minutes of the call to the dispatch centre 62.0% and 65.6% of the time, respectively. The other five EMS systems (RTR > 70%) reached patients within 8 minutes of the call to the dispatch centre 70.4% up to 95.5% of the time. EMS systems arriving relatively later at the patients side (RTR < 70%) initiate CPR less frequently and admit fewer patients alive to hospital (calculated per 100,000 inhabitants/year) (CPR incidence (1/100,000 inhabitants/year) RTR > 70% = 57.2 vs RTR < 70% = 36.1, OR = 1.586 (99% CI = 1.383 to 1.819); P < 0.01) (admitted to hospital with ROSC (1/100,000 inhabitants/year) RTR > 70% = 24.4 vs RTR < 70% = 15.6, OR = 1.57 (99% CI = 1.274 to 1.935); P < 0.01). Using ROSC rate and the multivariate RACA score to predict outcomes, we found that the two groups did not differ, but ROSC rates were higher than predicted in both groups (ROSC RTR > 70% = 46.6% vs RTR < 70% = 47.3%, OR = 0.971 (95% CI = 0.787 to 1.196); P = n.s.) (ROSC RACA RTR > 70% = 42.4% vs RTR < 70% = 39.5%, OR = 1.127 (95% CI = 0.911 to 1.395); P = n.s.)ConclusionThis study demonstrates that, on the level of EMS systems, faster ones more often initiate CPR and increase the number of patients admitted to hospital alive. Furthermore, we show that, with very different approaches, all centres that adhere to and are intensely trained according to the 2005 European Resuscitation Council guidelines are superior and, on the basis of international comparisons, achieve excellent success rates following CPR.

Introduction Both out of (OHCA) and in hospital (IHCA) pediatric cardiac arrest has traditionally been considered a futile medical condition with dismal outcomes. This is further magnified by resuscitation protocols are typically articulated from the perspective of ideal resource environment without consideration of applicability in district hospitals or non-tertiary centres. Purpose To determine clinical outcomes from both paediatric OHCA and IHCA in low-resource setting and to identify shortcomings in relation to resuscitation in these areas, possible solutions and to suggest future research priorities. Methods This was a multicenter retrospective study in a middle sized city (estimated population 390000) served by a single Emergency Medical Services (EMS) system. All records of OHCA and IHCA under 16 years old were reviewed from the Cardiac Arrest Registry from 2017 to 2022. Data collected included demographic profiles, etiology of cardiac arrest, initial cardiac rhythm, time of initiation of cardiopulmonary resuscitation (CPR) and adrenaline administration by EMS team and duration of CPR. Outcomes of interest included return of spontaneous circulation (ROSC) and survival to hospital discharge (STHD). Results From the 5-year study period, 68 children (mean age of 5.8±1.2 yrs) were included in this study. 22 (32.4%) were infants (&amp;lt;1 year old) and 7 (10.3%) were neonates (&amp;lt;28 days old). Total mortality was observed at 63.2% (n=43). Return of spontaneous circulation (ROSC) was achieved in 40 (58.8%) patients and 33.8% (n=23) survived to hospital discharge. OHCA was witnessed in 52 (83.8%) children from total OHCA and bystander CPR was delivered only in 19 (30.6%) cases. All IHCA were witnessed. Asystole was the most common (n=39) initial rhythm. A delay in initiating cardiopulmonary resuscitation (CPR) and adrenaline administration was observed in 49 cases of OHCA and 1 in IHCA. The median time from emergency call to CPR and from CPR to first adrenaline administration was 20.9±1.2 min and 2.9±1.3 min for OHCA and 0.4±0.2 min and 1.5±0.7min for IHCA [Table 1]. Longer time to CPR and adrenaline administration was associated with lower chance of achieving ROSC and STHD. Using multivariate analyses, fewer adrenaline doses (p&amp;lt;0.05), witnessed cardiac arrest (p=0.001), initial rhythm of ventricular fibrillation (p&amp;lt;0.05) and shorter CPR duration (p=0.007) were good prognostic factors for ROSC and STHD. Conclusion Outcomes from OHCA and IHCA in low resource settings are poor. Unwitnessed arrest, delays in initiation of CPR and adrenaline administration were associated with poor survival. Recognition and identification of at-risk patients, early high-quality CPR and adrenaline administration are imperative to improve mortality. Early recognition and effective resuscitation protocols for children in the community and encouraging bystander CPR should be developed collaboratively with local experts and the EMS team.

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 …

Factors associated with survival in children with traumatic cardiopulmonary arrest

Out-of-Hospital Pediatric Cardiac Arrest: Where Are We Now and Where Do We Need to Go?

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 …

Introduction: Ventricular fibrillation (VF) is the most common arrhythmia causing out-of-hospital cardiac arrest (OOHCA) and defibrillation remains the mainstay of its treatment. Successful defibrillation is linked to VF morphology characteristics, and is affected by VF duration, quality of cardiopulmonary resuscitation (CPR) and emergency medical service (EMS) responsiveness. This study aimed at comparing VF morphology characteristics and their relationships with patients and EMS characteristics, as well as outcomes, in an Asian community. Method: Electrocardiographic recordings of VF signals from automated external defibrillators (AEDs) in 2008 to 2012 were obtained from OOHCA subjects in Taipei city, a metropolitan with 2.65 million residents in 272km2. Amplitude spectrum analysis (AMSA) and DFAα2 were calculated and compared year by year in the study period. Results: A total of 612 OOHCA subjects with VF were included for analysis. Both DFA and AMSA changed significantly over time (χ 2 for trend: -0.128 for DFA, p&lt;0.01; 0.092 for AMSA, p=0.02). There was no change in gender, age, and bystander CPR rates; however, in later years there were more witnessed arrests, shortened EMS responses, and better sustained (&gt;2 hr) return of spontaneous circulation (ROSC) and neurological outcomes (CPC 1&amp;2). The time trend for DFAα2 (OR 0.98, CI 0.96-0.99, p=0.003), but not for AMSA (OR 1.07, CI 0.99-1.14), remained after adjustment for confounders. Both DFAα2 and AMSA were associated with sustained ROSC (DFA OR 0.08, CI 0.04-0.18, p&lt;0.001; AMSA OR 1.18, CI 1.01-1.38, p=0.03) and CPC 1&amp;2 (DFA OR 0.04, CI 0.01-0.16, p&lt;0.001; AMSA OR 1.30, CI 1.07-1.57, p=0.008) in multiple regression models. Conclusions: DFAα2 and AMSA, two important VF characteristics, changed significantly over time in an Asian community, and were associated with improved outcomes. This might reflect improvement in community chain of survival especially among EMS responses and community quality of CPR.

Do Vasopressors Improve Outcomes in Patients With Cardiac Arrest?

Extracorporeal Cardiopulmonary Resuscitation: Prehospital or In-Hospital Cannulation?

Out-of-hospital cardiac arrest (OHCA) is a public health problem of paramount importance all over the world. Many lives and life-years were lost because prompt basic life support (BLS), including bystander cardiopulmonary resuscitation (CPR) and defibrillation, is not provided in the community. Besides, currently most of the recommendation in BLS applied in our community was adopted from the western countries. Characteristics of OHCAs and composition of emergency medical service (EMS) in Taipei were different from the western sites. Therefore, we conducted a series of studies in three important issues with the knowledge gaps, including (1) the accessibility of bystander-initiated CPR, (2) effectiveness of different BLS pattern, and (3) the screening of salvageable patients for hospital transport. There were three studies included in the series. The first study is a cross-sectional design to assess the association between social determinant and chances of receiving bystander-initiated CPR for patients with cardiac arrest in community. We used the average of real estate price and hosehold income to surrogate the socioeconomic status (SES) of the community. The second study was a randomized control trial to determine the effectiveness of different patterns of BLS (compression first” (CF) versus “analyze first” (AF) strategies) in community of low prevalence of shockable rhythms. The third study was a cohort study to evaluate the applicability of rules for termination of resuscitation (TOR) and to determine whether BLS-TOR rules acceptable as the universal rule in a mixed-tire EMS as in Taipei. The first study revealed that patients who experienced an OHCA in low-SES areas of the city were less likely to receive bystander CPR, and demonstrated worse survival outcomes. The information could guide targeted community training to promote bystander CPR. In the second study, in Taipei City, a population with low rates of shockable rhythms and bystander CPR, there were no differences in sustained return of spontaneous circulation (ROSC) between compressions first vs. analyze first strategy. Considering the EMS operation situation, a period of CPR for up to 10 cycles by paramedic prior to rhythm analysis could be a feasible strategy in this Asian community. In the third study, ALS- and BLS-TOR rules performed well in decreasing unnecessary transport of OHCA patients, and BLS-TOR rule has better performance comparing to ALS TOR rule under all provider combinations in an area with a mixed-tier response EMS system. However, because greater than 1% of those lived would be misclassified as non-survivor by current TOR rules, implementation in this community or other areas with similar characteristics should be cautious. This series of studies provided informative knowledge to current scientific gaps, and would have implication for improving the basic life support for patients with cardiac arrest in our own community.

Team-focused, high-performance cardiopulmonary resuscitation (TF-HP-CPR) improves the return of spontaneous circulation (ROSC) among patients with out-of-hospital cardiac arrest (OHCA) events. In 2010, the American Heart Association began endorsing TF-HP-CPR (). A rural-area Virginia emergency medical services (EMS) system receives assistant medical oversight from an emergency nurse practitioner (ENP). The ENP is responsible for assisting the physician medical director in promoting continuous quality improvement (QI) within the EMS system. In January 2018, a QI project implemented a TF-HP-CPR protocol. The QI project encompassed the provision of education for EMS personnel about TF-HP-CPR with mock code evaluations. The protocol incorporated a newly designated blind insertion airway device and integrated the routine monitoring of end-tidal carbon dioxide (ETCO2) values. The QI project also introduced postresuscitation attempt report cards that were completed by the team leader at the conclusion of each CPR event. A random 16-week sample of patients with OHCA just before implementation of the QI project was analyzed and compared with patients who experienced an OHCA event within a 16-week period after implementation of the TF-HP-CPR protocol. The preimplementation group had 13 patients compared with 11 patients in the postimplementation group. The rate of ROSC in the preimplementation group was 38.46% compared with 54.55% in the postimplementation group. Although the rate of ROSC increased by 16.09%, the findings were not statistically significant (p = 0.6824) and were perceived to be likely due to the small sample sizes. The implementation of a TF-HP-CPR protocol improved the rate of ROSC among patients with OHCA; however, the findings were not statistically significant. A more extensive study is essential for further evaluation.