Cardiac Arrest Situations Research Articles

Emergency cardio-pulmonary bypass in cardiac arrest: Seventeen years of experience

AimEmergency cardiopulmonary bypass (E-CPB) is an advanced and rarely used procedure for patients in cardiac arrest that do not regain restoration of spontaneous circulation with standard resuscitation methods. The feasibility, safety and outcome of the intervention with E-CPB in cardiac arrest situations at our department have been evaluated. MethodsClinical presentation, time intervals, diagnosis and outcome of all patients who received E-CPB at an emergency department of a tertiary care university hospital were evaluated. Patient charts were reviewed regarding cardiac arrest variables and treatment data of all patients from 1993 to 2010. ResultsE-CPB was performed in 55 patients. Of all patients, 33 (60%) were male and the median age was 32 years (IQR 24–44). In all cases cardiac arrest was witnessed. The first recorded ECG rhythm showed pulseless electric activity in 23 (42%), ventricular fibrillation in 21 (38%) and asystole in 11 (20%) patients. Cardiac arrest occurred out-of-hospital in 33 (60%) patients. The median duration of CPR before performing E-CPB was 86min (IQR 69–121). The median ‘cannulation’-time was 33min (IQR 21–45) and the duration on bypass was 311min (IQR 161–953). Cardiac causes of arrest were found in 19 (35%) patients. Eight patients (15%) survived to 6 months with good neurological outcome. ConclusionE-CPB for cardiac arrest is feasible and safe. In this seemingly desperate patient population after prolonged cardiac arrest, we observed a high survival rate of 15%. E-CPB is a meaningful treatment option, which should be considered more often and earlier.

Effectiveness of using automated external defibrillator by trained healthcare professionals on survival outcomes among adult patients after in-hospital cardiac arrest: a systematic review.

Review question/objective The objective of this review is to synthesise the best available evidence of the effectiveness of using automated external defibrillator by trained healthcare professionals on survival outcomes in adult patients after in-hospital cardiac arrest. More specifically, the objectives are to identify: the effectiveness of using automated external defibrillator by trained healthcare professionals on return of spontaneous circulation and survival to hospital discharge in adult patients after in-hospital cardiac arrest. Inclusion criteria Types of participants This review will consider studies that include adults 18 years old and above; suffering from cardiac arrest requiring chest compression in in-patient wards, emergency department and out-patient procedures in hospital; presenting with an initial index pulseless (for example, but not limited to, ventricular fibrillation and pulseless ventricular tachycardia, asystole or pulseless electrical activities); presence or absence of co-morbidities such as congestive heart failure, myocardial infarction, diabetes mellitus, renal, hepatic or respiratory insufficiency, motor, cognitive or functional deficits, acute stroke, acute non-stroke neurological disorder, pneumonia, hypotension, sepsis, major trauma, metabolic or electrolyte abnormality, metastatic or haematology malignancy. The exclusion criteria are any age group who suffered out-of-hospital cardiac arrest or adults 18 years old and above suffered in-hospital cardiac arrest with a ‘do not resuscitate’ order (DNR). Types of intervention(s) This review will consider as interventions any use of commercially available automated external defibrillator by trained healthcare professionals for in-hospital cardiac arrest. The comparator of interest is use of manual/standard external defibrillator by trained healthcare professionals for in-hospital cardiac arrest. Types of outcomes This review will consider studies that include the following outcome measures: 1. survival with a return of spontaneous circulation for at least 20 minutes during resuscitation 2. survival to hospital discharge regardless of time to discharge 3. initial cardiac arrest rhythms

Abstract 229: Are There Any Cultural Barriers to Automated External Defibrillator Use in Middle Eastern Countries?

Background: To date, no study has explored the role of cultural barriers to use of an Automated External Defibrillator (AED) in Arab Gulf countries. This study examines the role of ethnicity on acceptability ratings for resuscitation and use of an AED. Methods: Male and female respondents (n=345) at an exhibition completed a questionnaire assessing knowledge and attitudes towards the use of an AED in sudden cardiac arrest situations in a public setting. Participants were provided with one of twelve different photographed vignette scenarios of a victim in cardiac arrest with a rescuer of three different ethnic groups (European, Indian Sub-Continent and Arab). Participants then completed acceptability ratings in relation to CPR, AED and x use. Results: Results demonstrated no significant effect of gender in relation to AED usage but a significant difference between those who know what an AED was used for and those who did not. Significant differences were found on acceptability ratings of questions in relation to CPR, AED and X when the victim was female. Specifically, participants were significantly more likely to express low acceptability ratings for male rescuer intervention when the male was from the Indian sub-continent. No differences were observed between scores in relation to a European male rescuer and an Arab male rescuer. Conclusion This study indicates a lack of knowledge and awareness in the Bahraini population in relation to the correct function of AED and when it should be used. Specific ethnic grouping of the Indian sub-continent appears to be a barrier to both AED use and CPR when the victim is an Arab female. This has implications for the delivery of training in AED usage and possibly the selection of those who should be trained. Any area in Gulf Arab countries, who purchase an AED, should ensure that a majority of female rescuers should be trained in cardiopulmonary resuscitation and use of the AED.

Video analysis of dispatcher–rescuer teamwork–Effects on CPR technique and performance

ObjectiveWe wanted to study the effect of continuous dispatcher communication on CPR technique and performance during 10min of simulated cardiac arrest. MethodWe reviewed video recordings and manikin data from 30 CPR trained lay people who where left alone in a simulated cardiac arrest situation with a manikin in a home-like environment (in a small, confined kitchen with the disturbing noise of a radio).CPR was performed for 10min with continuous telephone instructions via speaker function from a dispatcher. The dispatcher was blinded for CPR performance and video.Dispatcher communication, compression technique and ventilation technique was scored as accomplished or failed in the 1st and 10th minute. Results29/30 rescuers were able to hear instructions, answer questions from the dispatcher and perform CPR in parallel. Rescuer position beside manikin was initially correct for 13/30, improving to 21/30 (p=0.008). Compression technique was adequate for the whole episode, with an insignificant trend for improvement; 29 to 30/30 using straight arms, 28 to 30/30 in a vertical position over chest and 24 to 27/30 counting loudly. 17/29 placed their hands between the nipples initially, improving to 24/29 (p=0.065). Mean compression rate improved from 84 to 101min−1 (p<0.001), and compression depth maintained adequate (43 to 42mm). Initially, 17/29 used chin-lift manoeuvre, 14/30 used head-tilt and 19/29 used nose pinch to manage open airways, compared to 18, 20 and 22/29 (ns) in the 10th minute, respectively. Successful delivery of ventilation improved from 13/30 to 23/30 (p=0.006). ConclusionBystander and dispatcher can communicate successfully during ongoing CPR using a telephone with speaker function. CPR technique and quality improved or did not change over 10min with continuous dispatcher assistance. These results suggest a potential for improved bystander CPR using rescuer–dispatcher teamwork.

Parada Cardiorrespiratória: Conhecimento e Prática de uma Equipe de Saúde da Família

Objectives: The aim of this study is to investigate the perception of professionals from a Family Health Team on cardiopulmonary arrest. Material and Methods: This an exploratory and descriptive study, with quantitative and qualitative approaches, performed in a Family Health Unit in Joao Pessoa - PB. The study followed the ethical observances of 196/96 Resolution of the National Health Council, and data collection was conducted in January 2010. For database analysis, tables and charts were built descriptively in Microsoft Excel 2007. Results: Data showed that 80% of respondents said that the first signs revealing a cardiopulmonary arrest are apnea, unconsciousness, and absence of carotid pulse. 60% reported that the right order was mouth-to-mouth resuscitation / artificial circulation by external thoracic compression / and early defibrillation by use of automatic defibrillators. 60% of respondents reported that the correct support sequence in cardiopulmonary resuscitation maneuvers are 5 cycles of 30 compressions to 2 breaths, and 40% of professionals interviewed have never had an experience with patients in cardiac arrest. Conclusion: Although these professionals have technical and scientific knowledge, there is a lack of skills required when facing a situation of cardiac arrest. DESCRIPTORS: Cardiac Arrest. Family Health. Nursing.

Educating for teamwork - nursing students’ coordination in simulated cardiac arrest situations

The overarching aim was to explore and describe the communicative modes students employ to coordinate the team in a simulation-based environment designed for resuscitation team training. Verbal communication is often considered essential for effective coordination in resuscitation teams and enhancing patient safety. Although simulation is a promising method for improving coordination skills, previous studies have overlooked the necessity of addressing the multifaceted interplay between verbal and non-verbal forms of communication. Eighty-one nursing students participated in the study. The data were collected in February and March, 2008. Video recordings from 28 simulated cardiac arrest situations in a nursing programme were analysed. Firstly, all communicative actions were coded and quantified according to content analysis. Secondly, interaction analysis was performed to capture the significance of verbal and non-verbal communication, respectively, in the moment-to-moment coordination of the team. Three phases of coordination in the resuscitation team were identified: Stating unconsciousness, Preparing for resuscitation, Initiating resuscitation. Coordination of joint assessments and actions in these phases involved a broad range of verbal and non-verbal communication modes that were necessary for achieving mutual understandings of how to continue to the next step in the algorithm. This was accomplished through a complex interplay of taking position, pointing and through verbal statements and directives. Simulation-based environments offer a promising solution in nursing education for training the coordination necessary in resuscitation teams as they give the opportunity to practice the complex interplay of verbal and non-verbal communication modes that would otherwise not be possible.

Monitoring possibilities of resuscitation efforts during cath-lab resuscitation

Purpose of study: Cardiac arrest situations are often dramatic and it is difficult to perform studies on this patient category. In cardiac arrest situations in the cath-lab when prolonged resuscitation efforts are needed, the introduction of mechanical chest compression devices has shown promise to reduce mortality during continued percutaneous coronary interventions. We hypothesized that a continuous monitoring system in the cath-lab with the ability to save large data files could be used to depth analyze the vital parameters and resuscitation related parameters during resuscitation efforts in individual patients. Materials and methods: For mechanical chest compressions in the cath-lab, the LUCAS 1 V1US (Jolife AB, Lund, Sweden) was used. Hemodynamic measurements, ETCO2 and O2 saturation was collected every 2nd ms. Results: In one patient we were able to closely monitor arterial pressure and SpO2 from the start of coronary angiogram until the patient left the cath-lab after 90 min. Circulation was maintained with mechanical chest compressions for 52 min until he obtained ROSC. We were able to monitor ETCO2 for 50 min and venous pressure the last 30 min of resuscitation. The physiology parameters during 52 min of resuscitation and simultaneous percutaneous coronary interventions and during a 10 min period after return of spontaneous circulation was registered. Conclusion: The setting with mechanical chest compression devices in the cath-lab for prolonged resuscitation alone or as a bridge to full cardio pulmonary support, brings further knowledge of vital parameter's response to mechanical chest compression and pharmacological substances during resuscitation efforts.

Review of anaesthetic protocols used during pig cardio-pulmonary resuscitation (CPR) studies

This study was undertaken to review anaesthesia protocols used during closed chest external massage pig CPR studies. It is recognised that a number of drugs and techniques used during anaesthesia will have an impact on cardiovascular and neuro-endocrine function and that these effects may persist during the cardiac arrest situation. For fair comparison of different studies an appreciation of these anaesthesia related effects are important. In planning a study the effects and limitations of a particular protocol need to be understood. It is also essential that the welfare of the patient is protected at all times. An online search was carried out on the Resuscitation journal homepage (http://www.resuscitationjournal.com). The search terms used were ‘pig’ AND ‘arrest’ AND ‘anaesthesia’. 64 abstracts were returned. 37 papers reporting primary research involving closed chest external cardiac massage were considered further. A wide range of drug protocols were used. The majority of the pigs received atropine and either ketamine or tiletamine. All these drugs are known to cause cardiovascular responses and when give as the sole agent poor quality sedation. 18 Studies used oro-tracheal intubation and the remaining 19 studies undertook tracheostomy. In no study was the use of the invasive technique rationalised or justified. Fluid therapy varied significantly. In 14 studies for at least 1 h 30 ml/kg of crystalloid was administered. When ongoing lower rates are also considered these studies will have administered 50% off the normal circulating volume significantly altering preload. No studies described how the effectiveness of neuromuscular blockade was assessed. Only 2 detailed comments were identified considering the effects of the anaesthetic on the project outcomes. Refining anaesthetic technique will improve the quality of the study and improve the value of the results obtained. Consideration must be given to the effects of the anaesthetic drugs and techniques used when comparing study results.

In-hospital cardiac arrest-descriptions of cardiac arrest situations and predictors for survival and cerebral function from a gender perspective

Purpose: Only a few studies have described factors influencing survival and cerebral function after in-hospital cardiac arrest from a gender perspective. The purpose of the study is to describe in-hospital cardiac arrest situations with regard to gender and to find predictors for survival and cerebral function when controlling for time to treatment.

Resuscitation guidelines 2010: a scientific consensus

Resuscitation guidelines 2010: a scientific consensus

Part 12: Cardiac Arrest in Special Situations

This section of the 2010 AHA Guidelines for CPR and ECC addresses cardiac arrest in situations that require special treatments or procedures beyond those provided during basic life support (BLS) and advanced cardiovascular life support (ACLS). We have included 15 specific cardiac arrest situations. The first several sections discuss cardiac arrest associated with internal physiological or metabolic conditions, such as asthma (12.1), anaphylaxis (12.2), pregnancy (12.3), morbid obesity (12.4), pulmonary embolism (PE) (12.5), and electrolyte imbalance (12.6). The next several sections relate to resuscitation and treatment of cardiac arrest associated with external or environmentally related circumstances, such as ingestion of toxic substances (12.7), trauma (12.8), accidental hypothermia (12.9), avalanche (12.10), drowning (12.11), and electric shock/lightning strikes (12.12). The last 3 sections review management of cardiac arrest that may occur during special situations affecting the heart, including percutaneous coronary intervention (PCI) (12.13), cardiac tamponade (12.14), and cardiac surgery (12.15). Asthma is responsible for more than 2 million visits to the emergency department (ED) in the United States each year, with 1 in 4 patients requiring admission to a hospital.1 Annually there are 5,000 to 6,000 asthma-related deaths in the United States, many occurring in the prehospital setting.2 Severe asthma accounts for approximately 2% to 20% of admissions to intensive care units, with up to one third of these patients requiring intubation and mechanical ventilation.3 This section focuses on the evaluation and treatment of patients with near-fatal asthma. Several consensus groups have developed excellent guidelines for the management of asthma that are available on the World Wide Web: ### Pathophysiology The pathophysiology of asthma consists of 3 key abnormalities: Complications of severe asthma, such as tension pneumothorax, lobar atelectasis, pneumonia, and pulmonary edema, can contribute to fatalities. Severe asthma exacerbations are commonly associated with …

Lay basic life support: the current situation in a medium-sized German town

ObjectiveBasic life support (BLS) by laypersons is essential for surviving sudden cardiac death in the community. The present study investigates BLS skill knowledge of German laypersons in a public community...

Using a storyboarding technique in the classroom to address end of life experiences in practice and engage student nurses in deeper reflection

This paper evaluates the use of storyboarding within a classroom setting as a means of addressing end of life issues and engaging second year student nurses in creative, critical thinking and deeper reflection on practice. Storyboarding is a process that was developed to encourage learners to use the creative right brain and the critical left brain to formulate ideas in front of a group and then to look at those ideas critically ( Lottier, 1986). The session was evaluated using a questionnaire and group discussion to elicit perceived learning from students. The activity was to create the storyboards in small groups, then review the content generated by discussion with the whole group. Main themes identified by the students included breaking bad news, dealing with cardiac arrest situation, coping with families following bereavement and the dying patient. Evaluation of the teaching session suggested that students found storyboarding helped to identify cultural aspects and feelings related to the dying patient. Students valued sharing with each other and the opportunity to have their experiences heard. It was noted that although this method provided as valuable learning experience for the student it is staff and time intensive and attention is required to establish a climate of trust and safety. The risk of exposing unexpected emotions within individual students appears no greater than with other approaches to teaching about loss, death and dying.

Necessity of immediate cardiopulmonary resuscitation in trauma emergency

The ability to respond quickly and effectively to a cardiac arrest situation rests on nurses being competent in the emergency life-saving procedure of cardiopulmonary resuscitation. The objective of the current study was to evaluate the types of trauma and survival of patients that require immediate cardiopulmonary resuscitation in trauma emergencies. A total of 13301 patients treated as accident victims between July 2004 and December 2006 were evaluated in a prospective study. Patients requiring immediate cardiopulmonary resuscitation at admission were identified. The type of injury and the survival of these patients were evaluated.Of the 65 patients included in the study, 30% had suffered from gunshot wounds, 19% had been run over, 18% had been involved in car crashes, 13% in motor cycle accidents, 9% stabbings, 1% by cycle accidents and 10% other types of accidents including burns, hangings and falls. In only 12 of these patients, immediate resuscitation was successful and procedure such as chest drainage, exploratory laparotomy and interventions in the surgical center were performed. However all patients evolved to death; eight within 24 hours, two between 24 and 48 hours and the other 2 after 48 hours.Immediate cardiopulmonary resuscitation after accidents is a sign of high mortality requiring further studies to review indication and the ethical aspects involved.

Spinalanästhesie – Typische Komplikationen und wie man sie vermeiden kann

Spinal anesthesia is a safe procedure. The knowledge of complications may support efforts to minimize risks, speed up the recognition process and lead to adequate timely therapeutic approaches. Pain during insertion of the needle can be a warning signal for potential conus damage. Hypotension caused by spinal anesthesia should be treated by appropriate vasoactive drugs. Timely recognized cardiac arrest situations are usually well treatable. The incidence of postdural puncture headache should be less than 2% of cases. In case of a high degree of suffering the best currently available treatment is the epidural blood patch. Further complications like intracranial bleeding, infection, cauda equina syndrome or spinal hematoma need immediate differential diagnosis and therapeutic approaches. The residual risk for permanent harm can be estimated to be around 0,02 per thousand.

A Pilot Study to Determine Whether Undergraduate Paramedics are Able to Retain Basic Resuscitation and Respiratory Physiology Knowledge

Introduction While suboptimal bag ventilation has been well documented during cardiopulmonary resuscitation (CPR), we often do not consider how operator knowledge of ventilation guidelines may contribute to this outcome. The objective of this pilot study was to evaluate third year Monash University undergraduate paramedic students’ knowledge of the International Liaison Committee on Resuscitation (ILCOR) ventilation guidelines and basic respiratory physiology. Methods A cross-sectional study was used to elicit responses about ventilation rate, tidal volume and knowledge of lower oesophageal sphincter pressure in normal and cardiac arrest states for third year undergraduate paramedic students at Monash University. Ethics approval was granted Results There were 30 (41%) third year students who participated. Only 8 (27%) of the students who participated could identify the correct ventilation rate for an intubated patient in a cardiac arrest situation, with only 3 (10%) of students identifying the correct tidal volume. Overall, 27 (90%) of students had a poor knowledge of ventilation guidelines while 29 (97%) students were unable to recall basic lower oesophageal sphincter pressure values. Conclusion A greater emphasis on education of current ventilation guidelines, as well as the underpinning knowledge surrounding the guidelines, is needed to ensure students attain appropriate ventilation during CPR.

Prehospital emergency treatment of palliative care patients with cardiac arrest: a retrolective investigation.

BackgroundToday, prehospital emergency medical teams (EMTs) are confronted with emergent situations of cardiac arrest in palliative care patients. However, little is known about the out-of-hospital approach in this situation and the long-term survival rate of this specific patient type. The aim of the present investigation was to provide information about the strategic and therapeutic approach employed by EMTs in outpatient palliative care patients in cardiac arrest.MethodsDuring a period of 2 years, we retrolectively analysed emergency medical calls with regard to palliative care emergency situations dealing with cardiac arrest. We evaluated the numbers of patients who were resuscitated, the prevalence of an advance directive or other end-of-life protocol, the first responder on cardiac arrest, the return of spontaneous circulation (ROSC) and the survival rate.ResultsEighty-eight palliative care patients in cardiac arrest were analysed. In 19 patients (22%), no resuscitation was started. Paramedics and prehospital emergency physicians began resuscitation in 61 cases (69%) and in 8 cases (9%), respectively. A total of 10 patients (11%) showed a ROSC; none survived after 48 h. Advance directives were available in 43% of cases. The start of resuscitation was independent of the presence of an advance directive or other end-of-life protocol.ConclusionsStrategic and therapeutic approaches in outpatient palliative care patients with cardiac arrest differ depending on medical qualification. Although many of these patients do not wish to be resuscitated, resuscitation was started independent of the presence of advance directive. To reduce legal insecurity and to avoid resuscitation and a possible lengthening of the dying process, advance directives and/or “Do not attempt resuscitation” orders should be more readily available and should be adhered to more closely.

Use of a Battery-Operated Needle Driver for Intraosseous Access by Novice Users: Skill Acquisition With Cadavers

We determine skill acquisition and performance by using a battery-operated, intraosseous needle driver in cadavers. This was a prospective study of the EZ-IO, a battery-operated intraosseous needle driver (Vidacare Corp). Operators received a 5-minute presentation (with 1 insertion demonstration) and then performed 3 tibial insertions on a cadaver. Insertion time was measured from skin placement until stylet removal. Another participant recorded the time and determination of "success." Success required stable bone position and infusion of fluid without extravasation. After testing, operators completed a questionnaire including ease of use (1 to 5; 1=very difficult, 5=very easy), speed versus central line (faster, same, slower), ease of use versus a central line (easier, same, harder), and willingness to use the device in future cardiac arrest situations (yes, maybe, no). Operators included 42 emergency medicine attending physicians, 13 other physicians, 31 emergency medicine residents, and 13 nonphysicians (emergency medical services, etc). None had previous experience with the EZ-IO, and 80 of 99 (80.8%) had never placed an intraosseous needle. Two hundred eighty-nine of 297 insertions (97.3%) were successful. Success rates for the first, second, and third insertion were 96.9%, 94.9%, and 100%, respectively. Median insertion time was 6 seconds (range 3 to 25 seconds), with interquartile range 5 to 8 seconds. The mean ease of use rating was 4.8 (95% confidence interval 4.70 to 4.90). All operators subjectively rated the device faster and easier than a central line; 98 of 99 (99%) expressed willingness to use the device in a cardiac arrest. The EZ-IO requires minimal training, is easy to use, and is fast. Skill acquisition is rapid, with a high success rate on the initial insertion after a brief training session and a single demonstration.

The use of the laryngeal tube disposable (LT-D) by paramedics during out-of-hospital resuscitation—An observational study concerning ERC guidelines 2005

Summary In the current guidelines of the European Resuscitation Council (ERC), tracheal intubation, as an instrument for securing the airway during resuscitation, has become less important for persons not trained in this method. For those persons, different supraglottic airway devices are recommended by the ERC. The present investigation deals with the application of the laryngeal tube disposable (LT-D) during pre-hospital resuscitation by paramedics. Methods During a period of 2 years (2006–2008), we registered all cardiac arrest situations in which the LT-D had been applied according to the ERC guidelines 2005. Therefore, we investigated one emergency medical system in Germany. Results During the defined period, 92 resuscitation attempts, recorded on standardised data sheets, were included. The LT-D was used in 46% of all cardiac arrest situations. Overall, the LT-D was successfully inserted in more than 90% of all cases on first attempt. In 95% of all cases, no problems concerning ventilation of the patient were described. Conclusion As an alternative airway device recommended by the ERC in 2005, the LT-D may enable airway control rapidly and effectively. Additionally, by using the LT-D, a reduced “no-flow-time” and a better outcome may be possible.

Reduced hands-off-time and time to first shock in CPR according to the ERC Guidelines 2005

Background and aimChest compressions and early defibrillation are crucial in cardiopulmonary resuscitation (CPR). The Guidelines 2005 brought major changes to the basic life support and automated external defibrillator (BLS–AED) algorithm. We compared the European Resuscitation Council's Guidelines 2000 (group ‘00) and 2005 (group ‘05) on hands-off-time (HOT) and time to first shock (TTFS) in an experimental model. MethodsIn a randomised, cross-over design, volunteers were assessed in performing BLS–AED over a period of 5min on a manikin in a simulated ventricular fibrillation cardiac arrest situation. Ten minutes of standardised teaching and 10min of training including corrective feedback were allocated for each of the guidelines before evaluation. HOT was chosen as the primary and TTFS as the secondary outcome parameter. ResultsForty participants were enrolled; one participant dropped out after group allocation. During the 5-min evaluation period of adult BLS–AED, HOT was significantly (p<0.001) longer in group ‘00 [273±3s (mean±standard error)] than in group ‘05 (188±3s). The TTFS was significantly (p<0.001) longer in group ‘00 (91±3s) than in group ‘05 (71±3s). ConclusionIn this manikin setting, HOT and TTFS improved with BLS–AED performed according to Guidelines 2005.