Cycles Of Cardiopulmonary Resuscitation Research Articles

Does Real-time Feedback Guide Devices Improve the Quality of Chest Compressions in the Bystander (Naves) Provider?

Abstract Introduction: Cardiopulmonary resuscitation (CPR) is an important lifesaving technique that must taught to everyone. As most cardiac arrests occur outside of the hospital, training the general population in the recognition of cardiac arrest and performing high-quality CPR is vital. Thus, this study aimed to compare the chest compression quality data (rate, depth, and fraction) with and without the use of feedback devices during CPR. Methods: A crossover observational study was carried out at a tertiary hospital in September 2021. Five hundred and seventeen 1st-year university students were recruited, and the response rate was 90% (465). A feedback device was used to collect data. The data were numerically coded and statistical software (SPSS 21) was used to perform descriptive and inferential statistical analysis, including a paired t-test. Results: The mean compression rate with feedback was statistically significantly lower after performing one cycle of CPR (mean difference: −5.610; 95% confidence interval [CI]= −7.987–−3.233; P < 0.001), the difference between mean compression depth with and without feedback was not statistically significant (mean difference: = −0.006; 95% CI = −0.190–0.177; P = 0.944), and the mean compression target (%) with feedback was statistically significantly higher (mean difference: −15.951; 95% CI = −17.894–−14.009; P < 0.001). Conclusions: We found that the use of feedback devices during layperson-simulated CPR scenarios significantly improved the quality of chest compression in terms of depth and rate and resulted in more guidelines adherence. Moreover, national programs for CPR education should be implemented.

Effect of RapidShockTM Implementation on Perishock Pause in Out-of-Hospital Cardiac Arrest

Objectives Shorter pauses in cardiopulmonary resuscitation (CPR) are associated with better health outcomes after out-of-hospital cardiac arrest (OHCA). Our primary objective was to examine the effect of a RapidShockTM defibrillator software upgrade compared with standard defibrillator software on the length of perishock pause during care for OHCA among adults. Secondary objectives were to assess the effects of RapidShockTM on other CPR pauses. Methods We conducted a retrospective cohort study between September 1, 2015 and September 30, 2020. “Standard” cardiac defibrillator software in manual interpretation mode was used for CPR delivered on or before November 30, 2018, while “RapidShockTM” software (ZOLL® Medical Corporation) was used after this date. For each study group, we calculated the perishock, perianalysis, and total CPR pause; each CPR cycle was considered an independent event. We then calculated the median and interquartile range (IQR) for observed pauses with the “Standard” and “RapidShockTM” software. Percent change in median perishock pause (shockable rhythms), perianalysis pause (non-shockable rhythms), and total CPR pause were compared between CPR administered with each software using the Mann–Whitney test. Results There were 733 and 782 distinct CPR cycles administered using “Standard” and “RapidShockTM” software, respectively. A 31.8% reduction in median perishock pause was observed with “RapidShockTM” software compared with the “Standard” software (22.0 s (IQR 18.0 − 27.0 s) vs. 15.0 s (IQR 13.0 − 19.0 s); p < 0.01). The decrease in median perishock pause was driven by a reduction in the preshock phase (18 s vs. 10 s; 44.4% decrease in median pause; p < 0.01). No differences were observed in median perianalysis pause between the two groups. When combining shockable and non-shockable rhythms, we observed a reduction of 23.5% in median CPR pause (17.0 s (IQR 11.0 − 24.0 s) vs. 13s (IQR 10.0 − 17.0 s); p < 0.01). Conclusions Overall, we observed that the use of “RapidShockTM” defibrillator software was associated with shorter CPR pauses compared with the “Standard” software. Additional studies are required to examine whether further reductions in CPR pauses may be achieved and to investigate associations between shorter CPR pauses and health outcomes.

Clinical outcomes of patients with in-hospital witnessed cardiac arrest: effect of co-morbidities

IntroductionCardiopulmonary resuscitation (CPR) is frequently performed in hospitalized patients after in-hospital cardiac arrest (IHCA), especially in the intensive care unit (ICU) (J Crit Care 24:408-414, 2009). Despite the fact that nearly half of the in-hospital cardiac arrests (IHCA) actually happen in intensive care units (ICUs) (N Engl J Med 367:1912-1920, 2012), intensive care unit cardiac arrest (ICU-CA) compared to IHCA or out-of-hospital cardiac arrests (OHCA) has received little attention, and data on ICU-CA remains scanty (Intensive Care Med 40:1853-1916, 2014).AimWe aimed to evaluate the clinical status and factors associated with the survival of patients subjected to cardiopulmonary resuscitation (CPR) after a witnessed cardiac arrest (CA) inside the medical intensive care unit (MICU).PatientsThe study included 110 patients, mean age of 60 ± 18 years, 69 (63%) males, and 41 (37%) females. Co-morbidities included diabetes mellitus was present in 46 (42%), hypertension 57 (52%), central nervous system (CNS) disease 31 (29%), cardiovascular (CVS) 76 (69%), respiratory 63 (57%), hepatic 16 (15%), shock 35 (32%), and renal 44 (40%). Mechanical ventilation was present in 97 (88%) of patients. SOFA score < 9 was present in 38%, MPM III score < 10 in 37%, and GCS > 7 in 66% of patients. Non-shockable rhythm occurred in 95 (86%) while shockable rhythm in 15 (14%) of patients.MethodsData were collected prospectively at the medical ICU of Cairo University from Jan. 2013 to Feb 2013. A resuscitation protocol was done according to the latest recommendation of the European Society of Cardiology at the time of patient inclusion. Clinical data were recorded and surviving patients were clinically followed daily until hospital discharge.ResultsOut of 110 witnessed cardiac arrests, CPR was initially successfully manifested by return of spontaneous circulation (ROSC) in 60 patients (55%), of whom 22 (20%) survived hospital discharge and only 9 patients (8%) were functionally independent. Compared to non-survivors, 60 patients (55%) with ROSC had a MPM III < 10 (p 0.015), EF ≥ 50% (p 0.001), and non-shocked patients (p 0.008). Other factors such as DC shocks < 3 (p 0.02), CPR cycles < 2 (p < 0.001), resuscitation duration < 10 min (p 0.03), time to start CPR < 1 min (p 0.001), maintained HCO3 (p 0.03), and PaCO2 (p 0.002) were found to improve ROSC. Mortality before discharge decreased with asystole (p < 0.01). Mortality before discharge increased with CNS (p < 0.02) and respiratory comorbidities (p 0.02), shock (p < 0.001) and mechanical ventilation (p < 0.0001), SOFA > 9 (p 0.001), MPM III > 10 (0.018), and time to start CPR > 1 min (p 0.001).ConclusionNot all ROSC reached long-term survival and hospital discharge. Several co-morbidities affect ROSC and short-term and long-term patient survival after witnessed MICU cardiac arrest.

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

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

Acute white-out lung in mechanically ventilated patient

ABSTRACT A 64-year-old male with a history of chronic kidney disease-5, type 2 diabetes mellitus (T2DM), and hypertension presented with syncope and weakness. Initial examination revealed a heart rate (HR) of 18/min and blood pressure (BP) of 140/90 mmHg. Intravenous (iv) atropine was administered, increasing HR to 85/min. Subsequently, the patient became pulseless, unconscious, and unresponsive, necessitating cardiopulmonary resuscitation (CPR) as per Advanced Cardiovascular Life Support (ACLS) protocol. Return of spontaneous circulation (ROSC) was achieved after three CPR cycles, and the patient regained consciousness. He was intubated and transferred to the intensive care unit. The patient, a smoker with a 4.5 pack-year history, experienced increased positive end-expiratory pressure (PEEP), elevated plateau pressure, and inadequate tidal volume generation a day later. Auscultation revealed significantly reduced air entry on the right side. Arterial blood gas (ABG) analysis indicated CO2 retention. Chest X-ray showed a white-out right lung, intercostal narrowing, and mediastinal shift toward the ipsilateral side.

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

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

Designing of a High-Quality CPR Simulation Game Clinical Scenario for Nursing Students: A Qualitative Study

Cardiopulmonary resuscitation (CPR) is an important skill for nursing students. The process of learning high-quality CPR with a simulation-based learning method can be developed into a simulation game. In order to develop a CPR HQ simulation game, a clinical scenario that can be used as a guide in carrying out storyboards is needed. This research aims to formulate a simulation scenario that will serve as the basis for developing a high-quality CPR simulation game to increase nursing students' competency. This qualitative research uses a Participatory Action Research (PAR) approach by inviting 15 respondents from the prospective user population, namely Emergency Nursing Lecturers, Emergency Room Nurses, BLS Trainers, and nursing students, to carry out Focus Group Discussions. The study's results revealed clinical scenarios that were arranged based on 4 themes, including 1) suitability of the competency being tested, 2) minimum competency for 5 cycles of CPR, 3) settings in the pre-and intrahospital scope, and 4) choice of patient outcome. These components are crucial when designing simulation scenarios that support students’ cognitive processes to achieve High-Quality CPR in nursing students. Thus, the results of this research can then be used as a guide in developing the HQ-CPR game as a learning medium for nursing students.

Bag-mask ventilation by low- or untrained rescuers during adult and pediatric resuscitation: a randomized cross-over manikin study

AimBag-mask ventilation (BMV) is often applied during advanced cardiopulmonary resuscitation (CPR). Lay rescuers usually apply mouth-to-mouth ventilation, which is contraindicated in case of potential disease transmission (e.g., during the COVID-19 pandemic). This study evaluates the influence of rescuers' before BMV training in following the correct BMV procedures during adult and infant CPR.MethodsMedical students (n = 112) were enrolled in a randomized cross-over manikin study: 60 first-year students (53.6%) (untrained, without any prior knowledge of CPR) and 52 fourth-year students (46.4%) (BLS-trained, with three consecutive years of basic CPR training), excluding Basic Life Support (BLS) certificate holders or lifeguards. Student-formed duos (i.e., two students from the same year working together) received a 15-min just-in-time onsite training in full CPR cycle using BMV and were tested during five cycles of 2-person CPR following the European Resuscitation Council (ERC) guidelines with the inclusion of BMV. Tidal volumes of 300–600 ml (adults) and 20–60 ml (infants) were considered as correct ventilations.ResultsFrom the initial 56 duos, 17 (30.4%) were excluded after applying incorrect numbers of ventilation or uninterpretable values. In adult CPR, comparing BLS-trained rescuers to untrained ones in correctly administrating ventilations using BMV after a 15-min just-in-time onsite training revealed no statistically significant difference [first years: 63.0% (n = 136 out of 216 ventilations); fourth years: 59.5% (n = 119 out of 200 ventilations); with a proportional difference of −3.5% (−12.8; 5.9)]. In infant CPR, a significant difference was observed in effective ventilations [first years: 55.5% (n = 120 out of 216 ventilations); fourth years: 72.3% (n = 133 out of 184 ventilations); with a proportional difference of 16.8 (7.25; 26.21)].ConclusionTwo-person BMV is a complex skill to perform both in adults and children, requiring sufficient and regular training. Lay rescuers receiving a 15-min just-in-time onsite BMV training could perform decent BMV in an adult CPR setting. BMV during infant CPR requires more extensive prior training and should not be entrusted to lay rescuers, even after a 15-min just-in-time onsite training.

Accuracy of two-rescuer adult CPR performed by medical registrars at a South African university.

Cardiopulmonary resuscitation (CPR) is performed to manually keep brain function intact until the patient's spontaneous blood circulation and breathing are restored. In South Africa, registrars, who are qualified doctors training to specialise in a medical field, are usually the team leaders and oversee junior doctors and nurses during resuscitation. This study aimed to determine the accuracy of the execution of two-rescuer adult CPR on a Resusci-Anne® manikin performed by registrars from the University of the Free State, South Africa. A cross-sectional study was conducted. From a target population of 142 registrars, 47 participated, of whom 44 were included in the analysis. During five cycles of CPR, compression quality was assessed. During a subsequent five cycles, airway management was assessed. Participants were evaluated executing CPR on the Resusci-Anne® manikin, with a recently Basic Life Support trained student researcher as second rescuer. A modified version of the American Heart Association's tick sheet for two-rescuer adult CPR was completed by two student researchers. Department, gender and the date of the most recent CPR training attended were recorded. The median total percentage score was 82.2% (range 33.3% to 100.0%). Results showed that 88.6% of registrars consistently demonstrated correct hand placement, 25.0% correct compression rate, 93.2% correct compression depth, and 61.4% allowed complete chest recoil during compressions. Consistently correct E-C technique was found in 77.3%, and correct ventilation rate in 93.2%. Only 63.6% correctly managed an open airway, and 61.4% achieved visible chest rise. A consistently correct compression-to-ventilation ratio was performed by 59.1% of registrars. The study found that registrars were not consistently performing high-quality CPR on a Resusci-Anne® manikin and identified areas needing attention. The results of this study highlight the need for compulsory CPR training and regular fire drills for registrars.

Use of a Portable Mechanical Ventilator during Cardiopulmonary Resuscitation is Feasible, Improves Respiratory Parameters, and Prevents the Decrease of Dynamic Lung Compliance.

For practical and protective ventilation during cardiopulmonary resuscitation (CPR), a 150-grams mechanical ventilator (VLP2000E) that limits peak inspiratory pressure (PIP) during simultaneous ventilation with chest compressions was developed. To evaluate the feasibility of VLP2000E ventilation during CPR and to compare monitored parameters versus bag-valve ventilation. A randomized experimental study with 10 intubated pigs per group. After seven minutes of ventricular fibrillation, 2-minute CPR cycles were delivered. All animals were placed on VLP2000E after achieving return of spontaneous circulation (ROSC). Bag-valve and VLP2000E groups had similar ROSC rate (60% vs. 50%, respectively) and arterial oxygen saturation in most CPR cycles, different baseline tidal volume [0.764 (0.068) vs. 0.591 (0.123) L, p = 0.0309, respectively] and, in 14 cycles, different PIP [52 (9) vs. 39 (5) cm H2O, respectively], tidal volume [0.635 (0.172) vs. 0.306 (0.129) L], ETCO2[14 (8) vs. 27 (9) mm Hg], and peak inspiratory flow [0.878 (0.234) vs. 0.533 (0.105) L/s], all p < 0.0001. Dynamic lung compliance (≥ 0.025 L/cm H2O) decreased after ROSC in bag-valve group but was maintained in VLP2000E group [0.019 (0.006) vs. 0.024 (0.008) L/cm H2O, p = 0.0003]. VLP2000E ventilation during CPR is feasible and equivalent to bag-valve ventilation in ROSC rate and arterial oxygen saturation. It produces better respiratory parameters, with lower airway pressure and tidal volume. VLP2000E ventilation also prevents the significant decrease of dynamic lung compliance observed after bag-valve ventilation. Further preclinical studies confirming these findings would be interesting.

A Pilot Study to Examine the Effect of Passive Straight Leg Raise Performed During Cardiopulmonary Resuscitation on Cerebral Perfusion Measured by Noninvasive Cerebral Oximetry.

This was a double cross-over physiologic efficacy randomized study. Study in 10 subjects with in-hospital cardiac arrest for whom CPR was undertaken. Subjects were randomized to receive two cycles of CPR with PLR followed by two cycles of CPR without PLR (Group I) or vice-versa (Group II). Subjects had their foreheads (right and left) fitted with near infrared spectroscopy (NIRS) electrodes (O3 System-Masimo, Masimo corporation Forty Parker, Irvine CA) while undergoing CPR during the study. NIRS readings, a measure of mixed venous, arterial, and capillary blood oxygen saturation, act as a surrogate measure of cerebral blood perfusion during CPR. PLR was randomly used "first" in five of them, whereas it was used "second" in the remaining five subjects. In subjects in whom PLR was performed during first two cycles (Group I), NIRS values were initially significantly greater. The performance of PLR during CPR in Group II attenuated the decline in NIRS readings during CPR. PLR during CPR is feasible and leads to augmentation of cerebral blood flow. Furthermore, the expected decline in cerebral blood flow over time during CPR may be attenuated by this maneuver. The clinical significance of these findings will require further investigations.

Emergency treatment for iatrogenic lumbar arterial injury occurred during posterior lumbar interbody fusion: a case report

An iatrogenic vessel injury occurring during lumbar fusion is a rare but potentially serious complication. In this case report, we present a case of hypovolemic cardiac arrest attributable to an iatrogenic lumbar artery injury that occurred during posterior lumbar interbody fusion (PLIF), which is difficult to diagnose using CECT. A 70-year-old woman underwent PLIF surgery in a primary hospital for the treatment of degenerative spondylolisthesis (L2–L5). During the procedure, she experienced a blood loss of 3 liters, which necessitated the transfusion of packed red blood cells (6 units, about 200–250 mL per unit), fresh frozen plasma (6 units, about 150–170 mL per unit). Despite the transfusions, her vital signs remained unstable, leading to her transfer to our hospital. Upon arrival at our facility, the patient went into cardiac arrest, but spontaneous circulation was successfully restored after two cycles of cardiopulmonary resuscitation. In the emergency department, her hemoglobin level was measured at 2.7 g/dL, platelet level at 56,000/µL, and prothrombin international normalized ratio at 3.56. CECT did not indicate any active bleeding. For the initial 2 hours, her vital signs remained stable with a blood pressure of 92/53 mmHg, heart rate of 104 bpm, respiratory rate of 22 bpm. However, her blood pressure suddenly dropped to 78/43 mmHg. Subsequent angiography revealed active bleeding from the right fourth lumbar artery, prompting the performance of embolization. Following the procedure, the patient’s vital signs stabilized, and she was discharged on the 16th day of hospitalization. Iatrogenic vessel injuries during PLIF may pose challenges in their detection using CECT, especially when extravasation is not definitively visible or when artifacts are created by metal implants. Therefore, it is advisable for emergency physicians to consider emergency angiography in the diagnosis and treatment of such vessel injuries.

Left ventricle chest compression improves ETCO2, blood pressure, and cerebral blood velocity in a swine model of cardiac arrest and cardiopulmonary resuscitation

IntroductionDuring cardiopulmonary resuscitation (CPR), high quality chest compressions are critical to organ perfusion, especially the brain. Yet, the optimal location for chest compressions is unclear. It was hypothesized that compared with the standard chest compression (SCC) location, left ventricle chest compressions (LVCCs) would result in greater end-tidal carbon dioxide (ETCO2), blood pressure (BP), and cerebral blood velocity (CBV) during CPR in swine. MethodsFemale Landrace swine (N = 32; 35 ± 2 kg) underwent two mins of untreated asphyxiated cardiac arrest (CA). Thereafter, swine were treated with three 2-min cycles of either SCC or LVCC mechanical basic life support CPR (LUCAS 3). ETCO2 (in-line sampling), BP (arterial catheter line), and CBV (transcranial Doppler) were measured during the pre-CA, untreated-CA, and CPR-treated phases. ResultsETCO2, BP, and CBV were similar between groups at pre- and during untreated-CA (P ≥ 0.188). During CPR, ETCO2 (36 ± 6 versus 24 ± 10 mmHg, P < 0.001), mean arterial BP (MAP; 49 ± 9 versus 37 ± 9 mmHg, P = 0.002), and CBV (11 ± 5 versus 5 ± 2 cm/s, P < 0.001) were significantly greater in the LVCC versus SCC group. Moreover, a greater proportion of animals obtained targets for ETCO2 (ETCO2 ≥ 20 mmHg; 52 % (17/33) versus 100 % (32/32), P < 0.001) and diastolic BP (DBP ≥ 25 mmHg; 82 % (33/40) versus 97 % (48/49), P = 0.020) in the LVCC versus SCC group. ConclusionIndicators of cardiac output, BP, and cerebral perfusion during CPR were greatest in the LVCC group, suggesting the quality of chest compressions during BLS CPR may be improved by performing compressions over the left ventricle compared to the centre of the chest.

Temporal Changes in Epinephrine Dosing in Out-of-Hospital Cardiac Arrest: A Review of EMS Protocols across the United States.

Administration of epinephrine has been associated with worse neurological outcomes for survivors of out-of-hospital cardiac arrest. The publication of the 2018 PARAMEDIC-2 trial, a randomized and double-blind study of epinephrine in out-of-hospital cardiac arrest, provides the strongest evidence to date that epinephrine increases return of spontaneous circulation (ROSC) but not neurologically intact survival. This study aims to determine if Emergency Medical Services (EMS) cardiac arrest protocols have changed since the publication of PARAMEDIC-2. States in the US utilizing mandatory or model state-wide EMS protocols, including Washington DC, were included in this study. The nontraumatic cardiac arrest protocol as of January 1, 2018 was compared to the protocol in effect on January 1, 2021 to determine if there was a change in the administration of epinephrine. Protocols were downloaded from the relevant state EMS website. If a protocol could not be obtained, the state medical director was contacted. A 2021 state-wide protocol was found for 32/51 (62.7%) states. Data from 2018 were available for 21/51 (41.2%) states. Of the 11 states without data from 2018, all follow Advanced Cardiac Life Support (ACLS) guidelines in the 2021 protocol. Five (15.6%) of the states with a state-wide protocol made a change in the cardiac arrest protocols. Maximum cumulative epinephrine dose was limited to 4mg in Maryland and 3mg in Vermont. Rhode Island changed epinephrine in shockable rhythms to be administered after three cycles of cardiopulmonary resuscitation (CPR) and an anti-arrhythmic. Rhode Island also added an epinephrine infusion as an option. No states removed epinephrine administration from their cardiac arrest protocol. Simple statistical analysis was performed with Microsoft Excel. Several states have adjusted cardiac arrest protocols since 2018. The most frequent change was limiting the maximum cumulative dosage of epinephrine. One state changed timing of epinephrine dosing depending on the rhythm and also provided an option of an epinephrine infusion in place of bolus dosing. While the sample size is small, these changes may reflect the future direction of prehospital cardiac arrest protocols. Significant limitations apply, including the exclusion of local and regional protocols which are more capable of quickly adjusting to new research. Additionally, this study is only focused on EMS in the United States.

The Effects of Fatigue on Rescuers due to Wearing Level D Personal Protective Equipment while Performing Cardiopulmonary Resuscitation

This study aimed to provide data on high-quality cardiopulmonary resuscitation (CPR) by determining the fatigue effects on rescuers wearing level D personal protective equipment (PPE) while performing CPR. The study’s methodology entailed the comparative performance of two-person CPR; once while the participants wore level D PPE and once while they did not, over the 30 min course in seven cycles. The fatigues of 24 students from the department of emergency medical technology were measured pre-experiment and during CPR, after each cycle was measured. In this study, there were no differences in the blood lactate concentration, heart rate, oxygen saturation and subjective fatigue participants with or without level D PPE over the course of repeated CPR cycles. However, participants wearing level D PPE typically displayed the ‘somewhat hard’ and ‘hard’ stages of subjective fatigue a cycle faster than those not wearing level D PPE. Specifically, the proportion of such participants who reached more than the ‘somewhat hard’ stage of fatigue in the second cycle was higher than that among those not wearing level D PPE (p &lt; .05). Consequently, wearing level D PPE was found to increase the rate of subjective fatigue from the early course of performing CPR. Therefore, rescuers will be able to provide higher quality CPR if measures are conducted to reduce fatigue.

Physiologic effects of stress dose corticosteroids in in-hospital cardiac arrest (CORTICA): A randomized clinical trial

AimPostresuscitation hemodynamics are associated with hospital mortality/functional outcome. We sought to determine whether low-dose steroids started during and continued after cardiopulmonary resuscitation (CPR) affect postresuscitation hemodynamics and other physiological variables in vasopressor-requiring, in-hospital cardiac arrest. MethodsWe conducted a two-center, randomized, double-blind trial of patients with adrenaline (epinephrine)-requiring cardiac arrest. Patients were randomized to receive either methylprednisolone 40 mg (steroids group) or normal saline-placebo (control group) during the first CPR cycle post-enrollment. Postresuscitation shock was treated with hydrocortisone 240 mg daily for 7 days maximum and gradual taper (steroids group), or saline-placebo (control group). Primary outcomes were arterial pressure and central-venous oxygen saturation (ScvO2) within 72 hours post-ROSC. ResultsEighty nine of 98 controls and 80 of 86 steroids group patients with ROSC were treated as randomized. Primary outcome data were collected from 100 patients with ROSC (control, n = 54; steroids, n = 46). In intention-to-treat mixed-model analyses, there was no significant effect of group on arterial pressure, marginal mean (95% confidence interval) for mean arterial pressure, steroids vs. control: 74 (68–80) vs. 72 (66–79) mmHg] and ScvO2 [71 (68–75)% vs. 69 (65–73)%], cardiac index [2.8 (2.5–3.1) vs. 2.9 (2.5–3.2) L/min/m2], and serum cytokine concentrations [e.g. interleukin-6, 89.1 (42.8–133.9) vs. 75.7 (52.1–152.3) pg/mL] determined within 72 hours post-ROSC (P = 0.12–0.86). There was no between-group difference in body temperature, echocardiographic variables, prefrontal blood flow index/cerebral autoregulation, organ failure-free days, and hazard for poor in-hospital/functional outcome, and adverse events (P = 0.08–>0.99). ConclusionsOur results do not support the use of low-dose corticosteroids in in-hospital cardiac arrest.Trial Registration:ClinicalTrials.gov number: NCT02790788 (https://www.clinicaltrials.gov).

Prinzmetal’s variant angina during laparoscopy: a case report of vasospasm in the context of cardiac arrest

We report the case of a 43-year-old male patient who experienced cardiac arrest during two elective laparoscopies for cholecystectomy. The first procedure was prematurely interrupted after the return of spontaneous circulation (ROSC) while the other was continued under intravenous (IV) perfusion of nitrates (isosorbide dinitrate). At each time, after a cycle of cardiopulmonary resuscitation (CPR) and injection of atropine 0.5 mg, sinus rhythm was restored. Only 3-lead electrocardiogram (ECG) outlines were recorded, showing ST-elevation in lead II. During the first incident, a coronary angiography was performed showing a vasospasm of the left anterior descending (LAD) coronary artery, reversible upon intracoronary injection of nitrates. ECG during catheterization showed ST-elevation in the anterior coronary territory. Calcium-channel blockers (CCB) were prescribed, and oral nitrates were added after the second episode. Cardiovascular prevention consisted in smoking cessation, aspirin and statins. Reporting this case seems to be relevant due to its unusual presentation: Prinzmetal’s angina is usually described as morning chest pains, and it rarely concerns Caucasian men. Moreover, the vasospasm was associated with cardiac arrest and ECG changes suggestive of ST-elevation myocardial infarction (STEMI). The final diagnosis was myocardial infarction with non-obstructive coronary arteries (MINOCA) due to coronary vasospasm, a few minutes after insufflation of pneumoperitoneum. So far, few cases have been described during non-cardiac surgery, and even fewer during laparoscopy. Sharing our experience seems important to attract attention to cardiovascular events that can occur under general anesthesia, especially when clinical presentation is rare.

Human Reliability Analysis for Cardiopulmonary Resuscitation Process in Emergency Medicine Using a Modified Hybrid Method Based on the Markov Model and Fault Tree Analysis

Introduction:In emergency departments (ED), human reliability assessment is essential for improving the quality of treatment and preventing medical accidents. A medical accident is expressed as an injury to a patient caused by the negligence of a doctor or nurse who is providing medical care. This study aimed to assess the human reliability in the cardiopulmonary resuscitation (CPR) process and recommend some comments to minimize human errors and improve patient safety.Materials and Methods: The main factors in the CPR process (such as rate and depth of chest compression and rate of ventilation) are identified based on the American heart association (AHA) roles. Data were recorded during three months in the evening shifts in the ED and CPR room of Imam Reza Hospital in Mashhad, Iran. In total, 42 samples were collected, and a modified hybrid approach according to the fault tree analysis and Markov method was proposed for the analysis of CPR team (including emergency medicine, medical interns, and nurses) reliability in the resuscitation process. Finally, the important basic events (errors) were selected using the Boruta algorithm by R software.Results: An FTA-Markov-based hybrid method is considered to compute the human reliability in the CPR process. The obtained results from human reliability analysis using the sensitivity analysis via Boruta algorithm and the proposed hybrid method show that an interrupt between chest compression process for rhythm control, the cycle of CPR, the depth of chest compression, and the discussion about reversible causes are the most effective factors in the human reliability of CPR process.Conclusion:The human reliability of the CPR process in the ED has been assessed using a hybrid method based on the FTA and Markov method for the first time. To improve the quality of treatment and prevent medical accidents during the CPR process, the main factors in the process are identified, and then, the proposed hybrid method is used to calculate human reliability.

How should we teach cardiopulmonary resuscitation? Randomized multi-center study.

A 2017 update of the resuscitation guideline indicated the use of cardiopulmonary resuscitation (CPR) feedback devices as a resuscitation teaching method. The aim of the study was to compare the influence of two techniques of CPR teaching on the quality of resuscitation performed by medical students. The study was designed as a prospective, randomized, simulation study and involved 115 first year students of medicine. The participants underwent a basic life support (BLS) course based on the American Heart Association guidelines, with the first group (experimental group) performing chest compressions to observe, in real-time, chest compression parameters indicated by software included in the simulator, and the second group (control group) performing compressions without this possibility. After a 10-minute resuscitation, the participants had a 30-minute break and then a 2-minute cycle of CPR. One month after the training, study participants performed CPR, without the possibility of observing real-time measurements regarding quality of chest compression. One month after the training, depth of chest compressions in the experimental and control group was 50 mm (IQR 46-54) vs. 39 mm (IQR 35-42; p = 0.001), compression rate 116 CPM (IQR 102-125) vs. 124 CPM (IQR 116-134; p = 0.034), chest relaxation 86% (IQR 68-89) vs. 74% (IQR 47-80; p = 0.031) respectively. Observing real-time chest compression quality parameters during BLS training may improve the quality of chest compression one month after the training including correct hand positioning, compressions depth and rate compliance.

Rapid degradation of psychomotor memory causes poor quality chest compressions in frequent cardiopulmonary resuscitation providers and feedback devices can only help to a limited degree: A crossover simulation study.

Abstract Studies report a decline in the psychomotor memory of cardiopulmonary resuscitation (CPR) providers within months of training, but they are prone to subject bias. We hypothesized that this degradation is faster and more prevalent in real world practice. The aims of our study were to Forty anaesthetists and intensivists participated in a voluntary, half-day, randomized crossover study using case-based simulation. Participants were paired and randomly assigned into 2 groups; each receiving automated feedback either in the first or second cycle of CPR. Two cycles of CC and defibrillation (ACLS protocol) were administered on a manikin. CC parameters including overall quality were measured by a feedback device. The median proportion of good quality CC was poor at baseline but improved with feedback; 38.2% (IQR 27.7, 58.7) to 57.7% (IQR 38.0, 68.7), P &lt; .05. The median proportion of good quality CC fell after feedback withdrawal; 50.5% (IQR 24.5, 67.7) to 25.6% (9, 37.6), P &lt; .05. No carryover effect was observed. Treatment effect and period effect were detected. Baseline quality of CC amongst frequent CPR providers is poor, and can be improved partly by feedback devices. As psychomotor memory of good quality CCs degrades rapidly after removal of feedback, a multimodal approach is required for CPR skill retention. Future research on the optimal frequency of CPR training, including the use of feedback devices in clinical practice should be explored.