International Resuscitation Guidelines Research Articles

Family presence during resuscitation: a survey of Japanese physicians’ views

Abstract Aim This study aimed to clarify physicians’ awareness of and attitudes toward family presence during resuscitation (FPDR) and related factors. Subject and methods A web-based questionnaire survey was conducted of 7859 physicians who were members of the Japanese Society of Intensive Care Medicine (survey period: October 12, 2022, to December 31, 2022). Focusing on cardiopulmonary arrest, the survey questioned their awareness and attitudes, with a comparison of exogenous and non-exogenous patients. Results The proportion of respondents who have family present during resuscitation was 100 (25.0%) for exogenous and 105 (29.2%) for non-exogenous. The proportion who believed that the family’s acceptance of death is greater with FPDR was 255 (61.7%) for exogenous and 245 (65.7%) for non-exogenous. The proportion who believed that the family’s acceptance of death is greater with FPDR included a significantly higher number of respondents who had family present than in the proportion who believed that FPDR has no effect. The proportion who believed that the family is emotionally traumatized by FPDR was 251 (60.8%) for exogenous and 217 (58.2%) for non-exogenous. The proportion who believed that families are emotionally traumatized by FPDR included a significantly higher number of respondents who do not have family present than the proportion who believed that FPDR has no effect. Conclusion Various international resuscitation guidelines have recommended FPDR from an early stage to alleviate grief and prevent mental disorders. However, these guidelines are not always followed in Japan.

Invasive arterial blood pressure delineator for cardiopulmonary resuscitation patients during pauses of chest compressions

Invasive arterial blood pressure delineator for cardiopulmonary resuscitation patients during pauses of chest compressions

Professional Guidelines for the Care of Extremely Premature Neonates: Clinical Reasoning versus Ethical Theory.

AbstractProfessional statements guide neonatal resuscitation thresholds at the border of viability. A 2015 systematic review of international guidelines by Guillen et al. found considerable variability between statements' clinical recommendations for infants at 23-24 weeks gestational age (GA). The authors concluded that differences in the type of data included were one potential source for differing resuscitation thresholds within this "ethical gray zone." How statements present ethical considerations that support their recommendations, and how this may account for variability, has not been as rigorously explored. We performed a mixed-methods exploratory analysis of 25 current international guidelines for neonatal resuscitation at 22+0-25+0 weeks GA. Qualitative analysis using a modified grounded theory yielded 34 distinct codes, eight categories, and four overarching themes. Three themes, consequentialism, principlism, and rights-based, consisted of concepts central to these ethical frameworks. The fourth theme, clinical reasoning, described counseling practices, medical management, outcomes data, and prognostic uncertainty, without any ethical context. The theme of clinical reasoning appeared in 22 of 25 guidelines. Ten guidelines lacked any ethical theme. Guidelines with an identified ethical theme were more likely to recommend comfort care than guidelines without an identified ethical theme, and recommended it at a higher average GA (22.7 weeks vs. 22.0 weeks, p = 0.03). Thus, how ethical concepts are incorporated into guidelines potentially impacts resuscitation thresholds. We argue that inclusion of explicit discussion of ethical considerations surrounding resuscitation in the "gray zone" would clarify values that inform recommendations and facilitate discussions about how neonatology ought to approach periviability as outcomes continue to evolve.

Effectiveness of a Novel Tablet Application in Reducing Guideline Deviations During Pediatric Cardiac Arrest

Deviations from international resuscitation guidelines during the management of pediatric cardiac arrest are frequent and affect clinical outcomes. An interactive tablet application (app), PediAppRREST, was developed to reduce guideline deviations during pediatric cardiac arrest. To assess the effectiveness of PediAppRREST in improving the management of simulated in-hospital pediatric cardiac arrest. This multicenter 3-group simulation-based randomized clinical trial was conducted from September 2020 to December 2021 at 4 Italian university hospitals (Padua, Florence, Rome, Novara). Participants included residents in pediatrics, emergency medicine, and anesthesiology. Analyses were conducted as intention-to-treat. Data were analyzed from January to June 2022. Teams were randomized to 1 of 3 study groups: an intervention group that used the PediAppRREST app; a control group that used a paper-based cognitive aid, the Pediatric Advanced Life Support (PALS) pocket card; and a control group that used no cognitive aids. All the teams managed the same standardized simulated scenario of nonshockable pediatric cardiac arrest. The primary outcome was the number of deviations from guidelines, measured by a 15-item checklist based on guideline recommendations. The main secondary outcomes were quality of chest compressions, team clinical performance (measured by the Clinical Performance Tool), and perceived team leader's workload. Study outcomes were assessed via video reviews of the scenarios. Overall 100 teams of 300 participants (mean [SD] age, 29.0 [2.2] years; 195 [65%] female) were analyzed by intention-to-treat, including 32 teams randomized to the PediAppRREST group, 35 teams randomized to the PALS control group, and 33 teams randomized to the null control group. Participant characteristics (210 pediatric residents [70%]; 48 anesthesiology residents [16%]; 42 emergency medicine residents [14%]) were not statistically different among the study groups. The number of deviations from guidelines was significantly lower in the PediAppRREST group than in the control groups (mean difference vs PALS control, -3.0; 95% CI, -4.0 to -1.9; P < .001; mean difference vs null control, -2.6; 95% CI, -3.6 to -1.5; P < .001). Clinical Performance Tool scores were significantly higher in the PediAppRREST group than control groups (mean difference vs PALS control, 1.4; 95% CI, 0.4 to 2.3; P = .002; mean difference vs null control, 1.1; 95% CI, 0.2 to 2.1; P = .01). The other secondary outcomes did not significantly differ among the study groups. In this randomized clinical trial, the use of the PediAppRREST app resulted in fewer deviations from guidelines and a better team clinical performance during the management of pediatric cardiac arrest. ClinicalTrials.gov Identifier: NCT04619498.

The Beginning of an ECLS Center: First Successful ECPR in an Emergency Department in Romania-Case-Based Review.

According to the latest international resuscitation guidelines, extracorporeal cardiopulmonary resuscitation (ECPR) involves the utilization of extracorporeal membrane oxygenation (ECMO) in specific patients experiencing cardiac arrest, and it can be considered in situations where standard cardiopulmonary resuscitation efforts fail if they have a potentially reversible underlying cause, among which we can also find hypothermia. In cases of cardiac arrest, both witnessed and unwitnessed, hypothermic patients have higher chances of survival and favorable neurological outcomes compared to normothermic patients. ECPR is a multifaceted procedure that requires a proficient team, specialized equipment, and comprehensive multidisciplinary support within a healthcare system. However, it also carries the risk of severe, life-threatening complications. With the increasing use of ECPR in recent years and the growing number of centers implementing this technique outside the intensive care units, significant uncertainties persist in both prehospital and emergency department (ED) settings. Proper organization is crucial for an ECPR program in emergency settings, especially given the challenges and complexities of these treatments, which were previously not commonly used in ED. Therefore, within a narrative review, we have incorporated the initial case of ECPR in an ED in Romania, featuring a successful resuscitation in the context of severe hypothermia (20 °C) and a favorable neurological outcome (CPC score of 1).

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.

Pro: We Should Routinely Intubate All Patients in Cardiac Arrest

IN RECENT years, persuasive evidence has emerged that questions the benefits of tracheal intubation in the course of treatment for cardiac arrest, both in and out of the hospital. However, international resuscitation guidelines continue to recommend either a supraglottic airway or tracheal intubation to oxygenate the patient during cardiac arrest, according to operator experience and preference. Herein, the author argues that physicians should understand that routine endotracheal intubation of patients in cardiac arrest is the most protective and definitive airway management while actively managing the risks inherent in this procedure.

Cardiac arrest centers-certification fosters inflow of patients by emergency medical services

Since 2015, the international resuscitation guidelines recommend the implementation of specialized hospitals (so-called cardiac arrest centers, CAC) for patients with out-of-hospital cardiac arrest (OHCA). The aim was to investigate the potential influence of hospital certification as aCAC on the decision of emergency medical service staff (EMS, including out-of-hospital emergency physicians and paramedics) when transporting OHCA patients to ahospital. Aweb-based, anonymous questionnaire with 20items was performed from 15May2018 to 15June2018 in Germany. Target groups were out-of-hospital emergency physicians and paramedics. Of 437 respondents, 378 responses (n = 292 emergency physicians, n = 86paramedics) were included in the statistical analysis. In all, 75.1% (n = 284) indicated that CAC certification of hospitals would matter in their own transportation decisions for OHCA patients in future transportations, 78.3% (n = 296) expected that CAC certification will result in an improvement in patient care, and 78.8% (n = 298) were in favor of implementing the CAC certification. Respondents would accept an additional 16.3 min (95% confidence interval 15.2-17.3) of transportation time to reach aCAC. Certification of hospitals as CAC has the potential to influence emergency medical personnel decisions about which hospital to transport OHCA patients to. Due to the limited additional acceptable transport time to reach aCAC, aclose network of certified hospitals is needed nationwide.

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.

Perlite is a suitable model material for experiments investigating breathing in high density snow

Outdoor breathing trials with simulated avalanche snow are fundamental for the research of the gas exchange under avalanche snow, which supports the development of the international resuscitation guidelines. However, these studies have to face numerous problems, including unstable weather and variable snow properties. This pilot study examines a mineral material perlite as a potential snow model for studies of ventilation and gas exchange parameters. Thirteen male subjects underwent three breathing phases—into snow, wet perlite and dry perlite. The resulting trends of gas exchange parameters in all tested materials were similar and when there was a significant difference observed, the trends in the parameters for high density snow used in the study lay in between the trends in dry and wet perlite. These findings, together with its stability and accessibility year-round, make perlite a potential avalanche snow model material. Perlite seems suitable especially for simulation and preparation of breathing trials assessing gas exchange under avalanche snow, and potentially for testing of new avalanche safety equipment before their validation in real snow.The study was registered in ClinicalTrials.gov on January 22, 2018; the registration number is NCT03413878.

First aid guidelines for environmental topics: Educational approach and adaptation

Extreme environmental conditions and exposure to very high or low temperatures, particularly when this happens quickly, can lead to severe illness and injury. As the climate changes and temperature differences become more pronounced, these instances are likely to increase. First aid education which deals with environmental conditions is particularly important in circumstances where people are unprepared, more vulnerable due to age or have existing medical conditions. Remoteness or inaccessibility to medical care also increases vulnerability. This paper reviews a selection of the environmental topics covered in the International First Aid, Resuscitation and Education Guidelines 2020 (IFRC, 2020) which seek to blend clinical first aid evidence with educational evidence, principles and expertise. Covering Hyperthermia, Dehydration, Hypothermia, Frostbite, Altitude Sickness, and Motion Sickness, we provide educational and adaptation interpretation in different contexts, stimulate debate and identify gaps. We also review how the 2020 Guidelines viewed these topics through the lens of the Chain of Survival Behaviors and identify the most pertinent stages in that chain to focus learning on these topics. The 2020 Guidelines emphasize the need for content and educational adaptation according to the learner, which is central to these topics. First aid instructors and program designers need to frame action relevant to their audience and local needs. The teaching of environmental first aid topics should be contextualized to the local geography, legal requirements, culture and behaviors of the learners and their context. For these topics, we conclude that facilitation tips for environmental conditions requiring first aid should focus on prevention and helping learners to recognize early warning signs of the different conditions so they can take preventative action before serious illness sets in.

Quality of Cardiopulmonary Resuscitation and 5-Year Survival Following in-Hospital Cardiac Arrest.

PurposeTo improve cardiac arrest survival, international resuscitation guidelines emphasize measuring the quality of cardiopulmonary resuscitation (CPR). We aimed to investigate CPR quality during in-hospital cardiac arrest (IHCA) and study long-term survival outcomes.Patients and MethodsThis was a cohort study of IHCA from December 2011 until November 2014. Data were collected from the hospital switch board, patient records, and from defibrillators. Impedance data from defibrillators were analyzed manually at the level of single compressions. Long-term survival at 1-, 3-, and 5 years is reported.ResultsThe study included 189 IHCAs; median (interquartile range (IQR)) time to first rhythm analysis was 116 (70–201) seconds and median (IQR) time to first defibrillation was 133 (82–264) seconds. Median (IQR) chest compression rate was 126 (119–131) per minute and chest compression fraction (CCF) was 78% (69–86). Thirty-day survival was 25%, while 1-year-, 3-year-, and 5-year survival were 21%, 14%, and 13%, respectively. There was no significant association between any survival outcomes and CCF, whereas chest compression rate was associated with survival to 30 days and 3 years. Overall, 5-year survival was associated with younger age (median 68 vs 74 years, p=0.003), less comorbidity (Charlson comorbidity index median 3 vs 5, p<0.001), and witnessed cardiac arrest (96% vs 77%, p=0.03).ConclusionWe established a systematic collection of IHCA CPR quality data to measure and improve CPR quality and long-term survival outcomes. Median time to first rhythm check/defibrillation was <3 minutes, but median chest compression rate was too fast and median CCF slightly below 80%. More than half of 30-day survivors were still alive at 5 years.

Barrier resuscitation by lay rescuers during COVID-19 pandemic

Aerosols generated from chest compressions and ventilation attempts in patients with cardiac arrest may cause airborne infections. Accordingly, the interim international resuscitation guidelines have restricted basic life support by lay rescuers to compression only and the use of an automated external defibrillator during the COVID-19 pandemic. Although these measures may diminish the risk of infection for laypersons, the missing respiratory support can be detrimental for patients with hypoxia-related cardiac arrest. To overcome this shortcoming we want to introduce a special tool that allows ventilation during barrier resuscitation by laypersons. We hypothesize that the application of a device made of a polyvinyl chloride shield with a centrally installed S-shaped ventilation pipe with integrated filter can provide adequate ventilation while concurrently protecting patient and rescuer from airborne agents. Aerosols from air leakage are removed by adhesion and drainage below the barrier. No specific training other than basic life support is needed. We suggest that a tool of this kind be considered essential equipment and stored together with disposable gloves in public access locations.

First aid education guidelines for peer learning: The approach in practice

The International Federation of the Red Cross and Red Crescent (IFRC) updated its guidelines in 2020. The result of this process is the International First Aid, Resuscitation, and Education Guidelines 2020 (IFRC, 2020) that are grounded in the Chain of Survival Behaviors to support Red Cross and Red Crescent National Societies in effective implementation of first aid education. This paper is written by first aid educators as they reflect on the evidence expressed in the 2020 Guidelines and their own experience to provide opinion and contextual application to the educational approach of peer learning. While peer learning is one tool in the toolbox that has an appropriate role for maximum effectiveness, it will not serve as a replacement for a facilitator. Peer learning can be very effective to ensure that the knowledge and skills explored in first aid education are adapted, contextualized, and locally implemented. In addition, humility is an important trait for the facilitator in that they must be comfortable in the unknown. By using peer learning, the facilitator is decentralizing the teaching, which can have both predictively positive and unintended or less desirable results. To mitigate the likelihood of unintended aspects, the authors suggest three stages to effectively implement peer learning approaches: the setup, ongoing support, and debriefing. In this review of the Guidelines to inform contextual application, the limited evidence base available in creating the Guidelines is acknowledged and built upon by exploring learner groups that provide alternative forms of peer learning to those described (children and school-aged learners). Finally, this paper examines how peer learning is reflected in the Principles of First Aid Education (IFRC, 2020), particularly the principles which link to learners and discovery.

Association between time of out-of-hospital cardiac arrest and survival: Examination of the all-Japan Utstein registry and comparison with the 2005 and 2010 international resuscitation guidelines

Existing studies have yielded conflicting results regarding the relationship between the time of occurrence of out-of-hospital cardiac arrests and the associated outcomes. We examined whether the one-month survival rate for out-of-hospital cardiac arrests differed depending on whether the cardiac arrest occurred during the day or night. Further, we examined whether this rate differed when comparing the period succeeding the 2005 International Resuscitation Guidelines (2006-2010) with that following the 2010 guidelines (2011-2015). Using data from the All-Japan Utstein Registry for 2006-2015, adult out-of-hospital cardiac arrest patients whose collapse was witnessed and for whom the collapse-to-hospital-arrival interval was shorter than 120min were included in this study. Patients were categorized in terms of whether their arrest occurred during the post-2005- or post-2010-guideline period. The primary measure was the one-month survival with a favorable neurological outcome. Of 481,624 cases analyzed, 20% occurred at night. For both guideline periods, nighttime out-of-hospital cardiac arrests were associated with significantly lower one-month survival rates than daytime incidents (used as a reference; adjusted odds ratio: 0.69 and 0.63, 95% confidence interval: 0.65-0.73 and 0.60-0.65, and P<0.001 and <0.001 for the 2005 and 2010 guideline periods, respectively). One-month survival with a favorable neurological outcome was significantly lower for patients who experienced nighttime out-of-hospital cardiac arrests, compared to daytime out-of-hospital cardiac arrests. This could be addressed by improving cardiopulmonary resuscitation training for bystanders and expanding and improving nighttime emergency medical services.

Concordance between the 2010 and 2015 Resuscitation Guidelines of International Liaison Committee of Resuscitation Councils (ILCOR) members and the ILCOR Consensus of Science and Treatment Recommendations (CoSTRs)

Cardiac arrests are associated with poor outcomes. The International Liaison Committee on Resuscitation (ILCOR) evaluates resuscitation science and produced, until 2015, five-yearly consensus on science and treatment recommendations (CoSTRs), informing global resuscitation guidelines. We aimed to identify similarities/differences in resuscitation guidelines from ILCOR members, noting concurrence over time, and CoSTRs influence on these guidelines. We considered the component elements of paediatric and adult, basic and advanced resuscitation guidelines, published in 2010 and 2015, along with matching ILCOR CoSTRs to examine their influence. We contacted the responsible councils when guidelines were unavailable online. Complete resuscitation guidelines were found for six of the seven ILCOR council members. The Resuscitation Council of Asia only had adult basic life support (BLS) guidelines in English. Three members used the AHA guidelines. Therefore, five rather than seven sets of resuscitation guidelines were compared to the CoSTRs. Concurrence between CoSTRs recommendations and ILCOR council member's resuscitation guidelines has improved over time. Minor variations were identified in both basic and advanced life support, with most variance in paediatric guidelines, but these narrowed over time. The improved concurrence across the resuscitation guidelines with the CoSTRs suggests that ILCOR members accept and hence incorporate CoSTRs recommendations to inform their own resuscitation guidelines. This is one step towards the development of international universal guidelines for adult and paediatric resuscitation.

Applications of Postresuscitation Debriefing Frameworks in Emergency Settings: A Systematic Review.

Postresuscitation debriefing (PRD) is a valuable educational tool in emergency medicine. It is recommended by international resuscitation guidelines, has been shown to improve both patient outcomes and resuscitation team performance, and is frequently requested by medical learners. However, there is limited research comparing standardized debriefing frameworks. Not only does this hinder the ability of interested emergency departments (EDs) to adopt PRD, but it limits the quality of future debriefing research. We sought to identify and compare existing PRD frameworks to inform the implementation of effective PRD in emergency medicine. We conducted a systematic review following PRISMA standards to identify debriefing frameworks used in the ED and other acute care settings for further analysis. Identified frameworks were analyzed and compared based on a method previously described in the literature. Our search identified six frameworks, which ranged from simple tools for immediate feedback to complex, hospital-wide systems engineering-based approaches to quality improvement. Key findings were the importance of ensuring debriefing facilitators are properly selected and trained and of tailoring framework design to specific organizational targets. However, there is limited validation data for these frameworks, and more study is needed to identify and validate true best practices in PRD. All six identified frameworks seem to be effective methods of debriefing. Given the breadth in debriefing methods and goals identified, this suggests that there may not be a one-size-fits-all approach to PRD and that organizations should instead identify their own unique needs and barriers and adopt the debriefing framework that best addresses those needs. Other findings were the importance of well-trained debriefing facilitators and the use of clear roles in organizing debriefings. Further research is needed to assess the effectiveness of postresuscitation frameworks with regard to both team performance and patient outcomes.

Evaluation Of CPR Quality Via Smartphone With A Video Livestream – A Study In A Metropolitan Area

Background Telephone-assisted cardiopulmonary resuscitation (CPR) is an effective and proven tool to improve patient survival and outcome after cardiac arrest, and is therefore recommended in international resuscitation guidelines. A new technology that provides the emergency medical services (EMS) dispatcher with a video livestream from a smartphone during telephone-assisted CPR was investigated to assess whether a correct judgment of CPR quality is feasible. Material and Methods After Ethics Committee approval, we conducted this study from August to September 2018 in the University Hospital of Cologne and its metropolitan area. Our study team set up a full-scale resuscitation mannequin on 54 study sites. Video telephony between caller and EMS dispatcher was established, and CPR was initiated with randomized common quality issues concerning compression frequency, compression depth, and compression point. It was evaluated whether the dispatcher recognized correct and incorrect resuscitation performance. Results Forty-six video calls were established successfully. EMS dispatching staff identified correct compression frequency (100-120/min) in 87.5% of the cases, too low frequency (<80/min) was correctly identified in 92%, and too high frequency (>140/min) in 58.5%, respectively. Correct compression depth (5-6 cm) was identified in 70.6%, shallow compressions (<3cm) in 92.9% and a continuous decrease of depth in 100% of all cases. Correct compression point was identified in 87.5%, incorrect epigastric compression in 92.3%, incomplete release in 58.8%. Conclusion A video livestream from a smartphone can support an EMS dispatcher’s assistance in resuscitation. Typical resuscitation mistakes, like incorrect compression frequency or depth, and incorrect compression points could be recognized and corrected efficiently via video livestream.

Adrenaline in cardiac arrest

The use of adrenaline during a cardiac arrest is well-established and supported by international guidelines. However, recent studies1–2 have questioned the appropriateness of adrenaline administration whereas other papers indicate that any benefit from adrenaline maybe time-sensitive.3–4 Two recently published studies have both challenged the use of adrenaline during resuscitation and whilst both papers used different methodologies they demonstrated similar results. The Paramedic 2 study1 was a placebo-based randomised control trial whereas the paper by Loomba et al.,2 used a meta-analysis of 14 peer-reviewed publications recruiting 655,853 patients, 7.4% of whom received adrenaline. Neither study was able to demonstrate any meaningful survival benefit associated with adrenaline administration (Table 1 and 2). However, both studies noted poor neurological outcome in post-cardiac survivors. It is noteworthy that both of these studies used different, but validated,5 neurological scoring systems (either the Modified Rankin Scale or the Cerebral Performance Category).Whilst there is an acceptable correlation between the Modified Rankin Scale or the Cerebral Performance Category (Table 3) there is a degree of variation.5 This variation is partly due to what the two scales accept as being a good neurological outcome as well as an inbuilt degree of subjectiveness of any assessment of neurological status.5 Whilst The Paramedic 2 study1 and Loomba et al.,2 meta-analysis demonstrated no benefit of adrenaline, studies by Goto et al.,3 and Donnino et al., (adults)4 have published contradictory findings. Importantly Donnino et al.,4 reported improved neurological status in non-shockable cardiac arrest when adrenaline was administered.2 However, to date no study has demonstrated a benefit of adrenaline when used to treat shockable cardiac arrest.Interestingly both Goto et al.,3 and Donnino et al.,4 indicated that any benefit from adrenaline administration was time-sensitive. Goto et al.,3 noted that the optimal time for adrenaline administration was < 9 minutes. Whereas, Donnino et al.,4 reported on the impact of increasing time delay to the first dose noting that when adrenaline was administered < 1 minute of confirmation of cardiac arrest, 12% of patients survived, but that this dropped to 9% after the fourth minute and was down to 7% after seven minutes (p < 0.001). The findings of Goto et al.,3 and Donnino et al.,4 represent a clinical challenge. Notably, during the Paramedic 2 study the average time of administration of adrenaline was approaching 20 minutes (6.6 minutes response time and 13.8 minutes) raising the question would the results of Paramedic 2 have been different if adrenaline was administered faster and whether adrenaline should only be administrated in witnessed cardiac arrest?The routine use of adrenaline as the mainstay of resuscitation is being challenged, especially with regards to long-term patient survival and its role in the management of shockable cardiac arrest. However, in specific patients, when given early, adrenaline may still have a role to play in resuscitation. The 2020 International Resuscitation Guidelines are eagerly awaited.

P2666Association of out-of-hospital cardiac arrest occurrence time and the survival in all-Japan utstein registry: difference between international resuscitation guidelines 2005 and 2010

Abstract Background/Introduction Previous studies have shown that out-of-hospital cardiac arrest (OHCA) occurring at night have poor outcomes compared with OHCA occurring during daytime. On the other hand, nationwide OHCA outcomes have gradually improved in Japan. Purpose We sought to examine whether one-month survival of OHCA differed between daytime and nighttime occurrences, and they differed between the periods of International Resuscitation Guidelines 2005 and 2010. Methods Using the All-Japan Utstein Registry between 2005 and 2015, adult OHCA patients whose collapse was witnessed by a bystander and the call-to-hospital admission interval was shorter than 120 min were included in this study. OHCA patients were divided by period of the International Resuscitation Guideline 2005 and 2010. Guideline 2005 included years from 2006 to 2010, while Guideline 2010 included years from 2011 to 2015. The primary outcome was one-month survival with favorable neurological outcome, defined as Cerebral Performance Category scale of 1 or 2. Daytime, evening, and night were defined as 0700 to 1459 h, 1500 to 2259 h, and 2300 to 0659 h, respectively. Results Among 479,046 cases, 20.3% revealed OHCA occurring at night. OHCA patients occurring at night had lower rate of bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator use than those occurring at both daytime and evening. In addition, of those who received bystander CPR, higher rate of patients received CPR by family members. OHCA patients occurring at night in both guideline periods had significantly worse one-month survival than those occurring during daytime (reference) (adjusted odds ratio, 0.69, 0.64; 95% confidence interval 0.65–0.72, 0.61–0.67; P&lt;0.001, P&lt;0.001, Guideline 2005 and 2010 respectively). OHCA patients occurring during daytime in Guideline 2010 had better one-month survival than those in Guideline 2005 (adjusted odds ratio, 1.29; 95% confidence interval 1.24–1.34; P&lt;0.001). Conclusions One-month survival with favorable neurological outcome in OHCA patients occurring at night remains to be significantly worse than those occurring during daytime, even improved by the periods during daytime. CPR training for the family members should be more expanded and strengthened against the night time imperfection.