Cardiopulmonary Resuscitation Guidelines Research Articles

Chest Decompressions - The Driver of CPR Efficacy: Exploring the Relationship Between Compression Rate, Depth, Recoil Velocity, and End-Tidal CO2

Objective Cardiopulmonary arrest survival is dependent on optimization of perfusion via high quality cardiopulmonary resuscitation (CPR), defined by a complex dynamic between rate, depth, and recoil velocity. Here we explore the interaction between these metrics and create a model that explores the impact of these variables on compression efficacy. Methods This study was performed in a large urban/suburban fire-based emergency medical services (EMS) system over a nine-month period from 2019 to 2020. Manual chest compression parameters [rate/depth/recoil velocity] from a cohort of out-of-hospital cardiac arrest (OOHCA) victims were abstracted from monitor defibrillators (ZOLL X-series) and end-tidal carbon dioxide (ETCO2) from sensors. The mean values of these parameters were modeled against each other using multiple regression and structural equation modeling with ETCO2 as a dependent variable. Results Data from a total of 335 patients were analyzed. Strong linear relationships were observed between compression depth/recoil velocity (r = .87, p < .001), ETCO2/depth (r = .23, p < .001) and ETCO2/recoil velocity (r = .61, p < .001). Parabolic relationships were observed between rate/depth (r = .39, p < .001), rate/recoil velocity (r = .26, p < .001), and ETCO2/rate (r = .20, p = .003). Rate, depth, and recoil velocity were modeled as independent variables and ETCO2 as a dependent variable with excellence model performance suggesting the primary driver of stroke volume to be recoil velocity rather than compression depth. Conclusions We used manual CPR metrics from out of hospital cardiac arrests to model the relationship between CPR metrics. These results consistently support the importance of chest recoil on CPR hemodynamics, suggesting that guidelines for optimal CPR should emphasize the importance of maximum chest recoil.

Cardiopulmonary Resuscitation Without Aortic Valve Compression Increases the Chances of Return of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest: A Prospective Observational Cohort Study.

Following current cardiopulmonary resuscitation (CPR) guidelines, which recommend chest compressions at "the center of the chest," ~50% of patients experiencing out-of-hospital cardiac arrest (OHCA) undergo aortic valve (AV) compression, obstructing blood flow. We used resuscitative transesophageal echocardiography (TEE) to elucidate the impact of uncompressed vs. compressed AV on outcomes of adult patients experiencing OHCA. Prospective observational cohort study. Single center. This study included adult OHCA patients undergoing resuscitative TEE in the emergency department. Patients were categorized into AV uncompressed or AV compressed groups based on TEE findings. None. The primary outcome was sustained return of spontaneous circulation (ROSC). The secondary outcomes included end-tidal co2 (Etco2) during CPR, any ROSC, survival to ICU and hospital discharge, post-resuscitation withdrawal, and favorable neurologic outcomes at discharge. Additional analyses on intra-arrest arterial blood pressure (ABP) were also conducted. The sample size was pre-estimated at 37 patients/group. From October 2020 to January 2023, 76 patients were enrolled, 39 and 37 in the AV uncompressed and AV compressed groups, respectively. Intergroup baseline characteristics were similar. Compared with the AV compressed group, the AV uncompressed group had a higher probability of sustained ROSC (53.8% vs. 24.3%; adjusted odds ratio [aOR], 4.72; p = 0.010), any ROSC (56.4% vs. 32.4%; aOR, 3.30; p = 0.033), and survival to ICU (33.3% vs. 8.1%; aOR, 6.74; p = 0.010), and recorded higher initial diastolic ABP (33.4 vs. 11.5 mm Hg; p = 0.002) and a larger proportion achieving diastolic ABP greater than 20 mm Hg during CPR (93.8% vs. 33.3%; p < 0.001). The Etco2, post-resuscitation withdrawal, and survival to discharge revealed no significant intergroup differences. No patients were discharged with favorable neurologic outcomes. Uncompressed AV seemed critical for sustained ROSC across all subgroups. Absence of AV compression during OHCA resuscitation is associated with an increased chance of ROSC and survival to ICU. However, its effect on long-term outcomes remains unclear.

Finite Element Analysis of a Rib Cage Model: Influence of Four Variables on Fatigue Life during Simulated Manual CPR.

Cardiopulmonary resuscitation (CPR) is a life-saving technique used in emergencies when the heart stops beating, typically involving chest compressions and ventilation. Current adult CPR guidelines do not differentiate based on age beyond infancy and childhood. This oversight increases the risk of fatigue fractures in the elderly due to decreased bone density and changes in thoracic structure. Therefore, this study aimed to investigate the correlation and impact of factors influencing rib fatigue fractures for safer out-of-hospital manual cardiopulmonary resuscitation (OHMCPR) application. Using the finite element analysis (FEA) method, we performed fatigue analysis on rib cage models incorporating chest compression conditions and age-specific trabecular bone properties. Fatigue life analyses were conducted on three age-specific rib cage models, each differentiated by trabecular bone properties, to determine the influence of four explanatory variables (the properties of the trabecular bone (a surrogate for the age of the subject), the site of application of the compression force on the breastbone, the magnitude of applied compression force, and the rate of application of the compression force) on the fatigue life of the model. Additionally, considering the complex interaction of chest compression conditions during actual CPR, we aimed to predict rib fatigue fractures under conditions simulating real-life scenarios by analyzing the sensitivity and interrelation of chest compression conditions on the model's fatigue life. Time constraints led to the selection of optimal analysis conditions through the use of design of experiments (DOE), specifically orthogonal array testing, followed by the construction of a deep learning-based metamodel. The predicted fatigue life values of the rib cage model, obtained from the metamodel, showed the influence of the four explanatory variables on fatigue life. These results may be used to devise safer CPR guidelines, particularly for the elderly at a high risk of acute cardiac arrest, safeguarding against potential complications like fatigue fractures.

A new method of pulse control in cardiopulmonary resuscitation; Continuous femoral pulse check

ObjectivesThe reliability of manual pulse checks has been questioned but is still recommended in cardiopulmonary resuscitation (CPR) guidelines. The aim is to compare the 10-s carotid pulse check (CPC) between heart massage cycles with the continuous femoral pulse check (CoFe PuC) in CPR, and to propose a better location to shorten the interruption times for pulse check. MethodsA prospective study was conducted on 117 Non-traumatic CPR patients between January 2020 and January 2022. A total of 702 dependent pulse measurements were executed, where carotid and femoral pulses were simultaneously assessed. Cardiac ultrasound, end-tidal CO2, saturation, respiration, and blood pressure were employed for pulse validation. ResultsThe decision time for determining the presence of a pulse in the last cycle of CPR was 3.03 ± 1.26 s for CoFe PuC, significantly shorter than the 10.31 ± 5.24 s for CPC. CoFe PuC predicted the absence of pulse with 74% sensitivity and 88% specificity, while CPC predicted the absence of pulse with 91% sensitivity and 61% specificity. ConclusionCoFe PuC provides much earlier and more effective information about the pulse than CPC. This shortens the interruption times in CPR. CoFe PuC should be recommended as a new and useful method in CPR guidelines.

Impact of Updating the Cardiopulmonary Resuscitation Guidelines on Out-of-Hospital Shockable Cardiac Arrest: A Population-Based Cohort Study in Japan.

International consensus on cardiopulmonary resuscitation (CPR) and emergency cardiovascular care science and treatment recommendations (CoSTR) have reported updates on CPR maneuvers every 5 years since 2000. However, few national population-based studies have investigated the comprehensive effectiveness of those updates for out-of-hospital cardiac arrest due to shockable rhythms. The primary objective of the present study was to determine whether CPR based on CoSTR 2005 or 2010 was associated with improved outcomes in Japan, as compared with CPR based on Guidelines 2000. From the All-Japan Utstein Registry between 2005 and 2015, we included 73 578 adults who had shockable out-of-hospital cardiac arrest witnessed by bystanders or emergency medical service responders. The study outcomes over an 11-year period were compared between 2005 of the Guidelines 2000 era, from 2006 to 2010 of the CoSTR 2005 era, and from 2011 to 2015 of the CoSTR 2010 era. In the bystander-witnessed group, the adjusted odds ratios for favorable neurological outcomes at 30 days after out-of-hospital cardiac arrest by enrollment year increased year by year (1.19 in 2006, and 3.01 in 2015). Similar results were seen in the emergency medical service responder-witnessed group and several subgroups. Compared with CPR maneuvers for shockable out-of-hospital cardiac arrest recommended in the Guidelines 2000, CPR maneuver updates in CoSTR 2005 and 2010 were associated with improved neurologically intact survival year by year in Japan. Increased public awareness and greater dissemination of basic life support may be responsible for the observed improvement in outcomes. URL: https://www.umin.ac.jp/ctr/; Unique identifier: 000009918.

Gender, Socioeconomic Status, Race, and Ethnic Disparities in Bystander Cardiopulmonary Resuscitation and Education-A Scoping Review.

Social determinants are associated with survival from out-of-hospital sudden cardiac arrest (SCA). Because prompt delivery of bystander CPR (B-CPR) doubles survival and B-CPR rates are low, we sought to assess whether gender, socioeconomic status (SES), race, and ethnicity are associated with lower rates of B-CPR and CPR training. This scoping review was conducted as part of the continuous evidence evaluation process for the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care as part of the Resuscitation Education Science section. We searched PubMed and excluded citations that were abstracts only, letters or editorials, and pediatric studies. We reviewed 762 manuscripts and identified 24 as relevant; 4 explored gender disparities; 12 explored SES; 11 explored race and ethnicity; and 3 had overlapping themes, all of which examined B-CPR or CPR training. Females were less likely to receive B-CPR than males in public locations. Observed gender disparities in B-CPR may be associated with individuals fearing accusations of inappropriate touching or injuring female victims. Studies demonstrated that low-SES neighborhoods were associated with lower rates of B-CPR and CPR training. In the US, predominantly Black and Hispanic neighborhoods were associated with lower rates of B-CPR and CPR training. Language barriers were associated with lack of CPR training. Gender, SES, race, and ethnicity impact receiving B-CPR and obtaining CPR training. The impact of this is that these populations are less likely to receive B-CPR, which decreases their odds of surviving SCA. These health disparities must be addressed. Our work can inform future research, education, and public health initiatives to promote equity in B-CPR knowledge and provision. As an immediate next step, organizations that develop and deliver CPR curricula to potential bystanders should engage affected communities to determine how best to improve training and delivery of B-CPR.

Pilot testing of mobile app-based blended learning on selected skills of cardiopulmonary resuscitation among nursing students.

Background Cardiopulmonary resuscitation (CPR) is a skill-oriented training programme required to be practised and updated periodically by every healthcare provider. Methods In an open-label randomized controlled trial, 81 fourth-year BSc Nursing students were randomized to experimental (n=41) and control (n=40) groups using a computer-generated table. The learning resource material was shared through a mobile-app with the experimental group (EG) and the control group (CG) received the internet link for retrieving the learning resource material, 4 days before a 1-day training programme. Baseline knowledge and skills assessment of the students was done before the commencement of the training programme, using a pre-validated self-developed questionnaire based on standardized CPR guidelines of professional bodies. Post-intervention assessment of knowledge, skills, confidence and satisfaction of the students with the training methodology was done at the end of the training programme. The confidence and satisfaction of the students with the training methodology were assessed using a standardized confidence scale and a self-developed satisfaction scale, respectively. Results The baseline knowledge and skills scores of the students were comparable (EG v. CG, knowledge: 16.04 [2.35] v. 15.52 [2.69], p=0.34; skill: 13.41 [5.28] v. 15.02 [4.66], p=0.16). A comparable improvement was seen in post-intervention knowledge and skills scores between the groups (EG v. CG, knowledge 17.78 [1.49] v. 17.70 [1.51], p=0.82; skill 29.85 [2.44] v. 30.08 [2.79], p=0.60). The post-intervention confidence in performing the skills (20.22 [2.76] v. 19.41 [3.63], p=0.331) and satisfaction with the method of dissemination of educational resource material (29.85 [2.4] v. 30.08 [2.79], p=0.73) were also comparable in both the groups. Conclusion Both mobile app-based and internet link-based learning resource material along with hands-on sessions were effective in bringing comparable improvement in knowledge, skills, self-confidence and satisfaction of students in performing the selected skills of cardiopulmonary resuscitation.

2023 American Heart Association and American Academy of Pediatrics Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This 2023 focused update to the neonatal resuscitation guidelines is based on 4 systematic reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Systematic reviewers and content experts from this task force performed comprehensive reviews of the scientific literature on umbilical cord management in preterm, late preterm, and term newborn infants, and the optimal devices and interfaces used for administering positive-pressure ventilation during resuscitation of newborn infants. These recommendations provide new guidance on the use of intact umbilical cord milking, device selection for administering positive-pressure ventilation, and an additional primary interface for administering positive-pressure ventilation.

Compliance with cardiopulmonary resuscitation guidelines in witnessed in-hospital cardiac arrest events and patient outcome on monitored versus non-monitored wards

BackgroundAdherence to cardiopulmonary resuscitation (CPR) guidelines in treatment of in-hospital cardiac arrest (IHCA) have been associated with favourable patient outcome. The aim of this study was to evaluate if compliance with initial CPR guidelines and patient outcome of witnessed IHCA events were associated with the place of arrest defined as monitored versus non-monitored ward. MethodsA total of 956 witnessed IHCA events in adult patients at six hospitals during 2018 to 2019, were extracted from the Swedish Registry of Cardiopulmonary Resuscitation. Initial CPR guidelines were: ≤1 min from collapse to alert of the rapid response team, ≤1 min from collapse to start of CPR, ≤3 min from collapse to defibrillation of shockable rhythm. ResultsThe odds of compliance with guidelines was higher on monitored wards vs non-monitored wards, even after adjustment for factors that could affect staffing and resources. The place of arrest was not a significant factor for sustained return of spontaneous circulation, survival at 30 days, or neurological status at discharge, when adjusting for clinically relevant confounders. Compliance with initial CPR guidelines remained a significant factor for survival to 30 days and favourable neurological outcome at discharge regardless of other confounders. ConclusionCompliance with initial CPR guidelines was higher in witnessed IHCA events on monitored wards than on non-monitored wards, which indicates that healthcare professionals in monitored wards are quicker to recognize a cardiac arrest and initiate treatment. When initial CPR guidelines are followed, the place of arrest does not influence patient outcome.

Out-of-Hospital Cardiac Arrest in the Elderly: Unique Considerations and Challenges – A Case Series

Introduction: Out-of-hospital cardiac arrest (OHCA) is a significant public health issue. Developed countries have observed an increasing number of OHCAs in the elderly population. Emergency medical technicians (EMTs) are facing a growing number of OHCA cases in elderly patients, requiring special attention and consideration. As of 2020, the latest cardiopulmonary resuscitation (CPR) guidelines prioritize chest compressions as the initial course of action in OHCA situations. Methods: A year-long statistical analysis (2020-2021) of elderly individuals in the pre-hospital system of Hamadan province examined 10 cases of OHCA in the elderly in 2020-21 that occurred after consuming food (postprandial myocardial infarction). Results: Ten of 90 cardiac arrest cases attended by EMTs occurred in elderly individuals after eating, and despite resuscitation efforts by the EMTs, none of these cases were successful. Consequently, this complication significantly reduces the chances of successful resuscitation in these patients. Therefore, addressing the issue of aspiration in elderly individuals during resuscitation is crucial. Conclusion: Continued research, collaboration, and adaptation of resuscitation protocols will contribute to advancements in the field and enhance the life-saving potential of elderly individuals who experience cardiac arrest.

Hemodynamic Effect of Repeated Epinephrine Doses Decreases With Cardiopulmonary Resuscitation Cycle Progression.

Epinephrine is administered to increase coronary perfusion pressure during advanced life support and promote short-term survival. Recent cardiopulmonary resuscitation (CPR) guidelines recommend an epinephrine dosing interval of 3 to 5 minutes during resuscitation; however, scientific evidence supporting this recommendation is lacking. Therefore, we aimed to investigate the hemodynamic effects of repeated epinephrine doses during CPR by monitoring augmented blood pressure after its administration in a swine model of cardiac arrest. A secondary analysis of data from a published study was performed using a swine cardiac arrest model. The epinephrine dose was fixed at 1 mg, and the first dose of epinephrine was administered after no-flow and low-flow times of 2 minutes and 8 minutes, respectively, and subsequently administered every 4 minutes. Four cycles of dosing intervals were defined because a previous study was terminated 26 minutes after the induction of ventricular fibrillation. Augmented blood pressures and corresponding timelines were determined. Augmented blood pressure trends following cycles and the epinephrine effect duration were also monitored. Among the 140 CPR cycles, the augmented blood pressure after epinephrine administration was the highest during the first cycle of CPR and decreased gradually with further cycle repetitions. The epinephrine effect duration did not differ between repeated cycles. The maximum blood pressure was achieved 78 to 97 seconds after epinephrine administration. Hemodynamic augmentation with repeated epinephrine administration during CPR decreased with cycle progression. Further studies are required to develop an epinephrine administration strategy to maintain its hemodynamic effects during prolonged resuscitation.

2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Cardiac arrest is common and deadly, affecting up to 700 000 people in the United States annually. Advanced cardiac life support measures are commonly used to improve outcomes. This "2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support" summarizes the most recent published evidence for and recommendations on the use of medications, temperature management, percutaneous coronary angiography, extracorporeal cardiopulmonary resuscitation, and seizure management in this population. We discuss the lack of data in recent cardiac arrest literature that limits our ability to evaluate diversity, equity, and inclusion in this population. Last, we consider how the cardiac arrest population may make up an important pool of organ donors for those awaiting organ transplantation.

O conhecimento da equipe de enfermagem acerca do atendimento na parada cardiorrespiratória em unidade de terapia intensiva

The study aims to identify the level of knowledge of the nursing team about the CPR protocol and its influence on care for cardiorespiratory arrest in the intensive care unit of a hospital in Greater Vitória. The chosen methodology was field research of the observational type of descriptive character with a quantitative approach. To this end, a closed questionnaire was carried out with twelve questions divided into three levels of difficulty with 65 professionals, 21.5% nurses and 78.5% nursing technicians, with a general average of 67.6% correct answers. It was observed that, as the level of difficulty increased, there was a decrease in the number of correct answers. Despite acknowledging the importance of the topic, the team had a deficit in knowledge regarding the current recommended guidelines for cardiopulmonary resuscitation. Therefore, the importance of continuing education is emphasized in order to promote quality care and minimize iatrogenic events.

Treatment strategy for an unstable chest wall after cardiopulmonary resuscitation

Every year ca. 60,000 people in Germany undergo cardiopulmonary resuscitation (CPR). The two most frequent underlying causes are of cardiopulmonary and traumatic origin. According to the current CPR guidelines chest compressions should be performed in the middle of the sternum with a pressure frequency of 100-120/min and to adepth of 5-6 cm. In contrast to trauma patients where different injury patterns can arise depending on the accident mechanism, both the type of trauma and the injury pattern are similar in patients after CPR due to repetitive thorax compression. It is known that an early reconstruction of the thoracic wall and the restoration of the physiological breathing mechanics in trauma patients with unstable thoracic injuries reduce the rates of pneumonia and weaning failure and shorten the length of stay in the intensive care unit. As a result, it is increasingly being propagated that an unstable thoracic injury as a result of CPR should also be subjected to surgical treatment as soon as possible. In the hospital of the authors an algorithm was formulated based on clinical experience and the underlying evidence in a traumatological context and a surgical treatment strategy was designed, which is presented and discussed taking the available evidence into account.

Chest compressions for pediatric organized rhythms: A hemodynamic and outcomes analysis

AimPediatric cardiopulmonary resuscitation (CPR) guidelines recommend starting CPR for heart rates (HRs) less than 60 beats per minute (bpm) with poor perfusion. Objectives were to (1) compare HRs and arterial blood pressures (BPs) prior to CPR among patients with clinician-reported bradycardia with poor perfusion (“BRADY”) vs. pulseless electrical activity (PEA); and (2) determine if hemodynamics prior to CPR are associated with outcomes. Methods and ResultsProspective observational cohort study performed as a secondary analysis of the ICU-RESUScitation trial (NCT028374497). Comparisons occurred (1) during the 15 seconds “immediately” prior to CPR and (2) over the two minutes prior to CPR, stratified by age (≤1 year, >1 year). Poisson regression models assessed associations between hemodynamics and outcomes. Primary outcome was return of spontaneous circulation (ROSC). Pre-CPR HRs were lower in BRADY vs. PEA (≤1 year: 63.8 [46.5, 87.0] min−1 vs. 120 [93.2, 150.0], p < 0.001; >1 year: 67.4 [54.5, 87.0] min−1 vs. 100 [66.7, 120], p < 0.014). Pre-CPR pulse pressure was higher among BRADY vs. PEA (≤1 year (12.9 [9.0, 28.5] mmHg vs. 10.4 [6.1, 13.4] mmHg, p > 0.001). Pre-CPR pulse pressure ≥ 20 mmHg was associated with higher rates of ROSC among PEA (aRR 1.58 [CI95 1.07, 2.35], p = 0.022) and survival to hospital discharge with favorable neurologic outcome in both groups (BRADY: aRR 1.28 [CI95 1.01, 1.62], p = 0.040; PEA: aRR 1.94 [CI95 1.19, 3.16], p = 0.008). Pre-CPR HR ≥ 60 bpm was not associated with outcomes. ConclusionsPulse pressure and HR are used clinically to differentiate BRADY from PEA. A pre-CPR pulse pressure >20 mmHg was associated with improved patient outcomes.

2023 American Heart Association and American Academy of Pediatrics Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This 2023 focused update to the neonatal resuscitation guidelines is based on 4 systematic reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Systematic reviewers and content experts from this task force performed comprehensive reviews of the scientific literature on umbilical cord management in preterm, late preterm, and term newborn infants, and the optimal devices and interfaces used for administering positive-pressure ventilation during resuscitation of newborn infants. These recommendations provide new guidance on the use of intact umbilical cord milking, device selection for administering positive-pressure ventilation, and an additional primary interface for administering positive-pressure ventilation.

Abstract 295: Predicting Outcomes in Adult Patients With Out-of-Hospital Cardiac Arrest; Results From the All-Japan Utstein Registry

Background: The recent cardiopulmonary resuscitation (CPR) Guideline addressed that there was no evidence to clearly define what should constitute selected patients in case of performing invasive CPR, such as extracorporeal CPR, for patients with cardiac arrest (CA). However, emergency physicians often need to determine the treatment strategy immediately upon arrival in emergency departments. The present study aimed to clarify the helpful factor of prehospital care to predict adult CA patients' prognosis using the All-Japan Utstein Registry data, a prospective, nationwide, population-based registry of out-of-hospital CA (OHCA). Methods: From the data of this registry, between 2005 and 2020, we included adult OHCA patients due to cardiac etiology. The endpoint was the favorable neurological outcome at 30 days after OHCA. The multivariable logistic regression analysis included potential confounding factors based on biological plausibility and previous studies. We scored based on the odds ratio. Receiver operating characteristic analysis was performed, and the area under the curve (AUC) was calculated for factors of the total score in order to assess the 30-day neurological outcome. Results: Of the 1,930,273 patients registered in this Registry, the data of 1,099,908 patients were included in this analysis. The table showed the adjusted odds ratio for 30-day favorable neurological outcomes in OHCA patients in the multivariate analysis, and the score based on the odds ratio. The AUC of the total scores was 0.956 (p &lt; 0.001) with a cutoff value of 7, a sensitivity of 92%, and a specificity of 88%. In the case of this total score of less than 7, the 30-day favorable neurological outcome in CA patients was significantly low (total score &lt; 7 vs. total score &gt; 7 = 0.3% vs. 18.7%: p&lt;0.001). Conclusion: This score might be a helpful factor in prehospital care information in CA patients to determine the treatment strategy upon arrival in emergency departments.

Abstract 307: In-Situ Simulation-Based Booster ACLS Training to Increase the Confidence and Performance of Internal Medicine Residents as Code Blue Leaders - A Quality Improvement Project

Background: In the United States, nearly 290,000 adult patients develop in-hospital cardiac arrest (IHCA) every year. Delivery of guideline-based resuscitation has improved patient outcomes. During 2022, our hospital had 68 inpatient i.e., approximately 1 code/resident. Residents have reported desire for more exposure. The 2020 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommended: 1) booster training, 2) in-situ simulation-based resuscitation training, and 3) specific teamwork and leadership training for healthcare providers. We aimed to implement such training to achieve an improvement in resident confidence and performance as code blue leaders. Methods: Pre-intervention, residents completed a 5-item 0-100 continuous scale to assess confidence in major code leader skills (Fig 1-A). Interventions included: 1) Calling residents to patient rooms to run simulation-based codes, and 2) a didactic session that discussed common errors during codes. Time to key ACLS steps was recorded during the simulations. At the end of the project, residents completed the post-intervention survey of confidence and balancing measures. Results: 13 residents led simulation-based codes, 20 attended the didactic session, and 25 completed the survey. Resident confidence in the defined skills increased by an average of 30%. (P&lt;0.05) (Fig 1-A). Residents who led codes after the didactic session had shorter times to key ACLS steps (Fig 1-B). Balancing measures included resident-reported satisfaction and perceived disruption to clinical workflow (100% and 0% of responses, respectively). Conclusions: In-situ simulation-based booster ACLS training was associated with an increase in the confidence and performance of IM residents as code blue leaders. Incorporation of such training in IM residency curriculum should be considered as a practical application to sustain the gains of this QI initiative.

Abstract 217: Chest Compression on Aortic Valve Decreases Chance of Return of Spontaneous Circulation for Patients Experiencing Out-of-Hospital Cardiac Arrest

Background: Current CPR guidelines recommend applying chest compression at "the center of the chest" for patients undergoing out-of-hospital cardiac arrest (OHCA). However, studies revealed that following this recommendation, around half of OHCA patients would receive compressions on the aortic valve (AV), potentially obstructing blood flow and worsening prognosis. Hypothesis and Aim: We aimed to use transesophageal echocardiography (TEE) during cardiopulmonary resuscitation (CPR) to test the hypothesis of the impact of AV compression vs AV non-compression on adult OHCA patients' outcomes. Methods: This prospective cohort study included OHCA patients receiving TEE exams during CPR. Exclusion criteria were the return of spontaneous circulation (ROSC) before TEE, unidentifiable compression site, or unqualified TEE image. Patients were divided into AV-compressed or non-compressed groups based on initial TEE findings. Patient characteristics, TEE recordings, resuscitation data, and critical time points were analyzed. Primary outcome was sustained ROSC. Secondary outcomes included any ROSC, survival to admission, survival to discharge, and favorable neurological outcomes upon discharge defined by MRS ≤ 2. The sample size was pre-estimated as 37 patients per group. Results: A total of 76 patients from October 2020 to January 2023 were enrolled for analysis, with 39 in the AV non-compressed group and 37 in the AV-compressed group. Baseline characteristics were similar between groups. Compared to the compressed group, the non-compressed group had a better chance of sustained ROSC [adjusted odds ratio (aOR) 4.72, p=0.010], any ROSC (aOR 3.30, p=0.033), and survival to admission (aOR 6.74, p=0.010). The main results were tabulated as below. Conclusions: CPR with compressed AV decreased the chances of ROSC among OHCA patients.

2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.