Pre-shock Pause Research Articles

Effect of non-technical skills teaching on performance – An evaluation of additional non-technical skills teaching in Resuscitation Council ALS course

Sudden cardiac arrest remains the most common cause of cardiovascular death in the world. The delivery of timely and high quality cardiopulmonary resuscitation (CPR) is the key to patient survival. Observational studies have consistently demonstrated that quality of CPR delivered in training and in the clinical setting is substandard. Tremendous effort has been put into training healthcare providers in performing high quality CPR. Advanced life support (ALS) is now a core competency in both undergraduate and postgraduate medical training. ALS encompasses simple technical skills such as chest compression and ventilation and more complex technical skills such as the safe delivery of an appropriate defibrillating shock. Non-technical skills describe situational awareness, decision making, task management, leadership and team working. The importance of non-technical skills in emergency situations is now widely accepted across many acute medical specialties including resuscitation. A survey of advanced life support trained doctors revealed many did not feel ready to lead a cardiac arrest and did not feel equipped with adequate leadership skills. Simulation studies have found that competent ALS providers often lacked leadership attributes such as task allocation, effective communication. Previous research has demonstrated that leadership behaviour is correlated with quality of CPR, with shorter hands off time, pre-shock pauses and time to first shock. Understanding and improving non-technical skills may help to reduce errors, create more effective teams and improve patient outcome. In 2014, the ALS course will be updated with additional non-technical skills teaching in both online and face to face teaching. The planned launch of the updated ALS course in 2014 presents a unique opportunity to evaluate the impact of additional non-technical skills training on non-technical and technical skill performance compared to standard ALS course.

Association Between Chest Compression Interruptions and Clinical Outcomes of Ventricular Fibrillation Out-of-Hospital Cardiac Arrest.

Minimizing pauses in chest compressions during cardiopulmonary resuscitation is a focus of current guidelines. Prior analyses found that prolonged pauses for defibrillation (perishock pauses) are associated with worse survival. We analyzed resuscitations to characterize the association between pauses for all reasons and both ventricular fibrillation termination and patient survival. In 319 patients with ventricular tachycardia/fibrillation out-of-hospital cardiac arrest, we analyzed recordings from all defibrillators used during resuscitation and measured durations of all cardiopulmonary resuscitation pauses. Median durations were 32 seconds (25th and 75th percentile, 22 and 52 seconds) for the longest pause for any reason, 23 seconds (25th and 75th percentile, 14 and 34 seconds) for the longest perishock pause, and 24 seconds (25th and 75th percentile, 11 and 38 seconds) for the longest nonshock pause. Multivariable regression models showed lower odds for survival per 5-second increase in the longest overall pause (odds ratio, 0.89; 95% confidence interval, 0.83-0.95), longest perishock pause (odds ratio, 0.85; 95% confidence interval, 0.77-0.93), and longest nonshock pause (odds ratio, 0.83; 95% confidence interval, 0.75-0.91). In 36% of cases, the longest pause was a nonshock pause; this subgroup had lower survival than the group in whom the longest pause was a perishock pause (27% versus 44%, respectively; P<0.01) despite a higher chest compression fraction. Preshock pauses were 8 seconds (25th and 75th percentile, 4 and 17 seconds) for shocks that terminated ventricular fibrillation and 7 seconds (25th and 75th percentile, 4 and 13 seconds) for shocks that did not (P=0.18). Prolonged pauses have a negative association with survival not explained by chest compression fraction or decreased ventricular fibrillation termination rate. Ventricular fibrillation termination was not the mechanism linking pause duration and survival. Strategies shortening the longest pauses may improve outcome.

Amplitude-spectral area and chest compression release velocity independently predict hospital discharge and good neurological outcome in ventricular fibrillation out-of-hospital cardiac arrest

ObjectiveIn out-of-hospital cardiac arrest (OHCA) with ventricular fibrillation (VF) the frequency-based waveform characteristic, amplitude-spectral area (AMSA) is associated with hospital discharge and good neurological outcome, yet AMSA is also known to increase in response to chest compressions (CC). In addition to rate and depth, well performed CC provides good chest recoil without leaning, reflected in the release velocity (RV). We hypothesized that AMSA is associated with hospital discharge and good neurological outcome independent of CC quality. MethodsOHCA patients (age≥18), with initial rhythm of VF from an Utstein-Style database were analyzed. AMSA was measured prior to each shock, and averaged for each subject (AMSA-avg). Primary endpoint was hospital discharge and secondary endpoint was a good neurological outcome. Univariate and stepwise multivariable logistic regression, and receiver–operator–characteristic (ROC) analyses were performed. Factors analyzed were age, sex, witnessed status, time from dispatch to monitor/defibrillator application, number of shocks, first shock AMSA (AMSA1), AMSA-avg, averaged pre-shock pause, CC rate, depth, and RV. Results140 subjects were analyzed. Hospital discharge was 31% and with good neurological outcome in 24% (77% of those discharged). AMSA-avg (p<0.001), RV (p=0.002), and age (p=0.029) were independently associated with hospital discharge, with a non-significant trend for witnessed status (p=0.069), with AUC=0.846 for the multivariate model. For good neurological outcome, AMSA-avg (p=0.001) and RV (p=0.001) remained independently significant, with AUC=0.782. ConclusionIn OHCA with an initial rhythm of VF, AMSA-avg and CC RV are both highly and independently associated with hospital discharge and good neurological outcome.

Measuring and improving cardiopulmonary resuscitation quality inside the emergency department

Aim of studyTo evaluate CPR quality during cardiac resuscitation attempts in an urban emergency department (ED) and determine the influence of the combination of scenario-based training, real-time audiovisual feedback (RTAVF), and post-event debriefing on CPR quality. MethodsCPR quality was recorded using an R Series monitor-defibrillator (ZOLL Medical) during the treatment of adult cardiac arrest patients. Phase 1 (P1; 11/01/2010-11/15/2012) was an observation period of CPR quality. Phase 2 (P2; 11/15/2012-11/08/2013) was after a 60-min psychomotor skills CPR training and included RTAVF and post-event debriefing. ResultsA total of 52 cardiac arrest patients were treated in P1 (median age 56yrs, 63.5% male) and 49 in P2 (age 60yrs, 83.7% male). Chest compression (CC) depth increased from 46.7±3.8mm in P1 to 61.6±2.8mm in P2 (p<0.001), with the percentage of CC≥51mm increasing from 30.6% in P1 to 87.4% in P2 (p<0.001). CC release velocity increased from 314±25mm/s in P1 to 442±20mm/s in P2 (p<0.001). No significant differences were identified in CC fraction (84.3% P1 vs. 88.4% P2, p=0.1), CC rate (125±3cpm P1 vs. 125±3cpm P2, p=0.7), or pre-shock pause (9.7s P1 vs. 5.9s P2, p=0.5), though CC fraction and pre-shock pause were within guideline recommendations. ConclusionImplementation of the bundle of scenario-based training, real-time audiovisual CPR feedback, and post-event debriefing was associated with improved CPR quality and compliance with CPR guidelines in this urban teaching emergency department.

Pre-shock chest compression pause effects on termination of ventricular fibrillation/tachycardia and return of organized rhythm within mechanical and manual cardiopulmonary resuscitation

BackgroundShorter manual chest compression pauses prior to defibrillation attempts is reported to improve the defibrillation success rate. Mechanical load-distributing band (LDB-) CPR enables shocks without compression pause. We studied pre-shock pause and termination of ventricular fibrillation/pulseless ventricular tachycardia 5s post-shock (TOF) and return of organized rhythm (ROOR) with LDB and manual (M-) CPR. MethodsIn a secondary analysis from the Circulation Improving Resuscitation Care trial, patients with initial shockable rhythm and interpretable post-shock rhythms were included. Pre-shock rhythm, pause duration (if any), and post-shock rhythm were obtained for each shock. Associations between TOF/ROOR and pre-shock pause duration, including no pause shocks with LDB-CPR, were analyzed with Chi-square test. A p-value <0.05 was considered statistically significant. ResultsFor TOF and ROOR analyses we included 417 LDB-CPR patients with 1476 and 1438 shocks, and 495 M-CPR patients with 1839 and 1796 shocks, respectively. For first shocks with LDB-CPR, pre-shock pause was associated with TOF (p=0.049) with lowest TOF (77%) for shocks given without pre-shock compression pause. This association was not significant when all shocks were included (p=0.07) and not for ROOR. With M-CPR there were no significant associations between shock-related chest compression pause duration and TOF or ROOR. ConclusionFor first shocks with LDB-CPR, termination of fibrillation was associated with pre-shock pause duration. There was no association for the rate of return of organized rhythm. For M-CPR, where no shocks were given during continuous chest compressions, there were no associations between pre-shock pause duration and TOF or ROOR.

Rhythm analysis and charging during chest compressions reduces compression pause time

PurposeProlonged chest compression interruptions immediately preceding and following a defibrillation shock reduce shock success and survival after cardiac arrest. We tested the hypothesis that compression pauses would be shorter using an AED equipped with a new Analysis during Compressions with Fast Reconfirmation (ADC-FR) technology, which features automated rhythm analysis and charging during compressions with brief reconfirmation analysis during compression pause, compared with standard AED mode. MethodsBLS-certified emergency medical technicians (EMTs) worked in pairs and performed two trials of simulated cardiac resuscitation with a chest compression sensing X Series defibrillator (ZOLL Medical). Each pair was randomized to perform a trial of eight 2-min compression intervals (randomly assigned to receive four shockable and four non-shockable rhythms) with the defibrillator in standard AED mode and another trial in ADC-FR mode. Subjects were advised to follow defibrillator prompts, defibrillate if “shock advised,” and switch compressors every two intervals. Compression quality data were reviewed using RescueNet Code Review (ZOLL Medical) and analyzed using paired t-tests. ResultsThirty-two EMT-basic prehospital providers (59% male; median 25 years age [IQR 22–27]) participated in the study. End of interval compression interruptions were significantly reduced with ADC-FR vs. AED mode (p<0.001). For shockable rhythms, pre-shock pause was reduced significantly with ADC-FR compared with AED use (7.35±0.16s vs. 12.0±0.22s, p<0.001) whereas post-shock pause was similar (2.08±0.14s vs. 1.77±0.14s, p=0.1). ConclusionChest compression interruptions associated with rhythm analysis and charging are reduced with use of a novel defibrillator technology, ADC-FR, which features automated rhythm analysis and charging during compressions.

The association between manual mode defibrillation, pre-shock pause duration and appropriate shock delivery when employed by basic life support paramedics during out-of-hospital cardiac arrest

BackgroundPre-shock pause duration of <20s is associated with improved survival after cardiac arrest. Manual mode defibrillation has been associated with the shortest duration of pre-shock pause but is largely practiced by advanced life support paramedics (ALS) whereas defibrillator only paramedics (basic life support or BLS) routinely use the defibrillator in automatic mode. ObjectiveWe sought to explore the relationship between manual mode defibrillation, pre-shock pause duration and rate of inappropriate shocks when defibrillation is provided by ALS vs. BLS trained in manual mode defibrillation. MethodsWe performed a retrospective review of all treated non-traumatic adult out-of-hospital cardiac arrest (OHCA) presenting in a shockable rhythm over a one year period beginning January 1, 2012. Our primary outcome measure was the proportion of manual mode shocks delivered by BLS with pre-shock pause duration of <20s when compared to ALS. Our secondary outcome measures were the duration of pre-, post- and peri-shock pause and the proportion of appropriate shocks (defined as correct identification and shock delivery to patients in a shockable rhythm) delivered by either level of paramedic. This study had a power of 90% to detect an absolute difference of 15% between paramedic levels in proportion of shocks delivered with pre-shock pause duration <20s. ResultsAmong 2019 treated OHCA, 335 (20%) presented in a shockable rhythm. Manual defibrillation was performed in 155 (46%) of these cases (196 shocks by ALS, 143 shocks by BLS). There were no differences in the proportion of shocks delivered with pre-shock pause duration <20s (ALS 82.8% vs. BLS 84.8%, p=.65) nor pre-shock pause duration (s) (median, Q1, Q3); ALS: 12.0 (7.0,17.0) vs. BLS: 11.0 (5.0,17.0), p=.13 while BLS had a significantly shorter peri-shock pause duration (s) (median, Q1, Q3); ALS: 17.0 (12.0, 23.0) vs. BLS: 15.0 (9.0, 22.0), p=.05. There were no differences in the rate of inappropriate shocks (ALS 1.0% vs. BLS 0.7%), p=1.0 between levels of paramedics. ConclusionsManual mode defibrillation by BLS paramedics produced similar measures of pre-shock pause duration when compared to ALS paramedics without increasing the incidence of inappropriate shocks. Further study is required to determine the potential impact of BLS manual mode defibrillation on clinical outcomes.

Abstract 115: Video Review and Time-Motion Analysis of the Causes of No-Flow Intervals as Recorded by Accelerometer During Cardiopulmonary Resuscitation

Objectives: Accelerometer (Q-CPR) has been developed and promoted to monitor the quality of cardiopulmonary resuscitation (CPR). Although the device registers the occurrence of no-flow intervals, it does not provide comprehensive information on the causes leading to these no-flow intervals. This study is aimed to analyze causes leading to CPR interruptions registered by Q-CPR by reviewing corresponding video recordings of the resuscitation sessions. Methods: Accelerometer recordings (Q-CPR, Philips) of 20 CPR episodes from December 2010 to April 2014 in a tertiary university ED were obtained. Frequency, timing, duration, and types of no-flow intervals, defined as no-flow duration &gt;= 1.5 seconds, were reviewed. Video recordings of the corresponding CPR sessions were reviewed. Causes leading no flow intervals registered by Q-CPR were categorized and analyzed. Results: The duration of CPR reviewed for the cases averaged 8.59 minutes (range 2.23 - 19.04 minutes). No-flow intervals (pauses &gt;= 1.5 seconds) occurred 122 times (averaged one interruption every 1.27 minutes of CPR) with an average no-flow intervals of 6.45 seconds (range 1.54 - 51.50 seconds). Through detail review of the video-recordings corresponding to the no-flow intervals registered by Q-CPR, the leading causes of no-flow intervals are associated with pulse checks for pulseless electric activity- PEA (19.5%), pre-shock pauses (13.9%), ultrasound exam (11.6%) and intubation (9.6%), as displayed in the following chart. Conclusion: Video recording and time-motion analysis provide detailed information on the causes leading to no-flow intervals registered by QCPR, and could complement information acquired by Q-CPR. Measures should be taken to address leading causes of CPR interruption, especially pulse checks for PEA and pre-shock pauses, to promote quality of CPR.

Abstract 98: The Association Between Manual Mode Defibrillation, Preshock Pause Duration and Appropriate Shock Delivery When Employed by Basic Life Support Paramedics During Out-of-Hospital Cardiac Arrest

BACKGROUND: Pre-shock pause duration of &lt; 20 seconds is associated with improved survival after cardiac arrest. Manual mode defibrillation has been associated with the shortest duration of pre-shock pause but is largely practiced by paramedics (EMT-P) whereas defibrillator only providers (EMT-D) routinely use the defibrillator in automatic mode. OBJECTIVE: We sought to explore the relationship between manual mode defibrillation, pre-shock pause duration and shock appropriateness when defibrillation is provided by EMT-P vs. EMT-D level of providers. METHODS: We performed a retrospective review of all treated non-traumatic adult OHCA presenting in a shockable rhythm over a one year period beginning January 1, 2012. Our primary outcome measure was the proportion of manual mode shocks delivered by EMT-D’s with pre- shock pause duration of &lt; 20 secs when compared to EMT-P’s. Our secondary outcome measures were the duration of pre-, post- and peri-shock pause and the proportion of appropriate shocks (defined as correct identification and shock delivery to patients in a shockable rhythm) delivered by either level of provider. This study had a power of 90% to detect an absolute difference of 15% between provider levels in proportion of shocks delivered with pre-shock pause duration &lt;20 secs. RESULTS: Among 2019 treated OHCA, 335(20%) presented in a shockable rhythm. Manual defibrillation was performed in 155 (46%) of these cases (196 shocks by EMT-P, 143 shocks by EMT-D). There were no differences in the proportion of shocks delivered with pre-shock pause duration &lt;20 secs (EMT-P 82.8% vs EMT-D 84.8%, p =.65) nor pre-shock pause duration (sec) (median, Q1, Q3); EMT-P: 12.0 (7.0,17.0) vs. EMT-D: 11.0 (5.0,17.0), p= .13 while EMT-D had shorter peri- shock pause duration (sec) (median, Q1, Q3); EMT-P: 17.0 (12.0, 23.0) vs. EMT-D: 15.0 (9.0, 22.0), p =.03. There were no differences in the rate of inappropriate shocks (EMT-P 1.0% vs EMT-D 0.7%), p=1.0. CONCLUSIONS: Manual mode defibrillation by EMT-D’s produced similar measures of pre-shock pause when compared to EMT-P’s without increasing the rate of inappropriate shocks. More widespread use of EMT-D manual mode defibrillation may have the potential to decrease shock pause duration and improve survival.

Abstract 152: Impact of Shock Timing During Mechanical CPR on Defibrillation Efficacy

Background: Mechanical CPR (mCPR) devices enable defibrillation shock delivery during ongoing chest compressions, without the pause required during manual CPR. It is unknown whether shock delivery during ongoing mCPR, vs. during a pause, affects VF termination efficacy. Animal studies suggest that during ongoing mCPR, timing a shock to a specific phase of the compression cycle may significantly affect shock efficacy. Methods: We retrospectively analyzed electronic defibrillator recordings from the Amsterdam Resuscitation Study (ARREST), a prospective out-of-hospital cardiac arrest registry. We identified cases with LUCAS mCPR and at least one shock delivered after mCPR initiation. Shocks were sorted by energy level, and the most prevalent (360 J) was selected for the present analysis. Continuous ECG and impedance signals were analyzed to determine VF termination (defined as absence of VF at 5 sec after shock) for each shock after mCPR initiation, and whether the shock was delivered during a pause or during mCPR. For shocks delivered during a pause we measured pre-shock pause duration; for shocks delivered without pausing we measured the exact timing of the shock during the compression cycle. Results: In 153 cases meeting analysis criteria, 509 360J shocks occurred after mCPR initiation; VF termination outcome could be determined for 460. VF termination for first eligible shock during mCPR in each case was 84/97 (87%) during a pause, and 79/93 (85%; p=0.74) during ongoing mCPR; for all eligible shocks, VF termination was 203/242 (83.9%) and 155/196 (79.1%; p=0.20) respectively. For shocks during mCPR, there were no statistically significant differences in VF termination rate for shocks during four equal length phases beginning with LUCAS piston upstroke: 39/44 (89%), 39/49 (80%), 35/51 (69%), 40/50 (80%) (p = 0.12). For shocks during a pause, VF termination rate did not differ for pre-shock pauses ≤5 sec (75/91, 82.4%) vs. &gt;5 sec (128/151, 84.8%; p=0.63). Conclusions: Our results indicate that shocks can be delivered during ongoing mCPR without reducing defibrillation efficacy. The exact shock timing during the mCPR compression cycle did not significantly alter shock efficacy. VF termination rate was not affected by pre-shock pause duration during mCPR.

Minimizing pre-shock chest compression pauses in a cardiopulmonary resuscitation cycle by performing an earlier rhythm analysis

BackgroundGuidelines recommend 2min of CPR after defibrillation attempts followed by ECG analysis during chest compression pause. This pause may reduce the likelihood of return of spontaneous circulation (ROSC) and survival. We have evaluated the possibility of analysing the rhythm earlier in the CPR cycle in an attempt to replace immediate pre-shock rhythm analysis. Methods and resultsThe randomized Circulation Improving Resuscitation Care (CIRC) trial included patients with out of hospital cardiac arrest of presumed cardiac aetiology. Defibrillator data were used to categorize ECG rhythms as shockable or non-shockable 1min post-shock and immediately before next shock. ROSC was determined from end-tidal CO2, transthoracic impedance (TTI), and patient records. TTI was used to identify chest compressions. Artefact free ECGs were categorized during periods without chest compressions. Episodes without ECG or TTI data or with undeterminable ECG rhythm were excluded. Data were analyzed using descriptive statistics.Of 1657 patients who received 3409 analysable shocks, the rhythm was shockable in 1529 (44.9%) cases 1min post-shock, 13 (0.9%) of which were no longer shockable immediately prior to next possible shock. Of these, three had converted to asystole, seven to PEA and three to ROSC. ConclusionWhile a shockable rhythm 1min post-shock was present also immediately before next possible defibrillation attempt in most cases, three patients had ROSC. Studies are needed to document if moving the pre-shock rhythm analysis will increase shocks delivered to organized rhythms, and if it will increase shock success and survival.

Compressions during defibrillator charging shortens shock pause duration and improves chest compression fraction during shockable out of hospital cardiac arrest

BackgroundPrevious studies have demonstrated significant relationships between shock pause duration and survival to hospital discharge from shockable out-of hospital (OHCA) cardiac arrest. Compressions during defibrillator charging (CDC) has been proposed as a technique to shorten shock pause duration. ObjectiveWe sought to determine the impact of CDC on shock pause duration and CPR quality measures in shockable OHCA. MethodsWe performed a retrospective review of all treated adult OHCA occurring over a 1 year period beginning August 1, 2011 after training EMS agencies in CDC. We included OHCA patients with an initial shockable rhythm, available CPR process data and shock pause data for up to the first three shocks of the resuscitation. CDC by EMS personnel was confirmed by review of impedance channel measures. We evaluated the relationship between CDC and shock pause duration as the primary outcome measure. Secondary outcome measures investigated the association between CDC and CPR quality measures. ResultsAmong 747 treated OHCA 149 (23.4%) presented in a shockable rhythm of which 129 (81.6%) met study inclusion criteria. Seventy (54.2%) received CDC. There was no significant difference between the CDC and no CDC group with respect to Utstein variables. Median pre-shock pause (15.0 vs. 3.5s; Δ 11.5; 95% CI: 6.81, 16.19), post-shock pause (4.0 vs. 3.0s; Δ 1.0; 95% CI: −2.57, 4.57), and peri-shock pause (21.0 vs. 9.0s; Δ 12.0; 95% CI: 5.03, 18.97) were all lower for those who received CDC. Mean chest compression fraction was significantly greater (0.77 vs. 0.70, Δ 0.07; 95% CI: 0.03, 0.11) with CDC. No significant difference was noted in compression rate or depth with CDC. Clinical outcomes did not differ between the two approaches (return of spontaneous circulation 62.7% vs. 62.9% p=0.98, survival 25.4% vs. 27.1% p=0.82), although the study was not powered to detect clinical outcome differences. ConclusionsCompressions during defibrillator charging may shorten shock pause duration and improves chest compression fraction in shockable OHCA. Given the impact on shock pause duration, further study with a larger sample size is required to determine the impact of this technique on clinical outcomes from shockable OHCA.

Automatic detection of chest compression pauses for rhythm analysis during 30:2 CPR in an ALS scenario

s / Resuscitation 85S (2014) S4–S14 S9 Results: Of 4978 indicated and delivered shocks, 1130 shocks were delivered during continuous LDB-c. All data parameters were available for 949 (84%) of these shocks. TOF for the three phases are showed in Table 1. Conclusion: TOF rates were not different for defibrillation delivered during the three different phases of the LDB-c cycle irrespective of initial rhythm. How TOF rates for each of the phases compares to LDB-c shocks with different pre-shock pauses warrants further investigation. http://dx.doi.org/10.1016/j.resuscitation.2014.03.030

Transthoracic impedance-guided AMSA threshold adjustment for robust defibrillation outcome prediction

s / Resuscitation 85S (2014) S4–S14 S9 Results: Of 4978 indicated and delivered shocks, 1130 shocks were delivered during continuous LDB-c. All data parameters were available for 949 (84%) of these shocks. TOF for the three phases are showed in Table 1. Conclusion: TOF rates were not different for defibrillation delivered during the three different phases of the LDB-c cycle irrespective of initial rhythm. How TOF rates for each of the phases compares to LDB-c shocks with different pre-shock pauses warrants further investigation. http://dx.doi.org/10.1016/j.resuscitation.2014.03.030

Pediatric resident resuscitation skills improve after “Rapid Cycle Deliberate Practice” training

IntroductionPrevious studies reveal pediatric resident resuscitation skills are inadequate, with little improvement during residency. The Accreditation Council for Graduate Medical Education highlights the need for documenting incremental acquisition of skills, i.e. “Milestones”. We developed a simulation-based teaching approach “Rapid Cycle Deliberate Practice” (RCDP) focused on rapid acquisition of procedural and teamwork skills (i.e. “first-five minutes” (FFM) resuscitation skills). This novel method utilizes direct feedback and prioritizes opportunities for learners to “try again” over lengthy debriefing. ParticipantsPediatric residents from an academic medical center. MethodsProspective pre-post interventional study of residents managing a simulated cardiopulmonary arrest. Main outcome measures include: (1) interval between onset of pulseless ventricular tachycardia to initiation of compressions and (2) defibrillation. ResultsSeventy pediatric residents participated in the pre-intervention and fifty-one in the post-intervention period. Baseline characteristics were similar. The RCDP-FFM intervention was associated with a decrease in: no-flow fraction: [pre: 74% (5–100%) vs. post: 34% (26–53%); p<0.001)], no-blow fraction: [pre: 39% (22–64%) median (IQR) vs. post: 30% (22–41%); p=0.01], and pre-shock pause: [pre: 84s (26–162) vs. post: 8s (4–18); p<0.001]. Survival analysis revealed RCDP-FFM was associated with starting compressions within 1min of loss of pulse: [Adjusted Hazard Ratio (HR): 3.8 (95% CI: 2.0–7.2)] and defibrillating within 2min: [HR: 1.7 (95% CI: 1.03–2.65)]. Third year residents were significantly more likely than first years to defibrillate within 2min: [HR: 2.8 (95% CI: 1.5–5.1)]. ConclusionsImplementation of the RCDP-FFM was associated with improvement in performance of key measures of quality life support and progressive acquisition of resuscitation skills during pediatric residency.

Prehospital Shocks: Be Quick!

As part of the Resuscitation Outcomes Consortium PRIMED trial involving 10 regional clinical centers across North America, investigators assessed the association between peri-shock pause and survival to hospital discharge in 2006 adults with nontraumatic out-of-hospital cardiac arrest and initial shockable rhythms. Pre-shock pause was defined as the …

Cardiopulmonary resuscitation guidance improves medical students’ adherence to guidelines in simulated cardiac arrest

The 2010 Resuscitation Guidelines require high-quality chest compression and rapid defibrillation for patients with ventricular fibrillation with rhythm analysis and defibrillation repeated every 2 min. A lack of adherence to the guidelines by medical students was observed during simulated resuscitation training. To assess whether real-time cardiopulmonary resuscitation guidance, including an audiovisual countdown timer, a metronome, a display of the chest compression quality and voice prompts, might improve adherence to the guidelines by medical students. Randomised cross-over simulation study. Studienhospital Münster, Faculty of Medicine University Münster, Germany One hundred and forty-one medical students (fifth year) in 47 teams. Simulated resuscitation with and without real-time cardiopulmonary resuscitation guidance. The preshock pause, postshock pause, fraction of time without chest compression and defibrillation intervals. Observed quality parameters were chest compression depth and chest compression rate. With real-time cardiopulmonary resuscitation guidance, there were improved mean (SD) chest compression rates (105 ± 8 vs. 121 ± 12 bpm; P < 0.005), fewer inappropriate shock intervals [median (interquartile range) 0 (1 to 5) vs. 4 (1 to 7); P < 0.005], a smaller fraction of time without chest compression (18.9 ± 4.4 vs. 22.5 ± 7.0%; P < 0.005) and shorter postshock pauses (2.3 ± 0.9 vs. 3.4 ± 1.2 s; P < 0.005). Real-time cardiopulmonary resuscitation guidance significantly increased adherence to the guidelines by medical students treating simulated out-of-hospital cardiac arrest. Using a simple tool such as a countdown timer makes it possible to reduce the number of inappropriate shock intervals and time without chest compression.

Abstract 266: The Impact of Chest Compression Release Velocity on Outcomes From Out-of-Hospital Cardiac Arrest

BACKGROUND: Previous studies have demonstrated significant relationships between CPR quality metrics and survival to hospital discharge from out-of hospital (OHCA) cardiac arrest. Recently a new metric, chest compression release velocity (CCRV) has been associated with improved survival from OHCA. OBJECTIVE: To determine the impact of CCRV on clinical outcomes from OHCA. METHODS: We performed a retrospective review of prospectively collected data on all treated adult OHCA occurring over a one year period (Jan 2012 - Jan 2013) in two Canadian EMS agencies. CPR metrics of chest compression fraction (CCF), compression rate, compression depth, shock pause duration and CCRV were abstracted from impedance channel measurements during each resuscitation. Cases of public access defibrillation, EMS witnessed arrest and those missing any Utstein variable or discharge status data were excluded. We performed a multivariable regression analysis to determine the impact of CCRV on survival to hospital discharge. Secondary outcome measures were the impact of CCRV on return of spontaneous circulation (ROSC) and neurologically intact survival (MRS ≤ 3). RESULTS: Among 908 treated OHCA, 611met inclusion criteria. The median (IQR) age was 71.7 (60.7, 81.6) with 395 (64.6%) being male. 140 (22.9%) presented in ventricular fibrillation, 122 (20%) pulseless electrical activity and 349 (57.1%) asystole. The median (IQR) CPR quality metrics were: CCF 0.81 (0.73, 0.85), compression rate 105/minute (101, 115), compression depth 49.9 mm (42.5, 56.7), pre-shock pause 13.5 secs (8, 19) and post-shock pause 3.5 secs (2.8, 5). The median (IQR) CCRV (mm/sec) amongst 49 survivors was 135.9 (115.4, 156.5) compared to 120 (102.9, 140) in 562 non survivors (p=0.009). When adjusted for CPR metrics and Utstein variables, the odds of survival to hospital discharge for each 5 mm/sec increase in CCRV was 1.02 (95% CI: 0.97, 1.08). Similarly the odds of ROSC and neurologically intact survival were 1.02 (95% CI: 0.99, 1.05) and 1.03 (95% CI: 0.98, 1.08), respectively. CONCLUSIONS: When adjusted for Utstein variables and CPR quality metrics, CCRV was not significantly associated with outcomes from OHCA. Our findings may have been impacted by the sample size of our study.

Abstract 268: Improvements in Emergency Department CPR Quality Utilizing Real-Time Audiovisual CPR Feedback

Background: CPR quality is closely linked to outcome in cardiac arrest. The AHA 2010 Guidelines recommend monitoring CPR quality performed by healthcare providers both inside and outside the hospital. However, most EDs currently do not monitor CPR quality. The goal of the present investigation was to assess the quality of CPR performed in an urban ED and determine the influence of training and real-time audiovisual feedback (RTAVF) on CPR quality and patient outcome. Methods: CPR quality was monitored using an R Series defibrillator (ZOLL Medical) during the treatment of adult cardiac resuscitation attempts. During phase 1 (P1; 11/2010-11/2012), real-time audiovisual chest compression feedback was disabled. During phase 2 (P2; 11/2012-3/2013), clinicians underwent a 60 minute didactic/hands-on CPR training session after which the RTAVF and the ECG artifact filtering feature were enabled. CPR quality data (fraction, depth, rate, release, peri-shock pause) were reviewed using Code Review software (ZOLL Medical). Student’s t-test and Wilcoxon-signed rank test were employed. Results: A total of 44 OHCA patients were treated in P1 (mean age 57±18 yrs, 59% male) and 24 in Phase 2 (mean age 63±15 yrs, 88% male). The majority of patients (89% P1; 96% P2) suffered prehospital arrest and were transported to the ED. Chest compression (CC) depth increased from 1.8±0.5 inches in P1 to 2.3±0.4 in P2 (p&lt;0.001), with the percentage of compressions exceeding 2 inches more than doubling from 36% in P1 to 79% in P2 (p&lt;0.001). CC release velocity increased from 1.25±0.36 inch/sec in P1 to 1.69±0.28 in P2 (p&lt;0.001). No significant differences were identified in CC rate (125±12 cpm P1 vs. 121±15 cpm P2, p=0.3) or CC fraction (82% P1 vs. 87% P2, p=0.1). Pre-shock pause (11.5±10.4 sec P1 vs. 8.0±6.2 P2, p=0.4) and post-shock pause (5.2±3.4 sec vs. 3.8±0.6, p=0.9) were statistically similar in P1 and P2. Conclusion: The bundle of real time audiovisual CPR feedback and training were associated with an improvement in chest compression depth and recoil and closer adherence to guidelines for CPR quality in this large urban ED.

The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation Outcomes Consortium PRIMED trial

BackgroundPrevious research has demonstrated significant relationships between peri-shock pause and survival to discharge from out-of-hospital shockable cardiac arrest (OHCA). ObjectiveTo determine the impact of peri-shock pause on survival from OHCA during the ROC PRIMED randomized controlled trial. MethodsWe included patients in the ROC PRIMED trial who suffered OHCA between June 2007 and November 2009, presented with a shockable rhythm and had CPR process data for at least one shock. We used multivariable logistic regression to determine the association between peri-shock pause duration and survival to hospital discharge. ResultsAmong 2006 patients studied, the median (IQR) shock pause duration was: pre-shock pause 15s (8, 22); post-shock pause 6s (4, 9); and peri-shock pause 22.0s (14, 31). After adjusting for Utstein predictors of survival as well as CPR quality measures, the odds of survival to hospital discharge were significantly higher for patients with pre-shock pause <10s (OR: 1.52, 95% CI: 1.09, 2.11) and peri-shock pause <20s (OR: 1.82, 95% CI: 1.17, 2.85) when compared to patients with pre-shock pause ≥20s and peri-shock pause ≥40s. Post-shock pause was not significantly associated with survival to hospital discharge. Results for neurologically intact survival (Modified Rankin Score≤3) were similar to our primary outcome. ConclusionsIn patients with cardiac arrest presenting in a shockable rhythm during the ROC PRIMED trial, shorter pre- and peri-shock pauses were significantly associated with higher odds of survival. Future cardiopulmonary education and technology should focus on minimizing all peri-shock pauses.