Cardiopulmonary Resuscitation Attempts Research Articles

Antiarrhythmic drug therapy during cardiopulmonary resuscitation: should we use it?

The optimal antiarrhythmic drug therapy (amiodarone or lidocaine) in the treatment of ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) cardiac arrest that is refractory to defibrillation is uncertain. This article reviews the evidence for and against these drugs, alternatives treatments for refractory VF/pVT and aims to define the role of antiarrhythmic drugs during cardiopulmonary resuscitation (CPR). A large randomized controlled trial that compared amiodarone, lidocaine and saline 0.9% sodium chloride for the treatment of refractory VF/pVT out-of-hospital cardiac arrest reported no difference in survival to hospital discharge or neurological outcome. In patients with witnessed arrest, survival was improved with antiarrhythmic drugs compared to saline. The benefit of antiarrhythmic drugs appears to be for those patients in whom initial early CPR and defibrillation attempts fail and the antiarrhythmic drug is given early. There does not appear to be any clear survival benefit for any one particular drug and other factors such as availability and cost should be considered when deciding which drug to use. Furthermore, other interventions (e.g. percutaneous coronary intervention and extra-corporeal CPR) may provide additional survival benefit when defibrillation attempts and antiarrhythmic drugs are not effective.

Out-of-hospital cardiac arrests in nursing homes and primary care facilities in Pirkanmaa, Finland.

Dispatching Emergency Medical Services to treat patients with deteriorating health in nursing homes and primary care facilities is common in Finland. We examined the cardiac arrest patients to describe this phenomenon. We had a special interest in patients for whom cardiopulmonary resuscitation was considered futile. We conducted an observational study between 1 June 2013 and 31 May 2014 in the Pirkanmaa area. We included cases in which Emergency Medical Services participated in the treatment of cardiac arrest patients in nursing homes and primary care facilities. Emergency Medical Services attended to a total of 355 cardiac arrest patients, and 65 patients (18%) met the inclusion criteria. The included patients were generally older than 65years, but otherwise heterogeneous. Nineteen patients (29%) had a valid do-not-attempt-resuscitation order, but paramedics were not informed about it in 10 (53%) of those cases. Eight (12%) of the 65 patients survived to hospital admission and 3 (5%) survived to hospital discharge with a neurologically favourable outcome. Two patients were alive 90days after the cardiac arrest; both were younger than 70years of age and had ventricular fibrillation as primary rhythm. There were no survivors in nursing homes. The do-not-attempt-resuscitation orders were often unavailable during a cardiopulmonary resuscitation attempt. Although resuscitation attempts were futile for patients in nursing homes, some patients in primary care facilities demonstrated a favourable outcome after cardiac arrest. Emergency Medical Services seem to be able to recognise potential survivors and focus resources on their treatment.

Risk factors for cardiopulmonary resuscitation-related injuries sustained during out-of-hospital cardiac arrests.

We aimed to determine the incidence of and associated risk factors for cardiopulmonary resuscitation (CPR)-related injuries in non-survivors of out-of-hospital cardiac arrests (OHCAs) in an emergency medical service (EMS) system in which all CPR procedures are performed on scene and patients are not routinely transported to the hospital with ongoing CPR. We conducted this prospective observational study between 1 June 2013, and 31 May 2014. Data were collected from EMS datasheets and forensic autopsy records. The exclusion criteria were OHCAs due to trauma in the thoracic or abdominal area. EMS adhered to the European Resuscitation Council Resuscitation Guidelines (2010) during the resuscitation attempts. Emergency medical service provided CPR in 280 attended OHCAs with 207 cases terminated on scene. A total of 149 patients underwent a forensic autopsy and 47% had a CPR-related injury. The most common injuries were multiple rib fractures (43%), with 22% of patients having more than eight fractured ribs. Abdominal visceral injuries or injuries related to airway management were rare. The injuries were associated with older age, male gender, initial shockable rhythm and public location of the cardiac arrest (P<.05 respectively). In the multivariable regression analysis, older age, male gender, and public location were independent predictors for injuries. There were no differences in the durations of the CPR attempt between the injured and non-injured groups. Older age, male gender, and public location were independently associated with CPR-related injuries. The duration of the resuscitation attempts did not affect the incident of injuries.

End-tidal carbon dioxide output in manual cardiopulmonary resuscitation versus active compression-decompression device during prehospital quality controlled resuscitation: a case series study

BackgroundActive compression–decompression (ACD) devices have enhanced end-tidal carbon dioxide (ETCO2) output in experimental cardiopulmonary resuscitation (CPR) studies. However, the results in out-of-hospital cardiac arrest (OHCA) patients have shown inconsistent outcomes,...

Refractory Out of Hospital Cardiac Arrest.

Refractory out of hospital cardiac arrest is a common problem that is associated with poor overall survival rates and neurological outcomes. There are various definitions that have been used but the most accepted one is cardiac arrest that requires more than 10 minutes of Cardiopulmonary Resuscitation (CPR) efforts or more than 3 defibrillation attempts. There have been different pharmacologic and non-pharmacologic therapies that were studied in these patients. None of the antiarrhythmic or vasopressor medications have been consistently shown to improve survival or neurological outcomes in this subset of patients. This has led to the introduction of various devices aimed at improving outcomes such as mechanical CPR devices, Extracorporeal Cardiopulmonary Resuscitation (ECPR), targeted temperature management and early invasive approach. There is accumulating evidence that there seems to be an improvement in outcomes when these devices are used in refractory cardiac arrest patients. But none of these devices have been shown to improve outcomes when used in isolation. This underscores the importance of systematic approach to these complex patients and using these therapies in combination. There has been a paradigm shift in the approach to these patients. Instead of repeated and prolonged CPR attempts in the field, it is suggested that these patients need to be moved to cardiac arrest centers with a mechanical CPR device in place, so a percutaneous Extracorporeal Membrane Oxygenator (ECMO) can be placed to “buy” time for other therapies such as therapeutic hypothermia and early coronary angiography followed by intervention as indicated. Careful selection of patients who might potentially benefit from this approach is critical to the success of these programs.

Advance care planning and outcome in pediatric palliative home care.

Pediatric advance care planning seeks to ensure end-of-life care conforming to the patients/their families’ preferences. To expand our knowledge of advance care planning and “medical orders for life-sustaining treatment” (MOLST) in pediatric palliative home care, we determined the number of patients with MOLST, compared MOLST between the four “Together for Short Lives” (TfSL) groups and analyzed, whether there was a relationship between the content of the MOLST and the patients’ places of death.The study was conducted as a single-center retrospective analysis of all patients of a large specialized pediatric palliative home care team (01/2013-09/2016). MOLST were available in 179/198 children (90.4%). Most parents decided fast on MOLST, 99 (55.3%) at initiation of pediatric palliative home care, 150 (83.4%) within the first 100 days. MOLST were only changed in 7.8%. Eighty/179 (44.7%) patients decided on a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) order, 58 (32.4%) on treatment limitations of some kind and 41 (22.9%) wished for the entire spectrum of life-sustaining measures (Full Code). Most TfSL group 1 families wanted DNACPR and most TfSL group 3/4 parents Full Code. The majority (84.9%) of all DNACPR patients died at home/hospice. Conversely, all Full Code patients died in hospital (80% in an intensive care setting).The circumstances of the childrens’ deaths can therefore be predicted considering the content of the MOLST. Regular advance care planning discussions are thus a very important aspect of pediatric palliative home care.

Exploring the implementation of family-witnessed resuscitation.

Cardiac arrest is a traumatic event, both for patients and their family members. Traditionally, healthcare professionals have often been reluctant to offer family members the opportunity to witness cardiopulmonary resuscitation (CPR) attempts. However, professional bodies globally have begun to recommend the use of family-witnessed resuscitation (FWR) during CPR, identifying a range of potential benefits including supporting the patient, increasing family members' confidence in healthcare professionals and, in some cases, promoting acceptance of the patient's death. This article explores the benefits of, and barriers to, the implementation of FWR during CPR. Despite the perceived benefits of FWR identified by professional bodies, healthcare professionals, and patients and their families, the evidence indicates there is ongoing reluctance among some healthcare professionals to incorporate FWR in practice. Therefore, standardised global policies aimed at the multidisciplinary implementation of FWR are required. Additionally, multidisciplinary training and education in CPR should be readily available, particularly in areas where CPR is frequently used, such as emergency departments.

An inquiry into what organised difficult advance care planning conversations in a Scottish residential care home using institutional ethnography.

This paper provides an institutional ethnographic analysis of how advance care planning discussions, which included advance decisions about serious illness, hospital admission and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms, were systematically placed into the hands of senior social care workers (SSCWs) in a residential care home (RCH). RCHs are care settings where there are no on-site nurses, and access to hospital and/or community doctors and nurses is limited. The paper traces the organising features of day-to-day work gathered from interviews with SSCWs (n = 4) and others (n = 6) whose (well-intentioned) work shaped what happened in the RCH. It shows how the experience of SSCWs was socially organised to happen as it did as they (and others) complied with powerful organising texts such as national and local policy documents, care plans and audit forms. The paper concludes that although SSCWs decision-making conversations were out of alignment with the national DNACPR policy, they cannot simply be described as poor practice. This is because they were socially organised by a complex web of institutional practices related to the occupancy rate in the RCH, the inspection process of the care home scrutiny body, the quality assurance process of the RCH company, the funding of palliative care education, and powerful political and fiscal drives to reduce spending on over-75s. These practices had little to do with the actual care needs of RCH residents or the actual support needs of RCH staff. The paper points towards necessary policy changes. It also highlights how 'competent' work driven by ideological institutional practices can result in ethically troubling situations in day-to-day working life. This emphasises the importance of carefully examining the social organisation of situations typically described as poor practice if we are to understand how they are (re)produced. It also offers a different account of care home deaths than is typically presented in the professional literature.

Medical students' experiences of resuscitation and discussions surrounding resuscitation status.

ObjectivesIn the UK, cardiopulmonary resuscitation (CPR) should be undertaken in the event of cardiac arrest unless a patient has a “Do Not Attempt CPR” document. Doctors have a legal duty to discuss CPR with patients or inform them that CPR would be futile. In this study, final-year medical students were interviewed about their experiences of resuscitation on the wards and of observing conversations about resuscitation status to explore whether they would be equipped to have an informed discussion about resuscitation in the future.MethodsTwenty final-year medical students from two medical schools were interviewed about their experiences on the wards. Interviews were transcribed verbatim, and thematic analysis was undertaken.ResultsStudents who had witnessed CPR on the wards found that aspects of it were distressing. A significant minority had never seen resuscitation status being discussed with a patient. No students reported seeing a difficult conversation. Half of the students interviewed reported being turned away from difficult conversations by clinicians. Only two of the twenty students would feel comfortable raising the issue of resuscitation with a patient.ConclusionIt is vital that doctors are comfortable talking to patients about resuscitation. Given the increasing importance of this aspect of communication, it should be considered for inclusion in the formal communication skills teaching during medical school.

Social attitude and willingness to attend cardiopulmonary resuscitation training and perform resuscitation in the Crimea.

To promote potentially life-saving bystander cardiopulmonary resuscitation (CPR), the proportion of CPR-trained general public and their attitude toward CPR should be assessed, which is yet to be done in the former Soviet Union countries. As a case study, the survey is aimed to investigate the prevalence of CPR training, CPR knowledge, attitude and willingness to attend training and attempt CPR in the general population of the Crimea. A personal interview survey was done from November 2017 to January 2018 with quota sampling reflecting age, gender and territorial distribution of the Crimean population. Out of 384 persons surveyed, 53% were trained in CPR. Of trained, 24% passed training within the last year, 44% attended a single course. Among the non-trained, 51% never thought about the need to attend training. Knowledge of CPR is generally poor. About 52% wish to learn CPR, 79% and 91% are willing to attempt CPR on a stranger or a loved one, respectively. Lack of knowledge is the strongest barrier to attempt CPR. People aged ≥60, those with educational level lower than high school, widowed and retired are mostly untrained and unwilling to learn CPR. Females and unemployed are mostly untrained, but willing to be educated. There is a need for increasing CPR training and retraining, and improving awareness and motivation to learn CPR in the Crimean population, targeting the least trained groups. The results could be used as a reference point for future studies in the former USSR countries, utilising the same methodology.

Outcome in survivors of out-of-hospital cardiac arrest in a tertiary care center of North India: A prospective observational study

Background: OHCA (out of hospital cardiac arrest) is a leading cause of death in developed countries, outcome of which depends upon various factors. Not much data is available in India, on outcome of OHCA. Thus, this study was conducted to assess various clinical and biochemical parameters in predicting outcome of survivors of out of hospital cardiac arrest. Methods: This prospective study was done in HDHI Unit of DMCH, Ludhiana over a period of 12 months (January, 2016 to December 2016). Patients of OHCA who were revived following CPR were enrolled for the study and outcome in terms of GCPS and NYHA was seen after one month. Results: A total of 542 patients of OHCA presented to the emergency, of which 49 (9.04%) patients were admitted after ROSC following CPR. Of these 49 patients, 18 (36.73%) survived to hospital discharge and 31 (63.26%) expired or took discharge in a critical condition and presumed to be expired. Mean age of patients was 58.06 ± 15.1 years and males constituted 67.35%. Mean time from arrest to hospital was 7.44 ± 6.9 minutes (survivors) compared to 13.23 ± 8.1 minutes (non survivors) (P value = 0.009). Mean duration of stay was more among discharged (P = 0.006). Patients presenting with VF/VT (P = 0.003) as first monitored rhythm compared to asystole (P = 0.004) had better outcome. On multivariate analysis VF, duration of hospital stay, raised urea and creatinine, time from arrest to first help and hospital were predictors of good outcome. Conclusion: Shorter time interval from arrest to reaching the hospital and shockable rhythm were associated with better outcome in patients of OHCA. Duration of CPR (cardiopulmonary resuscitation), age, gender, comorbidities, witnessed arrest and resuscitation attempt by bystander (bystander CPR) did not show any relation in predicting outcome in out of hospital cardiac arrest survivors. Raised urea and creatinine (correctable biochemical parameters) played a significant role in survival was cardiac arrest on way to hospital.

Analiza epidemioloških podataka vanbolničkog srčanog zastoja kod žena u Vojvodini

Objective: analysis of epidemiological data of out of hospital cardiac arrest (OHCA) in women of Vojvodina in comparison to up to date published studies. Methods: In our study we used data from the OHCA register from region of Vojvodina from 01. 10. 2014 to 01. 08. 2017. Data were derived from common database of Serbian Resuscitation Council collected by main researchers from 13 centers. Analysis was performed using statistical program SPSS. Results: In observed period in Vojvodina region, 1240 cases of OHCA were confirmed by Emergency Medical Service (EMS) teams. Cardiopulmonary resuscitation (CPR) was attempted in 706 patients, 237 (33.56%) of women. Average age of women was 68.2 years. Youngest patient had less than 1 year and eldest was 94 years old. Considering etiology, cardiovascular cause is most common, in197 (83%) cases, respiratory in 15 (6.4%) and other non-cardiological causes in 23 (9.8%) in women. Trauma as the cause of OHCA was not found in our analysis was not registered. Dominant location of OHCA in woman is at home, in 187 (88.6%) cases, followed by public spaces-street in 12 (5%), Nursing Homes in 7 (3%) and public institutions in 3 (1.2%). No cases of OHCA in women were registered on sports fields. Bystander CPR before EMS arrival was registered in 44 (18.6%) of OHCA in women. Shockable rhythm was registered in 61 women (25.7%). Return of spontaneous circulation (ROSC) was achieved in 74 (31.2%) while 12 (5%) patients were released from hospital alive and 30 days survival was registered in 11 (4.6%). Conclusion: According to epidemiological analysis of OHCA database in woman in region of Vojvodina, we can notice that it is less present than in man. Also, average age of woman with OHCA is grater. OHCA in woman happened less in presence of bystander. Bystander CPR attempt in woman is slightly higher than in man, but presence of shockable rhythm, as well as ROSC and survival to hospital discharge is less. Detailed analysis of bystanders who start CPR in women OHCA might indicate the reason of their rather willingness to perform it. Still it is not enough to increase survival.

Cardiac troponins and NT-proBNP in the forensic setting: Overview of sampling site, postmortem interval, cardiopulmonary resuscitation, and review of the literature

The possible use of biochemical markers in the postmortem diagnosis of myocardial ischemia is well known in the forensic setting, though several issues have limited its widespread adoption. The study presented herein focuses of N-terminal pro-B-type natriuretic peptide, troponin T, and troponin I, and the possible influence due to sampling site chosen, postmortem interval elapsed, and cardiopulmonary resuscitation attempts. Comparisons were performed between antemortem serum levels of these markers and postmortem levels measured in pericardial fluid and postmortem serum samples obtained from different sampling sites (n=16). Levels of these markers were also compared in cases characterized by various postmortem intervals (n=48, consisting of 24 ischemic heart disease cases and 24 controls) as well as in cases with and without cardiopulmonary resuscitation (n=22, consisting of 14 cases of hanging and 8 cases of drug intoxication). Our results indicate that N-terminal pro-B-type natriuretic peptide, troponin T, and troponin I values determined in postmortem serum from femoral blood (collected up to 24h after death) do not differ significantly from those measured in venous blood antemortem serum samples (collected at the upper limbs). In addition, our results reveal that the time elapsed after death should always be taken into consideration when cardiac troponins are measured in postmortem samples. Lastly, our findings reveal the absence of statistically significant differences between levels of the tested biomarkers (in postmortem serum from femoral blood) in cases without cardiopulmonary resuscitation compared to cases with cardiopulmonary resuscitation (at least for postmortem intervals up to 24h).

Do Not Attempt Cardiopulmonary Resuscitation Orders in General Surgery - Are we Getting It Right?

Do Not Attempt Cardiopulmonary Resuscitation Orders in General Surgery - Are we Getting It Right?

The futility of cardiopulmonary resuscitation attempts in nursing homes and primary care wards

Purpose of the study: Dispatching emergency medicine service (EMS) to treat nursing home residents or deteriorating patients in local hospitals is a growing phenomenon in Finland. We studied the epidemiology and the outcome after cardiac arrest (CA) in these situations [ 1 Soholm H. Bro-Jeppesen J. Lippert F.K. et al. Resuscitation of patients suffering from sudden cardiac arrests in nursing homes is not futile. Resuscitation. 2014; 85: 369-375 Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar , 2 Beesems S.G. Blom M.T. van der Pas M.H.A. et al. Comorbidity and favorable neurologic outcome after out-of-hospital cardiac arrest in patients of 70 years and older. Resuscitation. 2015; 94: 33-39 Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar ].

Delayed return of spontaneous circulation (the Lazarus phenomenon) after cessation of out-of-hospital cardiopulmonary resuscitation

IntroductionThe delayed return of spontaneous circulation (ROSC) after cessation of cardiopulmonary resuscitation (CPR), also known as the Lazarus phenomenon, is a rare event described in several case reports. This study aims to determine the incidence and the time of occurrence of the Lazarus phenomenon after cessation of out-of-hospital CPR. MethodsThis prospective observational cohort study was conducted in the Helsinki Emergency Medical Service in Finland from 1 January 2011 through 31 December 2016. All out-of-hospital CPR attempts were carefully monitored for 10min after the cessation of CPR in order to detect delayed ROSC. ResultsAltogether, 2102 out-of-hospital cardiac arrests occurred during the six-year study period. CPR was attempted in 1376 (65.5%) cases. In 840 cases (61.0% of all attempts) CPR attempts were terminated on site. The Lazarus phenomenon occurred five times, with an incidence of 5.95/1000 (95% CI 2.10–14.30) in field-terminated CPR attempts. Time to delayed ROSC from the cessation of CPR varied from 3 to 8min. Three of the five patients with delayed ROSC died at the scene within 2–15min while two died later in hospital within 1.5 and 26h, respectively. ConclusionsWe observed that the Lazarus phenomenon is a real albeit rare event and can occur a few minutes after the cessation of out-of-hospital CPR. We suggest a 10-min monitoring period before diagnosing death. CPR guidelines should be updated to include information of the Lazarus phenomenon and appropriate monitoring for it.

'One day I will find the right words, and they will be simple'-Rethinking DNACPR at a national level.

Evidence has shown a diversity of practices and terminology concerning the implementation and documentation of Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) notices across different hospital Trusts in England and Wales, and the Resuscitation Council (UK) has recently proposed a standard approach for how DNACPR notices can be better incorporated into overall care plans. However, the Council can only make recommendations for good practice. This discussion reviews current practices and suggests that the time has come for a national standardized approach to the process of initiating and documenting DNACPR, along with a dedicated programme to increase public understanding of what is involved. A national policy framework for DNACPR notices would avoid regional and institutional differences, bust current myths, and ensure communication with, and involvement of, the patient remains at the heart of medical practice and decision-making. Importantly, it would both ensure that the respective legal rights and obligations of patients and professionals are respected, as well as providing clear public health benefits. At the very least, a national conversation would help achieve common understandings and expectations.

Social workers’ experiences as the family support person during cardiopulmonary resuscitation attempts

ABSTRACTDuring inhospital cardiopulmonary resuscitation attempts, a designated family support person (FSP) may provide guidance and support to family members. Research on nurses and chaplains in this role has been published. Social workers also regularly fulfill this service, however, little is known about how they perceive and enact this role. To explore their experiences, qualitative interviews (n = 10) were conducted with FSP social workers. Critical realist thematic analysis identified five themes: walking in cold, promoting family presence, responding to the whole spectrum of grief, going beyond the family support role, and repercussions of bearing witness. Social workers perform a variety of tasks to promote family presence during resuscitation attempts and provide psychosocial support over the continuum of care. The FSP role impacts social workers emotionally and professionally. Implications for hospital policy, staffing, and clinical practice are discussed.

Do not attempt cardiopulmonary resuscitation decisions: joint guidance.

Since its introduction in the 1960s as a treatment to restart the heart after sudden cardiac arrest from a heart attack, attempts at cardiopulmonary resuscitation have become more common in other clinical situations. Cardiopulmonary resuscitation can be a lifesaving treatment, with the likelihood of recovery varying greatly depending on individual circumstances; however, overall, the proportion of people who survive following cardiopulmonary resuscitation is relatively low. Anticipatory decisions were recognised as being the best way of ensuring that cardiopulmonary resuscitation was not attempted against individuals' wishes. Since 2001, the British Medical Association, Resuscitation Council (UK) and Royal College of Nursing have published professional guidance on decisions relating to cardiopulmonary resuscitation. The latest version of this guidance was published in June 2016. This paper summarises the key legal and ethical principles that should inform all cardiopulmonary resuscitation decisions, with particular emphasis on the recent changes in law and policy.

Multiple myocardial abscesses secondary to late stent infection

A 53-year-old woman presented to our hospital with dizziness and low-grade fever. She underwent percutaneous coronary intervention to the obtuse marginal artery with a drug-eluting stent 20 months prior to this presentation. Physical examination was remarkable for bradycardia. Electrocardiogram showed a junctional rhythm with heart rate of 35 bpm. Blood and urine cultures were negative. Despite successful urgent pacemaker placement, she had cardiac arrest the following day with unsuccessful cardiopulmonary resuscitation attempt. Cardiac autopsy report revealed multiple abscesses involving the obtuse marginal and left anterior descending arteries as well as the adjacent myocardial regions.