Full Cardiopulmonary Resuscitation Research Articles

Enhancing Bystander Intervention: Insights from the Utstein Analysis of Out-of-Hospital Cardiac Arrests in Slovenia.

Background and Objectives: Out-of-hospital cardiac arrest (OHCA) and survival is a pressing matter all around the world. Despite years of research and great strides and advancements, survival remains alarmingly low. The aim of this study was to measure the survival and characteristics of patients having an OHCA in Slovenia, with an in-depth look at how the bystanders affect the return of spontaneous circulation (ROSC) and survival of OHCA. Materials and Methods: In this observational cross-sectional prospective study, we enrolled patients between 1 September 2022 and 30 November 2022, with a follow-up period of 1 month. All OHCAs attended by the emergency medical services were included. Data were collected and analyzed according to the Utstein 2015 reporting template. Independent predictors of ROSC and 30-day survival or survival were explored using ridge regression. Results: ROSC was achieved in 41% of cases where resuscitation was attempted. The overall 30-day survival rate where resuscitation was attempted was 14%. In 13% of all cases where resuscitation was attempted, patients had a favorable neurological outcome. Using our prediction model, we found that defibrillation under 20 min and ventricular fibrillation as an initial rhythm improves survival, whilst no defibrillation and bystander full cardiopulmonary resuscitation negatively predicted survival. Conclusions: Slovenia has OHCA 30-day survival comparable to the rest of the European Union. The favorable neurological outcome is high. Our data show that bystanders do not significantly improve survival. This represents an untapped potential of general public education in cardiopulmonary resuscitation and automatic external defibrillator use. Following good practices from abroad and improving layperson CPR knowledge could further improve OHCA survival.

Digital advance care planning with severe mental illness: a retrospective observational cohort analysis of the use of an electronic palliative care coordination system

BackgroundPeople living with severe mental illness (SMI) face significant health inequalities, including in palliative care. Advance Care Planning (ACP) is widely recommended by palliative care experts and could reduce inequalities. However, implementing ACP with this group is challenging. Electronic Palliative Care Coordination Systems such as Coordinate my Care (CMC) have been introduced to support documentation and sharing of ACP records with relevant healthcare providers. This study explores the use of CMC amongst those with SMI and aims to describe how those with a primary diagnosis of SMI who have used CMC for ACP, and makes recommendations for future research and policy.MethodA retrospective observational cohort analysis was completed of CMC records created 01/01/2010–31/09/2021 where the service user had a primary diagnosis of SMI, with no exclusions based on comorbidities. Descriptive statistics were used to report on characteristics including: age, diagnosis, individual prognosis and resuscitation status. Thematic analysis was used to report on the content of patients’ statements of preference.Results1826 records were identified. Of this sample most (60.1%) had capacity to make treatment decisions, 47.8% were aged under 70, 86.7% were given a prognosis of ‘years’ and most (63.1%) remained for full cardio-pulmonary resuscitation in the event of cardio-pulmonary arrest. Records with completed statements of preferences (20.3%) contained information about preferences for physical and mental health treatment care as well as information about patient presentation and capacity, although most were brief and lacked expression of patient voice.DiscussionCompared to usual CMC users, the cohort of interest are relatively able, younger people using CMC to make long-term plans for active physical and mental health treatment. ADM is a service user-driven process, and so it was expected that authentic patient voice would be expressed within statements of preference, however this was mostly not achieved.ConclusionsThis digital tool is being used by people with SMI but to plan for more than palliative care. This cohort and supporting professionals have used CMC to plan for longer term physical and mental healthcare. Future research and policy should focus on development of tailored digital tools for people with SMI to plan for palliative, physical and mental healthcare and support expression of patient voice.

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.

Prediction of Return of Spontaneous Circulation in a Pediatric Swine Model of Cardiac Arrest Using Low-Resolution Multimodal Physiological Waveforms.

Monitoring physiological waveforms, specifically hemodynamic variables (e.g., blood pressure waveforms) and end-tidal CO2 (EtCO2), during pediatric cardiopulmonary resuscitation (CPR) has been demonstrated to improve survival rates and outcomes when compared to standard depth-guided CPR. However, waveform guidance has largely been based on thresholds for single parameters and therefore does not leverage all the information contained in multimodal data. We hypothesize that the combination of multimodal physiological features improves the prediction of the return of spontaneous circulation (ROSC), the clinical indicator of short-term CPR success. We used machine learning algorithms to evaluate features extracted from eight low-resolution (4 samples per minute) physiological waveforms to predict ROSC. The waveforms were acquired from the 2nd to 10th minute of CPR in pediatric swine models of cardiac arrest (N = 89, 8-12 kg). The waveforms were divided into segments with increasing length (both forward and backward) for feature extraction, and machine learning algorithms were trained for ROSC prediction. For the full CPR period (2nd to 10th minute), the area under the receiver operating characteristics curve (AUC) was 0.93 (95% CI: 0.87-0.99) for the multivariate model, 0.70 (0.55-0.85) for EtCO2 and 0.80 (0.67-0.93) for coronary perfusion pressure. The best prediction performances were achieved when the period from the 6th to the 10th minute was included. Poor predictions were observed for some individual waveforms, e.g., right atrial pressure. In conclusion, multimodal waveform features carry relevant information for ROSC prediction. Using multimodal waveform features in CPR guidance has the potential to improve resuscitation success and reduce mortality.

Characteristics and resuscitation effects of out-of-hospital sudden death: a study based on Internet data

To collect the Internet news about "sudden death", analyze its characteristics and resuscitation effects, so as to provide reference for formulating intervention strategies. The Internet was used to search for "sudden death" and "cardiac arrest" on "Baidu" and "360" websites. Reports of sudden death events were collected from January 2013 to December 2022. The age, gender, characteristics of sudden death, implementation characteristics of cardiopulmonary resuscitation (CPR), and pre-hospital and final clinical outcomes of sudden death patients were recorded and analyzed. Subgroup analyses were performed for pre-hospital and final clinical outcomes. Unconditional multivariate Logistic regression analysis was used to screen the related factors affecting the pre-hospital and final clinical outcomes in patients with sudden death. 177 news reports were finally confirmed, involving 177 sudden death patients, including 152 males (85.9%) and 25 females (14.1%), aged (37.27±16.82) years old, and 53.1% in the 16-45 years old group. Triggering factors included strenuous exercise (29.9%), heart disease history (7.9%), overwork (6.2%), staying up late and insomnia (4.0%), activation of emotion (2.8%), and no obvious inducement (48.0%). After on-site first aid, 104 cases (58.8%) achieved restoration of spontaneous circulation (ROSC) before hospital admission, and 18 cases (10.2%) recovered consciousness. After clinical treatment, 109 cases (61.6%) achieved ROSC, 86 cases (48.6%) recovered consciousness, and 22 cases (12.4%) did not report the final outcome. Subgroup analysis showed that compared with patients who achieved pre-hospital ROSC (n = 104), sudden death in non-ROSC patients (n = 73) mainly occurred during sleep, in residence and without immediate CPR, full CPR, or automated external defibrillator (AED); and patients who ultimately did not recover consciousness clinically (n = 91) showed similar characteristics compared with patients who recovered consciousness (n = 86). Multifactorial Logistic regression analysis showed that immediate CPR [pre-hospital ROSC: odds ratio (OR) = 8.06, 95% confidence interval (95%CI) was 2.36-27.46; final recovery of consciousness: OR = 9.10, 95%CI was 2.46-33.68] and AED defibrillation (pre-hospital ROSC: OR = 36.31, 95%CI was 4.53-291.19; final recovery of consciousness: OR = 3.53, 95%CI was 1.45-8.61) facilitated pre-hospital achievement of sudden death patients ROSC and final recovery of consciousness. Out-of-hospital sudden death mainly occurs in young people, and vigorous exercise is one of the potential factors for out-of-hospital sudden death, with nearly half having no obvious cause. Immediate and rapid CPR and defibrillation are the simplest and most effective on-site first aid methods. Strengthening public CPR and defibrillation education and training, and advocating healthy lifestyle are effective ways to improve the survival rate of sudden death and reduce the occurrence of sudden death. Based on practical clinical rescue experience, the implementation of bystander CPR by medical personnel is also a factor that cannot be ignored in affecting the clinical outcomes of sudden death patients.

Preparing future Indian medical graduates for emergencies at the Foundation Course: Do the knowledge and self-confidence increase after basic cardiac life support training?

ABSTRACTBackground and Aims:Medical professionals must be able to perform life-saving skills like cardiopulmonary resuscitation (CPR) during emergency situations, even outside the hospital. The foundation course for the first-year medical students includes first aid and CPR training. This quasi-experimental study was conducted to assess the effectiveness of basic cardiac life support (BCLS) training based on Indian guidelines, on the self-confidence and knowledge regarding CPR of first-year medical students.Methods:This study was conducted during the foundation course for first-year medical students. The training included a common lecture for all the students followed by a 4 day long practical training in groups of 45–46 students, each day. BCLS training was carried out in three skill stations – airway, chest compressions and full sequence CPR. Students’ skills were recorded real time on a skill assessment manikin after completion of the hands-on training. The students were asked to fill a questionnaire regarding knowledge and self-confidence, before and after the training. The outcome measures were the difference in knowledge and self-confidence with regard to CPR before and after the training.Results:Out of the 199 students, 181 were included in the analysis. There was significant improvement in the knowledge score (pre-test – 1.46 versus post-test – 8.27, P < 0.001). The overall confidence regarding first aid skills, BCLS knowledge and self-confidence for performing BCLS improved significantly.Conclusion:There is improvement in knowledge and self-confidence regarding CPR and the students develop an acceptable level of skills after the training.

Public attitudes towards cardiopulmonary resuscitation training and performance in Singapore

BackgroundBystander cardiopulmonary resuscitation (CPR) rates remain fairly low through most communities despite multiple interventions through the years. Understanding the attitudes and fears behind CPR training and performance would help target education and training to raise the rates of bystander CPR and consequently survival rates of victims. 7909 participants at a single-day mass CPR training session in Singapore were given survey questionnaires to fill out. 6473 people submitted completed forms upon the conclusion of the training session. Some issues looked at were the overall level of difficulty of CPR, difficulty levels of specific skills, attitudes towards refresher training, attitudes towards performing CPR, and fears when doing so.ResultsThe mean level of difficulty of CPR was rated 3.98 (scale of 1–10), with those with previous CPR training rating it easier. The skills rated most difficult were performing mouth-to-mouth breathing and chest compressions, while the easiest rated was recognizing non-responsiveness. A majority (69.7%) would agree to go for refresher training every 2 years and 88.7% felt everyone should be trained in CPR. 71.6% would perform full CPR for a member of the public in cardiac arrest and only 20.7% would prefer to only do chest compressions. The most cited fear was a low level of confidence, and fears of acquiring infections or aversion to mouth-to-mouth breathing were low.ConclusionsThe survey results show that most participants in Singapore are keen to perform conventional CPR for a member of the public and can help to target future CPR training accordingly.

Pediatric hypothermic submersion incident \u2013 should we do chest compressions on a beating heart?

BackgroundDrowning is the third leading cause of unintentional injury death worldwide, with the highest rates of fatality among young children. To decide how to treat these patients prehospitally could be challenging in certain situations when uncertain about the adequacy of the patent’s circulation.Methods/case reportWe describe a 2 year old boy surviving a 15 min hypothermic submersion in a cold river. In spite of the presence of some vital signs, we decided to do full cardiopulmonary resuscitation to the hospital. The main reason was that we were uncertain about the adequacy of the spontaneous circulation, and the transport to hospital was fairly long. The patient suffered no obvious harm and the outcome was good.DiscussionWhat is regarded as adequate circulation when accidentally hypothermic between 24 and 250 C? A weak pulse was felt in the femoral artery with a rate of about 40–50 per minute. There were shallow, but regular respiration, and point of care ultrasound revealed a slightly dilated left ventricle and weak, but organised cardiac contractions. Despite these findings a decision was made to continue ventilations and chest compressions during helicopter transport to the University hospital.ConclusionIn an accidentally hypothermic pediatric submersion incident we decided to do full cardiopulmonary resuscitation to the hospital despite there were signs of circulation. We did no harm to the patient. Future guideline revisions should try to clarify how to handle situations with severly accidentally hypothermic patients like this, so the good outcome that is often seen in these patients could be even better.

Neonatal hospice care utilization in a tertiary hospital in Taiwan before and after the legalization of life-sustaining treatment withdrawal.

The advancements in neonatal critical care have not only improved the outcomes of extreme prematurity but also prolonged the process of death in terminally ill neonates. This study analyzed the characteristics of neonates who died at a single tertiary center in Taiwan. The utilization of neonatal hospice care before and after the legalization of life-sustaining treatment (LST) withdrawal in Taiwan in 2013 was also compared. This study enrolled the neonatal mortality cases in the Taipei Veterans General Hospital during January 2008 to December 2017 through chart review. Data on birth history, primary diagnosis, complications, and death circumstances were recorded and analyzed. In total, 105 neonatal deaths were analyzed. The circumstances of death were as follows: 22 (21%) cases of full LST and cardiopulmonary resuscitation (CPR) performed until death; 63 (60%) cases of LST initiated but no more CPR after do-not-resuscitate (DNR) consents signed; 8 (7.6%) cases of LST withdrawn; 4 (3.8%) cases of DNR signed without LST initiation; 3 (2.9%) cases of CPR not performed, although no DNR signed; and 5 (4.8%) cases of discharge against medical advice under critical condition. The incidence of written DNR consents (57.9% in 2008-2009 vs 93.8% in 2016-2017; p = 0.02) showed an increasing trend. Regarding the incidence of comorbidities, renal failure rate was higher in the DNR group than in the non-DNR group (p = 0.002). There was an increasing trend for written DNR consent and the utilization of neonatal hospice care. Renal failure, as a comorbidity, was significantly associated with the written DNR consent in the neonates. Further studies to evaluate the factors associated with neonatal hospice care utilization are suggested.

Cardiac arrest and ventricular tachycardia in a newborn with carnitine–Acylcarnitine translocase deficiency

We report a female infant who was diagnosed to have carnitine–acylcarnitine translocate deficiency (CACTD) and developed ventricular tachycardia followed by cardiac arrest. Following full feeding, the infant developed significant bradycardia, hypothermia, hypotonia, hypoglycemia, metabolic acidosis, and hyperammonemia. The hyperammonemia was successfully treated with continuous renal replacement therapy (CRRT). One day after the CRRT, she developed ventricular tachycardia that was refractory to medical treatment and synchronized cardioversion. She had cardiac arrest that was unresponsive to full cardiopulmonary resuscitation and died. Raising high index of suspicion of CACTD in the deferential diagnosis of infants present with sudden deterioration, hypoglycemia or hyperammonemia is crucial for early recognition and providing appropriate treatment in this highly lethal disorder.

Incidence of newborn resuscitative interventions at birth and short-term outcomes: a regional population-based study

ObjectivesTo determine the incidence and characteristics of resuscitative interventions at different gestational ages and short-term outcomes after resuscitation.Design, setting and patientsA prospective observational study in an unselected population at Stavanger...

Is it feasible “scoop and run while playing” resuscitation on a rescue water craft? A randomized simulation study with lifeguards

ObjectiveResponse time is a predictive factor for survival of drowning victims and lifesaving. Rescue Water Craft (RWC) are lifeboats very common in lifeguards operations. The aim of this study was to analyze the feasibility of providing effective mouth-to-mouth ventilations and/or cardiopulmonary resuscitation (CPR) on the RWC while sailing at different speeds. MethodA quasi-experimental cross-over block design was used to test during one minute efforts the effectiveness of Mouth to Mouth ventilation (MM-only) and CRP, at the beach and sailing at two diferents speeds 5 knots(kn) and 10 kn with calm sea. Quality CPR reference were 2015 ERC guidelines. ResultsThe data obtained from 13 lifeguards were included, that means that 78 resuscitation test were completed. The MM-only performance skills reached 69.7% ± 40.4 for 5 kn and 60.0% ± 41.8 for 10 kn (p = .59). For full CPR, performance was 74.4% ± 24.2 and 68.5% ± 23.9 respectively. Quality of MM and CPR decreased, not significantly, while sailing at 5 kn and 10 kn [(Q-MM; 5 kn: 59.9% ± 37.8 vs. 10 kn: 43.2% ± 41.4, p = .42)(Q-CPR; 5 kn: 64.8% ± 21.2 and 10 kn: 60.6% ± 21.0, p = .44)]. MM-only and CC variables were significantly worse on RJS when compared with resuscitation at the beach (p < .05). A trend for better results by lifeguards previously training on RJS was observed. ConclusionsResuscitation techniques on board of a RWC are feasible and therefore they could be an option for lifeguards when their training, sea conditions, distance and the victim's characteristics allow it. CPR maneuvers may be highly effective at 10 kn, both for MM-only and CPR, however, the quality of the ventilations dramatically worsen with increasing speed.

Postoperative myxedema coma in patients undergoing major surgery: Case series

ObjectiveMyxedema coma is a serious complication of hypothyroidism that can be precipitated by major surgery. It is extremely rare, with only a few reports in the literature. This study aims to present a relatively large case series of post-surgical myxedema coma and to analyze medical and surgical risk factors. MethodsAnalysis of the patients’ surgical records and medical charts. ResultsFour patients developed postoperative myxedema coma and were evaluated for risk factors. Three had known hypothyroidism. Two had undergone large head and neck composite resections necessitating a free flap repair for malignant disease. One had undergone coronary artery bypass graft for ischemic heart disease, and another had undergone endoscopic cholecystectomy for complicated cholecystitis. All four patients required prolonged hospitalization, including treatment in the intensive care unit. One patient had undergone full cardiopulmonary resuscitation directly related to the myxedema coma state. ConclusionWe present a series of four patients who developed myxedema coma following major surgery. We recommend that patients with known hypothyroidism who are scheduled for major surgery should be tested for thyroid function status and assessed for postoperative risk of hypothyroidism. Those who develop complications following major surgery, should be immediately tested for thyroid function to rule out myxedema coma.

Knowledge and attitude of Albaha Universitys students to perform Cardiopulmonary Resuscitation, Saudi Arabia

Background/Objective: In 2015, the Saudi Heart Association suggested that one in four adults is at risk for cardiac arrest within the next 10 years. Cardiopulmonary resuscitation is considered one of the important determinants for out-hospital cardiac arrest survival. The aim of this study was to assess level of cardiopulmonary resuscitation knowledge and .attitude among students of Albaha University. Methods: Following a cross-sectional study, questionnaires were distributed to500 students recruited via stratified random sampling technique. Only 341 (68.2%) completed the study. Results: A total of 341 students were completed the questionnaire; 49% of students had a previous knowledge of cardiopulmonary resuscitation. Most of students (90%) were not confident on having sufficient CPR knowledge, 69.5% of them knew emergency phone number in Saudi Arabia, and 8.8% of the students had personally witnessed a cardiac arrest victim, of those witnessed cardiac arrest no one did full cardiopulmonary resuscitation. Although 62% of students reported willing to perform cardiopulmonary resuscitation, when students confronted with 6 hypothetical cardiac arrest scenarios, the option of providing full cardiopulmonary resuscitation are less frequently chosen. Fear of doing mistakes when performing cardiopulmonary resuscitation due to lack of competence were reported in (42.5%) of students as a reason for being reluctant to perform rescue breathing. Conclusion: The study found that overall attitude toward CPR are positive. However, the proper knowledge of CPR was not sufficient. Thus, the incorporation of cardiopulmonary resuscitation learning approaches within university curricula will provide the opportunity to develop knowledge and skills required to save people lives.

Dispatcher-assisted compression-only cardiopulmonary resuscitation provides best quality cardiopulmonary resuscitation by laypersons: A randomised controlled single-blinded manikin trial.

High-quality cardiopulmonary resuscitation (CPR) by laypersons is a key determinant of both outcome and survival for out-of-hospital cardiac arrest. Dispatcher-assisted CPR (telephone-CPR, T-CPR) increases the frequency and correctness of bystander-CPR but results in prolonged time to first chest compressions. However, it remains unclear whether instructions for rescue ventilation and/or chest compressions should be recommended for dispatcher-assisted CPR. The aim of this study was to evaluate both principles of T-CPR with respect to CPR quality. Randomised controlled single-blinded manikin trial. University Hospital of Cologne, Germany, 1 July 2012 to 30 September 2012. Sixty laypersons between 18 and 65 years. Medically educated individuals, medical professionals and pregnant women were excluded. Participants were asked to resuscitate a manikin and were randomised into three groups: not dispatcher-assisted (uninstructed) CPR (group 1; U-CPR; n = 20), dispatcher-assisted compression-only CPR (group 2; DACO-CPR; n = 19) and full dispatcher-assisted CPR with rescue ventilation (group 3; DAF-CPR; n = 19). Specific parameters of CPR quality [i.e. no-flow-time (NFT) as well as compression and ventilation parameters] were analysed. To compare different groups we used Student's t test and P less than 0.05 was considered significant. Initial NFT was lowest in the DACO-CPR group (mean 21.3 ± 14.4%), followed by dispatcher-assisted full CPR (mean 49.1 ± 8.5%) and by unassisted CPR (mean 55.0 ± 12.9%). Initial NFT covering the time of instruction was lower in DACO-CPR (12.1 ± 5.4%) as compared to dispatcher-assisted full CPR (20.7 ± 8.1%). Compression depth was similar in all three groups: 40.6 ± 13.0 mm (unassisted CPR), 41.0 ± 12.2 mm (DACO-CPR) and 38.8 ± 15.8 mm (dispatcher-assisted full CPR). Average compression frequency was highest in the DACO-CPR group (65.2 ± 22.4 min) compared with the unassisted CPR group (35.6 ± 24.2 min) and the dispatcher-assisted full CPR group (44.5 ± 10.8 min). Correct rescue ventilation was given in 3.1 ± 11.1% (unassisted CPR) and 1.6 ± 16.1% (dispatcher-assisted full CPR) of all ventilation attempts. Best quality of CPR was achieved by DACO-CPR because of superior compression frequencies and reduced NFT. In contrast, the full dispatcher-assisted CPR with a longer initial instructing phase (initial NFT) did not result in enhanced CPR quality or an optimised compression depth.

Fat Embolism After Surgery for Gynecomastia

Gynecomastia is a benign enlargement of the male breast, secondary to gland proliferation and is a common problem among the male population. Treatment is primarily surgical. The most common intra- and postoperative complication is bleeding, followed by seroma, infection, insufficient results, inverted nipple and nipple necrosis. The embolism is one of the non-specific complications. A 24-year-old male was presented to the Surgery Department with a diagnosis unilateral gynecomastia. The operation proceeded without complication and around 10 hours later, the patient complained of weakness in all four limbs, later nausea, and vomiting and after full cardiopulmonary resuscitation, the patient died. The main reason for the patient’s death was concluded to be a postoperative pulmonary thromboembolism and fat embolism was discovered. In addition, there was a papillary carcinoma of the thyroid, which was missed before. We reported that unilateral gynecomastia associated with papillary carcinoma of the thyroid detected rarely at autopsy and fat embolism after surgery for gynecomastia is a rare complication.Key words: Gynecomastia, fat embolism, autopsy

G104(P) Resuscitation experience of professionals at a district general hospital (dgh)

Introduction The caseload of critically ill patients at a DGH is usually smaller compared to tertiary hospitals. There are some concerns that modern centralisation of services may deskill clinicians at DGHs. Technology Enhanced Learning has an important role to play in improving training. We aimed to analyse professionals’ experience, their role and confidence in performing resuscitation and also their opinion about simulation training. Method We conducted a survey at Ysbyty Gwynedd to determine experience of medical and nursing colleagues in managing critically ill children and neonates over last 6 months. A questionnaire asking various aspects of resuscitation was sent out to nursing colleagues and paediatric doctors working at all levels. Of the 50 distributed questionnaires, 40 were completed and returned to us. Results While only 30% had exposure to resuscitation more than twice over preceding 6 months period, approximately 35% had once or no experience. Those who had exposure more than twice felt confident in performing resuscitation. While only 10% were involved in full cardiopulmonary resuscitation, about 30% were involved in airway and breathing and another 20% in circulation. Over 90% stated that they would like to have regular simulation training at least monthly as they felt it will help in coping with actual resuscitation. Conclusion There is limited data available in literature to determine frequency of managing critically ill children at individual level. This study shows that most health professionals have limited exposure to resuscitation situations at a DGH and nearly all paediatric staff wishes to receive regular simulation training.

The evaluation of upper body muscle activity during the performance of external chest compressions in simulated hypogravity

BACKGROUND: This original study evaluated the electromyograph (EMG) activity of four upper body muscles: triceps brachii, erector spinae, upper rectus abdominis, and pectoralis major, while external chest compressions (ECCs) were performed in simulated Martian hypogravity using a Body Suspension Device, counterweight system, and standard full body cardiopulmonary resuscitation (CPR) mannequin. METHOD: 20 young, healthy male subjects were recruited. One hundred compressions divided into four sets, with roughly six seconds between each set to indicate ‘ventilation’, were performed within approximately a 1.5 minute protocol. Chest compression rate, depth and number were measured along with the subject's heart rate (HR) and rating of perceived exertion (RPE). RESULTS: All mean values were used in two-tailed t-tests using SPSS to compare +1 Gz values (control) versus simulated hypogravity values. The AHA (2005) compression standards were maintained in hypogravity. RPE and HR increased by 32% (p<0.001) and 44% (p=0.002), respectively, when ECCs were performed during Mars simulation, in comparison to +1 Gz. In hypogravity, the triceps brachii showed significantly less activity (p<0.001) when compared with the other three muscles studied. The comparison of all the other muscles showed no difference at +1 Gz or in hypogravity. CONCLUSIONS: This study was among the first of its kind, however several limitations were faced which hopefully will not exist in future studies. Evaluation of a great number of muscles will allow space crews to focus on specific strengthening exercises within their current training regimes in case of a serious cardiac event in hypogravity.

End of life, death and dying in neonatal intensive care units in Latin America

Most analyses of end of life decisions in Neonatal Intensive Care Units (NICUs) have come from Europe/English-speaking countries. Would decisions be different in Latin American NICUs? Therefore, we aim to evaluate the approach to dying infants/families in NICUs in Latin America. Multinational descriptive study of all deaths in babies born at >22 weeks in eight NICUs in five Latin American countries. Deaths were categorized as: (i) no Cardiopulmonary Resuscitation (CPR) or life support offered; (ii) life support initiated but do not resuscitate (DNR) orders written or no CPR provided; (iii) full life support and CPR; and (iv) unclassifiable. There were 100 deaths, 81% in >27 weeks. Seventeen infants received no CPR/life support at birth, 10 died in DR and seven in NICU. There were 27 infants in group 2, 54 in group three and two in group 4. No baby had care withdrawn or care withdrawn/CPR withheld. Thirty-two infants had 'do not resuscitate' order. Decisions without parents' involvement in 15%, both parents present at death 24% and sedatives/narcotics documented 14%. Latin American NICUs differ from those in Northern Europe/English-speaking countries. More deaths are accompanied by full life support and CPR. DNR orders are rare. Withdrawal of life support is virtually non-existent. Latin American's doctors are more likely to make decisions without the objections of family about withholding life-sustaining treatment.

Nurses’ participation in the end-of-life — process in two paediatric intensive care units in Brazil

The aim of this study was to evaluate the medical and nursing care provided to children in the last 24 hours of life in two Brazilian paediatric intensive care units and analyse the nurses' participation in the decision-making process for life support limitation (LSL). The study was based on an analysis of the patients' medical charts, looking at the medical and nursing care provided in the last 24 hours of life during a 6-month period in the two units, and on semi-structured interviews with 20 nurses to evaluate their participation in LSL decisions. The children were classified into two groups: those who were to receive full cardiopulmonary resuscitation (CPR) and a non-CPR group. A total of 34 deaths occurred during the study period. Of these, 17 (50%) were children that had been in the non-CPR group; there were only 10 recorded LSL plans in their medical charts. In the interviews, only 30% of the nurses mentioned active participation in LSL decisions. In conclusion, the paediatric intensive care nurses in these two Brazilian units did not participate much in LSL decisions, and the care offered in the last hours of life to children with terminal and irreversible illness was not primarily directed toward comfort and alleviating suffering.