Advanced Cardiopulmonary Resuscitation Research Articles

The Effectiveness of Electronic Learning and Lecture-Based Education in the Improvement of Interns’ knowledge About Advanced Cardiopulmonary Resuscitation Drug Pharmacology

Background:Conventional educational systems seem to be improper throughout the cardiopulmonary resuscitation (CPR) teaching process. The most common causes of failed resuscitation are unfamiliarity with cardiopulmonary resuscitation algorithms, poor performance of leader of the CPR team and lack of skilled personnel, coordination among members during resuscitation, and responsibility of staff.Objectives:Electronic learning, as a new educational method is controversial issue in medical education for improving physicians’ practical knowledge and it is inevitable that further research on its effectiveness should be done.Materials and Methods:The present study is a prospective, pre- and post-educational, cross-sectional research, in which 84 interns were randomly divided into two groups. pre- and post- educational interventions that took place in the Department of Emergency Medicine, interns were evaluated by 21 multiple choice questions related to American Heart Association guidelineson cardiopulmonary resuscitation drugs. Questions were assessed in terms of routes for CPR drugs administration, CPR drug dosage forms, clinical judgment and appropriate CPR drug administration, and the alternative drugs in emergency situations. Data were analyzed by generalized estimating equations regression models and P < 0.05 was considered statistically significant.Results:Evaluating the effectiveness of both educational methods revealed that the mean answering score for 21 questions before education was 7.5 ± 2.6 and no significant difference was observed in groups (P = 0.55). However, after education, the average scores significantly increased to 11.0 ± 3.9 (P < 0.001). Electronic learning method was not associated with considerable increase in the knowledge of interns in this group compared with the lecture-based group (P = 0.49).Conclusions:No significant differences were observed between electronic learning and lecture-based education in improving interns’ knowledge of CPR drugs.

Preventing ischemic brain injury after sudden cardiac arrest using NO inhalation.

Sudden cardiac arrest is a leading cause of death worldwide [1]. Despite advances in cardiopulmonary resuscitation (CPR) methods, including the introduction of the automatic electrical defibrillator (AED) and therapeutic hypothermia [2, 3], only about 10 % of adult out-of-hospital cardiac arrest (OHCA) victims survive to hospital discharge [4], and the majority of survivors have moderate to severe cognitive deficits 3 months after resuscitation [5]. Resuscitation from cardiac arrest is the ultimate whole body ischemia-reperfusion (I/R) injury affecting multiple organ systems including brain and heart [6]. No pharmacological agent is available to improve outcome from post-cardiac arrest syndrome.

Prehospital Immediate Therapeutic Hypotermia in Galicia: Results and Next Steps

Introduction: Despite mild therapeutic hypothermia (TH) being recommended as a post-resuscitation care by current international resuscitation guidelines, recent evidences have questioned its role. Our objective was to assess the results of immediate TH at the pre hospital level by the Galicia’s Emergencies Medical Service (GEMS) in order to know the potential impact on patient’s outcome. Methods: Observational retrospective study. Patients older than 18 years with a witnessed out-of-hospital cardiac arrest (OHCA), and with recovering of spontaneous circulation (ROSC) after advanced cardiopulmonary resuscitation (CPR) provided by sanitary personnel of the GEMS, between 2005 and 2013 were eligible. The survival and brain function at hospital discharge and one year after OHCA were assessed comparing the patients treated with immediate after ROSC pre hospital mild TH with patients receiving standard care. Results: One hundred ninety one patients were included, 94 (49.2%) with shockable rhythm (VF); 56 (29.3%) received TH; 36 of them (64.3%) with VF. Survival at hospital discharge and 1-year after OHCA was 55.4% and 51.8% in the TH group, versus 28.9% and 22.9% respectively in control group (p<0.001 both). Also, percentage of patients with CPC score 1-2 was higher in the TH group: 80.6% vs. 56.4 at hospital discharge (p<0.05) and 93.10% vs. 70.9% at one year follow-up (p<0.01). TH was an independent predictive factor of long-term survival, both in VF (OR=3.83; 95% CI: 0.40-36.96) as in no-shockable rhythms (OR=3.50; 95% CI: 0.31-39.15). Conclusions: In Galicia, immediate after ROSC pre hospital TH improved survival and functional status at short and long-term, independently of the first recorded ECG rhythm. Although limited, our data have been obtained from the real-life GEMS working conditions and should be considered in before radical modifications of CPR protocols.

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Introduction: Advances in cardiopulmonary resuscitation (CPR) have focused on the generation and maintenance of adequate myocardial blood flow to optimize the return of spontaneous circulation and survival. Much of the morbidity associated with cardiac arrest survivors can be attributed to global brain hypoxic-ischemic injury. Methods: Fiber-optic intracranial pressure and brain tissue oxygen tension (PbtO2) probes were placed in the left frontal cortex prior to induction of VF. After 7 minutes of untreated VF, 3 month old female swine were randomized to receive one of three resuscitation strategies (N = 7 for each group): 1) Hemodynamic Directed Care (CPP-20): chest compressions (CCs) with depth titrated to a target systolic blood pressure of 100 mmHg and titration of vasopressors to maintain coronary perfusion pressures (CPP) > 20 mmHg; 2) Depth 33mm(D33): target CC depth of 33mm with standard ACLS epinephrine dosing; or 3) Depth 51mm(D51 – American Heart Association (AHA) optimal care): target CC depth of 51mm with standard ACLS epinephrine dosing. All animals received manual CPR guided by audiovisual feedback for 10 minutes before first shock. Differences in cerebral perfusion pressures (CerePP) and PbtO2 over time and between groups were evaluated using generalized estimating equations. Results: CerePPs were significantly higher in the CPP-20 group compared to both D33 (p<0.01) and D51 (p=0.046), and higher in survivors compared to non-survivors irrespective of treatment group (p<0.01). Only the CPP-20 group was able to consistently generate CerePPs above 30 mm Hg. PbtO2 was also higher in the CPP-20 group compared to both D33 (p<0.01) and D51 (p=0.013), and higher in survivors compared to non-survivors irrespective of treatment group (p<0.01). CPP and CerePP in the minute epoch immediately prior to defibrillation were well correlated across treatment groups and survival status (R2= 0.66). Conclusions: Hemodynamic directed resuscitation targeting CPPs > 20 mmHg following VF arrest produced cerebral perfusion pressures > 30 mm Hg and improved brain tissue oxygen tension compared to optimal AHA care

Factores de riesgo de hipotermia al ingreso en el recién nacido de muy bajo peso y morbimortalidad asociada

IntroductionHeat loss in the newborn after delivery could interfere with post-natal adaptation due to metabolic and hemodynamic instability. Associated perinatal factors and their relationship with morbidity and mortality during the neonatal period have not been systematically studied in our unit. ObjectivesTo determine the temperature of very low birth weight (VLBW) infants on admission to our NICU, and to determine the associated perinatal variables, and the association of temperature with morbidity and mortality. Patients and methodsInfants born in our maternity from January 2006 to November 2012, with birth weights (BW) 401g to 1,499g and/or less than 30 weeks gestational age, were included. A multivariate analysis was performed using the perinatal variables and the temperature on admission, as well as a logistic regression between these and the morbidity-mortality variables, in order to detect any independent associations. ResultsA total of 635 infants were included, with a mean (±SD) birth weight and gestational age of 1,137.6±257.6g, and 29.5±2.0 weeks, respectively. The mean admission temperature was 35.8±0.6°C (range: 33.0-37.8°C). The proportion of infants with a temperature <36°C was 44.4%. Independently associated perinatal variables were chorioamnionitis, birth weight, vaginal delivery, and advanced cardiopulmonary resuscitation (CPR). Admission hypothermia was associated with severe intraventricular haemorrhage (IVH) (grades 3 and 4) (OR: 0.377; 95% CI: 0.221-0.643; P<.001), and mortality (OR: 0.329; 95% CI: 0.208-0.519; P=.012). ConclusionsHypothermia on admission is frequent among our VLBW infants. Birth weight, vaginal delivery, and advanced CPR were the principal variables associated with hypothermia. A low temperature on admission was related to an increased risk of IVH and mortality.

Influencia de la edad gestacional, el tipo de parto y la reanimación en el riesgo de neumotórax en neonatos mayores de 37 semanas

BackgroundElective caesarean section before 39weeks gestational age (GA) has been associated with a higher incidence of iatrogenic respiratory distress and pneumothorax in term newborn babies, probably because of a higher respiratory morbidity and the need for resuscitation. These factors have not been systematically evaluated in our patients. ObjectiveTo determine whether the gestational age, type of delivery, and intensity of resuscitation, are associated with an increase in the incidence of pneumothorax in term neonates. Patients and methodsFull term neonates (≥37weeks GA) born in our maternity unit from January 2006 to December 2010 were studied, along with the type of delivery (vaginal, forceps or caesarean section). Advanced cardiopulmonary resuscitation (CPR) was defined as the need of bag and mask intermittent ventilation, intubation, chest compression, and/or administration of medication. The diagnosis of pneumothorax was clinical and radiological in all cases. ResultsA total of 32,238 full term newborns were included. Type of delivery: vaginal 76.1%, C-section 12.4%, and forceps 11.5%. The incidence of pneumothorax was 0.316%. It was significantly higher in C-section (0.85%), than in forceps (0.59%), or non-instrumental vaginal deliveries (0.19%) (P<.001), and in infants ≥40weeks GA (0.37%) compared to ≤39weeks GA (0.24%) (P=.033), and in advanced CPR (4.29%) compared to basic CPR (0.18%) (P<.001). ConclusionsA GA≥40 weeks, C-section, or forceps delivery, and advanced CPR immediately after birth were significantly associated with a higher incidence of pneumothorax in full term newborn babies. In our population, we did not observe an increase in pneumothorax among neonates born by elective C-section before 39weeks of gestation.

Outcomes of cardiopulmonary resuscitation efforts in a Greek tertiary hospital

In-hospital cardiac arrest is a leading cause of death and despite recent advances in cardiopulmonary resuscitation, the survival to hospital discharge is poor. The aim of our study was to evaluate the success of resuscitation efforts in a tertiary hospital. We retrospectively collected and analysed data on all patients in whom cardiopulmonary resuscitation was attempted after in-hospital cardiac arrest in one-year period. 96 cardiac arrest victims were studied. Sustained return of spontaneous circulation was achieved in 15 (15.6%) patients, while all of them survived for 24 h. Training in cardiopulmonary resuscitation, initiation of resuscitation efforts in less than 5 min, and intubation time < 1 min after team arrival were predictive factors associated with restoration of spontaneous circulation. Non-certified residents resuscitated 87 (90.6%) patients with 6 (6.8%) of them achieving return of spontaneous circulation and surviving for 24 h. On the contrary, certified ward residents resuscitated nine (9.3%) patients with 100% immediate and 24-h survival. In our hospital, certified providers had remarkably higher successful resuscitation rates for in-hospital cardiac arrest than non-certified providers. This finding suggests that training in cardiopulmonary resuscitation, continuing medical education, and implementation of the existing legislation will result in increased survival.

Acute harm: unplanned extubations and cardiopulmonary resuscitation in children and neonates

Dear Editor, Invasive mechanical ventilation is a common therapy used for children and infants in the intensive care unit (ICU). The impact of unplanned extubation (UE) on morbidity and mortality in adults is well described [1, 2]. There remains a paucity of data related to the cardiovascular morbidity associated with UE events in children. Following review and approval by the institutional review board in accordance and compliance with international ethics standards, we performed a retrospective database review of all UE events in patients admitted to the neonatal, pediatric or cardiac ICU at our institution between July 2011 and December 2012. UE was defined as the removal of an endotracheal tube in a mechanically ventilated patient which was not directed or ordered by a licenced independent practitioner. Cardiovascular collapse was defined as the need for cardiopulmonary resuscitation (e.g., external chest compressions) or circulatory dysfunction immediately following the UE event. Patients with tracheostomies were excluded from our analysis. Preliminary data were presented at the Pediatric Academic Societies’ and Asian Society for Pediatric Research Joint Meeting in Denver, Colorado in 2011 [3]. There were 119 UE events involving 95 unique patients, and the UE rate (events/100 ventilator days) was 0.5. Cardiovascular collapse occurred in 24 events (20 %), of which 20 involved initiation of cardiopulmonary resuscitation. Four events were characterized by circulatory dysfunction requiring immediate re-intubation without initiation of cardiopulmonary resuscitation. There was no immediate mortality associated with these events. We compared UE event characteristics stratified by presence or absence of cardiovascular collapse (Table 1). Immediate re-intubation was performed in 75 (63 %) events and was more likely in patients with cardiovascular collapse (p = 0.01). Cardiovascular collapse was more likely in younger patients (p = 0.048). It has been recognized for some time that UE carries with it significant morbidity increasing the risk of nosocomial infection and length of mechanical ventilation and ICU stay [1]. This is the first study that we are aware of that assesses the frequency of cardiovascular morbidity associated with UE in children. While much of the cardiovascular morbidity occurred in our neonatal population, our data suggest that unplanned extubations in critically ill children and neonates can lead to previously unrecognized morbidity. Despite recent advances in cardiopulmonary resuscitation and extracorporeal membrane oxygenation, in-hospital cardiac arrest portends poor outcomes with survival to discharge rates hovering around 25 % [4]. Our study is limited by the lack of long-term followup data to assess the impact of UE on mortality. However, our data do suggest there is potential for increased mortality associated with UE events. In conclusion, the frequency of cardiovascular morbidity in children

Preparation for Cardiopulmonary Resuscitation in Medical Schools in Australia: A Survey of Current Practice

Introduction. Cardiopulmonary resuscitation (CPR) is acknowledged worldwide as a stressful clinical activity for all young doctors. The extent of standardisation of preparation for CPR within Australian curricula is unknown. Recent trends in the UK suggest the emergence of a common endpoint, Immediate Life Support (ILS) certification. The support for a similar shared endpoint in Australia is unknown. Methodology. A telephone questionnaire survey about the preparation for teaching CPR to medical students was undertaken in all Australian medical schools in early 2012; 88% of schools replied. Results. The majority favoured early basic CPR training. There was marked variation in how schools taught advanced CPR and how CPR competence was assessed. Only one school considered their graduates to be less than well prepared for CPR and all schools agreed that a common endpoint was desirable. Discussion. There is broad support for Immediate Life Support as a common end in resuscitation competence. Medical schools where students are prepared for a rural placement on graduation may still require a higher standard of competence.

Embolia de líquido amniótico que debuta como asistolia durante el trabajo de parto

Amniotic fluid embolism (AFE) is infrequent in pregnancy or the postpartum, but the consequences can be devastating for both the mother and the fetus. We report the case of a 35-year-old primipara with sudden cardiac arrest during labor. Advanced cardiopulmonary resuscitation and peri-mortem cesarean section were performed. The clinical course was poor with multiple cardiovascular complications and severe coagulopathy, requiring hysterectomy. The patient died at 8 days and the neonate at 5 days. According to the most recent broad population-based studies, the incidence of AFE is between 1/15000 and 1/50000 childbirths, with mortality that is classically around 60-80%. Treatment is largely based on support measures and symptomatic treatment. The principal complications are hemorrhagic, cardiovascular and respiratory. Advanced life support measures should be started as soon as possible, aiming to maintain oxygen supply and circulation and arrest coagulopathy.

Updates in Pediatric Resuscitation: Recent Advances and Current Concepts

Pediatric cardiac arrest is a rare condition generally associated with a low likelihood of neurologically intact survival. In pediatrics, cardiopulmonary resuscitation (CPR) has traditionally focused on the management of the airway and restoration of adequate ventilation. Recent advances in the understanding of resuscitation physiology and technology have dramatically changed the landscape for pediatric resuscitation. As is often the case, old habits die hard—global adoption of these newer concepts has been slow and incomplete. This article summarizes the recent advances in CPR, addressing both resuscitative and post-resuscitative care.

Wiedza personelu ratownictwa medycznego z zakresu zaawansowanych zabiegów resuscytacyjnych u dzieci

IntroductionThe performance of the cardiopulmonary resuscitation (CPR) on children differs from a performance on the adults. Procedure standards in a case of a circulatory arrest, which are changing every few years, require constant improvement of the level of knowledge from the medical personnel. AimThe purpose of the study was to evaluate a knowledge of the life-saving medical personnel of the advanced cardiopulmonary resuscitation procedures on children. Material and methodThe survey was performed on a group of 270 life-saving medical personnel workers. Having in mind their practiced professions, three groups had been created: doctors (n=50), nurses (n=62) and paramedical practitioners (n=158). A questionnaire survey was used in order to obtain the results. ResultsThe term „resuscitation” was known among 100% of doctors, among 100% of the paramedical practitioners and among only 84% of the nurses. The following issues were insufficiently known among the nurses: an estimation of the child's weight (52–76%), a second dose of Amiodaron given during the child's resuscitation (47–86%), volume of fluids during the performance of the fluid resuscitation (48–86%). ConclusionAmong the above mentioned three groups on which a survey was performed, nurses were the least trained in order to perform a child's resuscitation. Low level of knowledge of the advanced resuscitation procedures was presented by nurses. Courses of the advanced resuscitation procedures on children are to be held regular and performing skills as well as a knowledge of the CPR among life-saving medical personnel are to be put under verification.

Out-hospital donors after cardiac death in Madrid, Spain: A 5-year review

The Medical Emergencies Service of Madrid (Spain) (Servicio de Urgencias Medicas de Madrid), SUMMA112, forms part of an organ donor program involving patients who have suffered out-hospital cardiac arrest and fail to respond to advanced cardiopulmonary resuscitation maneuvers. Subjects meeting the inclusion criteria are moved to a transplant unit under sustained resuscitation maneuvering in order to harvest the organs. This paper presents compliance with the timelines of the program, the proportion of donors, the characteristics of donors and non-donors, and the number of organs obtained. A retrospective descriptive study was made based on the review of case histories. The SPSS(©) version 16.0 statistical package was used for data analysis. A total of 214 cases were recorded, of which 84% were males. The mean age was 40 years. The mean time to arrival on scene was 13 min and 34 s. The mean time to arrival in hospital was 88 min and 10 s. A total of 522 organs and tissues were harvested (250 kidneys, 33 livers, 123 corneas, 97 bone tissues and 19 lungs), corresponding to 3.2 organs/tissues per patient on average. A total of 21.7% of the patients were not valid. There were no differences between the valid and non-valid patients in terms of age and gender. The causes of non-donation included extracorporeal circuit failure (6.3%), family refusal (15.6%), patient refusal expressed in life (4.7%), legal denial (1.6%), biological causes (51.6%), and others (20.3%). Cardiac compressors were used in 85 cases, yielding 92 kidneys, 41 corneas, 30 bone tissues, 19 livers and 9 lungs, corresponding to 2.1 organs/tissues per patient on average. This program affords a very important number of organs for transplantation. Further studies are needed to assess the efficacy of mechanical cardiac compressor use in generating more organs.

Fatal stress-induced cardiomyopathy in a young patient treated with adrenomimetics

Sirs: Stress-induced cardiomyopathy (SIC), also known as Takotsubo cardiomyopathy, is characterized by potentially reversible extensive left ventricular (LV) akinesia. The typical presentation is that of an akinetic ballooning apex with hypercontractile basal segments. Post-menopausal women are the typical patients [1]. Excessive levels of catecholamines are believed to directly or indirectly cause cardiac dysfunction [2] and exogenously administered b-mimetics may trigger SIC [3]. Extrapolation of positive inotropic treatment strategies used in other forms of acute heart failure to SIC may therefore provide an additional catecholamine load on the heart and may be detrimental. We present a fatal case of stress-induced cardiomyopathy in an 18-year-old man with Aspergers syndrome in whom the cardiac dysfunction may have been iatrogenically exacerbated by repeated administration of inotropic agents. The patient was found unconscious and hypothermic in the vicinity of a demolished car 1 day after expressing suicidal thoughts. Trauma CT displayed subarachnoidal bleeding and an instable C2 fracture without any signs of dislocation. No injuries were found on CT examination of the thorax, abdomen or pelvis. The patient was admitted to the intensive care unit and kept sedated for 4 days. During this time intracranial pressure remained stable and no new pathology was detected on follow-up CT examination. He was then tracheotomized and transferred to the neurosurgical department where he remained stable on 25 % oxygen and positive pressure ventilation. The patient regained consciousness after 10 days. After an additional 12 days, a plan for neurorehabilitation care was initiated; but 3 days later when the patient had remained conscious and hemodynamically stable for a total of 15 days, he became septic and a pneumonic picture was seen on X-ray. Inotropic treatment (noradrenaline and dopamine) was started to prevent hypotension and antibiotic treatment was initiated. The patient soon developed ST segment depression and ventricular arrhythmias, including several episodes of spontaneously terminating ventricular fibrillation. He was defibrillated three times. Intermittent ventricular arrhythmias persisted for 30 min, after which the patient received amiodarone and heart rhythm was stabilized. Bedside transesophageal echocardiography revealed an almost globally hypokinetic left ventricle with normally contracting myocardium only in the basal regions of the left ventricle and an estimated ejection fraction of 20–30 % (Fig. 1). Coagulation parameters were stabilized and the patient received i.v. colloids and further inotropic support (noradrenaline). 5 h later, a pulmonary artery catheter was inserted and yielded cardiac output of 4.5 L/min and systemic vascular resistance 600 dyns/cm, i.e., cardiac output appeared to be near normal despite an echocardiographically estimated ejection fraction of only 20 %. The patient received further inotropic support in the form of adrenaline and rapidly developed severe heart failure and cardiogenic shock which terminated in ventricular fibrillation. Advanced cardiopulmonary resuscitation (CPR) was initiated and repeated boluses of adrenaline were administered. However, the patient progressed into circulatory collapse and echocardiography displayed an almost completely akinetic left ventricle. CPR was aborted and the patient was declared dead. B. Redfors (&) Y. Shao E. Omerovic Wallenberg Laboratory, Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden e-mail: Bjorn.redfors@wlab.gu.se

Protocols for uncontrolled donation after circulatory death

Organ shortages have led some countries, including Spain, France, and the USA, to start programmes of uncontrolled donation after circulatory death. 1 Wall SP Kaufman BJ Gilbert AJ et al. Derivation of the uncontrolled donation after circulatory determination of death protocol for New York City. Am J Transplant. 2011; 11: 1417-1426 Crossref PubMed Scopus (58) Google Scholar In these protocols, donors are people who have had unexpected out-of-hospital cardiac arrest. After ordinary life support attempts (30 min of advanced cardiopulmonary resuscitation [CPR]) by an emergency medical service are judged futile, patients are transported to the hospital with continuing mechanical chest compression and other interventions to preserve the organs, and declared dead at the hospital after a no-touch period of asystole (usually 5 min). Then, normothermic extracorporeal membrane oxygenation (ECMO) or in-situ cooling is started to preserve the organs until authorisation for donation is given by the family. 1 Wall SP Kaufman BJ Gilbert AJ et al. Derivation of the uncontrolled donation after circulatory determination of death protocol for New York City. Am J Transplant. 2011; 11: 1417-1426 Crossref PubMed Scopus (58) Google Scholar

Basic and advanced paediatric cardiopulmonary resuscitation – Guidelines of the Australian and New Zealand Resuscitation Councils 2010

Guidelines for basic and advanced paediatric cardiopulmonary resuscitation (CPR) have been revised by Australian and New Zealand Resuscitation Councils. Changes encourage CPR out-of-hospital and aim to improve the quality of CPR in-hospital. Features of basic CPR include: omission of abdominal thrusts for foreign body airway obstruction; commencement with chest compression followed by ventilation in a ratio of 30:2 or compression-only CPR if the rescuer is unwilling/unable to give expired-air breathing when the victim is 'unresponsive and not breathing normally'. Use of automated external defibrillators is encouraged. Features of advanced CPR include: prevention of cardiac arrest by rapid response systems; restriction of pulse palpation to 10 s to diagnosis cardiac arrest; affirmation of 15:2 compression-ventilation ratio for children and for infants other than newly born; initial bag-mask ventilation before tracheal intubation; a single direct current shock of 4 J/kg for ventricular fibrillation (VF) and pulseless ventricular tachycardia followed by immediate resumption of CPR for 2 min without analysis of cardiac rhythm and avoidance of unnecessary interruption of continuous external cardiac compressions. Monitoring of exhaled carbon dioxide is recommended to detect non-tracheal intubation, assess quality of CPR, and to help match ventilation to reduced cardiac output. The intraosseous route is recommended if immediate intravenous access is impossible. Amiodarone is strongly favoured over lignocaine for refractory VF and adrenaline over atropine for severe bradycardia, asystole and pulseless electrical activity. Family presence at resuscitation is encouraged. Therapeutic hypothermia is acceptable after resuscitation to improve neurological outcome. Extracorporeal circulatory support for in-hospital cardiac arrest may be used in equipped centres.

Mechanical assistance of the circulation during cardiogenic shock

Cardiogenic shock still has a grave prognosis. We present the recent advances in mechanical circulatory support (MCS) for the treatment of refractory cardiogenic shock. The contraindications for short-term MCS in rapid-onset cardiogenic shock are becoming fewer and the threshold for its application has been progressively lowered. Short-term MCS is increasingly used in refractory cardiac arrest and will be probably integrated as the last means in the advanced cardiopulmonary resuscitation algorithm (provided there is experienced team and technical support). Improved device technology has contributed to improved results of long-term MCS. Emergent application of long-term MCS in patients with critical cardiogenic shock after a long history of progressively deteriorating end-stage chronic heart failure should be interpreted as delayed application associated with increased mortality. Although MCS can be life saving in cardiogenic shock, the results are still suboptimal. Mortality is associated with the critical presupport state and the adverse events during MCS. Early initiation of support that meets the patient's requirements, potent support in the early phase, adverse event prevention, global combined management (surgical, interventional, medical), balanced support duration, bridging to further therapeutic modalities including heart transplantation or longer-term support, and advanced technology could offer improved results.

Toracotomía de urgencia. Indicaciones, técnica quirúrgica y resultados

Emergency thoracotomy is a surgical technique that has been extended in the last few years, and is currently included in advanced cardiopulmonary resuscitation protocols. Despite its proven use in patients with penetrating heart wounds, it is often not used due to lack of knowledge of the technique. Currently, the increase in chest wounds due to violence, traffic accidents, crashes or suicides, and advances in extra-hospital medical care systems, has currently awakened new interest in this technique. A review of emergency thoracotomy is presented in this article: indications, surgical technique, results, and its usefulness in the extra-hospital setting.

Advances in Cardiopulmonary Resuscitation

This article focuses on important advances in the science of cardiopulmonary resuscitation in the last decade that have led to a significant improvement in understanding the complex physiology of cardiac arrest and critical interventions for the initial management of cardiac arrest and postresuscitation treatment. Special emphasis is given to the basic simple ways to improve circulation, vital organ perfusion pressures, and the grave prognosis of sudden cardiac death.

Reanimación cardiopulmonar y Du-26. A propósito de un caso

A case of a patient in cardiac arrest, after suffering a myocardial infarction, is presented. Pulseless electrical activity (PEA) is showed by the electrocardiogram. 65 minutes after performing advanced cardiopulmonary resuscitation (CPR) maneuvers, PEA persisted, so we decided to stop the CPR. At that time, an intense stimulation on Governing Vessel 26 (GV-26) was done, and the rhythm turned into ventricular fibrillation (VF). Taking advantage of the induced period of VF due to GV-26 stimulation, the patient could be defibrillated, and recovered the native circulation.