Cases Of Cardiopulmonary Resuscitation Research Articles

Quality of Cardiopulmonary Resuscitation in Emergency Department Based on the AHA 2015 Guidelines; a Brief Report.

Adhering to existing guidelines on cardiopulmonary resuscitation (CPR) can increase the survival rate of the patients. The present study has been designed with the aim of determining the quality of CPR performed in the emergency department based on the latest protocol by the American heart association (AHA). In this prospective cross-sectional study CPR process was audited in patients above 18 years old in need of CPR presenting to the emergency departments of 3 teaching hospitals based on the AHA 2015 guidelines. Less than 60% agreement was considered as fail, 60-70% as poor, 70-80% as moderate, 80-90% as good, and 90-100% as excellent. 80 cases of CPR were audited (55% male). Location of arrest was the hospital in 58 (72.5%) cases and 48 (60.0%) of the cases happened during the day. 28 (35.0%) cases had orotracheal intubation before the initiation of CPR. 30 (37.5%) patients had a shockable rhythm at the initiation of CPR. Based on the findings, out of the 31 studied items, 9 (29.03%) had excellent agreement, 10 (32.25%) had good, 4 (12.90%) had moderate, 2 (6.45%) had poor, and 6 (19.35%) had fail agreement rate. Based on the findings of the present study, the quality of applying the principles of basic and advanced CPR in the emergency department of the studied hospital had intermediate, poor and fail agreement with the recommendations of the AHA 2015 in at least one third of the cases.

Prehospital advanced cardiac life support by EMT with a smartphone-based direct medical control for nursing home cardiac arrest

ObjectiveTo compare the survival to discharge between nursing home (NH) cardiac arrest patients receiving smartphone-based advanced cardiac life support (SALS) and basic life support (BLS). MethodsThe SALS registry includes data on cardiac arrest from 7 urban and suburban areas in Korea between July 2015 and December 2016. We include adult patients (>18) with out-of-hospital cardiac arrest (OHCA) of medical causes and EMS attended and dispatched in. SALS is an advanced field resuscitation including drug administration by paramedics with video communication-based direct medical direction. Prehospital resuscitation method was key exposure (SALS, BLS). The primary outcome was survival to discharge. ResultsA total of 616 consecutive out-of-hospital cardiopulmonary resuscitation cases in NHs were recorded, and 199 (32.3%) underwent SALS. Among the NH arrest patients, the survival discharge rate was a little higher in the SALS group than the BLS group (4.0% vs 1.7%), but the difference was not significant (P = 0.078). Survival discharge with good neurologic outcome rates was 0.5% in the SALS group and 1.0% in the BLS group (P = 0.119). On the other hand, in the non-NH group, all outcome measures significantly improved when SALS was performed compared to BLS alone (survival discharge rate: 10.0% vs 7.3%, P = 0.001; good neurologic outcome: 6.8% vs 3.3%, P < 0.001). ConclusionsAs a result of providing prehospital ACLS with direct medical intervention through remote video calls to paramedics, the survival to discharge rate and that with good neurologic outcome (CPC 1, 2) of non-NH patients significantly improved, however those of NH patients were not significantly increased.

Efficacy, Safety, and Usability of Remifentanil as Premedication for INSURE in Preterm Neonates.

Background: We previously reported a 67% extubation failure with INSURE (Intubation, Surfactant, Extubation) using morphine as analgosedative premedication. Remifentanil, a rapid- and short-acting narcotic, might be ideal for INSURE, but efficacy and safety data for this indication are limited. Objectives: To assess whether remifentanil premedication increases extubation success rates compared with morphine, and to evaluate remifentanil’s safety and usability in a teaching hospital context. Methods: Retrospective review of remifentanil orders for premedication, at a large teaching hospital neonatal intensive care unit (NICU). We compared INSURE failure rates (needing invasive ventilation after INSURE) with prior morphine-associated rates. Additionally, we surveyed NICU staff to identify usability and logistic issues with remifentanil. Results: 73 remifentanil doses were administered to 62 neonates (mean 31.6 ± 3.8 weeks’ gestation). Extubation was successful in 88%, vs. 33% with morphine premedication (p < 0.001). Significant adverse events included chest wall rigidity (4%), one case of cardiopulmonary resuscitation (CPR) post-surfactant, naloxone reversal (5%), and notable transient desaturation (34%). Among 137 completed surveys, 57% indicated concerns, including delayed drug availability (median 1.1 h after order), rapid desaturations narrowing intubation timeframes and hindering trainee involvement, and difficulty with bag-mask ventilation after unsuccessful intubation attempts. Accordingly, 33% of ultimate intubators were attending neonatologists, versus 16% trainees. Conclusions: Remifentanil premedication was superior to morphine in allowing successful extubation, despite occasional chest wall rigidity and unfavorable conditions for trainees. We recommend direct supervision and INSURE protocols aimed at ensuring rapid intubation.

Physician turnover effect for in-hospital cardiopulmonary resuscitation: a 10-year experience in a tertiary academic hospital.

Controversy exists as to whether the physician turnover affects patient outcome in academic hospitals. In-hospital cardiopulmonary resuscitation (CPR) is an important indicator of in-hospital mortality. This study aimed to investigate whether the physician turnover is associated with the in-hospital CPR rate. This retrospective cohort study was conducted at a single center; all in-hospital CPR cases among in-patients from 1 January 2007 to 31 December 2016 were analyzed. The turnover period was defined as the changeover of the trainee workforce in March, May, and November. The primary outcome was any variation in the monthly in-hospital CPR events (per 1000 admissions). The secondary outcomes were return of spontaneous circulation (ROSC), CPR in intensive care unit (ICU), monthly in-hospital deaths per 1000 admissions, and average length of hospital stay. A total of 2182 in-hospital CPR cases were included in the analysis. Monthly in-hospital CPR rates were greater during the turnover period when compared to the non-turnover period (4.66±1.02 vs. 4.18±1.56, P=0.027). There was no significant difference in ROSC rate, CPR in ICU rate, monthly in-hospital deaths per 1000 admissions, or average length of hospital stay between the two periods. Our findings indicate that physician turnover may be associated with in-hospital CPR rate. However, physician turnover was not associated with ROSC rate, rate of CPR in the ICU, in-hospital death, or length of hospital stay.

ROSC rates and live discharge rates after cardiopulmonary resuscitation by different CPR teams - a retrospective cohort study

BackgroundPrevious studies have reported that the quality of cardiopulmonary resuscitation (CPR) is closely associated with patient outcomes. The aim of this study was to compare patient CPR outcomes across resident, emergency medicine, and rapid response teams.MethodsThe records of patients who underwent CPR at the Seoul National University Bundang Hospital from January 1, 2013 to December 31, 2016 were analyzed retrospectively. Return of spontaneous circulation, 10- and 30-day survival, and live discharge after return of spontaneous circulation were compared across patients treated by the three CPR teams.ResultsOf the 1145 CPR cases, 444 (39%) were conducted by the resident team, 431 (38%) by the rapid response team, and 270 (23%) by the emergency medicine team. The adjusted odds ratios for the return of spontaneous circulation and subsequent 10-day survival among patients who received CPR from the resident team compared to the rapid response team were 0.59 (P = 0.001) and 0.71 (P = 0.037), respectively. There were no significant differences in the 30-day survival and rate of live discharge between patients who received CPR from the rapid response and resident teams; likewise, no significant differences were observed between patients who received CPR from the emergency medicine and rapid response teams.ConclusionsPatients receiving CPR from the rapid response team may have higher 10-day survival and return of spontaneous circulation rates than those who receive CPR from the resident team. However, our results are limited by the differences in approach, time of CPR, and room settings between teams.

Increased survival from out-of-hospital cardiac arrest when off duty medically educated personnel perform CPR compared with laymen

BackgroundBystander cardiopulmonary resuscitation (CPR) has been proved to save lives; however, whether survival is affected by the training level of the bystander is not fully described. AimTo describe if the training level of laymen and medically educated bystanders affect 30-day survival in out-of-hospital cardiac arrests (OHCA). MethodsThis observational study included all witnessed and treated cases of bystander CPR reported to the Swedish Registry of Cardiopulmonary Resuscitation between 2010 and 2014. Bystander CPR was divided into two categories: (a) lay-byCPR (non-medically educated) and (b) med-byCPR (off duty medically educated personnel). ResultsDuring 2010–2014, 24,643 patients were reported to the OHCA registry, of which 6850 received lay-byCPR and 1444 med-byCPR; 16,349 crew-witnessed and non-witnessed cases and those with missing information were excluded from the analysis. The median interval from collapse to call for emergency medical services was 2min in both groups (p=0.97) and 2min from collapse to start of CPR for lay-byCPR versus 1min for med-byCPR (p<0.0001). There were no significant differences in CPR methods used; 64.3% (lay-byCPR) and 65.7% (med-byCPR) applied compressions and ventilation, respectively (p=0.33). The 30-day survival was 14.7% for lay-byCPR and 17.2% for the med-byCPR group (p=0.02). The odds ratio adjusted for potential confounders regarding survival (med-byCPR versus lay-byCPR) was 1.34 (95% confidence interval, 1.11–1.62; p=0.002). ConclusionsIn cases of OHCA, medically educated bystanders initiated CPR earlier and an increased 30-day survival was found compared with laymen bystanders. These results support the need to improve the education programme for laypeople.

Outcomes of cardiopulmonary resuscitation in the emergency department

Objective: Cardiopulmonary resuscitation (CPR) is a lifesaving technique useful in the prevention of death or delaying it in a person with cardiac arrest. In this regard, demographic information about patients who need CPR is vital. Methods: In this cross-sectional study patients with cardiopulmonary arrest or arrhythmias admitted to Imam Reza and Sina educational hospitals of Tabriz University of Medical Sciences from 22 December 2013 to 21 December 2014 entered the study. Demographic information such as age, sex, cardiopulmonary resuscitation time, the place of cardiopulmonary arrest (outside or inside the hospital), the duration of resuscitation process, success or failure of the resuscitation process and the mechanism of cardiopulmonary arrest were obtained. Results: From a total of 354 cases of cardiopulmonary resuscitation, 281 cases (79%) were unsuccessful and 73 cases (21%) were successful. The average age of patients was 59 ± 22 years. The average time of the resuscitation process was 31 ± 12 minutes. There was a significant difference between the mean of age and resuscitation time in patients who had experienced successful or unsuccessful resuscitation (P = 0.0001). There was a significant relationship between sex and the success rate of resuscitation (P = 0.0001). In addition, a significant relationship between the success of the resuscitation operation and the ward of resuscitation was observed (P = 0.0001). Conclusion: The most common mechanism leading to cardiopulmonary arrest among patients was asystole. In this regard, no significant difference was observed between successful and unsuccessful resuscitation processes. It was also observed that the success of resuscitation from 8 am to 4 pm was more than any other time period.

Study of Pre-Hospital Cardio Pulmonary Resuscitation (CPR) Outcomes and Relevant Factors in Ardabil City between 2012 and 2013

&lt;p&gt;&lt;strong&gt;BACKGROUND &amp;amp; OBJECTIVES:&lt;/strong&gt; Cardio Pulmonary Resuscitation (CPR) is a procedure which was done both in hospital or pre-hospital in order to return life after clinical death. Although the most cardiac attacks happen out of hospital, but there are lack of existing studies related to CPR assessment in pre-hospital conditions. Then this study carried out in order to show the outcome of pre-hospital CPR procedures and its related factors in Medical Emergency Centers of Ardebil city.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;METHOD: &lt;/strong&gt;This descriptive cross-sectional study was conducted on 272 CPR cases in the Emergency Medical Center (EMS) in Ardabil, between 2012 and 2013. The researcher-made questionnaire was used. For data analyzing the descriptive and analytical statistical method such as the Chi-square test and the Chi-square details test were used with SPSS 16 software. The values of P&amp;lt;0.05 were considered significant.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;RESULTS:&lt;/strong&gt; The overall rate of successful CPR reported only 19.1%. The mean (SD) of patient’s age was 74.19±79.60 years and the most of them (66.2%) were men. The most patients (64.3%), had heart problems as a chief complaint. From all CPRs, 83.1% and 11.5% were done in patient homes and public place respectively. There was no statistically significant relationship between the successful CPR with age (p=0.15), sex (p=0.44), the arrival time of emergency personnel to the scene (p=0.98) and patient’s pulse rate (p=0.52). But there was statistically significant relationship between the successful CPR with underlying diseases (p=0.003), Location of CPR (P=0.002), patient blood pressure (p=0.00) and patient respiratory rate (p=0.04).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;CONCLUSION:&lt;/strong&gt; According to the findings, the rate of successful CPR was at a low level in the pre-hospital that need to be investigated further about its cause and its related factors.&lt;/p&gt;

Automated external defibrillator use for in-hospital emergency management.

The in-hospital spread of automated external defibrillators (AEDs) is aimed to allow for a shock-delivery within three minutes. However, it has to be questioned if the implementation of AED alone really contributes to a 'heart-safe hospital'. We performed a cohort study of 1008 in-hospital emergency calls in a university tertiary care hospital, analysing cardiopulmonary resuscitation (CPR) cases with and without AED use. In total, 484 patients (48%) had cardiac arrest and received CPR. Response time of the emergency team was 4.3 ± 4.0 minutes. Only 8% percent of the CPR cases had a shockable rhythm. In three of 43 placements a shock was delivered by the AED. There were no differences in survival between patients with CPR only and CPR with AED use. Our data do not support the use of an AED for in-hospital CPR if a professional response team is rapidly available.

Automated external defibrillator use for in-hospital emergency management

Summary The in-hospital spread of automated external defibrillators (AEDs) is aimed to allow for a shock-delivery within three minutes. However, it has to be questioned if the implementation of AED alone really contributes to a ‘heart-safe hospital’. Methods Cohort study of 1008 in-hospital emergency calls in a university tertiary care hospital. Analysis of cardio-pulmonary resuscitation (CPR) cases with and without AED use. Results A number of 484 patients (48%) had cardiac arrest and received CPR. Response time of the emergency team was 4.3 ± 4.0 minutes. 8% percent of the CPR cases had a shockable rhythm. In only three cases of 43 placements a shock was delivered by the AED. There were no differences in survival between patients with CPR only and CPR with AED use. Conclusion Our data do not support the use of an AED for in-hospital CPR if a professional response team is rapidly available.

A Prospective Study of Survival After In-Hospital Cardiopulmonary Resuscitation and its Related Factors.

BackgroundDespite several studies, there is no agreement on factors that affect survival after in-hospital cardiopulmonary resuscitation (CPR).ObjectivesThis study aimed to evaluate the survival rate of in-hospital CPR and its related factors at Shahid Beheshti hospital in Kashan, Iran, in 2014.Patients and MethodsA descriptive study was conducted on all cases of CPR performed in Kashan Shahid Beheshti hospital during a 6-month period in 2014. Through a consecutive sampling method, 250 cases of CPR were studied. A three-part researcher-made instrument was used. The outcome of CPR was documented as either survival to hospital discharge or unsuccessful (death of the patient). Chi-square test, t test, and logistic regression analysis were used to analyze the data.ResultsOf all CPR cases, 238 (95.2%) were unsuccessful and 12 (4.8%) survived to hospital discharge. Only 2.6% of patients who were resuscitated in medical units survived to hospital discharge, whereas this rate was 11.4% in the emergency department. Only 45 (18%) patients were defibrillated during resuscitation; in 11 patients, defibrillation was performed between 15 to 45 minutes after the initiation of CPR. The mean time from initiation of CPR to the first DC shock was 13.93 ± 8.88 minutes. Moreover, the mean duration of CPR was 35.11 ± 11.42 minutes. The survival rate was higher in the morning shift and lower during the time of shift change (9.4% vs. 0). The duration of CPR and speed of arrival of the CPR team were identified as factors that predicted the outcome of CPR.ConclusionsThe survival rate after in-hospital CPR was very low. The duration of CPR and the time of initiating CPR effects patients’ outcomes. These findings highlight the crucial role of an organized, skilled, well-established and timely CPR team.

Review and Outcome of Prolonged Cardiopulmonary Resuscitation.

The maximal duration of cardiopulmonary resuscitation (CPR) is unknown. We report a case of prolonged CPR. We have then reviewed all published cases with CPR duration equal to or more than 20 minutes. The objective was to determine the survival rate, the neurological outcome, and the characteristics of the survivors. Measurements and Main Results. The CPR data for 82 patients was reviewed. The median duration of CPR was 75 minutes. Patients mean age was 43 ± 21 years with no significant comorbidities. The main causes of the cardiac arrests were myocardial infarction (29%), hypothermia (21%), and pulmonary emboli (12%). 74% of the arrests were witnessed, with a mean latency to CPR of 2 ± 6 minutes and good quality chest compression provided in 96% of the cases. Adjunct therapy included extracorporeal membrane oxygenation (18%), thrombolysis (15.8%), and rewarming for hypothermia (19.5%). 83% were alive at 1 year, with full neurological recovery reported in 63 patients. Conclusion. Patients undergoing prolonged CPR can survive with good outcome. Young age, myocardial infarction, and potentially reversible causes of cardiac arrest such as hypothermia and pulmonary emboli predict a favorable result, especially when the arrest is witnessed and followed by prompt and good resuscitative efforts.

Abstract 16363: The Association Between Cerebral Oxygenation and Brain Waves Measured by Cerebral Oximetry and Electroencephalography (EEG) During Cardiopulmonary Resuscitation (CPR): A Feasibility Study

Background: Cerebral ischemia following cardiac arrest (CA) is associated with significant morbidity and mortality. A major hurdle to improving CA outcomes has been the lack of a real-time detection system capable of identifying cerebral ischemia/oxygenation as well as brain function during CPR as markers of global ischemia. In particular no studies have examined the feasibility of real-time EEG and cerebral oximetry monitoring during CPR to evaluate for these parameters. Methods: This was a single center study using a convenience sample of CA patients enrolled between 03/2014 and 03/2015. Inclusion criteria: In/out of hospital CA, age ≥ 18 years. Portable EEG (Masimo) and cerebral oximetry (Nonin) were used during CPR cases lasting &gt;10 minutes. Raw EEG data were captured as consecutive images (1/second) during each pause in CPR (10 seconds), while oximetry was captured continuously. Results: 16 patients were recruited; mean age = 70±13 years; 11 males and 5 females. All subjects exhibited interpretable EEG patterns, while 50% (n=8/16) had &gt;1 interpretable pattern. There were 428 EEG images. 40.7% (n=174/428) were artifactual due to electrical interference, poor electrode adhesion or movement. 59.3% (n=254/428) were interpretable with seven distinct patterns identified: marked voltage attenuation (MVA) (78%), theta (8%), delta (5%), diffuse quasi-periodic discharge (4%), burst suppression (2%), spike/wave (2%), generalized rhythmic delta activity (1%). Based on known neurological associations, these patterns were further categorized as a) favorable (theta/delta) or b) unfavorable (the remaining patterns). No significant association was observed between cerebral oxygenation (rSO2) and favorable vs. unfavorable EEG patterns (median rSO2 (IQR) = 43.8% (39-48%) vs. 47.5% (42-52%) respectively). Conclusions: Real-time monitoring of cerebral oxygenation and function during CA is feasible. While MVA is the commonest EEG pattern, other distinct patterns also exist. Further studies are needed to explore the association between cerebral oxygenation and EEG patterns during CA as well as to identify intra-CA EEG and oximetry thresholds as markers for therapeutic interventions aimed at ameliorating cerebral ischemia during CA in real-time.

Clinical Characteristics and Mortality of Life-Threatening Events Requiring Cardiopulmonary Resuscitation in Gastrointestinal Endoscopy Units.

Little is known about life-threatening events during gastrointestinal endoscopy (GIE). This study aimed to evaluate the clinical characteristics of emergency conditions requiring cardiopulmonary resuscitation (CPR) in GIE units and to assess the risk factors for mortality in these cases.We retrospectively collected life-threatening cases that occurred in the GIE units of 6 tertiary hospitals from January 2012 to June 2014. Cases were defined as alert calls for resuscitation teams in emergency situations of respiratory failure or cardiac arrest. Demographic data, clinical features, and probable causes were assessed. Factors associated with mortality were elucidated using logistic regression analysis.Among 263,426 endoscopies, 40 cases of CPR (0.015%) occurred during the period (male 67.5%, median age 62 yr). Gastrointestinal bleeding (GIB), such as hematemesis or melena, was the most common indication for endoscopy (55%). The types of clinical situations encountered were as follows: respiratory insufficiency (47.5%), decreased blood pressure (25%), and cardiac arrhythmia (25%). Although most of these conditions were detected during endoscopy (67.5%), one-third of cases (32.5%) were found before or after procedures. The most frequent probable cause of cases was aggravation of underlying diseases (57.5%), such as uncontrolled bleeding or exacerbation of lung disease. Despite efforts to resuscitate, 18 patients (45%) died. GIB was the single independent risk factor for mortality (odds ratio 28.45, 95% confidence interval 1.55–523.33, P = 0.024).Life-threatening situations requiring CPR can occur during endoscopy, even before or after the procedure. Greater attention should be paid while endoscopy is performed for GIB.

The combined use of mechanical CPR and a carry sheet to maintain quality resuscitation in out-of-hospital cardiac arrest patients during extrication and transport

BackgroundQuality of manual cardiopulmonary resuscitation (CPR) during extrication and transport of out-of-hospital cardiac arrest victims is known to be poor. Performing manual CPR during ambulance transport poses significant risk to the attending emergency medical services crew. We sought to use pre-hospital video recording to objectively analyse the impact of introducing mechanical CPR with an extrication sheet (Autopulse, Zoll) to an advanced, second-tier cardiac arrest response team. MethodsThe study was conducted prospectively using defibrillator downloads and analysis of pre-hospital video recording to measure the quality of CPR during extrication from scene and ambulance transport of the OHCA patient. Adult patients with non-traumatic OHCA were included. The interruption to manual CPR to during extrication and to deploy the mechanical CPR device was analysed. ResultsIn the manual CPR group, 53 OHCA cases were analysed for quality of CPR during extrication. The median time that chest compression was interrupted to allow the patient to be carried from scene to the ambulance was 270s (IQR 201–387s). 119 mechanical CPR cases were analysed. The median time interruption from last manual compression to first Autopulse compression was 39s (IQR 29–47s). The range from last manual compression to first Autopulse compression was 14–118s. ConclusionMechanical CPR used in combination with an extrication sheet can be effectively used to improve the quality of resuscitation during extrication and ambulance transport of the refractory OHCA patient. The time interval to deploy the mechanical CPR device can be shortened with regular simulation training.

Tension pneumothorax in unsuccessful cardiopulmonary resuscitation

Background. A well-known complication of cardiopulmonary resuscitation (CPR) and a potentially reversible cause of cardiac arrest (CA) is tension pneumothorax (TP). In TP external cardiac massage is ineffective because increased intrathoracic pressures hamper passive diastolic filling of the heart. Case Reports. As forensic practice reveals repeated cases of unsuccessful CPR with co-existing TP, we exemplarily describe 4 cases of unsuccessful CPR from different origins with TP, which prevented CPR from positive outcome. Why should a forensic pathologist be aware of this? Not only complications of medical therapies are of medico-legal relevance, but also omission of procedures. Autopsy cases with TP after CPR should be discussed regarding medical malpractice. Bilateral chest decompression before termination of CPR must be considered in all patients with CA and blunt chest trauma, i.e. external

Abstract 97: Analysis of Emergency Medical Service-initiated CPR Effectiveness in Out-of Hospital Cardiac Arrest (OHCA) Cases Without Bystander-CPR: From all-Japan OHCA Utstein Registry

Backgrounds: Bystander cardiopulmonary resuscitation (CPR) is essential for good neurological survival (GNS) in out-of-hospital cardiac arrest (OHCA). However previous reports from the All-Japan prospective, population-based OHCA Utstein registry of the Fire and Disaster Management Agency(J-OHCAUR) revealed that around 50% of OHCA did not receive bystander-initiated CPR and treated by the emergency medical service (EMS). The present study examined relationship among the time interval from the witnessed cardiac arrest to EMS-initiated CPR and shock, and GNS one month after the event. Methods and Results: From January 2005 through December 2011, we identified 140,363 witnessed OHCA cases from the J-OHCAUR. Among them, 74,541 cases (53.1%) did not receive bystander-CPR, and 14,911 cases had the initial rhythm of VF or VT. These EMS-initiated CPR cases were classified according to the time-interval from cardiac arrest to CPR and shock; 1,106 in the time-interval of 0 minute (shock first approach), 2.707 in 1 minute, 4.131 in 2 minutes, 2,304 in 3 minutes, 985 in 4 minutes, and 1,047 in 5 to 10 minutes. Rate of GNR (cerebral performance category scale 1 or 2) in each time-intervals were shown in the figure. Effectiveness of CPR was clearly time-dependent, and the earlier shock brought about the better GNS in any time-intervals. Conclusion: Even in OHCA cases without bystander-CPR, time-dependent effectiveness of EMS-initiated CPR and importance of the earlier shock were documented.

Life-Sustaining Treatment Preferences: Matches and Mismatches Between Patients' Preferences and Clinicians' Perceptions

ContextBetter clinician understanding of patients' end-of-life treatment preferences has the potential for reducing unwanted treatment, decreasing health care costs, and improving end-of-life care. ObjectivesTo investigate patient preferences for life-sustaining therapies, clinicians' accuracy in understanding those preferences, and predictors of patient preference and clinician error. MethodsThis was an observational study of 196 male veterans with chronic obstructive pulmonary disease who participated in a randomized trial. Measures included patients' preferences for mechanical ventilation (MV) and cardiopulmonary resuscitation (CPR) if needed in their current state of health, and outpatient clinicians' beliefs about those preferences. ResultsAnalyses were based on 54% of participants in the trial who had complete patient/clinician data on treatment preferences. Patients were more receptive to CPR than MV (76% vs. 61%; P<0.001). Preferences for both treatments were significantly associated with the importance patients assigned to avoiding life-sustaining therapies during the final week of life (MV: b=−0.11, P<0.001; CPR: b=−0.09, P=0.001). When responses were dichotomized (would/would not want treatment), clinicians' perceptions matched patient preferences in 75% of CPR cases and 61% of MV cases. Clinician errors increased as patients preferred less aggressive treatment (MV: b=−0.28, P<0.001; CPR: b=−0.32, P<0.001). ConclusionClinicians erred more often about patients' wishes when patients did not want treatment than when they wanted it. Treatment decisions based on clinicians' perceptions could result in costly and unwanted treatments. End-of-life care could benefit from increased clinician-patient discussion about end-of-life care, particularly if discussions included patient education about risks of treatment and allowed clinicians to form and maintain accurate impressions of patients' preferences.

A clinical observational study analysing the factors associated with hyperventilation during actual cardiopulmonary resuscitation in the emergency department

AimThis is the first study to identify the factors associated with hyperventilation during actual cardiopulmonary resuscitation (CPR) in the emergency department (ED). MethodsAll CPR events in the ED were recorded by video from April 2011 to December 2011. The following variables were analysed using review of the recorded CPR data: ventilation rate (VR) during each minute and its associated factors including provider factors (experience, advanced cardiovascular life support (ACLS) certification), clinical factors (auscultation to confirm successful intubation, suctioning, and comments by the team leader) and time factors (time or day of CPR). ResultsFifty-five adult CPR cases including a total of 673min sectors were analysed. The higher rates of hyperventilation (VR>10/min) were delivered by inexperienced (53.3% versus 14.2%) or uncertified ACLS provider (52.2% versus 10.8%), during night time (61.0 versus 34.5%) or weekend CPR (53.1% versus 35.6%) and when auscultation to confirm successful intubation was performed (93.5% versus 52.8%) than not (all p<0.0001). However, experienced (25.3% versus 29.7%; p=0.448) or certified ACLS provider (20.6% versus 31.3%; p<0.0001) could not deliver high rate of proper ventilation (VR 8–10/min). Comment by the team leader was most strongly associated with the proper ventilation (odds ratio 7.035, 95% confidence interval 4.512–10.967). ConclusionsHyperventilation during CPR was associated with inexperienced or uncertified ACLS provider, auscultation to confirm intubation, and night time or weekend CPR. And to deliver proper ventilation, comments by the team leader should be given regardless of providers’ expert level.

Primary respiratory arrest recognised by emergency medical technicians and followed by cardiac arrest in Japan: Identification of a subgroup of EMT-witnessed cardiac arrests with an extremely poor outcome

ReviewSome unconscious patients are found to be in primary respiratory arrest (PRA) by emergency medical technicians (EMTs). In contrast to citizens, EMTs manage PRA with artificial ventilation but not with cardiopulmonary resuscitation (CPR). This study aimed to investigate the characteristics and outcomes of PRA prior to EMT arrival and compare these data with those of a PRA-related group: patients with out-of-hospital cardiac arrests (OHCAs). MethodsBaseline data were prospectively collected by fire departments for their adult (16 years or older) OHCA and PRA patients from April 2003 through March 2010. We extracted those who had PRA prior to EMT arrival. The EMT- and bystander-witnessed OHCA patients who underwent CPR were also extracted as control groups. ResultsThere were 178 cases of PRA prior to EMT arrival. The majority (164/178) of these individuals were in a deep coma and met the criteria for the initiation of bystander CPR. Approximately 61% (108/178) of these PRAs were followed by cardiac arrests, which were classified as EMT-witnessed OHCAs by the Utstein template. The EMTs manually ventilated the patients until the cardiac arrest occurred. The 1-Y survival of this subgroup was the lowest of the PRA and PRA-related OHCA subgroups and was significantly lower than that of bystander-witnessed OHCAs with bystander CPR, when trauma and terminal illness cases were excluded (adjusted odds ratio=3.888 (1.103–24.827)). ConclusionsWe identified a subgroup of PRAs with unexpectedly poor outcomes. The BLS guidelines for healthcare providers including EMTs should be re-evaluated by a large prospective study.