Cardiopulmonary Resuscitation Research Articles

Interactive Serious Game to Teach Basic Life Support Among Schoolchildren in Brazil: Design and Rationale.

Cardiovascular diseases are leading causes of death and morbidity worldwide. CPR and early defibrillation significantly enhance survival rates. Serious Games (SG) improve learning through entertainment. Current strategies target Cardiopulmonary resuscitation for communities and schoolchildren, but none have been validated for children in low-to-middle-income settings. The SG Children Save Hearts, developed in Brazil, teaches the five resuscitation steps according to International Liaison Committee on Resuscitation 2020 guidelines and requires formal usability assessment. The study aimed to evaluate the usability of SG Children Save Hearts among IT and healthcare professionals using the System Usability Scale (SUS). The usability test was conducted in August 2022 in the university's IT department. The game was developed targeting schoolchildren aged 7 to 17. Categorical variables as absolute and relative frequencies, while continuous variables were presented as median with interquartile range (IQR). Normality was assessed using the Shapiro-Wilk test. Comparisons between IT and healthcare professionals were made using the independent t-test for normal distributions or the Mann-Whitney U test for non-normal distributions. We included 17 volunteers with a mean age of 22 years (IQR 20-26). All participants played the game and completed a 10-question survey on its usability using a Likert-type scale. The final grade was converted to a 0 to 100 scale, with a grade above 70 considered acceptable for a minimum viable product. The mean SUS score was 75 (IQR 72.5-87.5). Healthcare professionals gave higher grades to all five domains compared to IT professionals. The average time spent playing the game was 3.2 minutes. Novel technologies have shown promising results for CPR teaching using active teaching methods, but face challenges in developing countries, such as language barriers, device acquisition, cultural differences, and technical support. To our knowledge, this is the first SG developed in portuguese for brazilian schoolchidren. Despite some usability issues, the SG Children Save Hearts is considered adequate for teaching CPR to schoolchildren in Brazil.

Survival After Extracorporeal Cardiopulmonary Resuscitation Based on In-Hospital Cardiac Arrest and Cannulation Location: An Analysis of the Extracorporeal Life Support Organization Registry.

Explore whether extracorporeal cardiopulmonary resuscitation (ECPR) mortality differs by in-hospital cardiac arrest location and whether moving patients for cannulation impacts outcome. Retrospective cohort study. ECPR hospitals that report data to the Extracorporeal Life Support Organization (ELSO). Patients having ECPR for in-hospital cardiac arrest between 2020 and 2023 with data in the ELSO registry. None. Patient demographics, comorbidities, pre-cardiac arrest conditions, pre-ECPR vasopressor use, cardiac arrest details, ECPR cannulation information, major complications, and in-hospital mortality were recorded. Multivariable logistic regression model was used to examine the associations between in-hospital mortality and 1) cardiac arrest location and 2) moving a patient for ECPR cannulation. A total of 2515 patients met enrollment criteria. The adjusted odds ratio (aOR) for mortality was increased in patients who had a cardiac arrest in the ICU (aOR, 1.85; 95% CI, 1.45-2.38; p < 0.001) and in patients who had a cardiac arrest in an acute care bed (aOR, 1.68; 95% CI, 1.09-2.58; p = 0.02) compared with the cardiac catheterization laboratory. Moving a patient for cannulation had no association with mortality (aOR, 0.70; 95% CI, 0.18-2.81; p = 0.62). Advanced patient age was associated with increased mortality. Specifically, patients 60-69 and patients 70 years old or older were more likely to die compared with patients younger than 30 years old (aOR, 1.71; 95% CI, 1.17-2.50; p = 0.006 and aOR, 2.27; 95% CI, 1.49-3.48; p < 0.001, respectively). ECPR patients who experienced cardiac arrest in the ICU and in acute care hospital beds had increased odds of mortality compared with other locations. Moving patients for ECPR cannulation was not associated with improved outcomes.

Pediatric Extracorporeal Membrane Oxygenation in Restrictive and Hypertrophic Cardiomyopathy: A Single Center Experience

Patients with restrictive cardiomyopathy (RCM) and hypertrophic cardiomyopathy (HCM) were previously considered poor candidates for mechanical circulatory support due to technical limitations related to restrictive ventricular physiology and small ventricular size, limiting the ability to provide adequate flows and decompress the heart. Literature examining use of extracorporeal membrane oxygenation (ECMO) in this population consists of a single case series reporting no survivors. We report our experience providing ECMO in children with RCM or HCM at a large pediatric quaternary cardiac center. Between 2012 and 2022, five patients (four RCM, one HCM) were supported with seven ECMO runs. All patients were cannulated to ECMO with ongoing cardiopulmonary resuscitation. Four patients survived decannulation from ECMO (median support time 209 hr, interquartile range [IQR]: 48–265), of which three (60%) survived to hospital discharge after transitioning to a ventricular assist device (VAD) and undergoing orthotopic heart transplant (OHT). Two remain alive at long-term follow-up with normal or mildly impaired functional status. These findings suggest that while RCM and HCM have traditionally been considered contraindications to ECMO due to adverse outcomes, this population may be successfully supported with ECMO with survival comparable to international registry outcomes in select centers where VAD as a bridge to OHT is available.

ECPR-the evolving role in cardiac arrest.

Extracorporeal cardiopulmonary resuscitation (ECPR) describes the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) to restore blood circulation in patients during refractory cardiac arrest. So far, ECPR is not the standard of care but has become part of clinical routine for select patients in many places. As ECPR is ahighly invasive support option associated with considerable risks for fatal complications, premature use in patients who may have return of spontaneous circulation should be avoided. However, the selection criteria for ECPR are still evolving, as the search for evidence is ongoing. Recent randomized controlled trials of different ECPR strategies support its use within integrated systems built around highly specialized ECPR centers. The ECPR caseload is an important predictor of patient survival, and continuous training is key for evidence-based quality of care. Typical complications after ECPR include vascular injury or malposition of cannulas, thrombotic complications, hemolysis, and bleeding events that require early detection and interdisciplinary management. When provided by highly specialized and well-trained expert teams in dedicated ECPR centers within integrated pre-hospital and intra-hospital emergency care systems, ECPR may improve survival in select patients with refractory cardiac arrest. This article is freely available.

Effect of cardiopulmonary resuscitation on perfusion in a porcine model of severe hemorrhagic shock.

Pulseless electrical activity from hemorrhagic shock has not been shown to benefit from cardiopulmonary resuscitation (CPR). Using a porcine model, our objective was to determine the effects of CPR on brain and skin oxygenation as a measure of perfusion in the setting of severe hemorrhagic shock. Adult swine randomized to non-CPR and CPR were anesthetized. Tissue oxygen sensors were inserted into the parietal cerebral parenchyma and skin. Controlled hemorrhagic shock with mean arterial pressure (MAP) <30 mm Hg was achieved and allowed to persist for 10 minutes. Animals were randomized to either receive automated CPR or no treatment. They were then autotransfused with sufficient blood to achieve MAP >60 mm Hg. Measurements were obtained before, during, and after shock state. Outcomes were modeled using mixed-effects lognormal models. A total of 12 swine were used, and the results were analyzed (non-CPR, n = 5; CPR, n = 7). One animal in the CPR group died during shock. One cerebral probe sensor malfunctioned, and these data were excluded. Baseline characteristics were similar between groups. MAP during shock was similar between groups; however, the CPR group had significantly higher systolic blood pressure (62.8 vs. 48.8 mm Hg, p = 0.010) and lower diastolic blood pressure (12.8 vs. 27.8 mm Hg, p < 0.001). Both cerebral (pBO2) and skin oxygenation (TcO2) dropped significantly as a result of shock. The CPR group had lower overall measures of tissue perfusion during shock, but only TcO2 at the shoulder was significantly lower during shock (11.5 vs. 21.1 mm Hg, p = 0.027) and recovery (33.3 vs. 62 mm Hg, p = 0.033). Our model showed that adding CPR during hemorrhagic shock did not improve end-organ oxygenation/perfusion, but did significantly diminish skin perfusion. This experiment corroborates existing literature on the potential detrimental effects of CPR during hemorrhagic pulseless electrical activity, but further work is needed to confirm this observation.

Empowering Medical Students by Facilitating Cardiopulmonary Resuscitation Training for Their Peer

Cardiopulmonary Resuscitation (CPR) training is an essential component of medical education, equipping students with life-saving skills to respond effectively in emergencies. Following a CPR training program, this study investigates the impact of medical students’ knowledge and confidence levels as they facilitate hands-on CPR sessions for their peers. Through a review of literature and empirical analysis, this research elucidates the benefits of peer-assisted learning in CPR education. Results indicate a significant improvement in both knowledge and confidence levels among facilitators following the CPR training program. Overall, the findings highlight the invaluable role of medical student facilitators in enhancing CPR training outcomes and fostering a culture of peer support and empowerment within the medical community. This study underscores the significance of integrating peer-assisted learning strategies into CPR education programs, providing medical students with opportunities for both personal and professional growth. By leveraging the expertise and enthusiasm of medical student facilitators, educators can enhance the effectiveness and sustainability of CPR training initiatives, ultimately contributing to improved patient outcomes and community resilience in emergencies.

Inhaled Argon Dilates Pulmonary Vasculature in Rat Isolated Lungs.

During cardiopulmonary resuscitation, pulmonary vasoconstriction due to hypoxia and hypercarbia restricts blood flow from the right to the left heart, resulting in reduced cardiac output that further inhibits adequate oxygenation and the ability to distribute oxygenated blood and medications. An inhaled pulmonary vasodilator could attenuate vasoconstriction and, therefore, increase cardiac output. We used rat isolated lungs to test if inhaled Argon leads to pulmonary vasodilation in phenylephrine-treated lungs. Lungs of 13 adult male Sprague Dawley rats were isolated, ventilated, and perfused. Pulmonary artery and left atrium were cannulated and lungs perfused at constant flow with 4% albumin physiological saline solution. Controls (n=6) were ventilated with 65% N2, 5% CO2, 30% O2 and Argon lungs (n=7) with 65% Argon, 5% CO2, 30% O2. Pulmonary mean arterial pressure (pMAP) and airway pressure (AWP) were recorded continuously, and pulmonary vascular resistance (PVR) was calculated. Following baseline readings, phenylephrine, a pulmonary vasoconstrictor, was perfused at increasing concentrations from 10-7 M to 10-3 M every 5 min. Statistics: Student's t-Test, α=0.05. Argon led to significantly lower pMAPs and PVRs, independent of AWP. Thus, it significantly dilated pre-constricted pulmonary vessels in an ex-vivo lung model. When given during resuscitation, this might aid to increase cardiac output.

Veno-arterial extracorporeal membrane oxygenation uses in trauma: a retrospective analysis of the Japanese nationwide trauma registry.

Extracorporeal membrane oxygenation (ECMO) can provide temporary circulatory support and vital organ oxygenation and is potentially useful as a bridge therapy in some trauma cases. We aimed to demonstrate the characteristics and outcomes of patients with trauma treated with veno-arterial ECMO (V-A ECMO) using data from a Japanese nationwide trauma registry. This retrospective descriptive study analyzed data from the Japan Trauma Data Bank between January 2019 and December 2021. Patients with severe trauma (injury severity score [ISS] ≥ 9) and treated using V-A ECMO were assessed. Among the 72,439 patients with severe trauma, 51 received V-A ECMO. Sixteen patients (31.3%) survived until hospital discharge. On hospital arrival, six (37.5%) survivors and 15 (42.9%) non-survivors experienced cardiac arrest. The median ISS for the survivor and non-survivor group was 25 (range, 25-39) and 25 (range, 17-33), respectively. Thoracic trauma was the most common type of trauma in both groups. In the non-survivor group, open-chest cardiopulmonary resuscitation, aortic cross-clamping, and resuscitative endovascular balloon occlusion of the aorta were performed in 10 (28.6%), 5 (14.3%), and 4 (11.4%) patients, respectively. However, these procedures were not performed in the survivor group. Peripheral oxygen saturation tended to be lower in the survivor group both before and upon arrival at the hospital. The results of this study suggest the potential benefit of V-A ECMO in some challenging trauma cases. Further studies are warranted to assess the indications for V-A ECMO in patients with trauma.

The Route to ROSC: Evaluating the Impact of Route and Timing of Epinephrine Administration in Out-of-Hospital Cardiac Arrest Outcomes

Objectives Previous investigations comparing intraosseous (IO) and intravenous (IV) epinephrine delivery in out-of-hospital cardiac arrest (OHCA) suggest that epinephrine is oftentimes more expeditiously administered via the IO route, but this temporal benefit doesn’t always translate to clinical benefit. However, very few studies adequately controlled for indication and resuscitation time biases, making the influence of first epinephrine route on OHCA outcomes unclear. To determine the association between first epinephrine route and return of spontaneous circulation (ROSC) while controlling for resuscitation time bias and other potential confounders. Methods We conducted a retrospective analysis using the 2020 ESO Data Collaborative dataset. Adult patients with a witnessed, non-traumatic OHCA prior to EMS arrival were included. Logistic regression was used to determine the association between medication route and ROSC. Linear regression was then used to calculate the probability of ROSC for each route across all call receipt-to-drug delivery intervals. Using these linear equations, the call receipt-to-drug delivery intervals were calculated that would yield equivalent probabilities of ROSC between the IV and IO routes. Results Data were available for 10,350 patients, of which 27.4% presented with a shockable rhythm, 29.7% received bystander CPR, and 39.6% experienced ROSC. After controlling for confounders, IO epinephrine was associated with decreased likelihood of ROSC (OR = 0.77, p < 0.001). The linear regression models provided differing slope coefficients for ROSC between each route, with the IV route associated with a higher likelihood of ROSC for any given call receipt-to-drug-delivery interval. From these equations, the additional time allowed to establish an IV and administer epinephrine intravenously beyond the time required for IO delivery, yet with an equivalent predicted probability of ROSC via the IO route, was calculated. This additional time interval for intravenous administration declined linearly from 9 min at a call receipt-to-intraosseous epinephrine interval of 4 min to no additional time at a call receipt-to-intraosseous epinephrine interval of 29 min. Conclusions This retrospective analysis of a national EMS database revealed that IO epinephrine was negatively associated with ROSC. Additionally, there appears to be a finite time window during which intravenous epinephrine remains superior to the intraosseous route even if there are brief initial delays in IV drug delivery.

The Role of Different Feedback Devices in the Survival of Patients in Cardiac Arrest: Systematic Review with Meta-Analysis

Background: Cardiac arrest is a critical condition affecting approximately 1 in every 1000 people in Europe. Feedback devices have been developed to enhance the quality of chest compressions during CPR, but their clinical impact remains uncertain. This study aims to evaluate the effect of feedback devices on key clinical outcomes in adult patients experiencing both out-of-hospital (OHCA) and in-hospital cardiac arrest (IHCA). The primary objective is to assess their impact on the return of spontaneous circulation (ROSC); secondary objectives include the evaluation of neurological status and survival to discharge. Methods: A systematic review was conducted following PRISMA guidelines, utilizing databases including PubMed, Scopus, Web of Science, and Embase. Studies published between 2000 and 2023 comparing CPR with and without the use of feedback devices were included. A fixed-effects network meta-analysis was performed for ROSC and survival, while a frequentist meta-analysis was conducted for neurological outcomes. Results: Twelve relevant studies met the inclusion criteria. The meta-analysis results showed that the use of audiovisual feedback devices significantly increases the likelihood of ROSC (OR 1.26, 95% CI 1.13–1.41, p &lt; 0.0001) and survival (OR 1.52, 95% CI 1.27–1.81, p &lt; 0.0001) compared to CPR without feedback. However, the effect of metronomes did not reach statistical significance. Conclusions: Feedback devices, particularly audiovisual ones, are associated with improved clinical outcomes in cardiac arrest patients. Their use should be encouraged in both training settings and real-life emergency scenarios to enhance survival rates and ROSC. However, further studies are needed to confirm long-term impacts and to explore the potential benefits of metronomes.

Proportional Versus Fixed Chest Compression Depth for Guideline-Compliant Resuscitation of Infant Asphyxial Cardiac Arrest

ABSTRACT OBJECTIVES Current guidelines for parameters of the delivery of chest compressions (CC) for infants and children are largely consensus based. Of the two recommended depth targets – 1.5 inches and 1/3 anterior-posterior chest diameter (APD) – it is unclear whether these have equal potential for injury. In previous experiments, our group showed in an animal model of pediatric asphyxial out-of-hospital cardiac arrest (OHCA; modeling ∼ 7 year-old children) that 1/3 APD resulted in significantly deeper CC and a higher likelihood of life-threatening injury. We sought to examine and compare injury characteristics of CC delivered at 1.5 inches or 1/3 APD in an infant model of asphyxial OHCA. METHODS Swine were sedated, anesthetized, paralyzed, intubated through direct laryngoscopy, and then mechanically ventilated (10ml/kg, FiO2:21%). APD was measured and confirmed by two investigators via a sliding T-square at the xiphoid. After instrumentation for vital signs monitoring, and while still anesthetized, the endotracheal tube was manually occluded to induce asphyxia, and occlusion was maintained for 9 minutes. Animals were then randomized to receive CC with a depth of 1.5 inches (Group 1) or 1/3 APD (Group 2), both with a rate of 100 per minute. Advanced life support drugs were administered at 13 minutes, and defibrillation at 14 minutes. Resuscitation continued until return of spontaneous circulation (ROSC) or 20 minutes of failed resuscitation. Survivors were sacrificed with KCl after 20 minutes of observation. Veterinary staff conducted necropsy to assay lung injury, rib fracture, hemothorax, airway bleeding, great vessel dissection, and heart/liver/spleen contusion. Injury characteristics were summarized and compared via Chi-Squared test or Mann-Whitney U-test using an alpha = 0.05. RESULTS A total of 36 animals were included for analysis (Group 1: 18; Group 2: 18). Mean (SD) APD overall was 5.58 (0.23) inches, yielding a mean 1/3 APD depth of 1.86 inches. APD did not differ between groups. ROSC rates did not differ between groups. No injury characteristics differed significantly between groups. CONCLUSIONS In an swine model of infant asphyxial OHCA and resuscitation considering 1/3 APD or 1.5 inches, neither CC depth strategy was associated with increased injury.

Sex and 30-day survival following out-of-hospital cardiac arrest in Scotland 2011–2020

BackgroundDifferences in 30-day survival between males and females following out-of-hospital cardiac arrest (OHCA) are well documented. Biological sex does not appear to be responsible for this survival gap independently of potential mediating factors. We investigated the role of potential mediating factors in the association between sex and 30-day survival after OHCA in Scotland.MethodsA retrospective cohort study of adult non-emergency medical services (EMS)-witnessed OHCA cases was conducted. We included incidents from the whole of Scotland where resuscitation was attempted by the Scottish Ambulance Service (SAS) between April 1, 2011 and March 1, 2020. Logistic regression was used to assess the contribution of age, socioeconomic status, urban–rural location of the incident, initial cardiac rhythm, bystander cardiopulmonary resuscitation (CPR) and location of the arrest (home or away from home).ResultsThe cohort consisted of 20,585 OHCA cases (13,130 males and 7,455 females). Median (IQR) age was 69 years (22) for males versus 72 years (23) for females. A higher proportion of males presented with initial shockable rhythm (29.4% versus 12.4%) and received bystander CPR (56.7% versus 53.2%) compared with females. A higher proportion of females experienced OHCA at home (78.8% versus 66.8%). Thirty-day survival after OHCA was higher for males compared with females (8.2% versus 6.2%). Males had higher age-adjusted odds for 30-day survival after OHCA than females (OR, 1.26; (95% CI), 1.12–1.41). Mediation analyses suggested a role for initial cardiac rhythm and location of the arrest (home or away from home).ConclusionMales had higher age-adjusted 30-day survival after OHCA than females. However, after adjusting for confounding/mediating variables, sex was not associated with 30-day survival after OHCA. Our findings suggest that initial cardiac rhythm and location of the arrest are potential mediators of higher 30-day OHCA survival in males than females. Improving proportions of females who present with initial shockable rhythm may reduce sex differences in survival after OHCA.

The effectiveness of simulation-based learning (SBL) on students’ knowledge and skills in nursing programs: a systematic review

BackgroundSimulation-Based Learning (SBL) serves as a valuable pedagogical approach in nursing education, encompassing varying levels of fidelity. While previous reviews have highlighted the potential effectiveness of SBL in enhancing nursing students’ competencies, a gap persists in the evidence-base addressing the long-term retention of these competencies. This systematic review aimed to evaluate the impact of SBL on nursing students’ knowledge and skill acquisition and retention.MethodA comprehensive search of electronic databases, including CINAHL, PubMed, Embase, Scopus, and Eric, was conducted from 2017 to 2023 to identify relevant studies. The Joanna Briggs critical appraisal tools were used to assess the methodological quality of the included studies. A total of 33 studies (15 RCTs and 18 quasi-experimental) met the inclusion criteria and were included in the review. A descriptive narrative synthesis method was used to extract relevant data.ResultsThe cumulative sample size of participants across the included studies was 3,670. Most of the studies focused on the impact of SBL on life-saving skills like cardiopulmonary resuscitation (CPR) or other life-support skills. The remaining studies examined the impact of SBL on critical care skills or clinical decision-making skills. The analysis highlighted consistent and significant improvements in knowledge and skills. However, the evidence base had several limitations, including the heterogeneity of study designs, risk of bias, and lack of long-term follow-up.ConclusionThis systematic review supports the use of SBL as a potent teaching strategy within nursing education and highlights the importance of the ongoing evaluation and refinement of this approach. While current evidence indicates enhancing knowledge and skill acquisition, limited studies evaluated the retention beyond five months, constraining generalisable claims regarding durability. Further research is essential to build on the current evidence and address gaps in knowledge related to the retention, optimal design, implementation, and evaluation of SBL interventions in nursing education.

Epidemiology, Process of Care, and Associated Outcomes of Pediatric Out-of-Hospital Cardiac Arrest in China: Results From a Prospective, Multicenter, Population-Based Registry

Objectives: To comprehensively describe the incidence, process of care, outcomes, and variation among different age groups of pediatric out-of-hospital cardiac arrest (OHCA) in China. Design: The Baseline Investigation of Out-of-Hospital Cardiac Arrest (BASIC-OHCA) is a prospective, multicenter, population-based registry of emergency medical services (EMS)-assessed OHCA in China. Setting: A total of 25 monitoring sites of all seven geographical regions were included, covering a pediatric population (age ≤ 19) of around 22.3 million in China. Patients: Pediatric patients enrolled in BASIC-OHCA from August 2019 to December 2020 were included. Interventions: None. Measurements and Main Results: A total of 1493 pediatric patients with EMS-assessed OHCA were enrolled, and resuscitation was attempted in 651 cases (43.6%). The crude incidence of EMS-assessed and EMS-treated OHCA was 5.5 (95% CI, 5.2–5.9) and 2.4 (95% CI, 2.2–2.6) per 100,000 pediatric population. Among 651 EMS-treated OHCA cases, 434 patients (66.7%) were male, and 353 (54.2%) had nonmedical causes (trauma, asphyxia, and drowning being the most common). There were 396 patients (60.8%) who collapsed at home, and the proportion of cases that occurred in public places such as streets and schools increased with age. There were 26 patients (4.0%) who had an initial shockable rhythm. For 626 non-EMS-witnessed patients, 152 patients (24.3%) received bystander cardiopulmonary resuscitation (CPR), 68 (10.9%) received dispatcher-assisted CPR, and 3 (0.5%) had automated external defibrillator applied. The survival to discharge or 30 days was 3.5% (23/651), and the favorable neurologic prognosis was 3.1% (20/651), with no differences among age groups. Conclusions: This study provides the first national exploration of pediatric OHCA in China. The high proportion of nonmedical causes underscores the importance of preventing accidents in children. Gaps in the chain of survival and patient outcomes provide a focus for improving the treatment of pediatric OHCA in China and other developing countries.

Safety management within the scope of teaching practical clinical skills: framing errors for cardiopulmonary resuscitation training – a multi-arm randomized controlled equivalence trial

Introduction Cardiopulmonary resuscitation (CPR) is among the most important skills in clinical practice. Errors can happen here, just like everywhere, and potentially have severe consequences. Two common error handling strategies known from practice are Error Management (EM) and Error Avoidance (EA). However, its effects on medical performance outcomes remain unclear. This study aimed to examine the role of error framing in basic life support (BLS) training for future healthcare professionals. Materials and Methods In an equivalence trial (N = 430), first-year medical, dentistry, physiotherapy, and midwifery students underwent BLS training. In the three study arms, participants received either (1) instructions framing errors positively (EM), (2) instructions framing errors to be avoided (EA), or (3) no further instructions (Control). CPR performance was assessed using a resuscitation manikin measuring compression depth (CD) and compression rate (CR). The self-confidence ratings were assessed using a questionnaire. Equivalence margins for the outcome parameters and sample size calculations were based on previous standard BLS studies, using two-sided 95% confidence intervals to determine significance of equivalence. Results The results regarding CD revealed equivalence with a trend toward superiority of EM over EA (proportional difference 23.3%-points; 95% CI 11.4%–34.2%) and EM over control (proportional difference 23.4%-points; 95% CI 11.5%–34.2%.) and significant equivalence of EA and control (proportional difference 0.1%-points; 95% CI −11.6%–11.7%). Significant equivalence was determined for all study arms with respect to CR and self-confidence. Conclusion Our study revealed that EM was not detrimental to learners’ CPR performance. Given existing research on long-term beneficial effects of EM on patient safety, coupled with the proven equivalence of EM and EA concerning short-term performance, we argue that EM is a promising approach for future medical education purposes. Raising awareness of error framing and teaching error-handling strategies is expected to benefit ongoing safety management efforts in medical education and beyond.

7165 A Case of Severe Myxedema Coma with Levothyroxine Allergy

Abstract Disclosure: A. Rothstein Costris: None. A. Yaseen: None. S. Levy: None. Introduction: Myxedema coma is a life threatening condition with a mortality rate of 25-60%. Untreated, it can lead to fatal physiological changes. The treatment is thyroid hormone replacement therapy, alongside supportive care for complications. Clinical Case: A 65-year-old woman, who has been dealing with untreated hypothyroidism since 2012 and reported allergies to various levothyroxine brands, presented with falls, weakness, and exacerbated leg numbness. During the examination, she exhibited periorbital edema, non-pitting edema in the lower extremities, bradycardia, and hypothermia. The blood work revealed an elevation in TSH levels at 301 uIU/L (0.45-5.33 uIU/mL). The patient was administered IV Synthroid (200 mcg), Atropine, and Hydrocortisone due to concerns about myxedema coma. After four hours, the patient experienced angioedema and hypotension, necessitating intubation. This situation was complicated by a pulseless electrical activity (PEA) arrest. Following cardiopulmonary resuscitation and the administration of epinephrine, the patient achieved return of spontaneous circulation. The allergy team assessed the patient for potential anaphylactic shock from IV Synthroid. Subsequently, the patient was initiated onIV Liothyronine and Hydrocortisone, leading to improvement in mental status over a period of a few weeks, and no adverse effects were reported. Thyroid labs improved to TSH of 53 (0.45-5.33 uIU/mL), FT3 of 3.3 (2.5-4.4 pg/mL) and total T3 of 133 (87-178 ng/dl). Upon discharge, the patient was prescribed Liothyronine, with plans to perform a Levothyroxine desensitization test in the outpatient setting. Conclusion: Myxedema coma is an endocrine emergency. Patients usually present with deteriorating mental status, hypothermia, and multiple organ system abnormalities. The diagnosis relies more on the clinical presentation and physical examination than on laboratory results. Thyroid replacement therapy serves as the cornerstone of treatment, with a preference for T4 due to its greater availability and lower likelihood of adverse events compared to Liothyronine, which may increase the risk of mortality at higher doses. Despite associated risks, incorporating low doses of Liothyronine is still considered in treatment plans, driven by concerns about reduced T4 to T3 conversion in myxedema patients. Hypersensitivity reactions to Levothyroxine are uncommon but may manifest as widespread hives, swelling, eczema-like skin rashes, elevated body temperature, and compromised liver function, with only one case reporting an anaphylactic reaction to Levothyroxine. In summary, the potential for experiencing an anaphylactic reaction to Levothyroxine exists, highlighting the need to contemplate alternative treatments, such as Liothyronine. Desensitization methods can be considered once the patient's condition is stable. Presentation: 6/2/2024

Effectiveness of Adult Chest Compressions during Resuscitation Performed by Children Aged 10–14 Years under Simulated Conditions

Introduction: Numerous educational programs recommend implementing the teaching principles of BLS from an early age. The aim of this study was to evaluate selected parameters of the quality of resuscitation performed by children aged 10–14 years during simulated circulatory arrest in an adult. Materials and Methods: The project involved four stages, culminating in students performing thoracic compressions on an adult simulator for 2 min. A digital analysis of the quality, depth, relaxation and rate of compressions allowed us to formulate results and conclusions. The authors’ proprietary questionnaire form allowed for the correlation of criteria such as age, gender, body mass and past experience in first aid training of the participant. Results: A total of 149 girls and 130 boys were studied. The mean age was 12 years (SD ± 1.41). A directly proportional increase in body mass with participant age was observed (p &lt; 0.000). Children as young as 10 years old achieved only 24.13% quality, while those at the age of 14 demonstrated a more than doubled value (67.61%). The minimum depth of chest compressions recommended for an adult (5–6 cm) was not reached in any age group. Girls from all grades achieved a mean quality of 44.69% (SD ± 32.57), while boys achieved a score of 60.23% (SD ± 31.74). On the other hand, in the case of evaluating thoracic relaxation, a significantly better result was achieved by girls compared to boys (66.14% vs. 56.78%; rho-Spearman test for p = 0.011). Conclusions: Age, sex and body mass play important roles in the quality of resuscitation provided by children. None of the age groups studied achieved the minimum mean depth during adult thoracic compressions under simulated conditions. It is recommended to modify school-based BLS classes to better match the exercises to students’ predispositions.

Retrospective Review of the Image Quality of Monoplane Transesophageal Echocardiography in Prehospital Out-of-Hospital Cardiac Arrest: A Single Center Pilot Study

Objectives Out of Hospital Cardiac Arrest (OHCA) is a frequently encountered pathology with resultant poor outcomes in the majority of patients. Echocardiography has been utilized to help guide clinical decision making and monitor effectiveness of resuscitative efforts. Transthoracic echocardiography (TTE) the mainstay of point-of-care ultrasound (POCUS) real time resuscitative imaging has limitations, most notably is the disruption of closed chest compressions. Trans-esophageal echocardiography (TEE) is an emerging technology in emergency care and can potentially overcome these limitations but image quality and accuracy of use in the prehospital environment remains unknown. Our primary objective is to identify the accuracy of Emergency Medical Services (EMS) fellow physicians in performing TEE via the identification of key cardiac structures. Secondarily we assess image quality as well as accuracy on cardiac activity interpretation as compared to TEE-experienced cardiologists. Methods A pilot study using descriptive analysis of a retrospective case-series with specific focus on inter-rater reliability as well as pragmatic management alterations based on real-time image interpretation by EMS physicians. After focused education, 13 patients were eligible for prehospital TEE who suffering OHCA from July 2022 to June 2023. Ultrasound (US) images were interpreted by EMS fellow physicians and over-read by cardiologists with specific focus on inter-rater reliability. After collection of patients presenting data and US images, analysis was performed. Results Of 13 patients initially screened, 10 patients were included in a study with a median age of 50 years old (41–70). Three patients were excluded due to equipment malfunction or insufficient image capture. An interrater reliability identified a kappa of 0.96 with respect to identification of cardiac structures and a kappa of 0.65 for identification of cardiac activity. Conclusions In this small study of prehospital TEE, EMS fellow physicians had high inter-rater reliability in image interpretation pertaining to anatomy and cardiac activity when compared with cardiologists. Further research is needed to determine its efficacy, safety, and widespread application in the prehospital setting.

The effect of hand and body position on chest compression quality and rescuer fatigue in prone cardiopulmonary resuscitation

AimThis study aimed to compare the quality of compressions in supine cardiopulmonary resuscitation (CPR) and prone CPR by performing chest compressions on a manikin. Evaluating the effect of prone CPR using different hand and body position on the quality of manual chest compressions and fatigue of participants. MethodsAfter completing 2 min of chest compression in the supine position (Supine Group), 25 participants randomly performed three sets of 2-minutes chest compressions on a prone position manikin. Stand + hands overlapped Group: participants stood beside the patient bed with their hands overlapped and placed on the posterior segment of the thoracic spine between the scapulae, Straddle + hands separated Group: participants straddled the patient bed with their hands placed above the scapulae on both sides at the mid-chest level, and Straddle + hands overlapped Group: participants straddled the patient bed with their hands overlapping on the posterior segment of the thoracic spine between the scapulae. Subsequently, the quality of chest compressions and participants fatigue were assessed. ResultsChest compression depth ratio and mean chest compression depth (MCCD) were worse in the three prone CPR groups (Stand + hands overlapped Group: 0.0(0.0,15.6) %, 39.8 ± 1.3 mm; Straddle + hands separated Group: 1.4(0.0,11.7) %, 42.4 ± 1.2 mm; Straddle + hands overlapped Group: 0.0(0.0,9.2) %, 40.9 ± 1.2 mm) than in the Supine group (87.1(68.1,94.0) %; p < 0.001, 52.4 ± 0.4 mm; p < 0.001). In the three prone CPR groups, Straddle + hands separated Group had the greatest MCCD, lowest changes in heart rate (p = 0.018) and lowest changes in RPE scores (p < 0.001). There were no significant differences between the four groups in terms of mean chest compression rate, accurate chest compression rate ratio, or correct recoil ratio. ConclusionThis simulation-based study showed that the quality of chest compressions was worse in the prone position than in the supine position. When prone chest compressions were performed using different hand and body position, prone CPR performed by a participant straddling a hospital bed with hands placed above the scapula on either side at the mid-chest level provided higher-quality chest compressions and lower rescuer fatigue.

Is It Possible to Detect Return of Spontaneous Circulation during Chest Compression? Evaluation of a Novel Method: Carotid Artery Compression Ultrasound.

Objectives: To evaluate the diagnostic accuracy of carotid artery compression using a point-of-care ultrasound probe (POCUS-CAC) in reducing pulse check times and facilitating the detection of the return of spontaneous circulation (ROSC) during cardiopulmonary resuscitation (CPR) compared to manual palpation (MP). The secondary aim of the study is to assess the ability of POCUS-CAC to detect ROSC during ongoing chest compressions. Methods: This prospective study was conducted in a tertiary emergency department between January and June 2023. During CPR, POCUS-CAC was performed by placing a linear ultrasound probe transversely on the lateral neck to assess the compressibility of the carotid artery. Complete compression of the artery without any visible pulsation indicated no ROSC, while resistance to compression or partial compression suggested the presence of ROSC. Simultaneously, another clinician performed manual palpation of the femoral artery. The primary outcome assessed in this study was comparing ROSC detection between POCUS-CAC and traditional methods, and the secondary outcome was comparing the time taken to detect ROSC with each method, and the ability to detect ROSC during ongoing chest compressions. Results: The study included 41 cardiac arrest patients and analyzed 496 MP pulse and 1984 POCUS-CAC checks. The mean time to identify a pulse using POCUS-CAC was significantly shorter, at 2.3 (0.5-7.8, SD ± 1.2, 95% CI [2.25, 2.35]) s, compared to 4.7 (2.0-10.5, SD ± 1.8, 95% CI [4.54, 4.86]) s with MP (p = 0.004). Additionally, 52.9% of ROSC cases were detected earlier using POCUS-CAC, even during ongoing chest compressions. The sensitivity of POCUS-CAC was 100% (95% CI [80.5-100%]) and the specificity was 87.5% (95% CI [67.6-97.3%]). The POCUS-CAC method required less than 5 s in 99.996% of cases. Conclusions: POCUS-CAC significantly reduces pulse check times and enhances the early detection of ROSC during CPR, offering a reliable and rapid alternative to traditional manual palpation methods in emergency settings.