High-quality CPR Research Articles

Immediate intravenous epinephrine versus early intravenous epinephrine for in-hospital cardiopulmonary arrest

BackgroundIntravenous epinephrine has been a key treatment in cardiopulmonary arrest since the early 1960s. The ideal timing for the first dose of epinephrinee is uncertain. We aimed to investigate the association of immediate epinephrine administration (within 1-min of recognition of cardiac arrest) with return of spontaneous circulation (ROSC) up to 24-h.MethodsThis was a multicenter retrospective analysis of patients who underwent cardiopulmonary resuscitation. We included the following patients: 1) ≥18 years-old, 2) non-shockable rhythms, 3) received intravenous epinephrine during cardiopulmonary resuscitation, 4) witnessed in-hospital arrest and 5) first resuscitation attempt (for patients requiring more than one resuscitation attempt). We excluded patients who suffered from traumatic arrest, were pregnant, had shockable rhythms, arrested in the operating room, with Do-Not-Resuscitate (DNR) order, and patient aged 17 years-old or less.ResultsA total of 360 patients were included in the analysis. Median age was 62 years old and median epinephrine administration time was two minutes. We found that immediate epinephrine administration (within 1-min) is associated with higher rates of ROSC up to 24-h (OR = 1.25, 95% CI; [1.01–1.56]), compared with early epinephrine (≥2-min) administration. After adjusting for confounding covariates, earlier administration of epinephrine predicted higher rates of ROSC sustained for up to 24-h (OR 1.33 95%CI [1.13–1.55]).ConclusionsImmediate administration of epinephrine in conjunction with high-quality CPR is associated with higher rates of ROSC.

A cross-sectional study to evaluate high-quality CPR maneuvers in rescuers and instructors attending the General Instructor Course

article: A cross-sectional study to evaluate high-quality CPR maneuvers in rescuers and instructors attending the General Instructor Course - Italian Journal of Emergency Medicine 2020 December;9(3):161-8 - Minerva Medica - Journals

Ventilation in Simulated Out-of-Hospital Cardiac Arrest Resuscitation Rarely Meets Guidelines

Objective The American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommend ventilation rates of eight to ten breaths per minute or two ventilations every 30 compressions, and tidal volumes between 500–600 ml. However, compliance with these guidelines is mainly unknown. The objective of this study is to estimate the proportion of simulated adult OHCA cases that meet guideline-based ventilation targets. Methods We conducted a blinded prospective observational study of standardized simulated cases of EMS-witnessed adult OHCA. During scheduled training sessions, resuscitations were performed by high-quality CPR trained EMS teams composed of four on-duty, full-time EMT/Paramedics from a large urban fire-based EMS agency. A high-fidelity simulation center allowed complete audio and video monitoring from a control room. Rescuers were unaware of the study, or that ventilation practices were being observed. All interventions, including airway and ventilation strategies, were at the discretion of the clinical team. A calibrated Laerdal SimMan 3 G manikin and associated Laerdal Debrief Viewer software recorded ventilation rate, tidal volume, and minute ventilation. Simulations achieving median ventilation rate 7–10 breaths/min, tidal volume 500–600 ml, and minute ventilation 3.5–6 liters/min were considered meeting guideline-based targets. Results A total of 106 EMS teams were included in the study. Only 3/106 [2.8% (95% CI: 0.6–8.0)] of the EMS teams demonstrated ventilation characteristics meeting all guideline-based targets. The median ventilation rate was 5.8 breaths/min (IQR 4.4–7.7 breaths/min) with 26/106 [24.5% (95% CI: 17.2–33.7)] between 7–10 breaths/min. The median tidal volume was 413.5 ml (IQR 280.5–555.4 ml), with 18/106 [17.0% (95% CI: 10.9–25.5)] between 500–600 ml. The median minute ventilation was 2.4 L/min (IQR 1.2–3.6 L/min) with 16/106 [15.1% (95% CI: 9.4–23.3)] between 3.5–6.0 L/min. Conclusion During simulated adult OHCA resuscitation attempts, ventilation practices rarely met guideline-based targets, despite being performed by well-trained EMS providers. Methods should be developed to monitor and ensure high-quality ventilation during actual OHCA resuscitation attempts.

Over the head and lateral position technique for cardiopulmonary resuscitation: which one is better?

Background: A high rate of cardiac arrest requires high-quality CPR. A valuable CPR rescuer has lower success than two or more rescuers, especially with the use of BVM. There is a complexity encountered with lateral CPR position as a commonly used position, which is the difficulty of position movement from compression to ventilation. On the other hand, Over the Head CPR position is used as an alternative position, which is considered more effective than a lateral position. It is also considered to be able to overcome the obstacles found in CPR with a single rescuer using BVM ventilation in the lateral position so that study is required to compare the quality of CPR between the two CPR positions.Technique: The quality of CPR between Over the Head position CPR and Lateral position CPR is compared. The technique testing was carried out on 24 students using a mannequin. CPR quality components include compression ratios: ventilation, speed, depth, hand placement, chest recoil, and the amount of time of chest compression interruption were observed strictly. The overall CPR quality score, particularly in terms of compression speed and the minimum interruption time of chest compression on Over the Head position, is better than lateral position CPR.Conclusion: Over the Head position, CPR significantly produces a better quality of CPR than Lateral position CPR.

Relief Alternatives during Resuscitation: Instructions to Teach Bystanders. A Randomized Control Trial.

To analyze the quality of resuscitation (CPR) performed by individuals without training after receiving a set of instructions (structured and unstructured/intuitive) from an expert in a simulated context, the specific objective was to design a simple and structured CPR learning method on-site. An experimental study was designed, consisting of two random groups with a post-intervention measurement in which the experimental group (EG) received standardized instructions, and the control group (CG) received intuitive or non-standardized instructions, in a public area simulated scenario. Statistically significant differences were found (p < 0.0001) between the EG and the CG for variables: time needed to give orders, pauses between chest compressions and ventilations, depth, overall score, chest compression score, and chest recoil. The average depth of the EG was 51.1 mm (SD 7.94) and 42.2 mm (SD 12.04) for the CG. The chest recoil median was 86.32% (IQR 62.36, 98.87) for the EG, and 58.3% (IQR 27.46, 84.33) in the CG. The use of a sequence of simple, short and specific orders, together with observation-based learning makes possible the execution of chest compression maneuvers that are very similar to those performed by rescuers, and allows the teaching of the basic notions of ventilation. The structured order method was shown to be an on-site learning opportunity when faced with the need to maintain high-quality CPR in the presence of an expert resuscitator until the arrival of emergency services.

Effect of Chest Compression Position Depending on the Rescuer’s Hip Joint Angle During Basic CPR

This study aims to investigate the improvement in basic CPR quality on the basis of the hip joint angle of the rescuer among students in the Department of Emergency Medical Technology who completed a basic CPR curriculum. In this study, we carried out a comparative analysis using SimPad SkillReporter and Resusci Anne® QCPR® to measure the quality of CPR (depth of chest compressions, full relaxation, compression speed, and more) on the basis of the rescuer’s hip joint angle in accordance with the 2015 AHA Guidelines and conducted chest compressions and CPR 5 times in a 30:2 ratio. It was found that maintenance of the rescuer’s hip joint angle at 90 degrees while compressing and relaxing the chest made a statistically significant difference in both the experimental and control groups. Moreover, this indicated that the closer the hip joint angle was to 90 degrees, the better was the quality of basic CPR. However, there was no significant difference in the hip joint angle, degree of CPR, depth of chest compressions, chest compression speed, chest compression and relaxation percentages (%), accuracy of chest compressions, hands-off time during CPR, and percentage of chest compression time (p &gt; 0.05). Maintaining the hip joint angle at 90 degrees for basic CPR was not significantly different from not maintaining this angle. Nonetheless, good results have been obtained at moderate depth and 100% recoil. Therefore, good outcome and high-quality CPR are expected.

Abstract WP477: Neuro-Cognitive Outcomes After Transitioning to Pit Crew Model for Out of Hospital Cardiac Arrest

Introduction: Survival and neurological outcomes from the out of hospital cardiac arrest (OHCA) varies from one region to another depending on the different practices followed by the emergency personnel. Our study looked into neuro-cognitive outcomes post OHCA before and after adopting a pit crew model approach in one of the largest counties in Kansas. Methods: The data was collected by the emergency medical services (EMS) before transitioning (from 2010 - 2012) and after transitioning (from 2013-2016) to the pit crew approach. The patient demographics and resuscitation variables were similar and comparable including the emergency and fire department personnel. The primary outcomes were the average number of pauses &gt;10 seconds and the cerebral performance post return of spontaneous circulation (ROSC) Results: The average number of CPR pause time &gt; 10 seconds post pit crew model was 1 vs 5 (p=0.01). Cerebral performance post return of spontaneous circulation using pit crew approach with good cerebral performance was 56% vs 47% (p=0.2), moderate cerebral disability was 17% vs 23% (p=0.19), severe cerebral disability was 8% vs 11% (p=0.44) and in coma/vegetative state was 8% vs 16% (p=0.001). Conclusion: This focused model of high-quality CPR performance with the individualized assigned task has shown a declining trend in the rates of cerebral disability especially with moderate and severe cerebral performance including the patients in coma or vegetative state. More studies with better neuro-cognitive follow-up care after ROSC is needed to further establish the superiority of pit crew model approach.

Cardiovascular System: Part I

This chapter reviews the cardiovascular system in its entirety. It begins with the details of the cardiac cycle, a highly coordinated sequence of electrical and mechanical events that allows blood flow from the atria to the ventricles, which then pump blood out to pulmonary, and systemic circulations. There is an overview of basic ventricular physiology, assessment of ventricular contractility, and systolic and diastolic function. Cardiac output, its determinants, regulation, and its measurement according to the Fick principle and other methods are also extensively reviewed. The chapter moves on to describe the importance of blood pressure and its determinants. It follows with a description of how arterial blood pressure and other intracardiac pressures are measured. Finally, in the event of cardiac arrest, the chapter describes high quality CPR, and several algorithms used in managing patients in cardiac arrest. This review contains 5 figures, and 51 references. Keywords: electrocardiogram (ECG), Frank-Starling law, myocardial contractility, Fick principle, cardiac output, blood pressure, intracardiac pressures, advanced cardiac life support

Abstract 466: Consideration of an Optimal Educational Strategy for High-Quality Cardiopulmonary Resuscitation and Chest Compression Fraction in Basic Life Support Simulation Training

Introduction: The American Heart Association (AHA) is pursuing higher-quality simulation training with the goal of “Optimizing educational strategies for healthcare providers” as one of the Science Gaps in the 2015 Cardiac Arrest Guidelines. The latest guidelines suggest that increasing CCF as much as possible during CPR increases the chance of ROSC. However, in simulation training, it is important to evaluate the percentage of CCF and maintain high-quality CPR. We evaluated CPR for 10 minutes in a “High-Performance Teams Activity” of an AHA-BLS course using the HQCPR quotient and CCF indexes. Methods: We measured the rhythm chest compressions (CCs), duration of two breaths, and chest rise two times using a bag valve mask, interruption and alternation time of CC, CC resumption time after AED (shock or no shock), and CCF, which was calculated from CPR recorded for 10 minutes using the video camera. This data was evaluated using the criteria of high-quality CPR based on AHA-BLS guidelines comprising 7 items, such as “100-120 frequency per min for CC,” and the HQCPR quotient was determined. The HQCPR quotient and CCF of each team were analyzed using logistic analysis. Moreover, the BLS techniques of each teams, such as the rhythm CCs were compared with the CCF of each teams, respectively. This study was approved by the Ethics Committee of Ryukyu University and the Japan ACLS Association. Results and Conclusions: Overall, 48 teams comprising 215 subjects participated in the study. The HQCPR achievement rate for the 48 teams was 65.9%. There was no correlation between the HQCPR quotient and CCF (R2 = 0.0003). In simulation training, the CCF height did not necessarily guarantee high-quality CPR (Figure 1). In particular, as CCF increased, the duration of two breaths decreased (R2 = 0.46). An adverse effect of breaths for a very short time was noted. We propose that it is essential to evaluate CCF with HQCPR quotient to achieve “Optimizing educational strategies for healthcare providers.”

Pediatric Toxidrome Simulation Curriculum: Bupropion Overdose.

Bupropion is a commonly used antidepressant, and overdose can lead to both neurologic and cardiovascular toxicity, including agitation, seizure, tachycardia, QT and QRS prolongation, and rhythm disturbances. We developed this simulation case for attendings, fellows, nurse practitioners, and nurses in the pediatric emergency department (ED). The scenario involved a 13-year-old male presenting to the ED with altered mental status and a generalized tonic-clonic seizure shortly after arrival. The team needed to quickly perform primary and secondary surveys, manage his airway and breathing, and initiate treatment for seizure. The team had to obtain an abbreviated history and include ingestion in the differential. The patient then developed pulseless ventricular tachycardia, and the team needed to respond with high-quality CPR, defibrillation, and advanced airway management. Preparatory materials, a debriefing guide, and scenario evaluation forms assisted with facilitation. Twenty-eight physicians, 56 nurses, 10 nurse practitioners, four pharmacists, two students, and one respiratory therapist completed this simulation in 13 sessions. On a 5-point Likert scale, participants agreed with the stated objective of ability to manage a patient with a bupropion overdose (M = 4.09; range, 2-5). The scenario was rated as highly relevant (M = 4.93) and the debriefing as very effective (M = 4.85). This scenario is a complete educational resource for setting up, implementing, and debriefing in an interprofessional setting. It was well received by learners from diverse professional backgrounds working together in actual care teams in the pediatric ED.

Extracorporeal Cardiopulmonary Resuscitation in a 36-Year-Old Man with Viral Myocarditis Who Survived Prolonged Cardiac Arrest and Bedside Decompressive Laparotomy Neurologically Intact

We report a case of prolonged cardiac arrest in a patient with viral myocarditis who was subsequently cannulated for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) while in cardiac arrest. The patient developed bowel ischemia and abdominal compartment syndrome on ECMO and required a bedside decompressive laparotomy and hemicolectomy. This case demonstrates that prolonged downtime with high quality CPR and potential ischemic complications of VA-ECMO should not preclude ongoing resuscitation and treatment as favorable neurologic outcome is still possible.

Mechanical adjuncts for cardiocerebral resuscitation

ABSTRACTIntroduction: Cardiac arrest remains a worldwide health problem with very poor outcome. In the absence of bystander resuscitation, survival rates decrease by 10% per minute of arrest and global ischemia. Even the best manual chest compressions, however, can only produce a fraction of normal cardiac output and blood flow to vital organs. Physiological principles and current evidence for the use of mechanical devices to increase survival and quality of life after cardiac arrest are highlighted in this review article.Areas covered: Mechanical adjuncts such as the Active Compression Decompression device, automated chest compressors and the use of a negative pressure valve (Impedance Threshold Device) can synergistically aid in improving quality of CPR and increasing cardiac output and vital organ perfusion.Expert opinion: The current conclusions that the use of mechanical adjunct devices in a preclinical setting is not recommended or neutral at best, need to be reevaluated, especially with regard to new advanced and promising treatments that require prolonged high-quality CPR during the transport to a hospital to improve the outcome of patients.

It is not about the machine, it's about the process: the role of simulation in the development of a prehospital eCPR-program

Objectives: Algorithm-compliant use of extracorporeal cardiopulmonary resuscitation, eCPR following refractory cardiac arrest CA is challenging. It may increase cognitive load and interfere with other advanced life support, ALS measures, increase interruptions to high-quality CPR. Accordingly, training and education play an important role for an eCPR program. Simulation (SIM) technology for integrated training from basic life support, BLS to ALS and eCPR is not commercially available. Also, the ALS-part of the eCPR-team is often under-emphasized in classic ECMO trainings. We describe the role of SIM and SIM-technology during the implementation of a prehospital eCPR program in Freiburg, Germany.

Using a smartwatch with real-time feedback improves the delivery of high-quality cardiopulmonary resuscitation by healthcare professionals

AimCardiopulmonary resuscitation (CPR) quality affects survival after cardiac arrest. We aimed to investigate if a smartwatch with real-time feedback can improve CPR quality by healthcare professionals. MethodsAn app providing real-time audiovisual feedback was developed for a smartwatch. Emergency Department (ED) professionals were recruited and randomly allocated to either the intervention group wearing a smartwatch with the preinstalled app, or to a control group. All participants were asked to perform a two-minute CPR on a manikin at a 30:2 compression-ventilation ratio. Primary outcomes were the mean CCR and CCD measured on the manikin. A secondary outcome was the percentage of chest compressions meeting both the guideline-recommended rate (100–120 min−1) and depth (50–60 mm) of high-quality CPR during a 2-min period. Differences between groups were evaluated with t-test, Chi-Square test, or Mann–Whitney U test depending on the distribution. ResultsEighty participants were recruited. 40 people were assigned to the intervention and 40 to the control group. The compression rates (mean ± SD, min−1) were significantly faster (but above the guideline recommendation, P < 0.001) in the control (129.1 ± 14.9) than in the intervention group (112.0 ± 3.5). The compression depths (mean ± SD, mm) were significantly deeper (P < 0.001) in the intervention (50.9 ± 6.6) than in the control group (39.0 ± 8.7). The percentage (%) of high-quality CPR was significantly higher (P < 0.001) in the intervention (median 39.4, IQR 27.1–50.1) than in the control group (median 0.0, IQR 0.0−0.0). ConclusionWithout real-time feedback, chest compressions tend to be too fast and too shallow. CPR quality can be improved with the assistance of a smartwatch providing real-time feedback.

Hemodynamic effects of chest compression interruptions during pediatric in-hospital cardiopulmonary resuscitation

AimAnimal studies have established deleterious hemodynamic effects of interrupting chest compressions. The objective of this study was to evaluate the effect of interruptions on invasively measured blood pressures (BPs) during pediatric in-hospital cardiac arrest (IHCA). MethodsThis was a single-center, observational study of pediatric (<18 years) intensive care unit IHCAs in patients with invasive arterial catheters in place. Interruptions were defined as ≥1 s between chest compressions. Diastolic BP (DBP) and systolic BP (SBP) were determined for individual compressions. For the primary analysis, the average DBP and SBP of the 20 compressions preceding each interruption were compared to the average DBP and SBP of the first 20 compressions following each interruption utilizing non-parametric paired analyses. Linear regression evaluated the change in DBP during interruptions and following interruptions. ResultsThirty-two IHCA events met inclusion criteria, yielding 161 evaluable interruptions. The median age was 2.1 years. Return of circulation was achieved in 24 (75%). The median interruption duration was 2.4 [1.4, 7.0] seconds. Most patients were intubated pre-arrest and received epinephrine during CPR. BPs were not different pre- vs. post-interruption (DBP: 28.7 [21.6, 38.2] vs. 28.3 [21.0, 37.4] mmHg, p = 0.81; SBP: 82.0 [51.7, 116.7] vs. 85.4 [55.7, 122.2] mmHg, p = 0.07). DBP decreased 8.41 ± 0.73 mmHg (p < 0.001) during the first second of interruptions and 0.19 ± 0.02 mmHg/s (p < 0.001) in subsequent seconds. ConclusionsBPs following chest compression interruptions did not differ from pre-interruption BPs. These findings suggest that in the setting of high-quality in-hospital CPR, brief chest compression interruptions do not have persistent detrimental hemodynamic impact.

Abstract 184: AED Application in Non-Shockable Out-of-Hospital Cardiac Arrest Does Not Reduce Survival

Introduction: It is well established that AEDs improve outcome in shockable out-of-hospital cardiac arrest (OHCA). An increasing proportion (now the majority) of OHCAs present with non-shockable rhythms. Survival from non-shockable OHCA depends on high-quality CPR in transit to definitive care. Studies of AED use in non-shockable in-hospital arrest (as opposed to OHCA) have shown reduced survival with AED application possibly due to CPR interruptions to apply pads and perform rhythm analysis. We sought to determine whether AED application in non-shockable public, witnessed OHCA has a significant association with survival to discharge. Methods: This is a retrospective analysis of OHCA from 2010-2015 at 10 Resuscitation Outcomes Consortium centers. All adult, public, witnessed non-shockable OHCAs were included. Non-shockable arrest was defined as no shock delivered by the AED or by review of defibrillator tracings (10%). The initial rhythm on EMS arrival was used to confirm the rhythm. The primary outcome was survival to hospital discharge with favorable neurological status (modified rankin score &lt;3). The OR was adjusted for the Utstein variables. Results: During the study period there were 1,597 non-shockable public, witnessed OHCA, 9.8% of which had an AED applied. The initial rhythm on EMS arrival was PEA or asystole in 86% of cases. Significantly more OHCA in the AED applied group had CPR performed. 6.5% of those without an AED applied survived with favorable neurologic status compared to 9% with an AED. After adjustment for the Utstein variables including bystander CPR, the aOR for survival with favorable neurologic outcome was 1.38 (95% CI:0.72-2.65). Conclusion: After adjusting for patient characteristics and bystander CPR, the application of an AED in non-shockable public witnessed OHCA had no significant association with survival or neurological outcome supporting the relative safety and potential benefit of AED application in non-shockable OHCA.

Abstract 180: Nursing Roles for In-Hospital Cardiac Arrest Response: A Qualitative Study

Introduction: Survival and favorable clinical outcomes for in-hospital cardiac arrest (IHCA) are highly dependent on a skilled resuscitation team, prompt initiation of high quality CPR and defibrillation, and organizational structures to support resuscitation care. While nurses are generally involved in resuscitation efforts, the purpose of this study was to examine their specific roles and factors that affect their contributions during an IHCA response. Methods: We conducted a qualitative study at 9 hospitals participating in the AHA Get-With-The-Guidelines Resuscitation registry. Purposeful sampling was used to select hospitals that vary in terms of geography, academic status, and risk-standardized IHCA survival. Participants included nurses, physicians, respiratory therapists, pharmacists, quality improvement staff, hospital administrators, and other staff, yet discussion of the nursing function was prominent across all stakeholder groups. Qualitative thematic text analysis was used to identify the distinct types of nursing roles in relation to IHCA and how these roles were supported across sites. Results: We conducted semi-structured interviews with 158 individuals at 9 hospitals. Nurses were identified as an integral part of the IHCA response at all sites, with three major IHCA nursing roles identified: bedside first responder, rapid response or code team member, and leader. There were distinct differences across sites in support for nurses in these different roles with regard to educational training and competency, organizational engagement, and empowerment (Table). Conclusion: Nurses are a critical component of effective IHCA response and processes, including diverse roles as bedside first responders, code team members, and leadership for resuscitation care. Mentoring and empowering frontline nurses and ensuring that clinical competency and training needs for IHCA care specific for nurses is essential for resuscitation care.

Abstract 105: Accuracy of Team Perception of Performance With Actual CPR Quality Metrics in Children

Background: American Heart Association (AHA) recommends high quality CPR to promote optimal patient outcomes. Few reports compare team members’ perceptions of CPR quality with quantitative CPR data during actual pediatric CPR. Hypothesis: Self-reported team perception of CPR performance will not meet quantitative CPR metrics using AHA BLS guideline criteria. Methods: Prospective data from an international pediatric (pediRES-Q) resuscitation collaborative from February 2016 to August 2017. A modified Team Emergency Assessment Measure framework for qualitative content analysis was used to assess data from “hot” debriefings (held soon after arrest) by language processing experts blinded to CPR data. Events without reported perception of CPR and quantitative CPR data were excluded. Comments regarding CPR perception were grouped as either Plus perceptions of performance (PPP) or Delta perceptions of performance (DPP). Grouped events were matched and compared to quantitative CPR data of chest compression (CC) fraction (CCF), rate, and depth as collected by CPR-recording defibrillators. Compliance with AHA BLS guidelines were defined as events with mean: CCF &gt;60%, CC rate 100-120/min; and CC depth for infants &lt;1yo, ~4 cm (3.6-4.4 cm.); children 1-18 yo, 5-≤6 cm. Results: Of 227 arrests, 108 (48%) hot debriefings were reported. Reported CPR perceptions with paired quantitative CPR data were available for 53/108 (49%) events; 32/53 (60%) PPP and 21/53 (39%) DPP. Event CPR metric summaries (median [IQR]) for PPP - CCF 0.87 [0.77, 0.93]; CC rate 116/min [108.5, 120]; CC depth age &lt;1yo 2.35 [2.01, 3.0] cm; &gt;1yr 4.2 [3.3, 5.05] cm. DPP - CCF 0.79 [0.69, 0.92]; CC rate 118/min [109,129]; CC depth &lt; 1 yo 2.03 [1.95, 2.2] cm; &gt;1yo 3.93 [3.3, 5.06] cm. PPP events, 28/32 (87%) met guideline criteria for CCF, 25/32 (78%) for CC rate; 6/32 (19%) for CC depth; and 4/32 (12%) met criteria for all 3 categories. For DPP events, 17/21 (80%) met guideline criteria for CCF; 15/21 (71%) for CC rate; and 3/21 (15%) for CC depth, and 2/21 (9%) met criteria for all 3 categories. Conclusions: Self-reported team perception of CPR quality does not match quantitative CPR metrics using AHA guideline criteria whether CPR was positively perceived or not, depth being main reason for non-compliance.

Optimal training frequency for acquisition and retention of high-quality CPR skills: A randomized trial

AimSpaced training programs employ short, frequent CPR training sessions to improve provider skills. The optimum training frequency for CPR skill acquisition and retention has not been determined. We aimed to determine the training interval associated with the highest quality CPR performance at one year. MethodsParticipants were randomized to 1-month, 3-month, 6-month, and 12-month CPR training intervals over the course of a 12-month study period. Practice sessions included repeated two-minute CPR practice sessions with visual feedback and verbal coaching until Excellent CPR was achieved, to a maximum of three attempts. Excellent CPR was defined as a two-minute CPR session with ≥90% of compressions with a depth of 50–60 millimeters, a rate of 100–120 per minute, and with complete chest recoil. CPR performance was assessed in all groups at 12 months. The primary outcome was the proportion of participants able to perform Excellent CPR in each group. ResultsA total of 167 participants were included in the analysis. Baseline assessment showed no difference in CPR performance (p = 0.38). Participants who were trained monthly had a significantly higher proportion of Excellent CPR performance (58%) than those in all other groups (26% in the 3-month group, p = 0.008; 21% in the 6-month group, p = 0.002; and 15% in the 12-month group, p < 0.001). ConclusionShort-duration, distributed CPR training on a manikin with real-time visual feedback is effective in improving CPR performance, with monthly training more effective than training every 3, 6, or 12 months.

An integrated program of extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation and uncontrolled donation after circulatory determination of death in refractory cardiac arrest

AimTo assess the feasibility of an integrated program of extracorporeal cardiopulmonary resuscitation (ECPR) and uncontrolled donation after circulatory determination of death (uDCDD) in refractory cardiac arrest (rCA). MethodsSingle center, prospective, observational study of selected patients with in-hospital (IHCA) and out-of-hospital (OHCA) rCA occurring in an urban area of ∼1.5 million inhabitants, between October-2016 and May-2018. 65 year old or younger patients without significant bleeding or comorbidities with witnessed nonasystolic cardiac arrests were triaged to ECPR if they had a reversible cause and high quality CPR lasting < 60 min. Otherwise they were considered for uDCDD after a ten minute no touch period using normothermic regional perfusion. Results58 patients were included, of which 41 (71%) were OHCA and 18 (31%) had ECPR initiated. Median age was 52 (IQR 45–56) years. Cannulation was successful in 49/58 (84%) cases. Compared to ECPR, patients referred for uDCDD were more frequently OHCA (90 vs. 28%), had bystander CPR (28 vs. 83%) and prolonged low-flow period (40 (35–50) vs. 60 (49–78) min). Survival to hospital discharge with full neurological recovery (cerebral performance category 1) occurred in 6/18 (33%) ECPR patients. uDCDD resulted in transplantation of 44 kidneys. ConclusionsAn integrated program for rCA consisting of a formal pathway to uDCDD referral in ECPR ineligible patients is feasible. ECPR-referred patients had a reasonable survival with full neurologic recovery. Successful kidney transplantation was achieved with uDCDD.