International Cardiopulmonary Resuscitation Guidelines Research Articles

Impact of the route of adrenaline administration in patients suffering from out-of-hospital cardiac arrest on 30-day survival with good neurological outcome (ETIVIO study)

BackgroundOver the past decades, international guidelines for cardiopulmonary resuscitation (CPR) have changed the recommendation for alternative routes for drug administration. Until now, evidence for the substantial superiority of one route with respect to treatment outcome after CPR has been lacking. The present study compares the effects of intravenous (IV), intraosseous (IO) and endotracheal (ET) adrenaline application during CPR in out-of-hospital cardiac arrest (OHCA) on clinical outcomes within the database of the German Resuscitation Registry (GRR).MethodsThis registry analysis was based on the GRR cohort of 212,228 OHCA patients between 1989 and 2020. Inclusion criteria were: OHCA, application of adrenaline, and out-of-hospital CPR. Excluded from the study were patients younger than 18 years, those who had trauma or bleeding as suspected causes of cardiac arrest, and incomplete data sets. The clinical endpoint was hospital discharge with good neurological outcome [cerebral performance category (CPC) 1/2]. Four routes of adrenaline administration were compared: IV, IO, IO + IV, ET + IV. Group comparisons were done using matched-pair analysis and binary logistic regression.ResultsIn matched-pair group comparisons of the primary clinical outcome hospital discharge with CPC 1/2, the IV group (n = 2416) showed better results compared to IO (n = 1208), [odds ratio (OR): 2.43, 95% confidence interval (CI): 1.54–3.84, p < 0.01] and when comparing IV (n = 8706) to IO + IV (n = 4353), [OR: 1.33, 95% CI: 1.12–1.59, p < 0.01]. In contrast, no significant difference was found between IV (n = 532) and ET + IV (n = 266), [OR: 1.26, 95% CI: 0.55–2.90, p = 0.59]. Concurrently, binary logistic regression yielded a highly significant effect of vascular access type (χ² = 67.744(3), p < 0.001) on hospital discharge with CPC1/2, with negative effects for IO (regression coefficient (r.c.) = − 0.766, p = 0.001) and IO + IV (r.c. = − 0.201, p = 0,028) and no significant effect for ET + IV (r.c. = 0.117, p = 0.770) compared to IV.ConclusionsThe GRR data, collected over a period of 31 years, seem to emphasize the relevance of an IV access during out-of-hospital CPR, in the event that adrenaline had to be administered. IO administration of adrenaline might be less effective. ET application, though removed in 2010 from international guidelines, could gain importance as an alternative route again.

Quality Evaluation Algorithm for Chest Compressions Based on OpenPose Model

Aiming at the problems of the low evaluation efficiency of the existing traditional cardiopulmonary resuscitation (CPR) training mode and the considerable development of machine vision technology, a quality evaluation algorithm for chest compressions (CCs) based on the OpenPose human pose estimation (HPE) model is proposed. Firstly, five evaluation criteria are proposed based on major international CPR guidelines along with our experimental study on elbow straightness. Then, the OpenPose network is applied to obtain the coordinates of the key points of the human skeleton. The algorithm subsequently calculates the geometric angles and displacement of the selected joint key points using the detected coordinates. Finally, it determines whether the compression posture is standard, and it calculates the depth, frequency, position and chest rebound, which are the critical evaluation metrics of CCs. Experimental results show that the average accuracy of network behavior detection reaches 94.85%, and detection speed reaches 25 fps.

A Study on the Role of Intelligent Medical Simulation Systems in Teaching First Aid Competence in Anesthesiology.

Anesthesiology is a subject with strong practicality and application. Undergraduate anesthesiology teaching needs to strike a balance between theoretical knowledge, clinical skill training, and clinical thinking development. Clinical probation and practice are an important part of undergraduate anesthesia teaching. Traditional clinical teaching uses real patients for demonstration and training, but as patients become more self-protective and less cooperative, there are not enough patients for clinical skill training. Simulation is to teach medical scenes in real life under the control of standardized technical guidelines and parameters. Since then, with the rapid development of computer technology, simulation technology and simulation teaching have been greatly developed and are more and more used in clinical teaching, skill evaluation, and scientific research. This study explores the effective methods of clinical teaching in anesthesiology by comparing the effectiveness of traditional teaching methods and simulation teaching methods in undergraduate clinical teaching. It is difficult to combine theory and practice in first aid, which does not allow them to directly receive and deal with emergency medical treatment and resuscitation. In China's current medical environment and patients' high demand for medical services, it is imperative to vigorously carry out simulated medical education. In the eastern part of Inner Mongolia, according to the advantages of teaching hospitals, our hospital took the lead in carrying out the simulation education project, which is still in the exploratory stage and not systematic enough. This study will help us to better carry out simulation teaching and improve the clinical skills of medical students in the future. Methods. The student group and class took the advanced simulator training as the experimental group, applied the advanced integrated simulator and other systems of the Norwegian company, referred to the international guidelines for cardiopulmonary resuscitation and cardiovascular first aid in 2005, and practiced in the emergency department during the clinical internship and “emergency clinical simulation training” course. The course includes basic life support, advanced life support, and comprehensive training of CPR (cardiopulmonary resuscitation) and endotracheal intubation. Results. The passing rate of simulated first aid practice was 94.4%; 100% of the students think it is necessary to set up the course, 91% of the students think it is practical, 91% of the students think the course content is reasonable and perfect, and 77%–100% of the students think the course has improved their first aid operation ability, comprehensive application of knowledge, and clinical thinking ability. Conclusion. Carrying out the course of “clinical simulated first aid training” through the advanced simulator system can effectively improve the interns' clinical first aid operation ability, teamwork ability, and self-confidence, improve the students' clinical thinking and judgment ability, and improve the service level to patients.

Design of a portable external cardiac compression device

Cardiopulmonary resuscitation (CPR) guidelines emphasize that external chest compressions should be started as soon as possible when CPR is performed in patients with cardiac arrest. Moreover, those guidelines stress on fast and hard compressions to make the chest fully rebound and minimize non-pressing time. Current mechanical recovery device has several problems such as displacement of the pressing position, high price, difficult to move, and easy dislocation of piston. Because of the physical loss of high-intensity unarmed CPR, the depth and frequency of external chest compression will decrease with the extension of CPR time, leading to CPR failure. Besides, there are other problems caused by non-professional staff, such as the deviation of compression position, the inaccuracy of compression depth and the unsatisfactory rebound of the chest wall. Based on the above factors, the medical staff from the intensive care unit of the Eighth Medical Center of the Chinese People's Liberation Army General Hospital designed a portable external chest cardiac compressor based on international CPR guidelines which obtained the National Utility Model Patent of China (ZL 2018 2 1173254.3). The portable external chest cardiac compressor is composed of a positioning sucker, elastic body, mounting shell, and pressing components. Rapid and accurate compression positioning, visible compression depth and full chest rebound can be achieved. This device is mobile, easy to operate, and suitable for a broad crowd and various occasions.

The Impact of Cardiopulmonary Resuscitation Guidelines Updates Against Out-of-Hospital Shockable Cardiac Arrest: A Population-Based Cohort Study

Background: International cardiopulmonary resuscitation (CPR) guidelines based on the best available evidence from resuscitation science have been updated since 2000. However, few nationwide population-based studies have been investigated comprehensive efficacy of those updates for out-of-hospital cardiac arrest (OHCA). Methods: From the All-Japan Utstein Registry between 2005 and 2015, we enrolled 73 578 adults who had witnessed shockable (ventricular fibrillation or pulseless ventricular tachycardia) OHCA. We examined temporal trends over eleven years (2005 on the Guidelines 2000 era, from 2006 to 2010 on the consensus on CPR and emergency cardiovascular care science with treatment recommendations [CoSTR] 2005 era, and from 2011 to 2015 on the CoSTR 2010 era). The primary end point was favorable neurological outcome (Cerebral Performance Category of 1 or 2) at 30 days after OHCA. Findings: Of 73 578 study patients, 61,080 (83%) were witnessed by bystander and 12 498 (17%) by emergency medical services (EMS) responder. After adjustment for Utstein variables, odds ratios for favorable 30-day neurological outcome increased year by year (reference, 2005): the bystander-witnessed group, 1∙19 (95% CI 1∙03-1∙37) in 2006, 2∙40 (95% CI 2∙10-2∙74) in 2010, 2∙45 (95% CI 2∙14-2∙80) in 2011 and 3∙02 (95% CI 2∙63-3∙46) in 2015; the EMS responder-witnessed group, 1∙27 (95% CI 1∙01-1∙60) in 2007, 1∙28 (95% CI 1∙02-1∙60) in 2010, 1∙54 (95% CI 1∙23-1∙94) in 2011 and 1∙58 (95% CI 1∙26-1∙99) in 2015. Similar results were seen in the subgroups receiving EMS-dispatcher CPR instruction, bystander chest compression-only CPR, early defibrillation, biphasic waveform defibrillators or advanced airway management. However, there was no evidence for any benefit from the addition of epinephrine. Interpretation: The international CPR guidelines updates for shockable OHCA had improved neurologically intact survival year by year. However, epinephrine is a topic for the future. Clinical Trial Registration Details: This study is registered with the University Hospital Medical Information Network Clinical Trials Registry, UMI09918. Funding Information: None. Declaration of Interests: We declare no competing interests. Ethics Approval Statement: A subcommittee of resuscitation science in the Japanese Circulation Society conducted this study with approval from the ethics committee at Nihon University Hospital.

Resuscitation Care in Out-Of-Hospital Cardiac Arrest: a Survey of the Emergency Medical Services Personnel in the Republic of Crimea

Introduction. The choice of the ways for optimizing management of out-of-hospital cardiac arrest by emergency medical services (EMS) should be based on the evidence from existing practice of resuscitation care. The study was aimed at evaluating personal experience of cardiopulmonary resuscitation (CPR) performance, timing of last training in resuscitation and level of self-perceived knowledge and skills of CPR among the employees of the EMS of the Republic of Crimea, as well as to assess their beliefs on significance of individual CPR procedures in terms of influence on success of resuscitation and to study their perceptions on factors that may have positive or negative impact on effectiveness of resuscitation care.Material and methods. An anonymous survey of the EMS personnel of the Republic of Crimea was conducted in July–December 2019. The questionnaire was utilized to collect demographic data, information on experience of conducting CPR for the last year, on a current practice of CPR debriefings and timing of last CPR training. The participants assessed their knowledge and skills of CPR and their perception of influence of early implementation of individual CPR procedures on success of resuscitation on a 5-point Likert scale, and indicated factors, that may limit or enhance the effectiveness of resuscitation.Results. A total of 251 specialist of the EMS participated in the survey, including 63 physicians, 129 feldshers and 4 nurses of ambulance teams, 45 dispatchers and 5 senior officers of the EMS stations, which corresponds to 28.8% of physicians, 13.0% of feldsher/nursing staff and 17.4% of dispatcher specialists of the republic. Percentage of male respondents was 35.5%, mean age — 41.5 years, mean duration of EMS work experience — 15.5 years. The mean declared number of cases of CPR conducted in the last 12 months was 2.2 (range: 0–20), and 23.5% specialists of the ambulance teams have not participated in any CPR attempt over the last year. About 60.2% respondents were trained in CPR within the last year. When compared to other specialists of ambulance teams, feldshers who work alone (without a coworker), were significantly less commonly performing a real-life resuscitation (p=0.008) or receiving training in CPR (p=0.020). Dispatchers were least covered with resuscitation training (only 33.3% were trained within the last year) and had the lowest level of CPR knowledge and skills. 25.9% of the specialists had an erroneous judgement that early drug administration and/or tracheal intubation have higher influence on success of resuscitation when compared to chest compressions and/or defibrillation. The level of knowledge and skills of CPR depend on the timing of last training (p&lt;0.001).Conclusions. The experience of participation in real-life attempts of CPR is severely limited for considerable part of the EMS employees, and many specialists have not been trained in resuscitation for a long time. The perceptions of the EMS specialists regarding the importance of individual CPR procedures are not always compliant with the statements of current international CPR guidelines. In order to enhance the effectiveness of resuscitation care in the Republic of Crimea, it is advisable to monitor the coverage of the EMS employees with resuscitation training and the rates of their participation in resuscitation attempts, as well as to perform additional targeted training in CPR, in particular, using alternative methods of education.

Outcome of cardiorespiratory arrest in patients with respiratory diseases in emergency department

Objective Cardiorespiratory arrest is rapidly fatal without resuscitation. The authors aimed to determine the outcome of cardiopulmonary resuscitation (CPR) for patient with respiratory disease presenting to the emergency setting with cardiorespiratory arrest. Materials and methods This prospective cohort study was carried out on 60 patients who presented to the emergency room with respiratory disorders and presented with or developed cardiorespiratory arrest. CPR was done guided by international guidelines for CPR. Patient demographic and clinical data, frequency of cardiopulmonary arrest, duration of resuscitation, length of hospital and ICU stay, and the outcome of resuscitation were recorded. Clinical and neurological examination and Glasgow coma scale were applied for all patients. Psychological assessment was done only for survivors (15 patients) using Beck depression inventory-II scale and Taylor manifest anxiety scale. Results Of 60 patients, 15 (25%) were discharged fully conscious, whereas 45 (75%) patients died. Age, sex, comorbidities, and cause of arrest did not show any statistically significant association with the outcome (P>0.05 for all). The duration of CPR was significantly lower in survivor group compared with nonsurvivor group (4.50±2.10 vs 12.87±8.52 min; P=0.001). There was a significant negative correlation between GSC and duration of CPR (r=−0.502, P Conclusion Cardiorespiratory arrest had unfavorable outcome, and there was an inverse correlation between CPR duration and survival to hospital discharge, neurological outcome, and psychological outcome.

Regurgitation and pulmonary aspiration during cardio-pulmonary resuscitation (CPR) with a laryngeal tube: A pilot crossover human cadaver study

BackgroundHigh-quality chest compressions are imperative for Cardio-Pulmonary-Resuscitation (CPR). International CPR guidelines advocate, that chest compressions should not be interrupted for ventilation once a patient’s trachea is intubated or a supraglottic-airway-device positioned. Supraglottic-airway-devices offer limited protection against pulmonary aspiration. Simultaneous chest compressions and positive pressure ventilation both increase intrathoracic pressure and potentially enhances the risk of pulmonary aspiration. The hypothesis was, that regurgitation and pulmonary aspiration is more common during continuous versus interrupted chest compressions in human cadavers ventilated with a laryngeal tube airway.MethodsTwenty suitable cadavers were included, and were positioned supine, the stomach was emptied, 500 ml of methylene-blue-solution instilled and laryngeal tube inserted. Cadavers were randomly assigned to: 1) continuous chest compressions; or, 2) interrupted chest compressions for ventilation breaths. After 14 minutes of the initial designated CPR strategy, pulmonary aspiration was assessed with a flexible bronchoscope. The methylene-blue-solution was replaced by 500 ml barium-sulfate radiopaque suspension. 14 minutes of CPR with the second designated ventilation strategy was performed. Pulmonary aspiration was then assessed with a conventional chest X-ray.ResultsTwo cadavers were excluded for technical reasons, leaving 18 cadavers for statistical analysis. Pulmonary aspiration was observed in 9 (50%) cadavers with continuous chest compressions, and 7 (39%) with interrupted chest compressions (P = 0.75).ConclusionOur pilot study indicate, that incidence of pulmonary aspiration is generally high in patients undergoing CPR when a laryngeal tube is used for ventilation. Our study was not powered to identify potentially important differences in regurgitation or aspiration between ongoing vs. interrupted chest compression. Our results nonetheless suggest that interrupted chest compressions might better protect against pulmonary aspiration when a laryngeal tube is used for ventilation.

How Ventilation Is Delivered During Cardiopulmonary Resuscitation: An International Survey.

Recommendations regarding ventilation during cardiopulmonary resuscitation (CPR) are based on a low level of scientific evidence. We hypothesized that practices about ventilation during CPR might be heterogeneous and may differ worldwide. To address this question, we surveyed physicians from several countries on their practices during CPR. We used a Web-based opinion survey. Links to the survey were sent by e-mail newsletters and displayed on the Web sites of medical societies involved in CPR practice from December 2013 to March 2014. 1,328 surveys were opened, and 548 were completed (41%). Responses came from 54 countries, but 64% came from 6 countries. Responders were mostly physicians (89%). From this group, 97% declared following specific CPR guidelines. Regarding practices, 28% declared always or frequently adopting only continuous chest compressions without additional ventilation. With regard to mechanical chest compression devices, 38% responded that such devices were available to them; when used, 28% declared always or frequently experiencing problems with ventilation such as frequent alarms. During bag-mask ventilation in intubated patients, 18% declared stopping chest compression during insufflation, and 39% applied > 10 breaths/min, which conflicts with international CPR guidelines. When a ventilator was used, the volume controlled mode was the most common strategy cited, but there was heterogeneity regarding ventilator settings for PEEP, trigger, FIO2 , and breathing frequency. SpO2 and end-tidal CO2 were the 2 most monitored variables cited. Physicians indicated heterogeneous practices that often differ significantly from international CPR guidelines. This may reflect the low level of evidence and a lack of detailed recommendations concerning ventilation during CPR.

No small matter: pediatric resuscitation.

To present advancements in pediatric cardiac arrest research, highlighting articles most relevant to clinical practice published since the latest international guidelines for cardiopulmonary resuscitation (CPR). Clinical trials examining targeted temperature management in children support avoidance of hyperthermia for both pediatric in-hospital cardiac arrest (PIHCA) and out-of-hospital cardiac arrest (POHCA), but no statistically significant outcome differences were confirmed comparing 33 and 36 °C in the limited populations studied. Retrospective analyses of population-based POHCA registries revealed several associations: both bystander CPR and public-access defibrillation were associated with improved POHCA outcomes; conflicting results overshadow the benefits of conventional versus compression-only CPR; extracorporeal CPR was associated with improved PIHCA outcomes regardless of cause; intubation in PIHCA was associated with decreased survival, whereas there were no significant differences in outcomes between advanced airway management and bag-valve-mask ventilation in POHCA; and early epinephrine delivery in nonshockable rhythms during PIHCA was associated with improved outcomes. Length, age, and weight-based dosing systems can reduce time to medication delivery, quantitative errors, and anxiety among care providers. Mounting evidence continues to align management priorities for resuscitation of children and adults.

Cardiocerebral and cardiopulmonary resuscitation - 2017 update.

Sudden cardiac arrest is a major public health problem in the industrialized nations of the world. Yet, in spite of recurrent updates of the guidelines for cardiopulmonary resuscitation and emergency cardiac care, many areas have suboptimal survival rates. Cardiocerebral resuscitation, a non‐guidelines approach to therapy of primary cardiac arrest based on our animal research, was instituted in Tucson (AZ, USA) in 2002 and subsequently adopted in other areas of the USA. Survival rates of patients with primary cardiac arrest and a shockable rhythm significantly improved wherever it was adopted. Cardiocerebral resuscitation has three components: the community, the pre‐hospital, and the hospital. The community component emphasizes bystander recognition and chest compression only resuscitation. Its pre‐hospital or emergency medical services component emphasizes: (i) urgent initiation of 200 uninterrupted chest compressions before and after each indicated single defibrillation shock, (ii) delayed endotracheal intubation in favor of passive delivery of oxygen by a non‐rebreather mask, (iii) early adrenaline administration. The hospital component was added later. The national and international guidelines for cardiopulmonary resuscitation and emergency medical services are still not optimal, for several reasons, including the fact that they continue to recommend the same approach for two entirely different etiologies of cardiac arrest: primary cardiac arrest, often caused by ventricular fibrillation, where the arterial blood oxygenation is little changed at the time of the arrest, and secondary cardiac arrest from severe respiratory insufficiency, where the arterial blood is severely desaturated at the time of cardiac arrest. These different etiologies need different approaches to therapy.

Recent Trend in Therapeutic Hypothermia and Early-Onset Pneumonia in Cardiac Arrest

The ultimate goal of cardiopulmonary resuscitation (CPR) is restoring spontaneous circulation and minimizing neurologic deficits. Since two human studies presented improved neurologic outcome and reduced mortality after cardiac arrest in 2002,[1,2] therapeutic hypothermia (TH) has been recommended consistently in the international CPR guidelines for post-cardiac arrest care.[3-5] TH improves the neurologic outcome due to attenuation of the inflammatory response in the brain.[1] On the other hand, TH can have systemic adverse effect such as high infection rate. Geurts et al.[6] emphasized in a meta-analysis of 23 studies that TH was a risk factor of both pneumonia and sepsis after return of spontaneous circulation in cardiac arrest patients. Even if TH is not used, infection is more common in post-cardiac arrest care,[7] and pneumonia is the most common type of infection in out-of-hospital cardiac arrest (OHCA).[8] The cause of this high incidence of pneumonia in OHCA is that factors such as loss of airway protection, changed mental status, pulmonary contusion by chest compression, emergent airway access, and mechanical ventilation increase the risk of pulmonary infection.[7] Some studies have suggested that post-resuscitation pneumonia could be divided into early-onset and late-onset pneumonia according to onset time and prevalent pathogens; however, the onset time varied from three to seven days depending on the study.[8-11] Perbet et al.[11] reported that TH was an independent risk factor of early-onset pneumonia (EOP), which prolonged mechanical ventilation support and intensive care unit (ICU) stay with unchanged neurologic outcome and ICU mortality in a retrospective and large (641 patients) cohort study. Therefore, intensivists should be aware of management of EOP while conducting HT. Prophylactic antibiotics decreased the incidence of EOP in comatose patients with a variety of causes such as head trauma, intracranial hemorrhage, stroke, or cardiac arrest.[12] In a recently published study, prophylactic antibiotics reduced the incidence of pneumonia in cardiac arrest survivors undergoing TH, but they did not reduce patient mortality.[13] However, the researchers did not distinguish earlyor late-onset pneumonia. Kim et al.[14] have reported that prophylactic antibiotics in OHCA patients undergoing TH does not reduce the incidence of EOP. The authors insisted that the study evaluated the effect of prophylactic antibiotics on EOP for the first time. The incidence of EOP was 29.2% and 30.0% in prophylactic antibiotics and non-antibiotics, respec-

Inhospital resuscitation : Decisive measures for the outcome

Approximately 18 million patients are treated in German hospitals annually. On the basis of internationally published data the number of in-hospital cardiac arrests can be estimated as 54,000 per year. A structured treatment of in-hospital resuscitation according to the current scientific evidence is essential. In-hospital resuscitation shows some special characteristics in comparison to resuscitation in emergency services, which are highlighted in this article. This article is based on the international guidelines for cardiopulmonary resuscitation (CPR) first published in 1992 by the European Resuscitation Council (ERC) and the American Heart Association (AHA) as well as the amendments (current version 2010). Some current studies are also presented, which could not be taken into consideration for the guidelines from 2010. High quality chest compressions with as few interruptions as possible are of utmost importance. Patients with cardiac rhythms which can be defibrillated should be defibrillated within less than 2 min after the collapse. There is no evidence that equipping hospitals with automated external defibrillators is an advantage for survival after in-hospital cardiac arrest. Endotracheal intubation represents the gold standard of airway management during CPR. During in-hospital resuscitation experienced anesthesiologists are mostly involved; however, the use of supraglottic airway devices may help to minimize interruptions in chest compressions especially before the medical emergency team arrives at the scene. Feedback devices may improve the quality of manual chest compressions; however, most devices overestimate the compression depth if the patient is resuscitated when lying in bed. There is no evidence that mechanical chest compression devices improve the outcome after cardiac arrest. Mild therapeutic hypothermia is still recommended for neuroprotection after successful in-hospital resuscitation. The prevention of cardiac arrest is of special importance. Uniform and low threshold criteria for alarming the medical emergency team have to be defined to be able to identify and treat critically ill patients in time before cardiac arrest occurs.

Resuscitation between the guidelines -- what has happened since 2010

The standards of treatment of patients suffering cardiac arrest is defined by international guidelines for cardiopulmonary resuscitation, that are updated every five years. Scientific knowledge is continuously increasing and recent studies should be considered and discussed to improve the results of daily emergency care. There are some leading topics of the ongoing discussion concerning airwaymanagement, mechanical ventilation, mechanical cpr-devices and extracorporal life support. The strategies of postresuscitation care are also in the focus of interest. This review presents and discusses the value of recent investigations on resuscitation science.

Evaluation of figure model training on improvement of the cardiopulmonary resuscitation skills in new medical recruits

Objective To study the effect of new figure pattern on the cardiopulmonary resuscitation (CPR) training for the new medical staff.Methods The keys of 2010 CPR were changed into figure pattern,and totals of 172 new medical staff were received the new training.They were assessed with questionnaire before and after the training on first-aid knowledge and skills.Results The average score of operation of new medical staff was significantly lower than that after the training [(56.88 ± 8.926) vs (96.20 ± 2.89),t =23.35,P ＜0.05],as well as the knowledge awareness rate (52％ vs 92.6％).Conclusions Compared to the traditional training model,the new training model made medical staff pay attention on every details and key data,and make sure the precise of practice in position,depth,dynamics and frequency. Key words: Cardiopulmonary resuscitation; International CPR guidelines (2010) ; Figure pattern

What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation?*

The 2010 international guidelines for cardiopulmonary resuscitation recently recommended an increase in the minimum compression depth from 38 to 50 mm, although there are limited human data to support this. We sought to study patterns of cardiopulmonary resuscitation compression depth and their associations with patient outcomes in out-of-hospital cardiac arrest cases treated by the 2005 guideline standards. Prospective cohort. Seven U.S. and Canadian urban regions. We studied emergency medical services treated out-of-hospital cardiac arrest patients from the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest for whom electronic cardiopulmonary resuscitation compression depth data were available, from May 2006 to June 2009. We calculated anterior chest wall depression in millimeters and the period of active cardiopulmonary resuscitation (chest compression fraction) for each minute of cardiopulmonary resuscitation. We controlled for covariates including compression rate and calculated adjusted odds ratios for any return of spontaneous circulation, 1-day survival, and hospital discharge. We included 1029 adult patients from seven U.S. and Canadian cities with the following characteristics: Mean age 68 yrs; male 62%; bystander witnessed 40%; bystander cardiopulmonary resuscitation 37%; initial rhythms: Ventricular fibrillation/ventricular tachycardia 24%, pulseless electrical activity 16%, asystole 48%, other nonshockable 12%; outcomes: Return of spontaneous circulation 26%, 1-day survival 18%, discharge 5%. For all patients, median compression rate was 106 per minute, median compression fraction 0.65, and median compression depth 37.3 mm with 52.8% of cases having depth <38 mm and 91.6% having depth <50 mm. We found an inverse association between depth and compression rate ( p < .001). Adjusted odds ratios for all depth measures (mean values, categories, and range) showed strong trends toward better outcomes with increased depth for all three survival measures. We found suboptimal compression depth in half of patients by 2005 guideline standards and almost all by 2010 standards as well as an inverse association between compression depth and rate. We found a strong association between survival outcomes and increased compression depth but no clear evidence to support or refute the 2010 recommendations of >50 mm. Although compression depth is an important component of cardiopulmonary resuscitation and should be measured routinely, the most effective depth is currently unknown.

Does the change of educational strategy for chest compression based on the change of guidelines affect on the quality of prehospital chest compression?

Background and Aims. International guidelines for cardiopulmonary resuscitation (CPR) changed their strategy with res-pect to the rate of chest compression (CC) and ventilation from 15:2 to 30:2. The object of this study was to clarify the effect of this change on the quality of CPR.Subjects and Methods. We recorded the frequency of CC and ventilation performed by Emergency Life Support Technici-ans (ELSTs) during CPR in ambulances, and compared the period when ELSTs performed 15:2 CPR with that when they performed 30:2 CPR.Results. During the first period, ELSTs actually performed CCs 15 times per 7.2 sec (128.1 times per minute), and perfor-med 2 ventilations per 4.5 sec. Thirty-six percent of patients received appropriate CCs (100-120/min), while 43% received high-frequency CCs (120-150/min) and 13% received CCs that were too fast (more than 150/min). During the second period, ELSTs performed CCs 30 times per 18.1 sec (101.6 times per minute), and performed 2 ventilations per 4.3 sec. Conclusions. The change in the CC-to-ventilation ratio for CPR in the international guidelines from 15:2 to 30:2 can improve the exactness of the frequency of CCs. However, ELSTs may not be able to perform CCs exactly as recommended. It is important to evaluate the exact frequency of CCs by ELSTs or paramedics in ambulances and to evaluate the relationship between the frequency of CCs and patient outcome.

The cardiocerebral resuscitation protocol for treatment of out-of-hospital primary cardiac arrest.

Out-of-hospital cardiac arrest (OHCA) is a significant public health problem in most westernized industrialized nations. In spite of national and international guidelines for cardiopulmonary resuscitation and emergency cardiac care, the overall survival of patients with OHCA was essentially unchanged for 30 years--from 1978 to 2008 at 7.6%. Perhaps a better indicator of Emergency Medical System (EMS) effectiveness in treating patients with OHCA is to focus on the subgroup that has a reasonable chance of survival, e.g., patients found to be in ventricular fibrillation (VF). But even in this subgroup, the average survival rate was 17.7% in the United States, unchanged between 1980 and 2003, and 21% in Europe, unchanged between 1980 and 2004. Prior to 2003, the survival of patients with OHCA, in VF in Tucson, Arizona was less than 9% in spite of incorporating previous guideline recommendations. An alternative (non-guidelines) approach to the therapy of patients with OHCA and a shockable rhythm, called Cardiocerebral Resuscitation, based on our extensive physiologic laboratory studies, was introduced in Tucson in 2003, in rural Wisconsin in 2004, and in selected EMS areas in the metropolitan Phoenix area in 2005. Survival of patients with OHCA due to VF treated with Cardiocerebral Resuscitation in rural Wisconsin increased to 38% and in 60 EMS systems in Arizona to 39%. In 2004, we began a statewide program to advocate chest compression-only CPR for bystanders of witnessed primary OHCA. Over the next five years, we found that survival of patients with a shockable rhythm was 17.7% in those treated with standard bystander CPR (mouth-to-mouth ventilations plus chest compression) compared to 33.7% for those who received bystander chest-compression-only CPR. This article on Cardiocerebral Resuscitation, by invitation following a presentation at the 2011 Danish Society Emergency Medical Conference, summarizes the results of therapy of patients with primary OHCA treated with Cardiocerebral Resuscitation, with requested emphasis on the EMS protocol.

(P2-3) Analysis of Chest Compression Rate and Its Affect on the Quality of Chest Compressions

BackgroundIn the last 50 years of modern-era cardiopulmonary resuscitation (CPR), survival rates remain dismal, worldwide. International CPR guidelines recommended a compression rate of at least 100 per minute. There is little evidence documenting if and to what extent high compression rates affect the quality of chest compressions.ObjectivesAn objective of this study was to evaluate the effect mean compression rate (MCR) had on the overall quality of chest compressions. Investigators hypothesized that MCRs &gt; 110 would result in a smaller percentage of adequate: compressions (PAC); depth (PAD); and recoil (PAR).MethodsIn this observational pilot study, basic life support providers were recruited from prehospital and in-hospital settings to provide 10 minutes of continuous chest compressions, based on the 2005 American Heart Association guidelines. An adequate compression was defined as a compression that was &gt; 35 mm, had full recoil, and correct hand position. Data were recorded using the Laerdal PC Skill reporting System.ResultsNinety four (91.3%) of 103 participants completed 10 minutes of compressions. Rescuers represented a variety of backgrounds, average age of 35.5 ± 11.0 years. Fifty eight (56.2%) rescuers had performed CPR in the last two years, and 54 (52.4%) practiced prehospital EMS. Providers that did not complete the entire 10 minutes tended to have a higher MCR than those completing 10 minutes, 114.2 ± 19.3 vs. 105.8 ± 15.4 respectively. Within the first two minutes, rescuers with a MCR &gt; 110 delivered 45% of their compressions adequately, compared to 60% when a rescuer's MCR was &lt; 110. This initial disparity was primarily due to decreased PAR, not decreased PAD. After 2 minutes, higher MCRs correlated with decreased PAC, due to decreased PAD.ConclusionsData indicates a higher MCR results in decreased PAC, PAD, and PAR, likely attributed to increased rescuer fatigue.

New cardiac arrest guidelines: implications for paramedic practice

New UK, European and international guidelines for cardiopulmonary resuscitation (CPR) were published in October 2010 ( Nolan et al, 2010 ). These guidelines marked the 50th anniversary of modern CPR ( Kouwenhoven et al, 1960 ). The new guidelines give greater emphasis on early bystander CPR, high quality chest compressions with minimal interruption, early effective defibrillation and good quality post cardiac arrest care for achieving neurological survival in cardiac arrest victims. Guidelines 2010 recommendations also attempt to make it easier for rescuers to achieve this in any setting. The full UK guidelines can be accessed from the Resuscitation Council (UK) website ( www.resus.org.uk ). In this article, the authors discuss issues relating to the new guidelines that they feel are relevant for paramedic practice.