Early Chest Compressions Research Articles

Abstract 308: Comparison of Cardiopulmonary Resuscitation Performance Between Integrated CPR Device Performing Chest Compression and External Defibrillation versus LUCAS3 With Automated External Defibrillator: A Animal and Manikin-Based Pilot Study

Background: Early chest compression and defibrillation are important components for successful resuscitation. The use of mechanical CPR has increased after the outbreak of COVID-19, and this trend continued in the post-pandemic period. We developed an automatic CPR performing chest compression and external defibrillation simultaneously following current CPR algorithm. Methods: This study was designed as a study to compare the performance of CPR and AED between automatic CPR apparatus (A-CPR) and commercially proven mechanical CPR device (LUCAS3) plus AED (C-CPR) during CPR in swine cardiac arrest model and the study to evaluate feasibility of A-CPR in simulated cardiac arrest model. Results: There were no significant differences in hemodynamic variables between the groups. Time to ECG analysis [38.0 sec in A-CPR, 48.0 sec in C-CPR, p =0.010], time to initial shock advice plus subsequent chest compression [46.0 sec in A-CPR, 57.0 sec in C-CPR, p =0.017], time to first defibrillation [48.5 sec in A-CPR, 65.0 sec in C-CPR, p =0.004], charge to shock interval [3.0 sec in A-CPR, 8.0 sec in C-CPR, p =0.001], and hands-off time [11.0 sec in A-CPR, 22.5 sec in C-CPR, p =0.001] were significantly shorter in A-CPR group than C-CPR group. In the simulation study, the pure chest compression time [101 sec in A-CPR, 110 sec in C-CPR, p< 0.001], hands-off time [75 sec in A-CPR, 94 sec in C-CPR, p< 0.001], time from power-on to first chest compression [55 sec in A-CPR, 82 sec in C-CPR, p< 0.001], time to first shock delivery [40 sec in A-CPR, 51 sec in C-CPR, p= 0.001] were significantly shorter in A-CPR group than C-CPR group, respectively. Chest compression fraction showed a significant higher in A-CPR than C-CPR [57% in A-CPR, 54% in C-CPR, p <0.001]. Conclusions: The A-CPR device demonstrated significant time savings effect than conventional mechanical CPR device and automated external defibrillation device. In addition, A-CPR and C-CPR showed similar hemodynamic effects and resuscitation outcomes in a swine model of cardiac arrest

Manual vs. mechanical ventilation in patients with advanced airway during CPR

Early chest compressions and rapid defibrillation are important components of cardiopulmonary resuscitation (CPR). American heart association (AHA) recommends two breaths to be delivered for every 30 compressions for an adult cardiac arrest victim. Patient with an advanced airway like endotracheal tube (ETT) should be given one breath every 6 s without interruptions in chest compression (10 breaths per minute). All of the modern mechanical ventilators have option to generate spontaneous breaths by the patient if the patient has spontaneous respiratory efforts. During CPR, the mechanical ventilator is fallaciously sensing the chest compressions as patient's spontaneous trigger and thereby it delivers higher respiratory rates. Avoiding excessive ventilation is one of the components of high quality CPR as excessive ventilation decreases venous return thereby decreasing the cardiac output and also it affects intra-thoracic pressure thereby adversely affects intra-arterial pressure. As modern ventilators have trigger for spontaneous breaths and they will be erroneously triggered by chest compressions, it would be prudent to use volume marked resuscitation bags or manual breathing devices (manual self-inflating resuscitation bag, Bain's circuit) for delivering breaths which can be synchronised with compression phase of CPR at RR of 10 breaths per min with advanced airway in place. If any patient who is on mechanical ventilation develops cardiac arrest, patient should be disconnected from the mechanical ventilator and should be ventilated manually. Manual ventilation with aforementioned breathing devices should be used in a patient without and with advanced airway devices during CPR.

Abstract 14171: Prehospital Outcomes and Patient Characteristics Associated With PulsePoint Dispatches for Out-of-Hospital Cardiac Arrest in Pittsburgh, Pennsylvania

Background: Mobile phone-based dispatch of volunteers to out-of-hospital cardiac arrest (OHCA) has been shown to increase the likelihood of early chest compressions and AED application. In the United States, limited characterization of patients encountered as a result of such systems exists, including PulsePoint Respond, a smartphone-based volunteer dispatch system. Objective: Examine prehospital case characteristics and outcomes from a multi-year deployment of PulsePoint in Pittsburgh, Pennsylvania. Methods: Case data, including PulsePoint determinant triggers and timing, prehospital electronic health records (EHRs), and computer aided dispatch records were obtained for suspected EMS-treated OHCA cases that did and did not generate PulsePoint alerts within the service area of Pittsburgh EMS for the period July 2016 to October 2020. EHRs were reviewed to determine true OHCA status, and OHCA case characteristics were extracted according to the Utstein template. Key characteristics and the outcome of prehospital return of spontaneous circulation (ROSC) were summarized and compared between cases with and without PulsePoint dispatches. Chi-squared tests were used to determine statistical significance of relationships. Results: There were 1229 OHCA cases overall in the capture period, with an estimated 29.6% occurring in public. Of 840 total PulsePoint dispatches, 68 (8.1%) were for true OHCA. Forty-five (66.2%) of these were witnessed, 43 (63.2%) received bystander CPR, and 17 (25%) had an AED applied prior to first responder arrival. Twenty-seven (39.7%) had an initial shockable rhythm, and 34 (50%) achieved ROSC in the field. Compared to non-PulsePoint dispatch generating OHCA, PulsePoint alert-associated patients were significantly more likely to be male (p=0.024), have bystander CPR/AED application performed (p<0.001), have an initial shockable rhythm (p<0.001), and achieve ROSC (p<0.001). EMS response time, age, ALS response time, and witnessed status were not significantly different. Conclusions: A minority of PulsePoint dispatches in Pittsburgh were triggered by true OHCA. Among cases that did generate a PulsePoint dispatch, case characteristics were prognostically favorable.

Rapid cycle deliberate practice improves and sustains paediatric resident PALS performance

ObjectivesPaediatric cardiopulmonary arrest resuscitation is a critically important skill but infrequently used in clinical practice. Therefore, resuscitation knowledge relies heavily on formal training which is vulnerable to rapid knowledge decay....

Variations in chest compression time, ventilation time and rescuers' heart rate during conventional cardiopulmonary resuscitation in trained male rescuers.

ObjectiveThis study was conducted to determine why rescuers could maintain adequate chest compression depth for longer periods during conventional cardiopulmonary resuscitation (CPR).MethodsVarious CPR parameters, including average compression depth (ACD), average compression rate, average ventilation time (AVT), and rescuers’ heart rates were recorded in real-time when 20 health care providers performed 10 minutes of conventional CPR during a simulation experiment.ResultsThe ACD was maintained above 50 mm and was not significantly different during 19 consecutive CPR cycles. The average compression rate increased from 114.9±10.0/min (2nd cycle) to 120.1±13.8/min (18th cycle) (P=0.007), and the AVT increased from 8.7±1.5 seconds (3rd cycle) to 10.1±2.6 seconds (18th cycle) (P=0.002). The rescuers’ heart rates also increased gradually for 10 min; however, they increased rapidly and were highest during the ventilation phase. Their heart rates then decreased and were lowest during the early chest compression phases of each CPR cycle. Decreases in heart rates were significant in all CPR cycles (average decrease: 14.5±4.5 beats/min, P<0.001).ConclusionThe ACD was maintained adequately during 10 minutes of conventional CPR. However, the AVT increased significantly during the 10-minute period. The rescuers’ heart rates increased and decreased throughout all CPR cycles. These results showed that the ventilation phase might play a role as a resting period and be a reason for the maintenance of adequate chest compression depth for prolonged periods during conventional CPR.

Assessing the efficacy of the new protocol for chest compressions before definitive cardiac arrest in emergency medical service-witnessed adult out-of-hospital cardiac arrests

AimsJapanese emergency medical services (EMS) personnel providing advance life support confirm the absence of a carotid pulse before initiating chest compressions (CCs) in adult out-of-hospital cardiac arrest (OHCA). This study aims to investigate the efficacy of a new protocol facilitating early CCs before definitive cardiac arrest in enhancing the outcomes of OHCA. MethodsThe 2011 new protocol facilitated EMS to initiate CCs when the carotid pulse was weak and/or <50/min in comatose adult patients with respiratory arrest (apnoea or agonal breathing) and loss of the radial pulse. During 2008–2015, we compared the neurologically favourable 1-year survival rate of EMS-witnessed OHCA and EMS-confirmed out-of-hospital respiratory arrest (OHRA) in adults before (N = 257 and 34, respectively) and after (N = 255 and 54, respectively) the implementation of the new protocol. ResultsAfter the new protocol, EMS initiated CCs >1.5 min before definitive cardiac arrest in 31% (80/255) and 33% (18/54) of EMS-witnessed OHCA and EMS-confirmed OHRA, respectively. While the new protocol was not significantly associated with survival of EMS-confirmed OHRA, it was significantly associated with survival of EMS-witnessed OHCA: 9.0% and 14.9%, before and after, P by univariate analysis <0.03; adjusted OR (95% CI) by multivariable logistic regression analysis, 2.01 (1.04–3.90). Neither early start of CCs nor the new protocol was associated with the progression to cardiac arrest in 212 cases with impending cardiac arrest. ConclusionsA new EMS protocol facilitating early CCs before definitive cardiac arrest was associated with higher survival of EMS-witnessed OHCA.

Implementation of a real-time qualitative app to evaluate resuscitation performance in an Advanced Cardiac Life Support course.

Objective:In addition to high-quality chest compression, parameters of resuscitation efficiency such as early chest compression, early defibrillation, and decreased hands-off time are also vital in the Advanced Cardiac Life Support (ACLS) protocol. However, because of limited time and equipment in ACLS courses, efficiency of performance is difficult to evaluate.Materials and Methods:A free, easy-to-use iOS and Android app (CodeTracer®) was developed for real-time recording of cardiopulmonary resuscitation (CPR) performance. Interventions performed during resuscitation were set up as buttons. When the simulated scenario in the ACLS course began, instructors recorded every intervention and the team performed by pushing the appropriate buttons. When the scenario ended, the CodeTracer® automatically computed parameters, including the percentage of no-flow time, time to initiating CPR, and time to initiating defibrillation and also generated a graphic log for later discussion.Results:A total of 76 resuscitation episodes were recorded, 27 in the practice scenarios and 49 in the final Megacode simulations. After the course, the average percentage of no-flow time decreased 5.79%, time to initiating CPR decreased 3.05 s, and time to initiating defibrillation decreased up to 20.27 s. Of note, physicians as leaders seem to have better performance after the ACLS course than before, but the results were insignificant except for the percentage of no-flow time.Conclusions:CodeTracer® can record and calculate objective parameters for resuscitation performance in ACLS courses and can assist instructors in disseminating important concepts to participants. It can be a useful tool in ACLS courses.

Compression-only life support (COLS) for cardiopulmonary resuscitation by layperson outside the hospital.

The cardiopulmonary resuscitation (CPR) guidelines of compression-only life support (COLS) for management of the victim with cardiopulmonary arrest in adults provide a stepwise algorithmic approach for optimal outcome of the victim outside the hospital by untrained laypersons. These guidelines have been developed to recommend practical, uniform and acceptable resuscitation algorithms across India. As resuscitation data of the Indian population are inadequate, these guidelines have been based on international literature. The guidelines have been recommended after discussion among Indian experts and the recommendations modified to ensure its practical applicability across the country. The COLS emphasises on early recognition of cardiac arrest and activation, early chest compression and early transfer to medical facility. The guidelines emphasise avoidance of any interruption of chest compression, and thus relies primarily on chest compression-only CPR by laypersons.

Impact of a "Team-focused CPR" Protocol on Out-of-hospital Cardiac Arrest Survival in a Rural EMS System.

More than 300,000 persons in the United States experience an out-of-hospital cardiac arrest every year. The American Heart Association emphasizes on the rapid, effective delivery of cardiac arrest interventions by bystanders and emergency medical services (EMS) on scene. In July 2013, the EMS of Randolph County, a rural county in central North Carolina, implemented a team-focused cardiopulmonary resuscitation(CPR) protocol. The protocol emphasized early chest compressions and resuscitation on scene until the return of spontaneous circulation (ROSC) or until efforts were deemed futile. Data were collected on all cardiac out-of-hospital cardiac arrest cases from June 30, 2012 to June 30, 2014. Outcomes for the year before the institution of the team-focused CPR protocol were compared with rates for the year following implementation. A significantly higher proportion of patients achieved ROSC after protocol implementation: 25/38 [66%, 95% confidence interval (CI), 49%-80%] versus 19/67 (28%; 95% CI, 18-41%, P < 0.001). More patients survived to hospital admission in the team-focused CPR group (16/38, 42.1%, 95% CI, 26%-59%) versus the preprotocol period (10/67, 14.9%, 95% CI, 7.4%-26%, P = 0.004). Although survival to discharge was higher in the team-focused protocol period (6/38, 15.8%, 95% CI, 6.0%-31%) than the preprotocol period (4/67, 6.0%, 95% CI, 1.7%-14.6%), this did not meet statistical significance (P = 0.16). The introduction of a team-focused CPR protocol in a single rural county-based EMS system dramatically improved ROSC and hospital admission rates, but not survival to discharge. Continued surveillance, as well as evaluation and optimization of inpatient care, is warranted.

Results of Out-of-Hospital Cardiopulmonary Arrest Cases with Intervention by Lay Rescuers and Emergency Health Workers

Aim: In this study, all interventions made by lay rescuers and health professionals and the shortcomings for cardiopulmonary arrest management outside the hospital were examined. Materials and Methods: The study was conducted between December 2012 and May 2014 in the Emergency Department of Gaziantep University. To ensure orderly and standardized records, a study form was prepared that consisted of 31 questions. The time and location of the cardiac arrest, information regarding the lay rescuers and professional health workers, and the practices followed during transport and at the emergency service were examined. Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) for Windows software version 22.0, and p<0.05 was accepted as statistically significant. Results: Of the 205 cardiac arrests, 69.8% were male and 30.2% were female. The mean age in all of the cases was 58.34±19.1 years. The cardiac arrests mostly occurred in the home environment (62.4%) and happened between 13.00 and 20.00 hours (43.4%). The most frequent conditions that caused a worsening of the cases were syncope (unresponsiveness) (35.6%). The people who identified the cardiac arrest case and called for help by informing emergency health personnel (EHP) were mostly family members (50.7%). The activation time was 14.27±20.30 min. The time to arrive at the scene was 8.4±6.4 (1–35) min. Lay rescuers performed resuscitation in 19.5% of cases. The most frequent rhythms on the arrival of the EHP were asystole (74.1%). EHP evaluated the glaskow coma scale (GCS) of 88.3% of the cases as ≤7 at the scene. EHP performed basic life support (BLS) on all cases (100%) and endo-tracheal intubation (ETI) on 29.3% of the cases at the scene. The on-scene time and transport time to ED were 8.09±8.82 and 9.02±7.92 (1-50) min, respectively. The average duration of CPR at ED was 35.15±16.9 min. Of all the cases, 7.8% were discharged from intensive care unit (ICU) to homes. Of all the cases, 77.6% died at the ED, and 14.6% died in ICU. Conclusion: The intervention rate by lay rescuers was far less than the international rates. The survival rates were generally below the internationally reported rates. There is no adequate public awareness in our area for identifying cardiac arrest in patients and for initiating early chest compressions. (Eurasian J Emerg Med 2016; 15: 7-14)

Interaction effects between highly-educated neighborhoods and dispatcher-provided instructions on provision of bystander cardiopulmonary resuscitation

BackgroundSocioeconomic factors of a community are associated with bystander cardiopulmonary resuscitation (BCPR) rates and outcomes of out-of-hospital cardiac arrest (OHCA). This study aimed to test whether dispatcher-provided CPR instruction modifies the association between education level of a community and provision of BCPR. MethodsA population-based observational study was conducted with OHCAs of cardiac etiology who were witnessed by laypersons between 2012 and 2013. Exposure variable was the proportion of highly-educated residents (high school graduates and higher) in a community categorized into quartile groups. Endpoints were provision of BCPR and early chest compression (≤4min of collapse, ECC). Multivariable logistic regression analysis was performed. A final model with an interaction term was evaluated to test interactive effects of community education level with dispatcher-provided CPR instruction. ResultsA total of 10,694 OHCAs were analyzed. BCPR was performed in 5112 (47.8%), and early CPR was done in 3080 (28.8%). Compared with the highest educated communities, AORs (95%CIs) for BCPR were 0.84 (0.74–0.95) in higher, 0.78 (0.66–0.92) in lower, and 0.71 (0.60–0.85) in the lowest educated communities. For ECC, AORs (95%CIs) were 0.81 (0.66–0.99) in lower and 0.62 (0.50–0.76) in the lowest. In an interaction model of 4122 OHCA patients who received dispatcher-provided CPR instruction, OHCAs occurring in higher (AOR: 0.80 (0.67–0.96)), lower (AOR: 0.67 (0.52–0.87)), and the lowest (AOR: 0.59 (0.43–0.82)) were less likely to receive BCPR compared with the highest educated communities. ConclusionOHCA patients in communities with a higher proportion of highly-educated residents were more likely to receive BCPR, and the disparity was more prominent in the group that received dispatcher-provided CPR instruction.

Resumption of chest compressions after successful defibrillation and risk for recurrence of ventricular fibrillation in out-of-hospital cardiac arrest.

Prior investigation of out-of-hospital cardiac arrest has raised the concern that ventricular fibrillation (VF) recurrence may be triggered by chest compression (CC) resumption. We investigated predictors of VF recurrence after defibrillation, including timing of CC resumption. Patients with witnessed out-of-hospital cardiac arrest and initial rhythm of VF from an Utstein-style database were analyzed. For each shock that defibrillated VF, CC resumption and VF recurrence times were determined. Shocks were classified according to postshock rhythm. Factors (age, sex, time from dispatch to monitor/defibrillator application, and CC resumption) that could predict VF recurrence were analyzed. CC resumption was categorized into groups: CC1, 1 to 5 seconds; CC2, 6 to 10 seconds; CC3, 11 to 30 seconds; and CC4, >30 seconds. Eighty-eight subjects were analyzed, with a total of 285 shocks, with 226 shocks that achieved asystole (n=102), organized rhythm (n=120), or monomorphic ventricular tachycardia (n=4). After a successful shock, CC resumption occurred at a median (interquartile range) of 8 (5-18) seconds. VF recurred after 166 shocks (74%) and recurred within 30 seconds in 69 shocks. There was no significant relationship between VF recurrence and factors analyzed including CC resumption time, nor stratified by postshock rhythm. The hazard ratios (HRs) for VF recurrence within 30 seconds for later CC groups (CC2, CC3, and CC4) relative to early CC resumption (CC1) were as follows: HR(CC2)=1.05 (P=0.9); HR(CC3)=1.75 (P=0.1); and HR(CC4)=0.67 (P=0.4). VF recurrence within 30 seconds of a defibrillatory shock was not dependent on timing of CC resumption in patients with witnessed arrest and initial rhythm of VF.

Primary Cardiac Arrest Following Sport or Exertion in Children Presenting to an Emergency Department

The objective of this study was to describe the characteristics and outcome of pediatric patients presenting to an emergency department (ED) following out-of-hospital primary cardiac arrest (OHPCA), to determine if long-term survival is influenced by specific resuscitation interventions. This was a prospective observational study of cases of OHPCA during sport or exertion in young patients presenting to an ED over a 5-year period. Cases were identified from a resuscitation database, which documented patient demographics, nature of event, emergency treatment, response times, and clinical progress. These data were analyzed to determine outcomes. Nine children were identified who presented following OHPCA during the study period. The mean age was 10.7 (±4.2) years. All were subsequently diagnosed with an underlying primary cardiac disorder. Six patients (66.6%) survived to make a full recovery. All patients who survived had received early chest compressions (within 5 minutes) and early defibrillation (within 10 minutes). The initial cardiac arrest rhythm in all survivors had been an electrically cardiovertable rhythm. Five (83%) of the 6 survivors did not receive epinephrine during resuscitation. The importance of early chest compressions and defibrillation in collapsed young athletes is highlighted in this report. These interventions can result in full long-term neurological recovery. Use of epinephrine in these patients may be dangerous. We suggest that special consideration should be given to this subgroup of patients in the development of future resuscitation guidelines.

Right ventricular cardiomyopathy: timing of heart transplantation in Uhl's anomaly and arrythmogenic right ventricular cardiomyopathy

Transplant indications for right ventricular (RV) cardiomyopathy have not been defined. We report on two boys, aged 18 and 17 years, one with arrhythmogenic right ventricular cardiomyopathy (ARVC) and one with Uhl's anomaly. Both had implantable cardioverter defibrillator (ICD) for the prevention of sudden death (SD), but were not considered urgent heart transplant candidates due to the absence of heart failure symptoms. A ventricular tachycardia-induced cardiac collapse occurred at school in the Uhl patient and in hospital in the ARVC patient. In both patients, ICD shocks intermittently restored sinus rhythm but with inadequate circulation. Only the ARVC patient received early chest compressions and was saved to heart transplantation. Due to RV failure, both patients had evidence of Fontan-type physiology, in whom pulmonary blood flow is passive and propelled by the transpulmonary pressure gradient and intrathoracic pressure alterations produced by breathing. In these cases, at resuscitation, systemic circulation is not established until after pulmonary blood flow is restored by breathing or chest compressions. An ICD alone is therefore not sufficient for the prevention of SD. When invasive data show evidence of Fontan-type circulation, the patient may be considered for heart transplantation.

A Resuscitation Protocol That Minimizes Hands-Off Time Improves Survival

Recent research suggests that minimizing interruptions during cardiopulmonary resuscitation improves coronary perfusion pressure and increases the likelihood of return of spontaneous circulation (ROSC). The Kansas City, Missouri, emergency medical services system changed its cardiac arrest protocol to emphasize early chest compressions and de-emphasize airway management for resuscitation of adult patients with primary cardiac arrest (ventricular fibrillation [VF] or pulseless ventricular tachycardia). Changes …

Prehospital bicarbonate use in cardiac arrest: A 3-year experience

The American Heart Association no longer recommends the routine use of sodium bicarbonate in cardiac arrests. Reasons cited include the lack of documented effect on clinical outcome and potential adverse effects of metabolic alkalosis and hypernatremia. We reviewed 36 months of experience with 619 nontrauma adult, prehospital cardiac arrest patients to identify 273 successful resuscitations who had emergency department blood gases and electrolytes performed. Determination of complications associated with prehospital intravenous sodium bicarbonate and its impact on survival in resuscitated patients was undertaken. Fifty-eight patients did not receive sodium bicarbonate (NO HCO 3 group) and had short cardiopulmonary resuscitation (CPR) times (7.4 ± 5.5 minutes). Two hundred fifteen patients did receive sodium bicarbonate (HCO 3 group) and had significantly longer CPR times (23.3 ± 13.5 minutes, P ≤ .001). Both groups demonstrated routine early chest compression and hyperventilation as evidenced by no significant difference in paramedic response time or rate of intubations. Initial emergency department blood gas results of both groups were not significantly different. No patients in the NO HCO 3 group had hypernatremia (sodium [Na] + > 150), whereas four patients (2%) in the HCO 3 group were hypernatremic. Eight patients (14%) in the NO HCO 3 group and 37 patients (17%) in the HCO 3 group were alkalotic with pH values greater than 7.49 ( P = NS). Six patients (10%) of the NO HCO 3 group and 24 patients (11%) of the HCO 3 group had a metabolic component to the alkalosis as defined by a positive base excess value ( P = NS). Survival was examined in both groups following standardization for the presenting rhythm of ventricular fibrillation and CPR time intervals of 5 minutes. Survival did not differ significantly between the NO HCO 3 group and the HCO 3 group during any CPR time interval. However, base changes were significantly improved in the 15 to 20 minute CPR time interval ( P ≤ .05). Because only resuscitated patients were evaluated in this study, no determination could be made regarding bicarbonate's influence on survival following cardiac arrest. We describe the incidence of alkalosis, metabolic alkalosis, hypernatremia, and survival in patients receiving HCO 3 and not receiving HCO 3 who were successfully resuscitated from prehospital cardiac arrest.