Minutes Of Cardiopulmonary Resuscitation Research Articles

Alda-1 alleviates brain injury after cardiopulmonary resuscitation by regulating acyl-CoA synthetase long-chain family member 4/glutathione peroxidase 4 pathway-mediated ferroptosis in swine

To investigate whether the acetaldehyde dehydrogenase 2 specific activator, Alda-1, can alleviate brain injury after cardiopulmonary resuscitation (CPR) by inhibiting cell ferroptosis mediated by acyl-CoA synthetase long-chain family member 4/glutathione peroxidase 4 (ACSL4/GPx4) pathway in swine. Twenty-two conventional healthy male white swine were divided into Sham group (n = 6), CPR model group (n = 8), and Alda-1 intervention group (CPR+Alda-1 group, n = 8) using a random number table. The swine model of CPR was reproduced by 8 minutes of cardiac arrest induced by ventricular fibrillation through electrical stimulation in the right ventricle followed by 8 minutes of CPR. The Sham group only experienced general preparation. A dose of 0.88 mg/kg of Alda-1 was intravenously injected at 5 minutes after resuscitation in the CPR+Alda-1 group. The same volume of saline was infused in the Sham and CPR model groups. Blood samples were collected from the femoral vein before modeling and 1, 2, 4, 24 hours after resuscitation, and the serum levels of neuron specific enolase (NSE) and S100 β protein were determined by enzyme-linked immunosorbent assay (ELISA). At 24 hours after resuscitation, the status of neurologic function was evaluated by neurological deficit score (NDS). Thereafter, the animals were sacrificed, and brain cortex was harvested to measure iron deposition by Prussian blue staining, malondialdehyde (MDA) and glutathione (GSH) contents by colorimetry, and ACSL4 and GPx4 protein expressions by Western blotting. Compared with the Sham group, the serum levels of NSE and S100β after resuscitation were gradually increased over time, and the NDS score was significantly increased, brain cortical iron deposition and MDA content were significantly increased, GSH content and GPx4 protein expression in brain cortical were significantly decreased, and ACSL4 protein expression was significantly increased at 24 hours after resuscitation in the CPR model and CPR+Alda-1 groups, which indicated that cell ferroptosis occurred in the brain cortex, and the ACSL4/GPx4 pathway participated in this process of cell ferroptosis. Compared with the CPR model group, the serum levels of NSE and S100 β starting 2 hours after resuscitation were significantly decreased in the CPR+Alda-1 group [NSE (μg/L): 24.1±2.4 vs. 28.2±2.1, S100 β (ng/L): 2 279±169 vs. 2 620±241, both P < 0.05]; at 24 hours after resuscitation, the NDS score and brain cortical iron deposition and MDA content were significantly decreased [NDS score: 120±44 vs. 207±68, iron deposition: (2.61±0.36)% vs. (6.31±1.66)%, MDA (μmol/g): 2.93±0.30 vs. 3.68±0.29, all P < 0.05], brain cortical GSH content and GPx4 expression in brain cortical was significantly increased [GSH (mg/g): 4.59±0.63 vs. 3.51±0.56, GPx4 protein (GPx4/GAPDH): 0.54±0.14 vs. 0.21±0.08, both P < 0.05], and ACSL4 protein expression was significantly decreased (ACSL4/GAPDH: 0.46±0.08 vs. 0.85±0.13, P < 0.05), which indicated that Alda-1 might alleviate brain cortical cell ferroptosis through regulating ACSL4/GPx4 pathway. Alda-1 can reduce brain injury after CPR in swine, which may be related to the inhibition of ACSL4/GPx4 pathway mediated ferroptosis.

In-Hospital Cardiac Arrest in Adult Patients Admitted to a Quaternary Children's Center.

This study aimed to describe baseline and event characteristics and outcomes for adult patients who experience in-hospital cardiac arrest (IHCA) in a quaternary children's hospital and compare IHCA outcomes in younger (18-24 years) versus older (≥25 years) adults. We hypothesized that the rate of survival to hospital discharge would be lower in the older adult group. We performed a retrospective single-center cohort study of inpatient areas of a quaternary children's center. Adult patients (≥18 years of age) with an index pulseless IHCA requiring at least 1 minute of cardiopulmonary resuscitation or defibrillation were included. Thirty-three events met the inclusion criteria with a median patient age of 23.9 years (interquartile range, 20.2-33.3 years). Twenty-one (64%) patients had congenital heart disease, and 25 (76%) patients had comorbidities involving ≥2 organ systems. The most common prearrest interventions were invasive mechanical ventilation (76%) and vasoactive infusions (55%). Seventeen patients (52%) survived to hospital discharge.Survival to discharge was lower in patients 25 years or older compared with patients aged 18 to 24 years old (3 of 15 [20%] vs 14 of 18 [78%], respectively; P = 0.002). The majority of adult patients with IHCA in our pediatric hospital had preexisting multisystem comorbidities, the most common of which was congenital heart disease. Overall survival to discharge after IHCA was 52%, similar to that reported for the general pediatric population. Survival to discharge was significantly lower in the subgroup of patients 25 years or older when compared with those between the ages of 18 and 24 years.

Factors Associated with Pediatric In-Hospital Recurrent Cardiac Arrest

AbstractThe objective of this article was to identify demographic and clinical factors associated with early recurrent arrest (RA) (&lt;48 hours) and late RA (≥48 hours) among pediatric inpatients following an initial in-hospital cardiac arrest. A retrospective cohort study of inpatients was performed in a free-standing academic quaternary care children's hospital. All inpatients were &lt;18 years old with a cardiac arrest event requiring ≥1 minute of cardiopulmonary resuscitation with the return of spontaneous circulation sustained for ≥20 minutes at Seattle Children's Hospital from February 1, 2012 to September 18, 2019. Of the 237 included patients, 20 (8%) patients had an early RA and 30 (13%) had a late RA. Older age and severe pre-arrest acidosis were associated with a higher risk of early RA, odds ratios (OR) 1.2 (95% confidence interval [CI] 1.1–1.3) per additional year and 4.6 (95% CI 1.2–18.1), respectively. Pre-arrest organ dysfunction was also associated with a higher risk of early RA with an OR of 3.3 (95% CI 1.1–9.4) for respiratory dysfunction, OR 1.4 (95% CI 1.1–1.9) for each additional dysfunctional organ system, and OR 1.1 (95% CI 1–1.2) for every one-point increase in PELOD2 score. The neonatal illness category was associated with a lower risk of late RA, OR 0.3 (95% CI 0.1–0.97), and severe post-arrest acidosis was associated with a higher risk of late RA, OR 4.2 (95% CI 1.1–15). Several demographic and clinical factors offer some ability to identify children who sustain a recurrent cardiac arrest, offering a potential opportunity for intervention to prevent early recurrent arrest.

Initial five and ten-minute regional cerebral oxygen saturation as a predictor of the futility of resuscitation for out-of-hospital cardiac arrest

This study aimed to investigate the usefulness of cerebral regional oxygen saturation (rSO2) during the initial 5 and 10 minutes of cardiopulmonary resuscitation (CPR) compared with an initial rSO2 and mean rSO2 during entire CPR to predict the futility of resuscitation for patients without of-hospital-cardiac arrest (OHCA). This was a prospective study involving 52 adult patients presenting in OHCA and whose cerebral rSO2 values were measured until either CPR was terminated or sustained return of spontaneous circulation (ROSC) was achieved. Receiver operating characteristics analyses were used to evaluate which time and type of measurement is better to predict non-ROSC. The area under the curve (AUC) of each rSO2 value according to measurement time (overall, initial 5 minutes and 10 minutes) were the highest value of 0.743, 0.724, and 0.739, mean values of 0.724, 0.677 and 0.701 and ∆rSO2 (Changes in values of regional cerebral oxygen) value of 0.722, 0.734 and 0.724, respectively, while all of the initial values had a poor AUC (&lt;0.7) and also were not statistically significant. The optimal cut-off value of each rSO2 values during overall, initial 5 minutes and 10 minutes were the highest value of 26% (sensitivity, 53.9%; specificity, 92.3%), 24% (sensitivity, 56.4%; specificity, 92.3%), and 30% (sensitivity, 61.5%; specificity, 84.6%), mean value of 15.2%, 15.3% and 16%, respectively. None of the patients with a persistent rSO2 ≤18% during the overall period achieved ROSC. Initial 5 minutes and 10 minutes cerebral rSO2 values an out-of-hospital-cardiac arrest (OHCA) are a better predictor in deciding the futility of CPR, compared to initial and overall measurements.

Abstract 11269: Recombinant Soluble Thrombomodulin in Prolonged Porcine Cardiac Arrest

Introduction: Sudden Cardiac Arrest (CA) affects more than 400,000 people per year in the United States. Although a third of these patients survive to hospital admission, another 60-70% go on to die due to failed recovery of vital organ function. Microvascular thrombosis has been suggested as a potential contributor to prolonged organ dysfunction, but no antithrombotic therapies have been shown to be beneficial and coagulofibrinolytic abnormalities in prolonged CA remain poorly understood. Objectives: To establish key biomarkers of porcine coagulation and fibrinolysis in the setting of prolonged CA and cardiopulmonary resuscitation (CPR) and test the ability of ART-123 (recombinant human thrombomodulin alpha) to reverse these abnormalities. Methods: 15 pigs (n=5 per group) underwent 8 minutes of no-flow CA followed by 50 minutes of mechanical CPR. Animals were randomized to receive saline or ART-123 (~1mg/kg) pre-arrest (5 minutes prior to ventricular fibrillation) or post-arrest (2 minutes after initiation of CPR). Results: Robust and ongoing activation of coagulation and fibrinolysis were detected throughout the resuscitation. After 50 minutes of CPR, plasma tests suggested consumptive coagulopathy, while whole blood testing (thromboelastography) indicated a persistent hypercoagulable state. ART-123 had a clear anticoagulant effect irrespective of timing (TAT complexes 381±25 vs. 238±18 vs. 226±12, p&lt;0.01, and d-dimer 4.86±0.54 vs. 2.39±0.2 vs. 2.46±0.21 for vehicle, pre-arrest, post-arrest, p = 0.05). A pro-fibrinolytic effect was also observed, but only when the drug was given before no-flow, with a significant increase in levels of free endogenous tPA (1.2±0.12 vs. 3.29±0.29 vs. 1.72±0.3, p &lt; 0.001) and corresponding suppression of free PAI-1 (0.59±0.15 vs. 0.14±0.01 vs. 0.41±0.09, p &lt; 0.001). Conclusion: Our porcine CA model provides an excellent platform for evaluating antithrombotic interventions. Plasma testing after prolonged CA/CPR suggests consumptive coagulopathy, although TEG indicates a persistent hypercoagulable state. ART-123 given before no-flow or just after CPR demonstrates antithrombotic effects, although the specific modes of action depending on the timing of administration.

Two-Thumb Technique Is Superior to Two-Finger Technique in Cardiopulmonary Resuscitation of Simulated Out-of-Hospital Cardiac Arrest in Infants.

BackgroundTo compare the 2‐finger and 2‐thumb chest compression techniques on infant manikins in an out‐of‐hospital setting regarding efficiency of compressions, ventilation, and rescuer pain and fatigue.Methods and ResultsIn a randomized crossover design, 78 medical students performed 2 minutes of cardiopulmonary resuscitation with mouth‐to‐nose ventilation at a 30:2 rate on a Resusci Baby QCPR infant manikin (Laerdal, Stavanger, Norway), using a barrier device and the 2‐finger and 2‐thumb compression techniques. Frequency and depth of chest compressions, proper hand position, complete chest recoil at each compression, hands‐off time, tidal volume, and number of ventilations were evaluated through manikin‐embedded SkillReporting software. After the interventions, standard Likert questionnaires and analog scales for pain and fatigue were applied. The variables were compared by a paired t‐test or Wilcoxon test as suitable. Seventy‐eight students participated in the study and performed 156 complete interventions. The 2‐thumb technique resulted in a greater depth of chest compressions (42 versus 39.7 mm; P<0.01), and a higher percentage of chest compressions with adequate depth (89.5% versus 77%; P<0.01). There were no differences in ventilatory parameters or hands‐off time between techniques. Pain and fatigue scores were higher for the 2‐finger technique (5.2 versus 1.8 and 3.8 versus 2.6, respectively; P<0.01).ConclusionsIn a simulation of out‐of‐hospital, single‐rescuer infant cardiopulmonary resuscitation, the 2‐thumb technique achieves better quality of chest compressions without interfering with ventilation and causes less rescuer pain and fatigue.

GADOLINIUM-INDUCED CARDIOPULMONARY ARREST IN A 57-YEAR-OLD FEMALE

TOPIC: Allergy and Airway TYPE: Medical Student/Resident Case Reports INTRODUCTION: Magnetic resonance contrast agents are used to better characterize disease processes during Magnetic Resonance Imaging (MRI). Gadolinium based contrast agents (GBCA) are widely used due to their safety profile. The incidence of adverse events after receiving GBCAs is less than 2%, most being mild and transient [1,2]. Here, we see a patient who developed cardiopulmonary arrest after GBCA administration. CASE PRESENTATION: A 57 year old female with a past medical history of asthma, hypertension, diabetes, hyperlipidemia and mild COVID19 infection, presented to outpatient brain MRI for evaluation of new hearing loss. After receiving Gadobutrol, she developed shortness of breath, abdominal pain, and emesis. In the emergency department, the patient was hypothermic, tachypneic, and hypoxic;no urticaria or rash noted. She was placed on non-invasive ventilation and treated for presumed anaphylaxis, but remained hypoxic and in respiratory distress. Subsequent intubation (without angioedema visualized) was complicated by cardiac arrest, requiring six minutes of cardiopulmonary resuscitation. Initial imaging was significant for CT chest showing diffuse ground glass and consolidative opacities and normal CT head. Despite standard care treatment, the patient's neurological exam worsened, one week into her admission she was observed to have minimal brainstem reflexes, with head CT showing findings of anoxic brain injury, cerebral edema and possible uncal herniation. She worsened clinically and expired thirteen days after admission. Autopsy performed showed clinicopathological correlation attributing anoxic brain injury secondary to anaphylaxis. DISCUSSION: Gadobutrol is approved for multiple indications in most ages. It was introduced in 1998, its safety profile has been studied in patients worldwide. The incidence of adverse events of GBCA has been reported to be 0.32-3.8%, commonly nausea, vomiting, urticaria and dizziness. Risk factors include patients' history of respiratory allergic disease, asthma, COPD, or prior history of reactions to iodinated contrast media [1,2]. The incidence of serious adverse drug reactions (ADR) involving the cardiopulmonary system is reported to be <0.1%;from 1998-2012 there were 614 cases of ADR of which 7.2% were fatal [3]. Our case presentation shows a severe ADR to gadolinium contrast for MRI. Though the patient's pre-existing history of asthma put her at slightly higher risk, proven safety of gadolinium contrast significantly weighs towards continued use of contrast enhanced MRI. Nevertheless, awareness and timely response to possible contrast-induced ADR is important for all clinicians. CONCLUSIONS: GBCA are widely used agents with good safety profiles. Although severe adverse events are rare, it's important for physicians to have a high index of suspicion and use caution in patients that are identified with risk factors for adverse reactions to these agents. REFERENCE #1: [1] Marie-France Bellin. MR contrast agents, the old and the new. European Journal of Radiology volume 60, Issue 3, 2006, 314-323. doi.org/10.1016/j.ejrad.2006.06.021. REFERENCE #2: [2] Endrikat, Jan MD, PhD*†;Vogtlaender, Kai PhD‡;Dohanish, Susan RA§;Balzer, Thomas MD, PhD∥;Breuer, Josy MD, PhD*Safety of Gadobutrol, Investigative Radiology: September 2016 - Volume 51 - Issue 9 - p 537-543 doi: 10.1097/RLI.0000000000000270 REFERENCE #3: [3] Raisch, D. W., Garg, V., Arabyat, R., Shen, X., Edwards, B. J., Miller, F. H.,… West, D. P. (2013). Anaphylaxis associated with GADOLINIUM-BASED contrast AGENTS: Data from the food and DRUG Administration's adverse event reporting system and review of case reports in the literature. Expert Opinion on Drug Safety, 13(1), 15-23. doi:10.1517/14740338.2013.832752 DISCLOSURES: No relevant relationships by Lauren Blackwell, source=Web Response No relevant relationships by Rostislav Gorbatov, source=Web Response No relevant relationships by Chinazor Iwuaba, source=Web Response

Outcomes of Cardiopulmonary Resuscitation in the Pediatric Intensive Care of a Tertiary Center.

Understanding the factors affecting survival and modifying the preventable factors may improve patient outcomes following cardiopulmonary resuscitation (CPR). The aim of this study was to assess the prevalence and outcomes of cardiac arrest and CPR events in a tertiary pediatric intensive care unit (PICU). Outcomes of interest were the return of spontaneous circulation (ROSC) lasting more than 20 minutes, survival for 24 hours post-CPR, and survival to hospital discharge. We analyzed data from the PICU CPR registry from January 1, 2011 to January 1, 2018. All patients who underwent at least 2 minutes of CPR in the PICU were included. CPR was administered in 65 PICU instances, with a prevalence of 1.85%. The mean patient age was 32.7 months. ROSC occurred in 38 (58.5%) patients, 30 (46.2%) achieved 24-hour survival, and 21 (32.3%) survived to hospital discharge. Younger age ( p < 0.018), respiratory cause ( p < 0.001), bradycardia ( p < 0.018), and short duration of CPR ( p < 0.001) were associated with better outcomes, while sodium bicarbonate, norepinephrine, and vasopressin were associated with worse outcome ( p < 0.009). The off-hour CPR had no impact on the outcome. The patients' cumulative predicted survival declined by an average of 8.7% for an additional 1 minute duration of CPR ( p = 0.001). The study concludes that the duration of CPR, therefore, remains one of the crucial factors determining CPR outcomes and needs to be considered in parallel with the guideline emphasis on CPR quality. The lower survival rate post-ROSC needs careful consideration during parental counseling. Better anticipation and prevention of CPR remain ongoing challenges.

Survival after 43 minutes of cardiopulmonary resuscitation: A case report

Survival after 43 minutes of cardiopulmonary resuscitation: A case report

Effect on Chest Compression Fraction of Continuous Manual Compressions with Asynchronous Ventilations Using an i-gel® versus 30:2 Approach during Simulated Out-of-Hospital Cardiac Arrest: Protocol for a Manikin Multicenter Randomized Controlled Trial.

The optimal airway management strategy during cardiopulmonary resuscitation is uncertain. In the case of out-of-hospital cardiac arrest, a high chest compression fraction is paramount to obtain the return of spontaneous circulation and improve survival and neurological outcomes. To improve this fraction, providing continuous chest compressions should be more effective than using the conventional 30:2 ratio. Airway management should, however, be adapted, since face-mask ventilation can hardly be carried out while continuous compressions are administered. The early insertion of a supraglottic device could therefore improve the chest compression fraction by allowing ventilation while maintaining compressions. This is a protocol for a multicenter, parallel, randomized simulation study. Depending on randomization, each team made up of paramedics and emergency medical technicians will manage the 10-min scenario according either to the standard approach (30 compressions with two face-mask ventilations) or to the experimental approach (continuous manual compressions with early insertion of an i-gel® supraglottic device to deliver asynchronous ventilations). The primary outcome will be the chest compression fraction during the first two minutes of cardiopulmonary resuscitation. Secondary outcomes will be chest compression fraction (per cycle and overall), compressions and ventilations quality, time to first shock and to first ventilation, user satisfaction, and providers’ self-assessed cognitive load.

Abstract 372: Regional Cerebral Saturation in a Swine Model of Goal-directed Resuscitation of Prolonged Ventricular Fibrillation Cardiac Arrest

Introduction: The characteristics and limitations of near-infrared spectroscopy (NIRS) measurement of regional cerebral saturation (rSO2) for reflecting key moment-to-moment physiological changes needed to guide cardiopulmonary resuscitation (CPR) have yet to be fully determined. Objective: Examine the impact of NIRS sensor placement and resuscitation process variation on rSO2 measurements during prolonged cardiac arrest. Methods: Thirty mixed-breed domestic pigs (mean weight: 25.0kg+/-2.0) were sedated (ketamine / xylazine), anesthetized (fentanyl), paralyzed (vecuronium) and mechanically ventilated. Micromanometer pressure transducers were placed in the aorta and right atrium via femoral cutdown to measure central pressures, including mean arterial pressure (MAP) and coronary perfusion pressure (CPP). Two NIRS sensors were placed on the cranium: one on the skin surface and one on the bare skull. Ventricular fibrillation was induced electrically and untreated for 8 minutes followed by CPR. Initial BLS phase: 4 minutes of CPR at 100 compressions per minute (CPM) and 2 inches depth with manual ventilations (30:2). Randomized ALS phase: CPR with a pressor-titrated (Group A) or a compression rate/depth-titrated (Group B) strategy targeting 25mmHg CPP. Group A animals received pressor doses q1min and fixed rate/depth CPR. Group B animals received increasing rates and depth of CPR with epinephrine q3min. Defibrillation was attempted at 6min CPR q2min. rSO2 was compared between skin and skull across phases of resuscitation with t-tests and generalized estimating equations (GEE). Results: Mean skin and skull rSO2 differed marginally overall (63.8 vs 62.0, p &lt; 0.001), at baseline (69.9 vs 64.9, p &lt; 0.001), during BLS CPR (56.9 vs 48.7, p &lt; 0.001), during ALS CPR (59.5 vs 51.0, p &lt; 0.001), and following ROSC (70.0 vs 60.5, p&lt;0.001). rSO2 measured on either skull or skin both varied throughout phases of the experiment but not between CPR groups. In GEE models, rSO2 measured on skin or skull was not associated with MAP at baseline, but was directly associated during BLS (coef 0.13; p&lt;0.001) &amp; ALS CPR (coef 0.09; p&lt;0.001), and after ROSC (coef 0.02; p=0.017). Conclusion: rSO2 measures differ between skin and skull though both correlate with MAP.

Abstract 131: Chest Molding in Extended Cardiopulmonary Resuscitation

Introduction: Cardiopulmonary resuscitation (CPR) is a forceful procedure that may change characteristics of the subject. Little clinical data has been published relating applied forces and depth responses, particularly in increasingly prevalent extended sessions of CPR. We analyzed synchronous force and depth records to investigate how chests mold during the course of extended CPR. Hypothesis: Chest molding, characterized as decrease in stiffness from its initial value, will increase as CPR proceeds. Methods: Force and acceleration signals were extracted from CPR monitors used in adult cases of continuous compression CPR in out-of-hospital resuscitations attended by a single EMS agency (TVFR, Tigard, Oregon) during 2013 through 2017. We computed depth and velocity from acceleration, and identified chest compressions automatically where downward velocity crossed 25mm/s and force subsequently exceeded 5 kg-f. Series were defined as sequences without pauses exceeding 2 minutes. We analyzed initial series lasting at least 10 minutes. We calculated stiffness as force/depth at peak compression velocity. We calculated molding in 5 minute blocks of CPR as 100*(1- stiffnessblock/stiffnessminute 1), using medians as stiffness was not normally distributed. Dependence of molding on CPR duration was analyzed with Kruskal-Wallis ANOVA. Results and Conclusions: Of 616 available cases, 478 had initial CPR series &gt;= 10 minutes duration, including 997,254 compressions. Initial CPR series duration were &gt;= 30 minutes in 152 cases, and &gt;= 40 minutes in 48 cases. The longest initial series was 61 minutes. Chest molding increased steadily through the first 25 minutes of CPR, and plateaued thereafter (p &lt; 0.001). Median molding at &gt;= 25 minutes was 20%. The implications of declining stiffness warrant further investigation.

THE USE OF A STEP STOOL DURING CHEST COMPRESSIONS: DOES IT MAKE A DIFFERENCE, AND DO CLINICIANS CHOOSE TO USE IT?

SESSION TITLE: Education, Research, and Quality Improvement Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: High quality cardiopulmonary resuscitation (CPR) is the most important factor in surviving cardiac arrest. Using a step stool to improve chest compressions is universally recommended yet under-researched. This observational, simulation-based study sought to answer two questions: first, is CPR performance improved with the use of a step stool? Second, how often do adult healthcare providers use a step stool for chest compressions, and does the frequency increase following a brief educational session demonstrating the advantages of step stool use? METHODS: Over 3 years (2018-2020), 535 interdisciplinary providers (nurses, house staff, attendings, and pharmacists from internal medicine, intensive care, anesthesiology, and obstetrics) participated in this observational study. Participants first performed one minute of CPR on Resusci-Anne ®, a CPR mannequin, and were scored from 0-100 on their performance. A step stool was available for use next to Resusci-Anne ® if the participant desired. Thereafter, participants underwent an educational intervention on the advantages of using a step stool while performing CPR. They watched a demonstration by an instructor and were then given time to practice CPR with and without a step stool. Each participant was then asked to do another minute of CPR on the Resusci-Anne ® and again scored from 0-100 on their performance. A step stool was again in close proximity for use, if the participant desired. RESULTS: Participants were selected via convenience sampling at a large academic hospital with a pre-existing cardiac arrest simulation course. A total of 535 participants were tested pre-intervention, and 520 participants were tested post-intervention. Prior to the intervention, only 16.6% (n=89) of providers elected to use a step stool for chest compressions, compared to 97.5% (n=507) post-intervention (p=<0.001). The average CPR performance score (0-100) significantly improved from pre-intervention to post-intervention (74 vs. 95; p=<0.001). CONCLUSIONS: Our study demonstrates that the quality of CPR improves significantly with the use of a step stool. However, without education on the benefits of using a step stool and demonstration of the proper technique, few adult healthcare providers will elect to do so. A brief, hands-on intervention teaching adult healthcare providers about the benefits of CPR with a step stool significantly increased its use and the quality of chest compressions. CLINICAL IMPLICATIONS: This study demonstrates that adult healthcare providers across multiple disciplines can quickly and easily be taught to use a step stool during CPR, and that doing so significantly improves the quality of CPR they provide. Given that early and high-quality CPR is the cornerstone of advanced cardiovascular life support (ACLS), this intervention has the potential to improve the mortality of in-hospital cardiac arrest. DISCLOSURES: No relevant relationships by Timothy Clapper, source=Web Response No relevant relationships by Imaani Easthausen, source=Web Response No relevant relationships by Kelly Griffin, source=Web Response No relevant relationships by Elyse LaFond, source=Web Response No relevant relationships by Melissa Moulton, source=Web Response No relevant relationships by Kapil Rajwani, source=Web Response No relevant relationships by Nina Rusiewski, source=Web Response No relevant relationships by Samantha Smith, source=Web Response

Plastic blanket drowning kit: A protection barrier to immediate resuscitation at the beach in the Covid-19 era. A pilot study.

ObjectiveIntroducing a new, simple and inexpensive portable equipment for lifeguards, consisting of a pre-assembled full-size plastic blanket with a mask and HEPA filter, which could offer significant time-saving advantages to reduce COVID-19 risk transmission in the first few minutes of CPR after water rescue, avoiding the negative impact of delayed ventilation. MethodA pilot study was carried out to determine the feasibility of the pre-assembled kit of face-mask and HEPA filter adapted on a pre-set plastic-blanket. The first step consisted of washing hands, putting on safety glasses and gloves as the first personal protection equipment (PPE) and then covering the victim with an assembled plastic blanket. The second step consisted of 10 min of cardiopulmonary resuscitation (CPR) with PPE and plastic blanket, following the technical recommendations for ventilation during COVID-19. ResultsTen rescuers took part in the pilot study. The average time to wear PPE and place the pre-assembly kit on the victim was 82 s [IC 58–105]. After 10 min the quality of the resuscitation (QCPR) was 91% [87–94]. Quality chest compressions (CC) were 22% better than ventilations (V). Most of the rescuers (60%) thought that placing the plastic blanket on the victim on the beach was somewhat simple or very simple. ConclusionsResuscitation techniques in COVID-19 era at the beach have added complexities for the correct use of PPE. Plastic blanket plus basic ventilations equipment resource could be a new alternative to be considered for lifeguards to keep ventilation on use while reducing risk transmission.

Pediatric Cardiopulmonary Resuscitation Tasks and Hands-Off Time: A Descriptive Analysis Using Video Review.

To characterize tasks performed during cardiopulmonary resuscitation in association with hands-off time, using video recordings of resuscitation events. Single-center, prospective, observational trial. Twenty-six bed cardiac ICU in a quaternary care free standing pediatric academic hospital. Patients admitted to the cardiac ICU with cardiopulmonary resuscitation events lasting greater than 2 minutes captured on video. None. Videos of 17 cardiopulmonary resuscitation episodes comprising 264.5 minutes of cardiopulmonary resuscitation were reviewed: 11 classic cardiopulmonary resuscitation (87.5 min) and six extracorporeal cardiopulmonary resuscitations (177 min). A total of 209 tasks occurred in 178 discrete time periods including compressor change (36%), rhythm/pulse check (18%), surgical pause (18%), extracorporeal membrane oxygenation preparation/draping (9%), repositioning (7.5%), defibrillation (6%), backboard placement (3%), bagging (<1%), pacing (<1%), intubation (<1%). In 31 time periods, 62 tasks were clustered with 18 (58%) as compressor changes and pulse/rhythm check. In the 178 discrete time periods, 135 occurred with a pause in compressions for greater than or equal to 1 second; 43 tasks occurred without pause. After accounting for repeated measures from individual patients, providers were less likely to perform rhythm or pulse checks (p < 0.0001) or change compressors regularly (p = 0.02) during extracorporeal cardiopulmonary resuscitation as compared to classic cardiopulmonary resuscitation. The frequency of tasks occurring during cardiopulmonary resuscitation interruptions in the classic cardiopulmonary resuscitation group was constant over the resuscitation but variable in extracorporeal cardiopulmonary resuscitation, peaking during activities required for cannulation. On video review of cardiopulmonary resuscitation, we found that resuscitation guidelines were not strictly followed in either cardiopulmonary resuscitation or extracorporeal cardiopulmonary resuscitation patients, but adherence was worse in extracorporeal cardiopulmonary resuscitation. Clustering of resuscitation tasks occurred 23% of the time during chest compression pauses suggesting attempts at minimizing cardiopulmonary resuscitation interruptions. The frequency of cardiopulmonary resuscitation interruptions task events was relatively constant during classic cardiopulmonary resuscitation but variable in extracorporeal cardiopulmonary resuscitation. Characterization of resuscitation tasks by video review may inform better cardiopulmonary resuscitation orchestration and efficiency.

Is Thrombolytic Therapy appropriate at the Late Phase of Cardiopulmonary Resuscitation for Massive Pulmonary Thromboembolism?

Pulmonary thromboembolism in which hemostatic balance is disrupted is a disease with high morbidity and mortality rates with challenging diagnosis. A 73-year-old female patient presented to the emergency department with respiratory distress. She had undergone surgery for femoral neck fracture three months ago. She had gradually aggravating respiratory distress for the last 3-4 days. The patient was admitted to the hospital with the diagnosis of massive pulmonary embolism. She had a cardiac arrest after completion of thoracic computed tomography (thoracic CT). Cardiopulmonary resuscitation (CPR) was initiated. Alteplase (rt-PA) was infused at 100 mg/2 hours starting at the 37th minute of CPR in the late phase. As there was no room on the wards, she was admitted to the emergency room observation unit and extubated on the 9th day. Coumadin (warfarin) dose was adjusted and the patient was discharged on day 17 with an INR (International Normalized Ratio) of 2.3.

Survival and Hemodynamics During Pediatric Cardiopulmonary Resuscitation for Bradycardia and Poor Perfusion Versus Pulseless Cardiac Arrest.

The objective of this study was to compare survival outcomes and intra-arrest arterial blood pressures between children receiving cardiopulmonary resuscitation for bradycardia and poor perfusion and those with pulseless cardiac arrests. Prospective, multicenter observational study. PICUs and cardiac ICUs of the Collaborative Pediatric Critical Care Research Network. Children (< 19 yr old) who received greater than or equal to 1 minute of cardiopulmonary resuscitation with invasive arterial blood pressure monitoring in place. None. Of 164 patients, 96 (59%) had bradycardia and poor perfusion as the initial cardiopulmonary resuscitation rhythm. Compared to those with initial pulseless rhythms, these children were younger (0.4 vs 1.4 yr; p = 0.005) and more likely to have a respiratory etiology of arrest (p < 0.001). Children with bradycardia and poor perfusion were more likely to survive to hospital discharge (adjusted odds ratio, 2.31; 95% CI, 1.10-4.83; p = 0.025) and survive with favorable neurologic outcome (adjusted odds ratio, 2.21; 95% CI, 1.04-4.67; p = 0.036). There were no differences in diastolic or systolic blood pressures or event survival (return of spontaneous circulation or return of circulation via extracorporeal cardiopulmonary resuscitation). Among patients with bradycardia and poor perfusion, 49 of 96 (51%) had subsequent pulselessness during the cardiopulmonary resuscitation event. During cardiopulmonary resuscitation, these patients had lower diastolic blood pressure (point estimate, -6.68 mm Hg [-10.92 to -2.44 mm Hg]; p = 0.003) and systolic blood pressure (point estimate, -12.36 mm Hg [-23.52 to -1.21 mm Hg]; p = 0.032) and lower rates of return of spontaneous circulation (26/49 vs 42/47; p < 0.001) than those who were never pulseless. Most children receiving cardiopulmonary resuscitation in ICUs had an initial rhythm of bradycardia and poor perfusion. They were more likely to survive to hospital discharge and survive with favorable neurologic outcomes than patients with pulseless arrests, although there were no differences in immediate event outcomes or intra-arrest hemodynamics. Patients who progressed to pulselessness after cardiopulmonary resuscitation initiation had lower intra-arrest hemodynamics and worse event outcomes than those who were never pulseless.

Prevalence and Outcomes of Pediatric In-Hospital Cardiac Arrest Associated With Pulmonary Hypertension.

In adult in-hospital cardiac arrest, pulmonary hypertension is associated with worse outcomes, but pulmonary hypertension-associated in-hospital cardiac arrest has not been well studied in children. The objective of this study was to determine the prevalence of pulmonary hypertension among children with in-hospital cardiac arrest and its impact on outcomes. Retrospective single-center cohort study. PICU of a quaternary care, academic children's hospital. Children (<18 yr old) receiving greater than or equal to 1 minute of cardiopulmonary resuscitation (cardiopulmonary resuscitation) for an index in-hospital cardiac arrest with an echocardiogram in the 48 hours preceding in-hospital cardiac arrest, excluding those with cyanotic congenital heart disease. None. Of 284 in-hospital cardiac arrest subjects, 57 (20%) had evaluable echocardiograms, which were analyzed by a cardiologist blinded to patient characteristics. Pulmonary hypertension was present in 20 of 57 (35%); nine of 20 (45%) had no prior pulmonary hypertension history. Children with pulmonary hypertension had worse right ventricular systolic function, measured by fractional area change (p = 0.005) and right ventricular global longitudinal strain (p = 0.046); more right ventricular dilation (p = 0.010); and better left ventricular systolic function (p = 0.001). Children with pulmonary hypertension were more likely to have abnormal baseline functional status and a history of chronic lung disease or acyanotic congenital heart disease and less likely to have sepsis or acute kidney injury. Children with pulmonary hypertension were more likely to have an initial rhythm of pulseless electrical activity or asystole and were more frequently treated with inhaled nitric oxide (80% vs 32%; p < 0.001) at the time of cardiopulmonary resuscitation. On multivariable analysis, pulmonary hypertension was not associated with event survival (14/20 [70%] vs 24/37 [65%]; adjusted odds ratio, 1.30 [CI95, 0.25-6.69]; p = 0.77) or survival to discharge (8/20 [40%] vs 10/37 [27%]; adjusted odds ratio, 1.17 [CI95, 0.22-6.44]; p = 0.85). Pulmonary hypertension physiology preceding pediatric in-hospital cardiac arrest may be more common than previously described. Among this cohort with a high frequency of inhaled nitric oxide treatment during cardiopulmonary resuscitation, pulmonary hypertension was not associated with survival outcomes.

Conjunctival microcirculation is associated with cerebral cortex microcirculation in post-resuscitation mild hypothermia: A rat model.

This study aimed to compare the changes in sublingual and conjunctival microcirculation occurring with cerebral cortex microcirculation changes during mild hypothermia in a rat model of cardiac arrest. Twenty-four rats were randomized into mild hypothermia (M) or normothermia (C) groups. Ventricular fibrillation was electrically induced and left untreated for 8minutes, followed by 8minutes of cardiopulmonary resuscitation. The core temperature in group M reduced to 33±0.5°C at 13minutes after restoration of spontaneous circulation and was maintained for 8hours. In group C, the core temperature was maintained at 37±0.2°C. The hemodynamics and microcirculation in the sublingual region, bulbar conjunctiva, and cerebral cortex were measured at baseline and 1, 2, 3, 4, 6, and 8hours after restoration of spontaneous circulation. The M group showed significantly worse sublingual microcirculation at 6hours post-resuscitation. However, microcirculation in the conjunctiva and cerebral cortex at 3hours post-resuscitation were better in the M group. In the M group, microcirculation in the cerebral cortex was significantly correlated with that in the conjunctiva but not the sublingual microcirculation. Changes in conjunctival microcirculation are closely related to cerebral cortex microcirculation during mild hypothermia, indicating that cerebral cortex microcirculation could be monitored by measuring conjunctival microcirculation.

Cpr Quality among Paramedics and ambulance officers: A Cross-Sectional Simulation Study

Introduction High quality cardiopulmonary resuscitation (CPR) improves survival from cardiac arrest, yet CPR quality is often suboptimal, even among trained rescuers. St John Western Australia sought to gather anonymous baseline data on CPR performance by paramedics and ambulance officers in a simulation setting. Methods In a cross-sectional study, participants performed 2 minutes of CPR on a manikin. CPR quality was recorded and compared to recommended standards. Comparisons were also made between women and men. Results The final cohort comprised 1320 participants; 56% paramedics, 20% transport officers and 18% volunteer emergency medical technicians and emergency medical assistants. More than half achieved an overall score of 90% or greater. The median compression score was 96% (IQR 83–99%) while the median ventilation score was 94% (76–99%). Participants achieved the recommended chest compression fraction of ≥60% in 98% of cases. More than half of participants had 99% or more of their compressions reach a depth of ≥50 mm. Two-thirds (68%) recorded a mean compression rate in the range 100–120 compressions per minute. Although there were significant differences in the percentage of compressions deep enough (p&lt;0.01) and the 2-minute mean compression depth (p&lt;0.01) between men and women, the effect size was small. However, men were less likely than women to fully release pressure on the chest after compressions (p&lt;0.01). Conclusion This study provides useful baseline data about CPR quality in a manikin model. Participants achieved relatively high scores for most CPR quality metrics and complied with CPR guidelines in the majority of cases.