Closed Chest Compressions Research Articles

Retrospective Review of the Image Quality of Monoplane Transesophageal Echocardiography in Prehospital Out-of-Hospital Cardiac Arrest: A Single Center Pilot Study

Objectives Out of Hospital Cardiac Arrest (OHCA) is a frequently encountered pathology with resultant poor outcomes in the majority of patients. Echocardiography has been utilized to help guide clinical decision making and monitor effectiveness of resuscitative efforts. Transthoracic echocardiography (TTE) the mainstay of point-of-care ultrasound (POCUS) real time resuscitative imaging has limitations, most notably is the disruption of closed chest compressions. Trans-esophageal echocardiography (TEE) is an emerging technology in emergency care and can potentially overcome these limitations but image quality and accuracy of use in the prehospital environment remains unknown. Our primary objective is to identify the accuracy of Emergency Medical Services (EMS) fellow physicians in performing TEE via the identification of key cardiac structures. Secondarily we assess image quality as well as accuracy on cardiac activity interpretation as compared to TEE-experienced cardiologists. Methods A pilot study using descriptive analysis of a retrospective case-series with specific focus on inter-rater reliability as well as pragmatic management alterations based on real-time image interpretation by EMS physicians. After focused education, 13 patients were eligible for prehospital TEE who suffering OHCA from July 2022 to June 2023. Ultrasound (US) images were interpreted by EMS fellow physicians and over-read by cardiologists with specific focus on inter-rater reliability. After collection of patients presenting data and US images, analysis was performed. Results Of 13 patients initially screened, 10 patients were included in a study with a median age of 50 years old (41–70). Three patients were excluded due to equipment malfunction or insufficient image capture. An interrater reliability identified a kappa of 0.96 with respect to identification of cardiac structures and a kappa of 0.65 for identification of cardiac activity. Conclusions In this small study of prehospital TEE, EMS fellow physicians had high inter-rater reliability in image interpretation pertaining to anatomy and cardiac activity when compared with cardiologists. Further research is needed to determine its efficacy, safety, and widespread application in the prehospital setting.

Is there an association between 30-day mortality and adrenaline infusion rates in post-ROSC patients? A retrospective observational analysis.

Revised guidelines for the management of cardiac arrest have placed greater emphasis on early defibrillation and closed chest compressions; subsequently there has been a significant rise in the number of patients gaining a return of spontaneous circulation (ROSC). As a consequence, emergency medical services have realised the importance of therapies delivered during this phase of care. In some Trusts this includes the use of inotropic agents to augment the cardiovascular system and maintain adequate cerebral and coronary perfusion pressures to mitigate the effects of post-cardiac arrest syndrome. Currently, limited evidence exists with regards to the efficacy of such treatments in the pre-hospital phase. Retrospective observational analysis of out-of-hospital cardiac arrest patients who received an adrenaline infusion by critical care paramedics. Infusion rates, time of call (ToC) to ROSC and 30-day mortality were compared. Over a 2-year period, 202 patients were recorded as having an adrenaline infusion commenced. Of these, 25 were excluded as they did not meet criteria or had incomplete data and 22 were excluded as the infusion was stopped at scene; 155 patients were admitted to hospital. There were no survivors in the non-shockable group and three survivors in the shockable group at 30 days. A rare events analysis found no relationship between infusion rate, ToC to ROSC and 30-day mortality (Wald chi2, 1.37). Commencement of adrenaline infusions in post-ROSC was associated with significant 30-day mortality, especially in non-shockable rhythms. Further research is needed to elucidate whether this intervention has any benefit in the post-ROSC patient.

Abstract 296: Adult Swine Model of Ventricular Fibrillation Arrest for Resuscitation with Perfluorocarbon Emulsions

Background: The purpose of this study was to develop a model of ventricular fibrillation arrest with reliable outcomes and minimally invasive methods to study the use of perfluorocarbon emulsions (PFC) as agents to prevent ischemia-reperfusion injury after cardiac arrest as quantified by known biomarkers. Methods: Female Yorkshire swine underwent anesthesia and minimally invasive instrumentation for monitoring under ultrasound. Cardiac arrest was induced with spinal needle insertion at the apex and right parasternal space. Ventricular fibrillation was reliably obtained in all animals on initial attempts. A three-minute circulatory arrest state was observed. Administration of PFC was concurrent with resuscitation including closed chest compressions, epinephrine, amiodarone, and defibrillation at 1J/kg. Primary endpoint was induction of cardiac arrest and tolerance of PFC with return of spontaneous circulation. Blood levels of glial fibrillary acidic protein (GFAP) and ubiquitin C-Terminal Hydrolase-L1 (UCLH1) were secondary end points for three animals. Results: Six of six animals were induced into ventricular fibrillation on initial attempt and two of three survival experiments were able to obtain spontaneous circulation. PFC with pretreatment was tolerated well and no signs of increased pulmonary pressures. GFAP, UCHL1 were significantly lower in intervention animals compared to controls. Conclusions: The results obtained from this preliminary study and technical refinements via additional donated animals have allowed us to make modifications in the choice of PFC, vascular access, and anticoagulation plan. This model provides a consistent method for inducing ventricular fibrillation with minimally invasive techniques. The PFC tested was well tolerated. More robust evaluation of PFC as resuscitative agents is needed with appropriately powered studies.

The Effect of Chest Compression Location and Aortic Perfusion in a Traumatic Arrest Model

BackgroundRecent evidence demonstrates that closed chest compressions directly over the left ventricle (LV) in a traumatic cardiac arrest (TCA) model improve hemodynamics and return of spontaneous circulation (ROSC) when compared to traditional compressions. Selective aortic arch perfusion (SAAP) also improves hemodynamics and controls hemorrhage in TCA. We hypothesized that chest compressions located over the LV would result in improved hemodynamics and ROSC in a swine model of TCA using SAAP. Materials and methodsTransthoracic echo was used to mark the location of the aortic root (Traditional location) and the center of the LV on animals (n = 24), which were randomized to receive chest compressions in one of the two locations. After hemorrhage, ventricular fibrillation (VF) was induced to simulate TCA. After a period of 10 min of VF, basic life support (BLS) with mechanical CPR was initiated and performed for 10 min, followed by advanced life support (ALS) for an additional 10 min. SAAP balloons were inflated at min 6 of BLS. Hemodynamic variables were averaged over the final 2 min of the BLS and ALS periods. Survival was compared between this SAAP cohort and a control group without SAAP (No-SAAP) (n = 26). ResultsThere was no significant difference in ROSC between the two SAAP groups (P = 0.67). There was no ROSC difference between SAAP and No-SAAP (P = 0.74). ConclusionsThere was no difference in ROSC between LV and Traditional compressions when SAAP was used in this swine model of TCA. SAAP did not confer a survival benefit compared to historical controls.

The Effect of Chest Compression Location and Occlusion of the Aorta in a Traumatic Arrest Model

BackgroundRecent evidence demonstrates that closed chest compressions directly over the left ventricle (LV) in a traumatic cardiac arrest (TCA) model improve hemodynamics and return of spontaneous circulation (ROSC) when compared with traditional compressions. Resuscitative endovascular balloon occlusion of the aorta (REBOA) also improves hemodynamics and controls hemorrhage in TCA. We hypothesized that chest compressions located over the LV would result in improved hemodynamics and ROSC in a swine model of TCA using REBOA. Materials and methodsTransthoracic echo was used to mark the location of the aortic root (traditional location) and the center of the LV on animals (n = 26), which were randomized to receive chest compressions in one of the two locations. After hemorrhage, ventricular fibrillation was induced to simulate TCA. After a period of 10 min of ventricular fibrillation, basic life support (BLS) with mechanical cardiopulmonary resuscitation was initiated and performed for 10 min followed by advanced life support for an additional 10 min. REBOA balloons were inflated at 6 min into BLS. Hemodynamic variables were averaged during the final 2 min of the BLS and advanced life support periods. Survival was compared between this REBOA cohort and a control group without REBOA (no-REBOA cohort) (n = 26). ResultsThere was no significant difference in ROSC between the two REBOA groups (P = 0.24). Survival was higher with REBOA group versus no-REBOA group (P = 0.02). ConclusionsThere was no difference in ROSC between LV and traditional compressions when REBOA was used in this swine model of TCA. REBOA conferred a survival benefit regardless of compression location.

Abstract 253: The Efficacy of Left Ventricular versus Traditional Chest Compressions During Selective Aortic Arch Perfusion to Treat Traumatic Cardiopulmonary Arrest in a Swine Model

Introduction: Recent evidence has demonstrated that closed chest compressions (CC) directly over the left ventricle (LV) during traumatic cardiopulmonary arrest (TCPA) improve hemodynamics and return of spontaneous circulation (ROSC) when compared to traditional chest compressions. Selective Aortic Arch Perfusion (SAAP) is also able to improve hemodynamics as well as control hemorrhage during TCPA. Hypothesis: We hypothesized that LV compressions would increase ROSC when compared to traditional compressions in an animal model of TCPA where SAAP was being used. We also compared LV and Traditional compressions with SAAP to historical controls that received compressions without SAAP. Methods: Transthoracic echo was used to mark the location of the aortic root and the center of the left ventricle on animals (n=24, 12 in each arm) which were randomized to receive chest compressions in one of the two locations. One third of each animal’s blood volume was removed and ventricular fibrillation (VF) was induced to simulate traumatic cardiac arrest. After a period of ten minutes of VF, basic life support (BLS) with mechanical CPR was initiated and performed for ten minutes followed by advanced life support (ALS) and blood transfusion for an additional ten minutes. The SAAP balloon was inflated at minute 6 of BLS. Hemodynamic variables were averaged every two minutes. The same model was used for historical controls (n=26, 13 in each arm) without the use of SAAP, so comparisons were treated as a single study with a factorial design. Results: There were no differences in hemodynamic variables, ROSC (p=0.67) or survival (p=0.64) between SAAP groups. However, when the LV animals were compared to historic controls without SAAP, LV animals had higher ROSC (p=0.02) and survival rates (p=0.04) than Traditional animals. Conclusions: SAAP does not appear to show a synergistic effect with LV compressions, however, SAAP combined with LV compressions improves ROSC and survival when compared to Traditional compressions in our swine model of TCPA. More investigation into SAAP and compression position should be studied to improve treatment of TCPA.

Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest

Closed chest compressions (CCC) are recommended for medical cardiac arrest, but there is little evidence to support their inclusion for traumatic cardiac arrest (TCA).This laboratory study evaluated CCC following haemorrhage-induced TCA and whether resuscitation with blood improved survival compared to saline.The study was conducted with the authority of UK Animals (Scientific Procedures) Act 1986 (received institutional ethical approval and a Home Office Licence) using 39 terminally anesthetised, instrumented, juvenile Large White pigs. Following baseline measurements, animals underwent captive bolt injury to the right thigh and controlled haemorrhage (30% blood volume). Sixty minutes later there was a further haemorrhage to a MAP of 20 mmHg. The randomised resuscitation protocol was initiated within 5 min: CCC (Group 1); IV whole blood (Group 2); IV 0.9% saline (Group 3); IV whole blood + CCC (Group 4); and IV saline + CCC (Group 5). Fluid was administered as 3 × 10 ml/kg boluses using the Belmont® Rapid Infuser. The LUCAS™ II Chest Compression System delivered CCC. Primary Outcome was attainment of return of spontaneous circulation (ROSC MAP ≥ 50 mmHg) at Study End (fifteen minutes post-resuscitation) and secondary outcomes included haemodynamics.Mortality (MAP≤10 mmHg) was significantly higher in Group 1 compared to Groups 2 and 3 (P < 0.0001). Resuscitation with whole blood was significantly better than saline (P = 0.0069), no animals in Group 3 attained ROSC. The addition of chest compressions to fluid resuscitation resulted in a significantly worse outcome with saline resuscitation (P = 0.0023) but not with whole blood (P = 0.4411). Cardiovascular variables at the end of the Resuscitation Phase and Study End were significantly worse for Group 5 compared to Group 3. Some significant differences were present at the end of the Resuscitation Phase for Group 4 versus Group 2 but these differences were no longer present by Study End.CCC were associated with increased mortality and compromised haemodynamics compared to intravenous fluid resuscitation. Whole blood resuscitation was better than saline.

Bedside Ultrasonography in the Management of Penetrating Cardiac Injury Caused by a Nail Gun

BackgroundInjuries from nail guns are a unique type of penetrating trauma seen in emergency departments (EDs), rising in prevalence in the United States. These devices can lead to life-threatening injuries that require rapid diagnosis to help guide management. Case ReportAn elderly man was brought to the ED having sustained a nail gun injury to the chest. After loss of pulses, brief closed chest compressions and rapid blood product administration led to a return of spontaneous circulation. Using bedside ultrasound, a metallic foreign body was identified tracking through the right ventricle with associated pericardial fluid and pericardial clot. This rapid diagnosis with bedside ultrasound helped facilitate timely transport to the operating room for median sternotomy, foreign body removal, and pledgeted cardiac repair. Why Should an Emergency Physician Be Aware of This?With continued developments in image quality and acquisition, and improvements of physician operator performance, ultrasonography has continued to make significant impacts in traumatically injured patients in new ways. We present this case report to highlight precordial nail gun injuries and to emphasize the diagnostic capabilities of bedside ultrasound for these patients.

Treatment Effect or Effective Treatment? Cardiac Compression Fraction and End-tidal Carbon Dioxide Are Higher in Patients Resuscitative Endovascular Balloon Occlusion of the Aorta Compared with Resuscitative Thoracotomy and Open-Chest Cardiac Massage

The purpose of this study is to compare end-tidal carbon dioxide (EtCO₂) during resuscitation of open-chest cardiac massage (OCCM) with aortic cross-clamp (ACC) versus receiving resuscitative endovascular balloon occlusion of the aorta (REBOA) with closed-chest compressions (CCCs). Patients who received REBOA were compared with patients receiving OCCM for traumatic arrest using continuous vital sign monitoring and videography. Thirty-three patients were enrolled in the REBOA group and 18 patients were enrolled in the OCCM group. Of the total patients, 86.3 per cent were male with a mean age of 36.2 ± 13.9 years. Ninety-four percent of patients suffered penetrating trauma in the OCCM group compared with 30.3 per cent of the REBOA group (P = <0.001). Before aortic occlusion (AO), there was no difference in initial EtCO₂ values, but mean, median, peak, and final EtCO₂ values were lower in OCCM (P < 0.005). During CPR after AO, the initial, mean, and median values were higher with REBOA (P = 0.015, 0.036, and 0.038). The rate of return of spontaneous circulation was higher in REBOA versus OCCM (20/33 [60.1%] vs 5/18 [33.3%]; P = 0.04), and REBOA patients survived to operative intervention more frequently (P = 0.038). REBOA patients had greater total cardiac compression fraction (CCF) before AO than OCCM (85.3 ± 12.7% vs 35.2 ± 18.6%, P < 0.0001) and after AO (88.3 ± 7.8% vs 71.9 ± 24.4%, P = 0.0052). REBOA patients have higher EtCO₂ and cardiac compression fraction before and after AO compared with patients who receive OCCM.

Left ventricular compressions improve return of spontaneous circulation and hemodynamics in a swine model of traumatic cardiopulmonary arrest.

Prehospital cardiopulmonary resuscitation, including closed chest compressions, has commonly been considered ineffective in traumatic cardiopulmonary arrest (TCPA) because traditional chest compressions do not produce substantial cardiac output. However, recent evidence suggests that chest compressions located over the left ventricle (LV) produce greater hemodynamics when compared to traditional compressions. We hypothesized that chest compressions located directly over the LV would improve return of spontaneous circulation (ROSC) and hemodynamics when compared with traditional chest compressions, in a swine model of TCPA. Transthoracic echocardiography was used to mark the location of the aortic root (traditional compressions), and the center of the LV on animals (n = 26) which were randomized to receive chest compressions in one of the two locations. After hemorrhage, ventricular fibrillation was induced. After 10 minutes of ventricular fibrillation, basic life support (BLS) with mechanical cardiopulmonary resuscitation was initiated and performed for 10 minutes followed by advanced life support (ALS) for an additional 10 minutes. During BLS, the area of maximal compression was verified using transesophageal echocardiography. Hemodynamic variables were averaged over the final 2 minutes of the BLS and ALS periods. Five (38%) of the LV group achieved ROSC compared with zero of the aortic root group (p = 0.04). Additionally, there was an increase in aortic systolic blood pressure (SBP), aortic diastolic blood pressure (DBP) and coronary perfusion pressure (CPP) at the end of both the BLS (95% confidence interval, SBP, -49 to -21; DBP, -14 to -5.6; and CPP, -15 to -7.4) and ALS (95% confidence interval: SBP, -66 to -21; DBP, -49 to -6.8; and CPP, -51 to -7.5) resuscitation periods among the LV group. In our swine model of TCPA, chest compressions performed directly over the LV improved ROSC and hemodynamics when compared with traditional chest compressions.

Wilderness First Responder: Are Skills Soon Forgotten?

Wilderness first responders are trained to provide competent medical care in wilderness settings or until evacuation for more advanced treatment can be obtained. In light of the isolated environments in which they are called upon to respond to illnesses and injuries, their ability to effectively apply their training is crucial. Despite the responsibility assigned to them, there is an absence of research assessing the skill and knowledge retention of wilderness first responders, creating a gap in understanding whether a deficit in their ability to perform exists between certifications. Without such research, it is important to review knowledge and skill retention in related responder groups. The literature over the past 4 decades documents the loss over time of skills and knowledge across an array of trained responders, both professional and laypeople. Although the findings reviewed suggest that WFRs will exhibit a similar pattern of increasing skill loss beginning shortly after certification and a slower, but concurrent, decrease in knowledge, research is needed to document or refute this assumption.

9 Closed chest compressions reduce survival in a model of haemorrhage-induced traumatic cardiac arrest

BackgroundClosed chest compressions (CCC) are a key component of resuscitation from medical causes of cardiac arrest, but when haemorrhage, the leading cause of preventable battlefield deaths, is the likely cause...

Closed chest compressions reduce survival in a model of haemorrhage-induced traumatic cardiac arrest

Closed chest compressions reduce survival in a model of haemorrhage-induced traumatic cardiac arrest

Current recommendations on adult resuscitation

### Key points Cardiorespiratory arrest remains the most challenging of medical emergencies with ∼18% of in-hospital cardiac arrests surviving to leave hospital in the UK.1 Despite data showing improvement in survival rates after cardiac arrest internationally, only 7–8% of out-of-hospital cardiac arrest (OHCA)2 survive to hospital discharge in England compared with higher rates in other developed countries. In Seattle, North America, survival rates of 62% have been reported in patients who had witnessed OHCA with an initial rhythm of ventricular fibrillation (VF). Continual evaluation and adjustments in resuscitation guidelines aim to improve survival rates. Adult resuscitation guidelines were last reviewed in this journal in 2007. There have been two Resuscitation Council (UK) [RC (UK)] guideline updates since then: in 2010, and most recently October 2015.3 This article will discuss and summarize the main changes. In 1767, a Society in Amsterdam was established for the Recovery of Drowned Persons.4 This was the first resuscitation organization dealing with education, guidelines, and collaboration between physicians and lay people. Despite some rather unusual techniques, many described are still used in modern-day resuscitation, that is, warming the victim and artificial respiration. The first scientific paper on survival after closed chest compressions was published in 19605 and was followed by a national cardiopulmonary resuscitation …

Measured Progress in Cardiopulmonary Resuscitation.

> “…inspiration is easy. Implementation is the hard part.” > > –Bob Taylor, Taylor Guitars Eight months after Kouwenhoven et al1 published their 1960 landmark report of successful closed chest cardiac compressions for 2 children and 2 adults who developed perioperative cardiac arrest,1 a cardiologist provided that same closed chest cardiopulmonary resuscitation (CPR) in the operating suite after my 4-year-old brother experienced cardiac arrest during induction of anesthesia. My brother is alive today because of published resuscitation science applied to practice. In 1961, Peter Safar proposed combining mouth-to-mouth ventilation with closed chest compressions in a poster for the Pennsylvania chapter of the American Heart Association (AHA), and the ABCs of CPR were born. In 1966, the National Academy of Sciences–National Research Council conference on CPR charged the AHA with teaching CPR to healthcare providers. In 1973, the second conference on CPR and Emergency Cardiovascular Care recommended expanding teaching of CPR to the lay public. This conference also recommended that the AHA establish resuscitation guidelines based on scientific data and develop standards for basic and advanced life support training. The American Red Cross and other organizations, such as the Citizen CPR Foundation, soon supported the lay rescuer CPR training effort. Great enthusiasm existed for the potential of CPR, but little scientific data on which to base recommendations, with more emphasis on teaching CPR skills than on measuring CPR outcomes. By 1991, the chain of survival provided a metaphor for the priorities of resuscitation and training, emphasizing early bystander recognition of cardiac arrest and access to the emergency medical …

SELECTIVE AORTIC ARCH PERFUSION FOR THE REVERSAL OF HAEMORRHAGE-INDUCED TRAUMATIC CARDIAC ARREST IN A SWINE MODEL OF NON-COMPRESSIBLE TORSO HAEMORRHAGE

Objectives & BackgroundHaemorrhage is the leading cause of potentially survivable trauma death. Selective Aortic Arch Perfusion (SAAP) is an experimental resuscitative intervention that has the potential to improve trauma survival:...

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.

Intravenous lipid emulsion in the resuscitation of cocaine-induced cardiovascular arrest in a rat model

ContextIntravenous lipid emulsion (ILE) is a potential antidote for severe overdose of certain lipophilic drugs. Cocaine overdose is often fatal and has no antidote. The use of ILE after cocaine-induced cardiac arrest has been suggested but is not well characterized. ObjectiveThe objective of the study is to determine if ILE would reverse cocaine-induced cardiac arrest in a rat model. Materials and methodsTwelve Sprague-Dawley rats with intra-arterial and intravenous access were sedated with isoflurane and split into 2 cocaine dose groups, then given either ILE or normal saline (NS) intravenously (IV)—group A, 7 animals received cocaine (10 mg/kg IV) with 6 of 7 given ILE (15 mg/kg IV) and 1 of 7 given NS (equal volume); group B, 5 animals received cocaine (5 mg/kg IV) with 3 of 5 given ILE (15 mg/kg IV) and 2 of 5 given NS (equal volume). Closed chest compressions were initiated for asystole and continued for 15 minutes with rhythm checks every minute. ResultsAll 12 rats experienced cardiac arrest after cocaine bolus. Resuscitation was successful in 1 of 7 rats in group A and 0 of 5 in group B. ConclusionsIntravenous lipid emulsion administration did not affect outcome of cocaine-induced cardiac arrest compared with control in this model.

Comparative Effectiveness of Emergency Resuscitative Thoracotomy versus Closed Chest Compressions among Patients with Critical Blunt Trauma: A Nationwide Cohort Study in Japan.

BackgroundAlthough emergency resuscitative thoracotomy is performed as a salvage maneuver for critical blunt trauma patients, evidence supporting superior effectiveness of emergency resuscitative thoracotomy compared to conventional closed-chest compressions remains insufficient. The objective of this study was to investigate whether emergency resuscitative thoracotomy at the emergency department or in the operating room was associated with favourable outcomes after blunt trauma and to compare its effectiveness with that of closed-chest compressions.MethodsThis was a retrospective nationwide cohort study. Data were obtained from the Japan Trauma Data Bank for the period between 2004 and 2012. The primary and secondary outcomes were patient survival rates 24 h and 28 d after emergency department arrival. Statistical analyses were performed using multivariable generalized mixed-effects regression analysis. We adjusted for the effects of different hospitals by introducing random intercepts in regression analysis to account for the differential quality of emergency resuscitative thoracotomy at hospitals where patients in cardiac arrest were treated. Sensitivity analyses were performed using propensity score matching.ResultsIn total, 1,377 consecutive, critical blunt trauma patients who received cardiopulmonary resuscitation in the emergency department or operating room were included in the study. Of these patients, 484 (35.1%) underwent emergency resuscitative thoracotomy and 893 (64.9%) received closed-chest compressions. Compared to closed-chest compressions, emergency resuscitative thoracotomy was associated with lower survival rate 24 h after emergency department arrival (4.5% vs. 17.5%, respectively, P < 0.001) and 28 d after arrival (1.2% vs. 6.0%, respectively, P < 0.001). Multivariable generalized mixed-effects regression analysis with and without a propensity score-matched dataset revealed that the odds ratio for an unfavorable survival rate after 24 h was lower for emergency resuscitative thoracotomy than for closed-chest compressions (P < 0.001).ConclusionsEmergency resuscitative thoracotomy was independently associated with decreased odds of a favorable survival rate compared to closed-chest compressions.

Nurses, Doctors, and the Cardiac Arrest Paradigm: A Collaborative Endeavor.

This article explores the collaboration of doctors and nurses in establishing the Cardiac Arrest Paradigm (Paradigm), an intellectual and institutional framework that has shaped the practice of medicine for the past fifty years. An important manifestation of the Paradigm was the intensification of care, particularly at the end of life, whether or not it would help the patient. Paradigm also tended to narrow the physician's clinical gaze to single-organ systems, with the application of therapies based on narrow indications, often without regard to the whole patient. Cardiac arrest/resuscitation represents the quintessential indication/therapy dyad of the Paradigm and was formative in its creation. I argue that the interprofessional interactions between doctors and nurses constitute one of several factors that promoted the Paradigm within mid-twentieth-century medicine.Many of the underlying principles of the therapy for cardiac arrest were already established by the mid-twentieth century, when resuscitation still involved cutting open the body and squeezing the heart-open cardiac massage-and started moving out of the operating room onto the wards of the hospital in the 1950s. But the Paradigm clicked into existence after closed chest compressions and cardiopulmonary resuscitation (CPR) became the norm in the 1960s. At this time, a constellation of forces made resuscitation the default therapy for every patient whose heart stopped in the hospital, regardless of its expected efficacy, and cardiac arrest became the clinical condition we recognize today. This development marked a pivotal transformation in the history of medicine, not so much for the new technology-resuscitation had been practiced in various overlapping ways since the late eighteenth century-but because CPR and its indication, cardiac arrest, helped establish a model of care, a Paradigm that has gone largely unchallenged to the present day.A 1962 Circulation editorial on CPR is revealing. Most people who experience sudden stoppage or disruption of the heart beat (cardiac arrest) cannot be saved even under ideal circumstances in a hospital.1 authors specify the limited efficacy of CPR and infer in the next line that CPR had not yet become the default therapy for everyone whose heart stopped. The least measure of success has been experienced in coronary 'attack' cases. That this group experienced the least success implies that the comparison group was most likely patients whose heart stopped in the operating room, where cardiac resuscitation was initially developed and almost exclusively practiced until the 1950s. If everyone whose heart stopped in the hospital had been included in the resuscitation efforts, then those with cardiac arrest from other problems, including terminal conditions surely would have had the least measure of success. Although some patients from this group may have undergone resuscitation in 1962, it appears that they did not all receive resuscitation; CPR was not yet the default.One way of getting to the core of the Paradigm is to ask how a procedure that would not benefit most patients became the default treatment for everyone whose heart stopped in the hospital. accepted explanation for this phenomenon is the need for fire drill-like orchestration for the cardiac arrest team.2 Although precise and routinized execution of the therapy is doubtless a factor in the development of the Paradigm, there were many other forces that also drove it forward (see Table 1). One of the important forces in the early days of CPR was the interprofessional collaboration between nurses and physicians.Curiously, the 1962 Circulation editorial provided no additional guidance concerning who should and who should not receive CPR. Instead, the limitation is placed on who should perform it, with the last line stating, The undersigned organizations joining in the statement believe that emphasis should be placed at this time on training physicians, dentists, nurses, and specially qualified emergency personnel, so that the procedure will become more widely available. …