External Cardiopulmonary Resuscitation Research Articles

Survey on the application of external cardiopulmonary resuscitation in Chinese children with sudden cardiac arrest

Objectives: To investigate the current application status and implementation difficulties of extracorporeal cardiopulmonary resuscitation (ECPR) in children with sudden cardiac arrest. Methods: This cross-sectional survey was conducted in 35 hospitals. A Children's ECPR Information Questionnaire on the implementation status of ECPR technology (abbreviated as the questionnaire) was designed, to collect the data of 385 children treated with ECPR in the 35 hospitals. The survey extracted the information about development of ECPR, the maintenance of extracorporeal membrane oxygenation (ECMO) machine, the indication of ECPR, and the difficulties of implementation in China. These ECPR patients were grouped based on their age, the hospital location and level, to compare the survival rates after weaning and discharge. The statistical analysis used Chi-square test and one-way analysis of variance for the comparison between the groups, LSD method for post hoc testing, and Bonferroni method for pairwise comparison. Results: Of the 385 ECPR cases, 224 were males and 161 females. There were 185 (48.1%) survival cases after weaning and 157 (40.8%) after discharge. There were 324 children (84.2%) receiving ECPR for cardiac disease and 27 children (7.0%) for respiratory failure. The primary cause of death in ECPR patients was circulatory failure (82 cases, 35.9%), followed by brain failure (80 cases, 35.0%). The most common place of ECPR was intensive care unit (ICU) (278 cases, 72.2%); ECPR catheters were mostly inserted through incision (327 cases, 84.9%). There were 32 hospitals (91.4%) had established ECMO emergency teams, holding 125 ECMO machines in total. ECMO machines mainly located in ICU (89 pieces, 71.2%), and the majority of hospitals (32 units, 91.4%) did not have pre-charged loops. There were no statistically significant differences in the post-withdrawal and post-discharge survival rates of ECPR patients among different age groups, regions, and hospitals (all P>0.05). The top 5 difficulties in implementing ECPR in non-ICU environments were lack of ECMO machines (16 times), difficulty in placing CPR pipes (15 times), long time intervals between CPR and ECMO transfer (13 times), lack of conventional backup ECMO loops (10 times), and inability of ECMO emergency teams to quickly arrive at the site (5 times). Conclusion: ECPR has been gradually developed in the field of pediatric critical care in China, and needs to be further standardized. ECPR in non-ICU environment remains a challenge.

Community intervention to improve defibrillation before ambulance arrival in residential neighbourhoods with a high risk of out-of-hospital cardiac arrest: study protocol of a cluster-randomised trial (the CARAMBA trial)

IntroductionIn Denmark, multiple national initiatives have been associated with improved bystander defibrillation and survival following out-of-hospital cardiac arrest (OHCA) in public places. However, OHCAs in residential neighbourhoods continue to have...

The combination of chest compression synchronized ventilation and aortic balloon occlusion improve the outcomes of cardiopulmonary resuscitation in swine.

The primary mission of cardiopulmonary resuscitation (CPR) is to provide adequate blood flow and oxygen delivery for restoring spontaneous circulation from cardiac arrest (CA) events. Previously, studies demonstrated that chest compression synchronized ventilation (CCSV) improved systemic oxygen supply during CPR, and aortic balloon occlusion (ABO) augments the efficacy of external CPR by increasing blood perfusion to vital organs. However, both them failed to make a significant improvement in return of spontaneous circulation (ROSC). In this study, we investigated the effects of combined CCSV and ABO on the outcomes of CPR in swine. Thirty-one male domestic swine were subjected to 8 min of electrically induced and untreated CA followed by 8 min of CPR. CPR was performed by continuous chest compressions and mechanical ventilation. At the beginning of CPR, the animals were randomized to receive intermittent positive pressure ventilation (IPPV, n = 10), CCSV (n = 7), IPPV + ABO (n = 7), or CCSV + ABO (n = 7). During CPR, gas exchange and systemic hemodynamics were measured, and ROSC was recorded. After resuscitation, the function and injury biomarkers of vital organs including heart, brain, kidney, and intestine were evaluated. During CPR, PaO2 was significantly higher accompanied by significantly greater regional cerebral oxygen saturation in the CCSV and CCSV + ABO groups than the IPPV group. Coronary perfusion pressure, end-tidal carbon dioxide, and carotid blood flow were significantly increased in the IPPV + ABO and CCSV + ABO groups compared with the IPPV group. ROSC was achieved in five of ten (IPPV), five of seven (CCSV), six of seven (IPPV + ABO), and seven of seven (CCSV + ABO) swine, with the rate of resuscitation success being significantly higher in the CCSV + ABO group than the IPPV group (P = 0.044). After resuscitation, significantly improved myocardial and neurological function, and markedly less cardiac, cerebral, renal, and intestinal injuries were observed in the CCSV + ABO group compared with the IPPV group. The combination of CCSV and ABO improved both ventilatory and hemodynamic efficacy during CPR, promoted ROSC, and alleviated post-resuscitation multiple organ injury in swine.

Initiation timing of veno-arterial extracorporeal membrane oxygenation

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a salvage therapy for critical patients with refractory cardiogenic shock caused by various reasons. It can temporarily replace cardiopulmonary function, and rapidly improve hypoxemia, increase systemic oxygen content and remove carbon dioxide. Although the Extracorporeal Life Support Organization (ELSO) guideline proposed clear indication for VA-ECMO, the heterogeneity of cardiac pathogeny is large, so the clear timing of ECMO initiation is still vague. We discuss the timing of ECMO initiation for external cardiopulmonary resuscitation (ECPR) and cardiogenic shock which is caused by fulminant myocarditis, acute myocardial infarction, acute pulmonary embolism, acute right heart failure related to lung transplantation, corona virus disease 2019 (COVID-19)-associated cardiovascular collapse. Also, we look forward to making more suggestions for clinicians' judgment and choice for VA-ECMO.

Blocking vicious cycle of cardiac dysfunction by external cardiopulmonary resuscitation is the key to rescue acute aluminium phosphide poisoning.

Aluminium phosphide (ALP) and aluminium zinc phosphide (ZnP), the two main ingredients of fumigation drugs, are commonly used to kill insects or rodents in grain. When exposed to water, highly toxic phosphine gas is released and absorbed through the respiratory or digestive tract. Phosphine gas could non-selectively block cytochrome oxidase, inhibit electron transfer and suppress oxidative phosphorylation, leading to cellular hypoxia and organ dysfunction. The characteristic clinical manifestations are refractory shock and metabolic acidosis with high mortality. However, patients with ALP poisoning have a chance to be cured. Here, we report a case of oral ALP poisoning that was successfully treated by extracorporeal membrane oxygenation (ECMO) combined with continuous renal replacement therapy (CRRT) during frequent ventricular fibrillation and cardiac dysfunction.

Abstract 233: Characterizing Impact of State Legislation on Cardiac Arrest Outcomes at K-12 Schools

Background: Cardiac arrests that occur in schools are infrequent, but high-profile events. Many states have enacted school specific legislation regarding automated external defibrillators (AEDs) placement, CPR training and emergency response plans (EAP). Objective/Aim: To characterize out-of-hospital cardiac arrests (OHCA) that occur in K-12 schools; and, assess the relationship of U.S. state AED and CPR laws to outcomes of in school cardiac arrests. Methods: A retrospective review of in school OHCA was completed with data from the National EMS Information System (NEMSIS) 3.4 database, calendar years 2017-2018. Study subjects were non-traumatic OHCA occurring prior to EMS arrival on K-12 school grounds. Additionally, we conducted a search of Westlaw (Thomson Reuters) to identify current school specific AED, CPR and EAP laws for all 50 states, and created a structured taxonomy for these laws. Datasets were linked by an honest broker and the K-12 school CPR and AED provisions were compared to state legislation. Results: During the study period, there were 454 cases of in school cardiac arrest out of the 25.3 million incidents submitted to NEMSIS. We excluded 140, thus leaving 314 arrests for analysis. The average age was 46.7 (SD=24.1), most were over 18 years old (79.4%), and male 221 (70.4%). Bystander CPR (BCPR) was performed in 240 (76.4%) of cases, bystander AEDs were used in 160 (51.0%) cases, and 107 (34.1%) patients received an AED shock. State AED and CPR laws required student CPR training in 78%, school AED placement in 46%, teacher CPR certification in 14%, and school specific cardiac emergency response plans in 32%. We found no increase in BCPR or AED placement in states with school CPR, AED or EAP legislation. These findings persisted regardless of patient age, school type, or legislative mandate (all P > 0.05). Conclusion: Despite the perceived benefit of legislation supporting CPR and AED use in schools, we identified no improved provision of BCPR or AED use in schools in states with such legislation. Given the high proportions of BCPR and AED in states with and without statutes, we believe this data suggests that non-legislative initiatives, which exist in many states, may be an important driver of emergency cardiac care in K-12 schools.

Automated External Defibrillator Availability and CPR Training among Police Officers in the Campania Region: a Comparison of conventional and Peer-Led Trainings

Automated External Defibrillator Availability and CPR Training among Police Officers in the Campania Region: a Comparison of conventional and Peer-Led Trainings

Cardiopulmonary resuscitation (CPR) complications encountered in forensic autopsy cases

BackgroundCardiopulmonary resuscitation (CPR) provides a significant increase in survival rate, even if performed by bystanders. However, bystanders may refrain from performing CPR for fear of eventual malpractice litigation. Currently lack Guidelines specifying whether a particular CPR-related complication is in all likelihood unavoidable or not. To fulfill this gap a great number of studies is required to be published in the most relevant leading academic literature. This paper aims at making a contribution to addressing such a challenge.MethodsA retrospective observational study based on forensic autopsy material aiming at recording injuries resulting from the application of CPR. The severity of injuries was forensically evaluated.ResultsOut of 88 cases autopsied, only 26.7% had rib fractures (only 20% of which were located in the 6 lower ribs), 17.4% had sternal fractures (85.7% of which were detected in the body of the sternum and 14.3% in the manubrium). The ratio of sternal fractures to rib fractures is similar to the ratio cited in other studies reported in the literature (2:3, approximately). The number of fractures was 7.86 (4.11 on the right side and 4.75 on the left side). 16% of the cases were found to be mild, 48% were moderate, and 35% of the cases were severe. When a physician was present, a (not statistically significant) trend towards more severe complications was found.ConclusionThe findings are in accordance with other similar studies reported in the literature referring to the classic external CPR. This study offers a proposal aiming at making a contribution to develop Guidelines specifying whether a particular CPR-related complication is in all likelihood unavoidable or not.

Cardiac Arrest After Cardiac Surgery: An Evidence-Based Resuscitation Protocol.

More than 250 000 cardiac surgical procedures are performed annually in the United States. Postoperative cardiac arrest rates range from 0.7% to 5.2%. This article reviews current evidence for cardiac arrest resuscitation after cardiac surgery. The evaluation included resuscitation guidelines and 22 studies identified through a MEDLINE search. Evidence-based resuscitation differs from advanced cardiovascular life support guidelines. European Resuscitation Council guidelines include correcting reversible causes of arrest, applying defibrillation/pacing before external cardiopulmonary resuscitation, resternotomy within 5 minutes if electrical therapies fail, and restricting epinephrine use to avoid rebound hypertension. A 2017 Society of Thoracic Surgeons protocol derived from European Resuscitation Council guidelines is now standard of care in the United States. Evidence-based practices can improve survival and reduce resternotomy rates. This article describes the clinical implementation of the Society of Thoracic Surgeons guidelines.

Abstract 358: Aortic Balloon Occlusion Augments the Efficacy of External Cardiopulmonary Resuscitation After Traumatic Cardiac Arrest in Swine

Introduction: Following hemorrhage-induced traumatic cardiac arrest (TCA), the effectiveness of standard cardiopulmonary resuscitation (CPR) would be weakened or lost due to an inadequate circulating volume. Previous investigations demonstrated that aortic balloon occlusion (ABO) could control the bleeding and increase proximal organ perfusion during severe traumatic hemorrhage. In this study, we investigated the effect of ABO on the efficacy of CPR in a swine model of TCA. Hypothesis: ABO initiated during CPR would increase cardiac and cerebral perfusion so as to improve the outcomes of resuscitation after TCA in swine. Methods: Twenty-seven male domestic swine weighing 33±4 kg were utilized. Forty percent of estimated blood volume was removed within 20 mins. The animals were then subjected to 5 mins of untreated ventricular fibrillation and 5 mins of CPR. Coincident with the start of CPR, the animals were randomized to receive ABO (n=15) or control (n=12). Meanwhile, normal saline was intravenously infused at a speed of 0.7 ml/kg/min in all animals. Results: During CPR, significantly greater coronary perfusion pressure, regional cerebral oxygen saturation and end-tidal CO 2 were observed in animals treated with ABO when compared with the control group (Table). Consequently, the rate of resuscitation success was significantly higher in the ABO group than in the control group (15/15 vs. 9/12, p = 0.040). Additionally, shorter duration of CPR (5.1±0.5 vs. 7.5±4.5 min, p = 0.054) and less number of shocks (1.1±0.3 vs. 2.0±1.8, p = 0.058) were required for establishing spontaneous circulation in the ABO group compared to the control group. Conclusion: The implementation of ABO during CPR significantly increased cardiac and cerebral perfusion and improved the outcomes of resuscitation in TCA following massive hemorrhage.

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.

The Society of Thoracic Surgeons Expert Consensus for the Resuscitation of Patients Who Arrest After Cardiac Surgery

The Society of Thoracic Surgeons Task Force on Resuscitation After Cardiac Surgery provides this professional society perspective on resuscitation in patients who arrest after cardiac surgery. This document was created using a multimodal methodology for evidence generation and includes information from existing guidelines, from the International Liaison Committee on Resuscitation, from our own structured literature reviews on issues particular to cardiac surgery, and from an international survey on resuscitation hosted by CTSNet. In gathering evidence for this consensus paper, searches were conducted using the MEDLINE keywords "cardiac surgery," "resuscitation," "guideline," "thoracic surgery," "cardiac arrest," and "cardiac massage." Weight was given to clinical studies in humans, although some case studies, mannequin simulations of potential protocols, and animal models were also considered. Consensus was reached using a modified Delphi method consisting of two rounds of voting until 75% agreement on appropriate wording and strength of the opinions was reached. The Society of Thoracic Surgeons Workforce on Critical Care was enlisted in this process to provide a wider variety of experiences and backgrounds in an effort to reinforce the opinions provided. We start with the premise that external massage is ineffective for an arrest due to tamponade or hypovolemia (bleeding), and therefore these subsets of patients will receive inadequate cerebral perfusion during cardiac arrest in the absence of resternotomy. Because these two situations are common causes for an arrest aftercardiac surgery, the inability to provide effective external cardiopulmonary resuscitation highlights the importance of early emergency resternotomy within 5 minutes. In addition, because internal massage is moreeffective than external massage, it should be used preferentiallyif other quickly reversible causes are not found. We present a protocol for the cardiac arrest situation that includes the following recommendations: (1) successful treatment of a patient who arrests after cardiac surgery is a multidisciplinary activity with at least six key roles that should be allocated and rehearsed as a team on a regular basis; (2) patients who arrest with ventricular fibrillation should immediately receive three sequential attempts at defibrillation before external cardiac massage, and if this fails, emergency resternotomy should be performed; (3) patients with asystole or extreme bradycardia should undergo an attempt to pace if wires are available before external cardiac massage, then optionally external pacing followed by emergency resternotomy; and (4) pulseless electrical activity should receive prompt resternotomy after quickly reversible causes are excluded. Finally, we recommend that full doses of epinephrine should not be routinely given owing to the danger of extreme hypertension if a reversible cause is rapidly resolved. Protocols are given for excluding reversible airway and breathing complications, for left ventricular assist device emergencies, for the nonsternotomy patient, and for safe emergency resternotomy. We believe that all cardiac units should have accredited policies and protocols in place to specifically address the resuscitation of patients who arrest after cardiac surgery.

How to develop and execute a public health agenda: From grass roots to legislation.

Recent experiences with lay public cardiopulmonary resuscitation and use of ambulatory external defibrillators have been demonstrated to improve survival from out-of-hospital cardiac arrests from an abysmal 10% or less to as high as 30%. Though rare, sudden cardiac arrest in presumably healthy young people have been highly publicised over the last 25 years and have motivated the institution of school- and community-based programmes that facilitate first-responder resuscitation, including defibrillation. These efforts often begin at a grass roots level (usually parent-inspired advocacy groups) and through collaborative activities involving the schools, local businesses, and local administrative agencies are now having a meaningful impact in selected communities. The current focus of these activities is on school- and sports venue-based ambulatory external defibrillator programmes and formal cardiopulmonary resuscitation education in high schools. The extension of these programmes to the level of state mandates has been slower, and even when enacted, public funding has usually not been approved.

Intra-arrest percutaneous coronary intervention: a case series.

In patients with refractory cardiac arrest presumably from acute coronary occlusion, primary percutaneous coronary intervention (PPCI) may provide an opportunity for revascularisation and, subsequently, return of spontaneous circulation. We present our experience from a 24/7 primary percutaneous coronary intervention centre serving a population of approximately 800,000 individuals. A retrospective analysis was performed in patients with cardiac arrest treated from July 2011 to January 2014. Inclusion criteria were cardiac arrest and emergency coronary angiography performed during on-going external cardiopulmonary resuscitation (CPR). Course of treatment was analysed to outline the reasons for poor survival. Eight patients met the inclusion criteria; six (75 %) were male, and the mean age was 63 ± 16 years. Revascularisation under continuous cardiopulmonary resuscitation was achieved in all eight patients. Sustained return of spontaneous circulation was achieved in two patients (25 %). Both patients had poor neurological outcome (cerebral performance category 4), and both died within 3 months. We identified total duration of cardiopulmonary resuscitation (90.5 ± 33.3 min), lack of prehospital mechanical cardiopulmonary resuscitation devices and lack of extra-corporeal life support devices as the most likely reasons contributing to poor survival.

“Buddenbrook syndrome” - Toothache and its serious consequences

Background: Atypical symptoms of acute coronary syndrome are associated with increased mortality due to missed diagnosis and treatment delay. Misleading mandible pain as odontogenic instead of cardiac origin may be termed as Buddenbrook syndrome. The name is derived from Thomas Mann’s (1875-1955) novel Buddenbrooks, where one of the main characters, Consul Thomas Buddenbrook, further complained of jaw pain after teeth extraction and died shortly after due to myocardial infarction. Case Description: We present a patient with mandible pain, who collapsed at his dentist with the need of prolonged resuscitation due to incessant ventricular fibrillation (VF) caused by acute myocardial infarction. Despite uncertain neurologic prognosis after more than 60 minutes of external cardiopulmonary resuscitation (CPR) and persistent cardiogenic shock 24 hours later we decided to implant an ECMO as the last therapeutic option. The patient improved and could be discharged four weeks later in good neuro- and cardiologic condition. Clinical Implications: The primary cardiac cause of mandible or toothache may remain undiscovered if teeth also show a correlate for symptoms and may have adverse outcome. Dentists should think of cardiac origin especially in recurrent symptoms or patients with cardiovascular risk factors.

Thrombolysis with a recombinant plasminogen activator to treat a massive pulmonary embolus during emergency laparotomy

SummaryA previously healthy 38‐year‐old female presented with an enormous abdominal growth. Imaging confirmed a large, multiloculated left ovarian cyst. Surgery was expedited when she presented to hospital with an acute abdomen. Intraoperatively there was sudden cardiovascular collapse refractory to resuscitation with intravenous fluids and vasopressors. External cardiopulmonary resuscitation was commenced and an intraoperative transthoracic echocardiogram demonstrated a large pulmonary embolus.The patient received heparin anticoagulation without improvement and a decision was made to perform thrombolysis. The patient's condition stabilised, however postoperative intra‐abdominal haemorrhage ensued, with splenic decapsulation and a liver laceration requiring emergency splenectomy and packing respectively followed by transfer for tertiary hepatic surgical repair of the liver laceration. Remarkably, this patient recovered with no neurological or cognitive deficits.

External cardiac compression during cardiopulmonary resuscitation of patients with left ventricular assist devices.

A best evidence topic was written according to a structured protocol to determine whether there is evidence that cardiopulmonary resuscitation (CPR) by compressing the chest is safe and effective in patients with left ventricular assist devices (LVADs). Manufacturers warn of a possible risk of device dislodgement if the chest is compressed. AMED, EMBASE, MEDLINE, BNI and CINAHL were searched from inception to March 2014. Animal studies, case reports, case series, case-control studies, randomized controlled studies and systematic reviews were eligible for inclusion. Opinion articles with no reference to data were excluded. Of 45 unique results, 3 articles merited inclusion. A total of 10 patients with LVADs received chest compression during resuscitation. There was no report of device dislodgement as judged by postarrest flow rate, autopsy and resumption of effective circulation and/or neurological function. The longest duration of chest compression was 150 min. However, there are no comparisons of the efficacy of chest compressions relative to alternative means of external CPR, such as abdominal-only compressions. The absence of high-quality data precludes definitive recommendation of any particular form of CPR, in patients with LVADs. However, data identified suggest that chest compression is not as unsafe as previously thought. The efficacy of chest compressions in this patient population has not yet been investigated. Further research is required to address both the safety and efficacy of chest compressions in this population. Urgent presentation and publication of further evidence will inform future guidance.

Mechanical external CPR during OHCA

Introduction: The mechanical CPR project was initiated to improve cardiac arrests outcomes from EMS patients. The project also aimed to integrate organ retrieval following cardiac arrest and ECMO.

The Case for Interposed Abdominal Compression CPR in Hospital Settings

The Case for Interposed Abdominal Compression CPR in Hospital Settings Interposed abdominal compression (IAC)-CPR includes all steps of standard external CPR with the addition of manual midabdominal compressions in counterpoint to the rhythm of chest compressions. IAC-CPR can increase blood flow during CPR about two fold compared to standard CPR without IAC, as shown by multiple studies in computer and animal models. The technique increases the rate return of spontaneous circulation (ROSC) for inhospital resuscitations from roughly 25% to 50%. Improved survival to discharge is demonstrated in two in-hospital trials.

Complete neurological recovery after delayed onset resuscitation in a normothermic witnessed arrest

Cardiac arrest following aortic dissection carries high morbidity and mortality, primarily due to poor neurological outcomes. Most efforts are directed towards perfusing vital organs and replenishing oxygen and adenosine triphosphate (ATP) stores during and immediately after arrest. Methods of reperfusion (including external cardiopulmonary resuscitation (CPR), open CPR, extracorporeal life support and ventricular assist devices) and other ATP preservation methods, such as pharmaceutical agents and hypothermia, are maximally beneficial only if started early during cardiac arrest. We describe a case of aortic rupture with arrest on the table which was re-perfused after 20 minutes, using cardiopulmonary bypass (CPB), but still managed to recover without neurological sequelae.