Chest Compressions In Patients Research Articles

Abstract 13334: Safety of Chest Compressions in Patients With a Durable Left Ventricular Assist Device

Introduction: The safety of chest compressions (CC) during cardiopulmonary resuscitation (CPR) among pts with a durable left ventricular assist device (LVAD) is an area of controversy. Concerns regarding device malfunction or dislodgment with CC may result in significant delays or the withholding of life-sustaining intervention entirely. Current societal guidelines, based on small case reports, suggest that manual CC are probably not harmful, but offer no additional guidance. Furthermore, they acknowledge that there are no data regarding the use of machine-assisted CC. Methods: We retrospectively reviewed medical records of consecutive pts who underwent durable LVAD implantation at Duke University from 2013-2022. Charts were searched for “code”, “arrest”, “compressions”, and “rapid response team” to identify all instances of cardiac arrest (CA). Baseline pt characteristics, details of the arrest (including CC details), in-hospital care processes, and pt outcomes were abstracted. Results: Of 750 pts reviewed, 58 (mean age 64 years, 76% male, median LVAD support duration 19 months) had documented CA. Fifteen (26%) pts presented with an out-of-hospital CA. Twenty-four (41%) pts did not receive CC. The most commonly reported reason for avoiding CC was “LVAD in place - contraindicated.” The CPR duration was longer among those who received CC (median 30mins, range: 1-120 mins) than those who did not (median 20 mins, range: 2-79 mins). Two pts had support from a Lund University Cardiac Assist System (LUCAS) device. Among those who survived either manual and machine-assisted CC, 27% had a post-arrest TTE and none showed evidence of LVAD malfunction/dislodgment. Conclusions: Among pts with a durable LVAD who underwent CPR for CA we found no evidence of device dislodgment or safety concerns associated with either manual or LUCAS-assisted CPR. Future multicenter and prospective evaluation is necessary to both confirm these findings and to inform the guidelines.

The Association Between the Duration of Chest Compression and Thoracic Injuries in Patients With Non-Traumatic Out-of-Hospital Cardiac Arrest.

Current guidelines emphasize the indispensability of high-quality chest compression for improving survival in patients who experience out-of-hospital cardiac arrest (OHCA). However, chest compression can cause thoracic injuries that may contribute to poor prognosis; therefore, the purpose of this study is to identify the predictors of thoracic injuries and evaluate the association between thoracic injuries and prognosis.Methods and Results: Between June 2017 to July 2019, Utstein-style data on 384 consecutive adult patients who experienced non-traumatic OHCA and who were transferred to our hospital (Aso Iizuka Hospital) were collected. Each patient underwent a full-body computed tomography scan. Two-hundred and thirty-four patients (76%) had thoracic injuries (Group-T). The duration of chest compression was significantly longer in Group-T than in patients without thoracic injuries (Group-N; 43 vs. 32 min, respectively, P<0.001). Multivariate analysis revealed that older age and longer chest compression duration were predictors of thoracic injuries (odds ratios 1.03 and 1.07, respectively, P≤0.005). Among patients who achieved return of spontaneous circulation, Kaplan-Meier curves showed a significantly higher cumulative survival rate in Group-N than in Group-T at the 30-day follow up (log-rank test P=0.009). Older age and longer chest compression duration were independent predictors of thoracic injuries due to chest compression in patients who experienced non-traumatic OHCA. Moreover, the presence of thoracic injuries was associated with worse short-term prognosis.

Efficacy of AutoPulse for Mechanical Chest Compression in Patients with Shock-Resistant Ventricular Fibrillation.

Introduction: Sudden cardiac arrest is one of the most common causes of death. In cases of shock-resistant ventricular fibrillation, immediate transport of patients to the hospital is essential and made possible with use of devices for mechanical chest compression. Objectives: The efficacy of AutoPulse in patients with shock-resistant ventricular fibrillation was studied. Methods: This is a multicentre observational study on a population of 480,000, with 192 reported cases of out-of-hospital cardiac arrest. The study included patients with shock-resistant ventricular fibrillation defined as cardiac arrest secondary to ventricular fibrillation requiring ≥3 consecutive shocks. Eventually, 18 patients met the study criteria. Results: The mean duration of resuscitation was 48.4±43 min, 55% of patients were handed over to the laboratory while still in cardiac arrest, 83.3% of them underwent angiography and, in 93.3% of them, infarction was confirmed. Coronary intervention was continued during mechanical resuscitation in 50.0% of patients, 60% of patients survived the procedure, and 27.8% of the patients survived. Conclusions: Resistant ventricular fibrillation suggests high likelihood of a coronary component to the cardiac arrest. AutoPulse is helpful in conducting resuscitation, allowing the time to arrival at hospital to be reduced.

Can Cerebral Regional Oxygen Saturation (rSO2) Be Used as an Indicator of the Quality of Chest Compressions in Patients With Cardiopulmonary Arrest? A Study Evaluating the Association Between rSO2 and Mean Arterial Pressure: The PRESS Study.

IntroductionSudden cardiac arrest causes numerous deaths worldwide. High-quality chest compressions are important for good neurological recovery. Arterial pressure is considered useful to monitor the quality of chest compressions by the American Heart Association. However, arterial pressure catheter might be inconvenient during resuscitation. Conversely, cerebral regional oxygen saturation (rSO2) during resuscitation may be associated with a good neurological prognosis. Therefore, we aimed to evaluate the correlation between mean arterial pressure and rSO2 during resuscitation to evaluate rSO2 as an indicator of the quality of chest compressions.Materials and MethodsThis study was a single-center, prospective, observational study. Patients with out-of-hospital cardiac arrest who were transported to a tertiary care emergency center in Japan between October 2014 and March 2015 were included. The primary outcome was the regression coefficient between mean arterial pressure (MAP) and rSO2. MAP and rSO2 were measured during resuscitation (at hospital arrival [0 min], 3, 6, 9, 12, and 15 min), and MAP was measured by using an arterial catheter inserted into the femoral artery. For analysis, we used the higher value of rSO2 obtained from the left and right forehead of the patient measured using a near-infrared spectrometer. Regression coefficients were calculated using the generalized estimating equation with MAP and systolic arterial pressure as response variables and rSO2 as an explanatory variable since MAP and rSO2 were repeatedly measured in the same patient. Since the confounding factors between MAP or systolic arterial pressure and rSO2 were not clear clinically or from previous studies, the generalized estimating equation was analyzed using a univariate analysis.ResultsIn this study, 37 patients were analyzed. The rSO2 and MAP during resuscitation from hospital arrival to 15 min later were expressed as follows: (median [interquartile range, IQR]): rSO2, 29.5 (24.3–38.8)%, and MAP, 36.5 (26–46) mmHg. The regression coefficient (95% CI) of log-rSO2 and log-MAP was 0.42 (0.03–0.81) (p = 0.035).ConclusionThe values of rSO2 and MAP showed a mild but statistically significant association. rSO2 could be used to assess the quality of chest compressions during resuscitation as a non-invasive and simple method.

Abstract 8941: Efficacy and Safety of Mechanical versus Manual Compression in Cardiac Arrest and Cardiogenic Shock Patients

Introduction: Mechanical chest compression (MCC) provides consistent pressure and timing of each chest compression in line with latest evidenced-based practice. However, there has few evidence about the effectiveness of the mechanical device compared with manual chest compression. Furthermore, few studies focused on cardiogenic shock and cardiac arrest related to heart disease. Hypothesis: The aim in this study is to assess the effectiveness and safety of resuscitation strategies using MCC versus resuscitation strategies using standard manual chest compressions in patients with out of hospital cardiogenic shock and cardiac arrest due to heart disease. Methods: We conducted a retrospective observational study of comparing the outcomes of mechanical and manual chest compressions at our hospital. A total of 69 consecutive patients with out of hospital cardiogenic shock and cardiac arrest were enrolled between April 2014 and May 2018. 39 patients of them received only manual cardiopulmonary resuscitation (CPR) and 30 utilized a mechanical CPR device (LUCAS® Lund University Cardiac Arrest System, USA) during the resuscitation. Baseline characteristics, resuscitation details, and outcomes were compared between patients who received manual (manual group) and mechanical compressions (MCC group). Results: There was no significant difference in age, gender, the rate of bystander CPR, and arterial blood gases at baseline. No differences were found for the rate of ROSC and 30-day survival between two groups (manual group 42.8% vs MCC group 50.1% p=0.13). However, MCC group had significantly higher rate of bleeding events than manual group. In addition, fifty-four patients of them were treated for cardiac arrest or refractory cardiogenic shock with venoarterial extracorporeal membrane oxygenation (VA-ECMO). Among patients underwent VA-ECMO, the rate of 30-day survival was significantly lower in MCC group. (manual group 26.8% vs MCC group 39.1% p=0.014). Conclusions: This study showed that mechanical chest compression in cardiac arrest and cardiogenic shock increased bleeding events than manual chest compression. Furthermore, in the patients underwent ECMO, the use of mechanical chest compression might be associated with higher mortality.

Abstract 239: The Relationship Between Duration of Chest Compression and Traumatic Thoracic Injuries in Out-of-hospital Cardiac Arrest Patients

Background: Recent guidelines emphasized that high-quality chest compression is essential for improving the survival in out-of-hospital cardiac arrest (OHCA) patients. However, it may lead to critical traumatic injuries. Method: Between June. 2018 to Mar. 2019, we collected Utstein-style data on 130 consecutive adult patients with non-traumatic OHCA who were transferred to our hospital without return of spontaneous circulation (ROSC). Patients with aortic dissection and aortic aneurysmal rupture were excluded. Full-body CT scan was performed in all patients and chest compression-induced thoracic injuries were defined as rib fracture, sternum fracture, hemopneumothorax, mediastinal emphysema or intrathoracic hematoma. We identified the possible predictors for thoracic injuries and evaluated the relation between traumatic thoracic injuries and 30-day survival. Results: Patients with thoracic injuries were 105 (81%). The duration of chest compression in patients with thoracic injuries was significantly longer than that in patients without thoracic injuries (30 vs 38min, p&lt;0.01). ROC analysis identified a duration of chest compression of 35 minutes as the optimal cutoff point for predicting thoracic injuries (sensitivity 0.59, specificity 0.83, area under the curve 0.71). Multivariate analysis revealed that age and duration of chest compression were predictors of thoracic injuries (OR 1.05, 1.07, p≦0.01, respectively). The rates of 30-day survival in patients with thoracic injuries was significantly lower than those without thoracic injuries (1 % vs 16 %, p&lt;0.01). Conclusion: The duration of chest compression was one of the independent predictors for thoracic injuries in non-traumatic OHCA patients. Prolonger duration of chest compression are potential candidates for CT scan to diagnose thoracic injuries.

Abstract 12985: Efficacy and Safety of Mechanical versus Manual Compression in Cardiac Arrest and Cardiogenic Shock Patients

Introduction: Mechanical chest compression (MCC) provides consistent pressure and timing of each chest compression in line with latest evidenced-based practice. However, there has been no evidence from large randomized trials about the effectiveness of the mechanical device compared with manual chest compression. Furthermore, few studies focused on cardiogenic shock and cardiac arrest related to heart disease. Hypothesis: The aim is to assess the effectiveness and safety of mechanical chest compressions versus manual chest compressions in patients with out of hospital cardiogenic shock and cardiac arrest due to heart disease. Methods: We conducted a retrospective observational study of comparing the outcomes of mechanical and manual chest compressions. A total of 69 consecutive patients with out of hospital cardiogenic shock and cardiac arrest were enrolled between April 2014 and May 2018. 39 patients of them received only manual cardiopulmonary resuscitation (CPR) and 30 utilized a mechanical CPR device. Baseline characteristics, resuscitation details, and outcomes were compared between patients who received manual (manual group) and mechanical compressions (MCC group). Results: There was no significant difference in age, gender, the rate of bystander CPR and arterial blood gases at baseline. No differences were found for the rate of ROSC and 30-day survival between two groups. However, MCC group had significantly higher rate of bleeding events than manual group. In addition, fifty-four patients of them were treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO). Among patients underwent VA-ECMO, the rate of 30-day survival was significantly lower in MCC group. (Figure 1). Conclusions: This study showed that mechanical chest compression increased bleeding events than manual chest compression. Furthermore, in the patients underwent ECMO, the use of mechanical chest compression might be associated with higher mortality.

Efficacy of standard chest compressions in patients with Nuss bars.

BackgroundThe Nuss procedure temporarily places intrathoracic bars for repair of pectus excavatum (PE). The bars may impact excursion and compliance of the anterior chest wall while in place. Effective chest compressions during cardiopulmonary resuscitation (CPR) require depressing the anterior chest wall enough to compress the heart between sternum and spine. We assessed the force required to perform the American Heart Association’s recommended chest compression depth after Nuss repair.MethodsA lumped element elastic model was developed to simulate the relationship between chest compression forces and displacement with focus on the amount of force required to achieve a depth of 5 cm in the presence of 1–3 Nuss bars. Literature review was conducted for evidence supporting potential use of active abdominal compressions and decompression (AACD) as an alternative method of CPR.ResultsThe presence of bars notably lowered compression depth by a minimum of 69% compared to a chest without bar(s). The model also demonstrated a dramatic increase (minimum of 226%) in compressive forces required to achieve recommended 5 cm depth. Literature review suggests AACD could be an alternative CPR in patients with Nuss bar(s).ConclusionsIn our model, Nuss bars limited the ability to perform chest compressions due to increased force required to achieve a 5 cm compression. The greater the number of Nuss bars present the greater the force required. This may prevent effective CPR. Use of active abdominal compressions and decompressions should be studied further as an alternative resuscitation modality for patients after the Nuss procedure.

Resuscitation of the patient with suspected/confirmed COVID-19 when wearing personal protective equipment: A randomized multicenter crossover simulation trial.

The aim of the study was to evaluate various methods of chest compressions in patients with suspected/confirmed SARS-CoV-2 infection conducted by medical students wearing full personal protective equipment (PPE) for aerosol generating procedures (AGP). This was prospective, randomized, multicenter, single-blinded, crossover simulation trial. Thirty-five medical students after an advanced cardiovascular life support course, which included performing 2-min continuous chest compression scenarios using three methods: (A) manual chest compression (CC), (B) compression with CPRMeter, (C) compression with LifeLine ARM device. During resuscitation they are wearing full personal protective equipment for aerosol generating procedures. The median chest compression depth using manual CC, CPRMeter and LifeLine ARM varied and amounted to 40 (38-45) vs. 45 (40-50) vs. 51 (50-52) mm, respectively (p = 0.002). The median chest compression rate was 109 (IQR; 102-131) compressions per minute (CPM) for manual CC, 107 (105-127) CPM for CPRMeter, and 102 (101-102) CPM for LifeLine ARM (p = 0.027). The percentage of correct chest recoil was the highest for LifeLine ARM - 100% (95-100), 80% (60-90) in CPRMeter group, and the lowest for manual CC - 29% (26-48). According to the results of this simulation trial, automated chest compression devices (ACCD) should be used for chest compression of patients with suspected/confirmed COVID-19. In the absence of ACCD, it seems reasonable to change the cardiopulmonary resuscitation algorithm (in the context of patients with suspected/confirmed COVID-19) by reducing the duration of the cardiopulmonary resuscitation cycle from the current 2-min to 1-min cycles due to a statistically significant reduction in the quality of chest compressions among rescuers wearing PPE AGP.

Abstract 267: Injuries Associated With Mechanical Chest Compressions in Patients With Out-Of-Hospital Cardiac Arrest: A Comparison of LUCAS 2 and LUCAS 2 Active Decompression

Background: Skeletal injuries (rib or sternum fractures) are common complications after cardiopulmonary resuscitation (CPR). Visceral injuries are also reported. During manual chest compressions, incidence of rib fractures is reported to be 13-97% and sternal fractures 1-43%. Studies on active compression decompression (AD) devices report incidence on rib fractures ranging from 4-87% and sternal fractures 0-93%. The aim of the present study is to describe and compare injury patterns caused by two mechanical, piston-based chest compression devices; LUCAS 2 and LUCAS 2AD in patients with out-of-hospital cardiac arrest. Method: In the randomized clinical trial comparing standard LUCAS 2 with LUCAS 2AD, patients who died were eligible for medical or forensic autopsy. The pathologists described injury pattern in each patient focusing on CPR-related injuries, but was blinded for the device used. We used Pearson X 2 test with an alpha level of 0.05 to evaluate our findings. Results: Of the 221 patients included between April 2015 and April 2017, 204 patients died of whom 115 were autopsied, LUCAS 2 n=62 and LUCAS 2 AD n=53. Median age was 63 (range: 19-91) and men represented 70%. CPR related rib fractures occurred in 70%, and sternal fractures in 45% of all patients. When comparing LUCAS 2 to LUCAS 2AD we found no difference in incidence of rib fractures (69% vs. 70%; p-value: 0.9) or in sternal fractures (44% vs. 47%; p-value: 0.7). Most frequent non-skeletal complication was bleeding in pleura (25), pericardium (13), mediastinum (7), abdomen (5), and ventricle (3). Many patients had bleedings reported from more than one location, but the amount of blood was mostly small and considered to not contribute to the cause of death. A total of 10 patients had injuries on internal organs such as lungs (6), liver (2), spleen (1), and diaphragm (1). Conclusion: Comparing LUCAS 2 with LUCAS 2AD we found no difference in rib- or sternal fractures. CPR related injuries on internal organs were rare. We conclude that LUCAS 2AD do not cause more skeletal or non-skeletal injuries compared to LUCAS 2.

A meta-analysis of the resuscitative effects of mechanical and manual chest compression in out-of-hospital cardiac arrest patients

ObjectivesTo evaluate the resuscitative effects of mechanical and manual chest compression in patients with out-of-hospital cardiac arrest (OHCA).MethodsAll randomized controlled and cohort studies comparing the effects of mechanical compression and manual compression on cardiopulmonary resuscitation in OHCA patients were retrieved from the Cochrane Library, PubMed, EMBASE, and Ovid databases from the date of their establishment to January 14, 2019. The included outcomes were as follows: the return of spontaneous circulation (ROSC) rate, the rate of survival to hospital admission, the rate of survival to hospital discharge, and neurological function. After evaluating the quality of the studies and summarizing the results, RevMan5.3 software was used for the meta-analysis.ResultsIn total, 15 studies (9 randomized controlled trials and 6 cohort studies) were included. The results of the meta-analysis showed that there were no significant differences in the resuscitative effects of mechanical and manual chest compression in terms of the ROSC rate, the rate of survival to hospital admission and survival to hospital discharge, and neurological function in OHCA patients (ROSC: RCT: OR = 1.12, 95% CI (0.90, 1.39), P = 0.31; cohort study: OR = 1.08, 95% CI (0.85, 1.36), P = 0.54; survival to hospital admission: RCT: OR = 0.95, 95% CI (0.75, 1.20), P = 0.64; cohort study: OR = 0.98 95% CI (0.79, 1.20), P = 0.82; survival to hospital discharge: RCT: OR = 0.87, 95% CI (0.68, 1.10), P = 0.24; cohort study: OR = 0.78, 95% CI (0.53, 1.16), P = 0.22; Cerebral Performance Category (CPC) score: RCT: OR = 0.88, 95% CI (0.64, 1.20), P = 0.41; cohort study: OR = 0.68, 95% CI (0.34, 1.37), P = 0.28). When the mechanical compression group was divided into Lucas and Autopulse subgroups, the Lucas subgroup showed no difference from the manual compression group in ROSC, survival to admission, survival to discharge, and CPC scores; the Autopulse subgroup showed no difference from the manual compression subgroup in ROSC, survival to discharge, and CPC scores.ConclusionThere were no significant differences in resuscitative effects between mechanical and manual chest compression in OHCA patients. To ensure the quality of CPR, we suggest that manual chest compression be applied in the early stage of CPR for OHCA patients, while mechanical compression can be used as part of advanced life support in the late stage.

Abstract 209: The Triple CPR 16 study: Does rhythm truly needed to be checked every 2 minutes in Cardiopulmonary Arrest Patients?

Purpose: Current guidelines recommend rhythm checks every 2 minutes during cardiopulmonary resuscitation (CPR), but evidence for this recommendation is insufficient. Recent reports identified regional cerebral oxygen saturation (rSO 2 ) monitoring as useful in detecting return of spontaneous resuscitation (ROSC) and that coronary and cerebral perfusion decreases with the 2-minute rhythm check. On the basis of our previous study, we began the TripleCPR 16 study, which omits 2-minute rhythm checks because stopping chest compression to check rhythm may increase cerebral damage and decrease the ROSC. Methods: The multicenter, prospective TripleCPR 16 study began in January 2017. The inclusion criterion is a cardiopulmonary arrest patient aged ≥16 years with a non-shockable rhythm on hospital arrival. Subjects are divided into 3 groups based on their mean cerebral rSO 2 value in the first minute of arrival: ≥50%, &lt;50% to 40%, and &lt;40%. Continuous mechanical chest compression is performed on all subjects for 16 minutes or until their rSO 2 value exceeds the initial value by 10%, 20%, or 35%, respectively. We are comparing the TripleCPR 16 study results with our previous hospital data obtained from 90 patients who underwent every 2-minute rhythm checks and mechanical chest compression. Result: Currently, 162 patients are registered. Rates of ROSC were 32.1% for these patients and 38.9% for the previous 90 patients (p=0.33). There were no severe adverse events. Subanalysis of the data of Osaka University Hospital alone showed no significant increase of rSO 2 value in the 24 patients with non-sonographic cardiac activity and 21 patients with Stanford type A aortic dissection diagnosed by CT scan, and only one patient in each group achieved ROSC. When excluding the patients with Stanford type A aortic dissection, rates of ROSC were 49.4% for the patients in this study and 39.3% for the previous 90 patients (p=0.21). Conclusion: The TripleCPR 16 study is ongoing without severe adverse events. In the patients with non-sonographic cardiac activity or Stanford type A aortic dissection, rSO 2 values did not increase and it was difficult to achieve ROSC. The 2-minute rhythm check is not essential for chest compression in patients with a non-shockable rhythm.

Comparison of manual pulse palpation, cardiac ultrasonography and Doppler ultrasonography to check the pulse in cardiopulmonary arrest patients

ObjectiveFor health professionals, the absence of pulse checked by manual palpation is a primary indicator for initiating chest compressions in patients considered to have cardiopulmonary arrest (CA). However, using a pulse check to evaluate perfusion during CA may be associated with some risks of its own. Our objective was to compare the efficiency of cardiac ultrasonography (CUSG), Doppler ultrasonography (DUSG), and manual pulse palpation methods to check the pulse in CA patients. Material and methodsThis study was prospectively performed in 137 patients older than 16 years of age who underwent cardiopulmonary resuscitation (CPR). CUSG, DUSG, and manual pulse palpation were practiced simultaneously as suggested in the relevant guidelines. Findings of the patients were recorded at the first min, at min 15 and at the end of CPR. SPSS 18.0 was used for statistical analysis. FindingsA total of 72.3% (n = 99) of the cardiopulmonary arrest incidents occurred out-of-hospital. CUSG (4.76 ± 2.19, 4.33 ± 2.17, and 3.68 ± 2.14 s), DUSG (9.59 ± 2.37, 8.22 ± 2.86, and 7.60 ± 2.83 s), and manual pulse palpation (10.76 ± 1.03, 9.72 ± 3.01, and 9.29 ± 3.36 s) measurements of the first, second, and last inspections were detected, respectively. The false negative rates (100%, 28%, and 0%) and false positive rates (5.3%, 3.5%, and 0%) of manual pulse palpation the first, second, and last inspections were calculated, respectively, as well. ConclusionThe use of real-time CUSG during resuscitation provides a substantial contribution to the resuscitation team. CUSG will allow earlier and more accurate detection of pulse than manual pulse palpation and DUSG.

ACLS and Chest Compressions in Patients with Durable LVADs

Introduction Durable left ventricular assist devices (LVADs) are increasingly used to improve longevity in patients with advanced heart failure; however, optimal management of end-of-life issues including cardiopulmonary arrest remains uncertain for this relatively new population. We aim to assess the safety and efficacy of Advanced Cardiovascular Life Support (ALCS) including chest compressions in patients with LVADs. Methods We performed a retrospective chart review of all LVAD patients that received ACLS and chest compressions for in-hospital cardiopulmonary arrest at a single academic medical center between 2011 and 2017. We evaluated post-arrest survival, LVAD parameters/function, imaging studies, and autopsy results to assess for (1) structural issues such as LVAD dislodgment, aortic dissection/rupture, or pericardial effusion, and (2) LVAD mechanical issues such as hardware or software failure. Results Durable LVADs were implanted in 191 patients during the study period, of which 18 patients (9%) suffered in-hospital cardiopulmonary arrest necessitating ACLS (median of 22.5 days, range from 1 to 1323 days from implant). Of the patients requiring ACLS 11 (61%) survived the arrest with 7 (39%) surviving to hospital discharge. Ten patients (56%) received manual external chest compressions, and 7 (39%) received defibrillator shocks. Of the patients who received chest compressions and/or defibrillator shocks, no significant changes to LVAD parameters/function was noted after the arrest. Five autopsies were completed, all of which reported the LVAD in its proper position without evidence structural or mechanical LVAD complications. Two of the surviving patients were taken emergently to the operating room for treatment of cardiac tamponade; during the procedure the LVAD anastomoses were inspected, and no bleeding was noted in either case. Two echocardiograms were performed following chest compressions without evidence of LVAD dysfunction. There were no iatrogenic sequelae identified in any of the patients following ACLS. Conclusion While cardiopulmonary arrest in patients with LVADs is associated with high mortality, ACLS with chest compressions appears to be safe. Larger studies are warranted to identify patterns of post ALCS complications and define potential population-specific management.

Right ventricle chest compressions: do we need a new paradigm for LVAD patients needing resuscitation? A case report

The use of chest compressions in patients with left ventricular assist devices (LVAD) have been viewed to cause a potential damage to the outflow graft and hence have been a topic of controversy. We report a case of a LVAD patient who needed chest compressions during resuscitation for severe right ventricular failure. With the presence of trans-esophageal echocardiogram we noticed that the chest compressions did not need to be full ACLS compressions but modified to gentle right ventricular (RV) compressions in order to move blood into a normally functioning LVAD. We report this as a call for the LVAD medical providers to rethink concepts of standard resuscitation.

Comparative Hemodynamic Evaluation of the LUCAS® Device and Manual Chest Compression in Patients with Out-of-Hospital Cardiac Arrest

Comparative Hemodynamic Evaluation of the LUCAS® Device and Manual Chest Compression in Patients with Out-of-Hospital Cardiac Arrest

Open chest cardiac massage offers no benefit over closed chest compressions in patients with traumatic cardiac arrest

Open chest cardiac massage (OCCM) is a commonly performed procedure after traumatic cardiac arrest (TCA). OCCM has been reported to be superior to closed chest compressions (CCC) in animal models and in non-TCA. The purpose of this study is to prospectively compare OCCM versus CCC in TCA using end-tidal carbon dioxide (ETCO2), the criterion standard for determining the effectiveness of chest compressions and detection of return of spontaneous circulation (ROSC), as the surrogate for cardiac output and marker for adequacy of resuscitation. This prospective observational study enrolled patients over a 9-month period directly presenting to a level 1 trauma center after TCA. Continuous high-resolution ETCO2 measurements were collected every 6 seconds for periods of CCC and OCCM, respectively. Patients receiving CCC only were compared with patients receiving CCC followed by OCCM. Student's t tests were used to compare ETCO2 within and between groups. Thirty-three patients were enrolled (16 OCCM, 17 CCC-only). Mean time of CCC before OCCM was 66 seconds. Within the OCCM group, final, peak, mean, and median ETCO2 levels significantly increased when comparing the initial CCC period to the OCCM interval. Using a time-matched comparison, significant increases were observed in the final and peak but not mean and median values when comparing the first minute of CCC to the remaining time in the CCC-only group. However, when periods of OCCM were compared with equivalent periods of CCC-only, there were no differences in the initial, final, peak, mean, or median ETCO2 values. Correspondingly, no difference in rates of ROSC was observed between groups (OCCM 23.5% vs. CCC 38.9%; p = 0.53). Although we could not control for confounders, we found no significant improvement in ETCO2 or ROSC with OCCM. With newer endovascular techniques for aortic occlusion, thoracotomy solely for performing OCCM provides no benefit over CCC. Therapeutic study, level III.

Chest compressions may be safe in arresting patients with left ventricular assist devices (LVADs)

IntroductionThe number of patients with left ventricular assist devices (LVADs) is increasing each year. Despite a lack of evidence, many emergency medical systems and hospitals have recommended against performing chest compressions in these patients. This deviation from conventional resuscitation algorithms is secondary to concern that chest compressions could dislodge the LVAD. ObjectiveTo assess whether cannula dislodgment occurred in LVAD patients receiving chest compressions. MethodsWe retrospectively analyzed the outcomes of all LVAD patients who received chest compressions for cardiac arrest over a four year period in a large urban hospital. Eight cases were reviewed for both cannula integrity and outcomes. ResultsUsing autopsy and adequate flow through device as proxy for intact inflow/outflow cannulas, none of the eight patients receiving chest compressions had cannula dislodgment. Four of the 8 patients had return of neurologic function. ConclusionsIn this small retrospective case series, standard chest compressions in patients with LVADs did not cause cannula dislodgment. More research is necessary to determine the utility of chest compressions in the LVAD population.

Abstract 302: Chest Compressions Should Be Performed on Arresting Patients with Left Ventricular Assist Devices (LVAD)

Introduction: Patients with implanted Left ventricular assist devices (LVAD) are being assessed by an increasing number of health care providers. Despite a lack of evidence, many emergency medical systems and hospitals have discouraged providers from performing chest compressions in these patients when they present in cardiac arrest. This deviation from conventional resuscitation algorithms is secondary to concern that chest compressions could dislodge the LVAD. Objective: To determine the rate of cannula dislodgment for patients presenting in cardiac arrest with known implanted LVAD devices receiving standard chest compression cardiopulmonary resuscitation. Methods: We retrospectively analyzed the outcomes of all patients who received chest compressions for cardiac arrest over a 4 year period in a large urban hospital. Eight cases were reviewed for both cannula integrity and outcomes. Results: Using autopsy and adequate flow through device as proxy for intact inflow/outflow cannulas, none of the eight patients receiving chest compressions had cannula dislodgment. Four of the 8 patients had return of neurologic function. Two additional patients had return of effective circulation without return of neurologic function. One patient had documented flow on the device without return of native heart function. The final patient did not have documented flow during resuscitation but autopsy showed no dislodgment. Conclusions: In this small retrospective study, standard chest compressions in patients with LVADs appear to be safe, without evidence of cannula dislodgment. Standard chest compressions for LVAD patients in circulatory arrest should be performed.

Could we use abdominal compressions rather than chest compression in patients who arrest after cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether abdominal cardiopulmonary resuscitation (CPR) could be used instead of external cardiac massage either to protect the recent sternotomy or while chest compressions are not possible whilst a sternotomy is being performed. Altogether 386 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Patients who arrest after cardiac surgery and require chest reopening will have a period of no external chest compression and therefore, no cerebral or coronary perfusion. In addition, if a patient arrests prior to cardiac surgery there will be a period of time performing the sternotomy during which there will be no external compressions. We found only one paper in a porcine model that looked at the effectiveness of abdominal only CPR although it did show that abdominal CPR was actually 60% better than chest CPR. Interposed abdominal and chest compressions has been much more extensively studied and has been shown to be significantly better in return of spontaneous circulation than chest compressions alone. We conclude that currently there is very little evidence to support abdominal only CPR although these studies may support the concept that it may potentially increase the coronary and cerebral perfusion pressure.