Professional Rescuers Research Articles

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

The C-Zones Framework

Lifesavers often discuss and analyze rescue and drowning incidents. The C Zones Framework was designed to serve as an aid to such discussions. It is constituted by a number of zones (i.e. C1-concern, C2-crisis, C3-critical, C4-cardio-pulmonary resuscitation (CPR), C5-coma, and C6-conclusions) and is simple enough to be easily remembered and quickly drawn on a piece of paper yet sufficiently detailed to be a serious analytical tool. The use of multicolored or different style lines permits the comparison of numerous casualty variations and outcomes on the one framework. The standard framework has a 20 minute time limit describing the progress of an incident from its beginning to conclusion, but other versions of the framework are possible by adjusting the timing. Overall, this framework can serve as a teaching aid and useful feedback tool offering a visual overview of rescue options and their potential or likely consequences at various stages in the drowning process. This information can be valuable to lifesavers, lifeguards, professional rescuers, lawyers, expert witnesses, and judges.

Effectiveness of using automated external defibrillator by trained healthcare professionals on survival outcomes among adult patients after in-hospital cardiac arrest: a systematic review.

Review question/objective The objective of this review is to synthesise the best available evidence of the effectiveness of using automated external defibrillator by trained healthcare professionals on survival outcomes in adult patients after in-hospital cardiac arrest. More specifically, the objectives are to identify: the effectiveness of using automated external defibrillator by trained healthcare professionals on return of spontaneous circulation and survival to hospital discharge in adult patients after in-hospital cardiac arrest. Inclusion criteria Types of participants This review will consider studies that include adults 18 years old and above; suffering from cardiac arrest requiring chest compression in in-patient wards, emergency department and out-patient procedures in hospital; presenting with an initial index pulseless (for example, but not limited to, ventricular fibrillation and pulseless ventricular tachycardia, asystole or pulseless electrical activities); presence or absence of co-morbidities such as congestive heart failure, myocardial infarction, diabetes mellitus, renal, hepatic or respiratory insufficiency, motor, cognitive or functional deficits, acute stroke, acute non-stroke neurological disorder, pneumonia, hypotension, sepsis, major trauma, metabolic or electrolyte abnormality, metastatic or haematology malignancy. The exclusion criteria are any age group who suffered out-of-hospital cardiac arrest or adults 18 years old and above suffered in-hospital cardiac arrest with a ‘do not resuscitate’ order (DNR). Types of intervention(s) This review will consider as interventions any use of commercially available automated external defibrillator by trained healthcare professionals for in-hospital cardiac arrest. The comparator of interest is use of manual/standard external defibrillator by trained healthcare professionals for in-hospital cardiac arrest. Types of outcomes This review will consider studies that include the following outcome measures: 1. survival with a return of spontaneous circulation for at least 20 minutes during resuscitation 2. survival to hospital discharge regardless of time to discharge 3. initial cardiac arrest rhythms

Abstract 220: Analysis of Actual CPR Through a Review of YouTube Video: Poor Performance Is Common in Professional and Lay Rescuers

INTRODUCTION: Numerous studies have shown the performance of CPR in both prehospital and hospital settings often fails to meet recommended standards. We sought to analyze the quality of lay rescuer (LR) and professional rescuer (PR) CPR performance in real resuscitation events captured on video on the website YouTube.com. METHODS: We searched YouTube for videos of actual adult CPR recorded by bystanders. Videos which were staged for teaching, commercial use or entertainment were excluded. A convenience sample of 50 videos of CPR (in and out-of-hospital) was analyzed. Demographics and CPR quality parameters were collected. Compression depth was subjectively evaluated as adequate or inadequate (ie. not forceful enough). RESULTS: The 50 videos collected were uploaded between 12/2009 and 2/2011. They ranged from :07 to 9:57 minutes in length. Forty-two of 50 (84%) were of out-of-hospital arrests. CPR was done by LR in 17 and PR in 43. The mean chest compression (CC) rate was 110/m (SD 30, range 49-200) for all rescuers, 101/m (SD 29, range 46-166) for LR and 113/m (SD 28, range 49-200) for PR. In both groups, 40% of CC were slower than the recommended rate of 100/m. Inadequate release or leaning was seen in 66% of the time overall (11/17 (65%) of LR and 23/43 (53%) of PR). CC depth was adequate in 18/50 (36%) for both groups (3/17 for LR and 17/43 for PR). Depth was inadequate in 31/50 (62%) for both groups (14/17 for LR and 25/43 for PR). Compression depth adequacy was indeterminate in 1 video where the chest could not be seen. The mean time for rescue breath delivery was 7.8s (SD 4.4, range 3.4-25) overall, 6.3s (SD 3.1) for LR, 14.7s (SD 5.2) for PR. For PR, the mean ventilation rate by BVM alone or after intubation was 31/m (SD 17, range 3-66). 88% of ventilations were faster than the recommended 8-10/m. CONCLUSIONS: In actual bystander-recorded CPR, typical measures of CPR quality are often poor. Slow compression rates, excessive ventilation and significant periods of ‘leaning’ are common, in lay as well as professional rescuers. Mean CC rate is close to recommended rates, but with a very wide range making overall compliance poor. Poor compression depth was more common in LR CPR.

Part 5: Adult Basic Life Support

Part 8 : Advanced life support : 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Part 13: First Aid

Part 13: First Aid

Web 2.0 and Internet Social Networking: A New tool for Disaster Management? - Lessons from Taiwan

BackgroundInternet social networking tools and the emerging web 2.0 technologies are providing a new way for web users and health workers in information sharing and knowledge dissemination. Based on the characters of immediate, two-way and large scale of impact, the internet social networking tools have been utilized as a solution in emergency response during disasters. This paper highlights the use of internet social networking in disaster emergency response and public health management of disasters by focusing on a case study of the typhoon Morakot disaster in Taiwan.DiscussionIn the case of typhoon disaster in Taiwan, internet social networking and mobile technology were found to be helpful for community residents, professional emergency rescuers, and government agencies in gathering and disseminating real-time information, regarding volunteer recruitment and relief supplies allocation. We noted that if internet tools are to be integrated in the development of emergency response system, the accessibility, accuracy, validity, feasibility, privacy and the scalability of itself should be carefully considered especially in the effort of applying it in resource poor settings.SummaryThis paper seeks to promote an internet-based emergency response system by integrating internet social networking and information communication technology into central government disaster management system. Web-based networking provides two-way communication which establishes a reliable and accessible tunnel for proximal and distal users in disaster preparedness and management.

Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations

Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations

Mechanical loading of the low back during cardiopulmonary resuscitation

Aim Back pain is often seen in professional rescuers after carrying out resuscitation. Back loading is known to be affected by the working surface height, but the relationship between the surface height and back loading during cardiopulmonary resuscitation (CPR) is poorly understood. The purpose of this study was to examine how back loading changes in response to CPR posture and surface height. Methods Twenty-two experienced professional rescuers performed CPR using three surface heights; the floor (F), a table at a height of 63 cm (HT) and one at a height of 37 cm (LT). Results The mean and maximal low back moment and compression force at HT were significantly smaller than those at LT and F. Conclusion The results suggest that the HT task of chest compression produces the lowest low back moment and compression force. Thus, HT positioning may decrease the probability of low back pain and is suggested to be optimal height for inexperienced resuscitators, those with back injury, or those requiring a long operating duration.

Miniaturization of a Chest Compressor for Cardiopulmonary Resuscitation

A miniaturized chest compressor (MCC®) for cardiopulmonary resuscitation (CPR) was designed to serve as a compact portable device to overcome limitations of manual chest compression and of currently marketed mechanical devices. We sought to especially address constraints of size and weight of current devices, together with the need for ease of application and consistent compressions with appropriate force and depth. We further intended that the device allows for ease of evacuation and transport through small spaces. These objectives are responsive to the increasingly recognized requirements for uninterrupted chest compression including that which results from operator fatigue during manual compressions. Utilizing a garment applied to the torso, the device incorporated a telescopic piston for chest compression. The compressor was pneumatically powered so as to avoid the added weight and potential electrical adversity of power delivered by batteries. Pneumatic power was supplied by the same compressed air or oxygen tank, which is routinely carried by professional emergency medical rescuers. The MCC® was tested on a porcine model during cardiac arrest and resuscitation with comparisons to the current industry standard, the Michigan Thumper®. Arterial, carotid, and coronary perfusion pressures, together with end-tidal carbon dioxide as a surrogate for cardiac output, were measured. The MCC® threshold levels of pressure, flow, and end-tidal PCO2 are achieved, which were predictive of successful defibrillation with restoration of spontaneous circulation. We conclude that the MCC® is as effective as that of the established industry standard, the Michigan Thumper®, with the potential advantage of portability and facile application, especially for out-of-hospital resuscitation.

Abstract 2690: A Compression/Ventilation Metronome Prevents Hyperventilation by Professional Rescuers

Background : The recent recommendation for hands-only (continuous chest compression) CPR has caused concern that professional rescuers may over-ventilate to compensate for a lack of ventilation before their arrival. Previous research shows that over-ventilation can be deleterious. Methods : We conducted a prospective, randomized, parallel design study of the effectiveness of a customized metronome to guide both compressions and ventilations during CPR with an unsecured airway or a secured airway. Firefighter EMTs performed 2-rescuer CPR on an instrumented manikin, 34 EMTs with and 34 EMTs without metronome guidance. Each session consisted of 2 min of 30:2 CPR with an unsecured airway, then 4 min of CPR with a secured airway (100/min continuous compressions and 8 –10 ventilations/min), repeated after the rescuers switched roles. The metronome gave “tock” prompts for compressions and a spoken “ventilate” prompt. Endpoints included compression and ventilation rates. Results : Metronome use significantly decreased the incidence of over-ventilation (11/34 CPR sessions vs 0/34; p&lt;0.001). As previously documented, compression rate errors were significantly less with the metronome. For unsecured airways, mean compression rate error was 21/min for control vs. 0 for the metronome group, (p&lt;0.001); for secured airways, mean compression rate error was 18/min for control vs. 1/min for the metronome group (p&lt;0.001). Conclusions : A compression/ventilation metronome helps avoid over-ventilation and improves compression rate when used by professional rescuers on a manikin. The metronome may be highly effective in avoiding over-ventilation during CPR with a secured airway.

Time used for ventilation in two-rescuer CPR with a bag-valve-mask device during out-of-hospital cardiac arrest

Professional rescuers only deliver chest compressions 39% of the available time before intubation during out-of-hospital cardiac arrest. In manikin-studies lay rescuers need approximately 15s to deliver two ventilations. It is not known how much time professional rescuers use for two ventilations and we hypothesised that the time used for two ventilations with a bag-valve-mask device before tracheal intubation is longer than recommended and that the extended time contributes to the high no flow time. Quality of CPR was available for analysis in 628 cases of out-of-hospital cardiac arrest in the ambulance service in Oslo, Akershus, London, and Stockholm from 2002 to 2005. The 2000 Guidelines were used as the reference. Ventilations were registered from changes in transthoracic impedance as measured through the standard defibrillation pads. We included episodes only with CPR with a 15:2 pattern for at least 1 min and identified all pauses between chest compressions before intubation. In the remaining 172 episodes we identified 3097 chest compression pauses. In 1587 (51%) of the pauses we identified two ventilations and a mean pause length for each episode was calculated. The median of these means was 5.5s (IQR; 4.5, 7). These pauses comprised a median 9% (IQR; 4%, 15%) of the time before intubation in these episodes. In 892 (29%) of the pauses we identified a different number of ventilations, or other interventions in addition to ventilation. In the remaining 618 pauses (20%) no ventilations were registered. Professional rescuers delivered two bag-valve-mask ventilations within the 5-6s as indicated in the 2000 Guidelines, slightly longer than the 3-4s recommended in the 2005 Guidelines. However, only half the pauses were used for two ventilations, and the total time for two ventilations accounted for only 27% of the time without chest compressions. Excessive time for ventilation cannot explain the high no-flow time during CPR by professional rescuers before intubation.

Reducing Barriers for Implementation of Bystander-Initiated Cardiopulmonary Resuscitation

Sudden cardiac arrest (SCA) is a leading cause of death in the United States and Canada. In the United States, each year ≈330 000 people die of coronary heart disease out of the hospital or in emergency departments. Of these, >150 000 SCAs occur out of the hospital.1,2 Despite the development of electrical defibrillation and the more recent implementation of lay rescuer defibrillation programs, the vast majority of these victims do not leave the hospital alive. In studies over the past 15 years, only 1.4% of patients with out-of-hospital arrest in Los Angeles, Calif, survived to hospital discharge3; in Chicago, Ill, the number was 2%,4 and in Detroit, Mich, it was <1%.5 Conversely, a few municipalities such as Seattle, Wash, report much higher survival rates from SCA—more than 15% in 1 study6—which suggests that survival rates need not remain so low. Recent work in Europe and elsewhere has confirmed that a higher survival-to-hospital discharge rate is indeed a realistic goal, with survival rates as high as 9% reported in Amsterdam7 and 21% in Maribor, Slovenia.8 The American Heart Association (AHA) uses 4 links in the “chain of survival” to illustrate the time-sensitive actions required for victims of SCA: (1) early recognition of the emergency and activation of emergency medical services (EMS), (2) early bystander cardiopulmonary resuscitation (CPR), (3) early delivery of shock(s) from a defibrillator if indicated, and (4) early advanced life support and postresuscitation care. Immediate bystander recognition of the emergency and EMS activation are critical. In many communities, however, these actions may be followed by significant delays, because the time interval from activation of EMS to arrival of these medical personnel may be 7 to 8 minutes or longer.4 Therefore, initial care in the first critical minutes after …

ELECTROMYOGRAPHY ACTIVITY OF SELECTED TRUNK MUSCLES IN RESCUERS DURING CARDIOPULMONARY RESUSCITATION

INTRODUCTION Low back pain is highly prevalent among the professional rescuers. Previous studies found that almost 96% of ambulance officers and over 80% of nurses experienced a back discomfort during or after the cardiopulmonary resuscitation (CPR) procedure. The cause of their back injury was related to the CPR delivery [1]. Chest compression in the procedure is an important step to maintain circulation. It is also a repetitive and laborious movement which is prone to cause low back injury. Despite the prevalence of pain, the relationship between trunk muscle activity during CPR and the risk of musculoskeletal injury was poorly understood. Surface EMG-based methods provide an easy access to the physiological processes that cause muscles to generate force and to produce movement. Therefore, the aim of this study is to investigate the patterns of trunk muscle activity for the manual chest compression during CPR.

Continuous physical education of cadets and students at the initial stage of formation of professional rescuers on the water

Continuous physical education of cadets and students at the initial stage of formation of professional rescuers on the water

Single rescuer cardiopulmonary resuscitation: Can anyone perform to the guidelines 2000 recommendations?

The Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommend that for adult cardiac arrest the single rescuer performs "two quick breaths followed by 15 chest compressions." This cycle is continued until additional help arrives. Previous studies have shown that lay persons and medical students take 16 +/- 1 and 14 +/- 1 s, respectively, to perform these "two quick breaths." The purpose of this study was to determine the time required for trained professional paramedic firefighters to deliver these two breaths and the effects that any increase in the time it takes to perform rescue breathing would have on the number of chest compressions delivered during single rescuer BLS CPR. We hypothesized that trained professional rescuers would also take substantially longer then the Guidelines recommendation for delivering the two rescue breaths before every 15 compressions during simulated single rescuer BLS CPR. Twenty-four paramedic firefighters currently certified to perform BLS CPR were evaluated for their ability to deliver the two recommended breaths within 4 s according to the AHA 2000 CPR Guidelines. Alternatively, a simplified technique of continuous chest compression BLS CPR (CCC) was also taught and compared with standard BLS CPR (STD). Without revealing the purpose of the study the paramedics were asked to perform single rescuer BLS CPR on a recording Resusci Anne while being videotaped. The mean length of time needed to provide the "two quick breaths" during STD-CPR was 10 +/- 1 s. The mean number of chest compressions/min delivered with AHA BLS CPR was only 44 +/- 2. Continuous chest compression CPR resulted in 88 +/- 5 compressions delivered per minute (STD versus CCC; p < 0.0001). Trained professional emergency rescue workers perform rescue breathing somewhat faster than lay rescuers or medical students, but still require two and one half times longer than recommended. The time required to perform these breaths significantly decreases the number of chest compressions delivered per minute. This may affect outcome as experimental studies have shown that more than 80 compressions delivered per minute are necessary for survival from prolonged cardiac arrest.

Key advances in critical care in the out-of-hospital setting: the evolving role of laypersons and technology

During the past decade, critical care in the out-of-hospital setting has transcended the original emphasis on on-scene advanced life support interventions by doctors, paramedics, and nurses. Many of the life-saving efforts and advances in critical care situations have now begun to focus more and more on how, through evolving technology, the average person can save lives and perhaps even spare precious intensive care unit (ICU) resources. A striking example was the recent study conducted at the Chicago airports at which automated external defibrillators (AEDs) were deployed throughout the airline terminals for use by the public at large. Not only did random bystanders on the concourses save an extremely high percentage of cardiac arrest patients with the AEDs, most patients rapidly awakened, even before the arrival of professional rescuers. Thus, this technology-assisted intervention, performed by an average person, pre-empted the need for many other critical care interventions and prolonged care in the ICU. Equipped with automated prompts to improve performance, new technology also exists to help to monitor the inadequacies and too-frequent interruption of life-saving chest compressions during basic cardiopulmonary resuscitation. As a result of these technological advances, survival rates for cardiac arrest are now expected to improve significantly.

L'utilisation des défibrillateurs semi-automatiques en France : état des lieux et perspectives en 2005

Automatic external defibrillation is one of the main parameter of cardiopulmonary resuscitation. This technique must be performed as soon as possible in order to induce a positive impact on survival rate. Since the last ten years, early defibrillation has been approved all over the world and specially in France. Devices are accurate and allow a simple use from professional or non professional rescuers. Implementation of this kind of device is going progressively in specific and public areas in France. Even though this phase of basic cardiopulmonary resuscitation must have an important place in the treatment of cardiac arrest, one must still focus on global teaching and training on basic gestures.

Over-the-Head Cardiopulmonary Resuscitation Improves Efficacy in Basic Life Support Performed by Professional Medical Personnel with a Single Rescuer: A Simulation Study

Two-rescuer cardiopulmonary resuscitation (CPR) is considered the best method for professional basic life support (BLS). However, in many prehospital cardiac arrest situations, one rescuer has to begin CPR alone while the other performs additional tasks. In theory, over-the-head CPR is a suitable alternative in this situation, with the added benefit of allowing the single rescuer to use a self-inflating bag for ventilation. In this trial, we compared standard single-rescuer CPR with over-the-head CPR in manikins. We planned this study using a crossover study design where each participant administered both CPR techniques in a randomized order. Ventilation and chest compression data were collected with analysis software during a 2-min CPR test for each technique. Sixty-seven emergency medical technician students participated in this trial. Over-the-head CPR allowed for superior ventilation compared to standard CPR (number of correct ventilations: 330 of 760 versus 279 of 779; P = 0.002). The quality of delivered chest compressions did not differ between the two groups (correct chest compressions: 4293 of 6304 versus 4313 of 6395; P = 0.44). In conclusion, our study has shown that over-the-head CPR may be an effective alternative BLS technique when a single professional rescuer has to perform CPR, likely offering superior ventilation and comparable chest compression quality compared with standard BLS.

What is the optimal chest compression-ventilation ratio?

Despite a more widespread knowledge of basic cardiopulmonary resuscitation maneuvers in the community, the survival rate for patients with cardiac arrest has remained essentially unchanged in the past 30 years. Over the past few decades, many different compression-ventilation ratios have been studied in terms of best coronary and cerebral oxygen delivery, restoration of spontaneous circulation, and neurologic outcome. This article summarizes the recent evidence presented at the International Consensus on Resuscitation Science in January 2005. Recent data from animal and mathematical models suggest a move to a higher compression-ventilation ratio to maximize coronary and cerebral oxygen delivery during cardiac arrest and long-term neurologic outcome. Prospective randomized human data on alternative compression-ventilation ratios are missing and new evidence seems to indicate the inadequacy of both lay and professional rescuers in providing chest compression and ventilating the victim in cardiac arrest. Finally, observational and animal studies highlight the hidden danger of inadvertent hyperventilation during advanced cardiac life support as a reduction of both coronary and perfusion pressure secondary to increased intrathoracic pressure and decreased venous return. The optimal compression-ventilation ratio is still unknown and the best tradeoff between oxygenation and organ perfusion during cardiopulmonary resuscitation is probably different for each patient and scenario. A discrepancy between what is recommended by the current guidelines and the 'real world' of cardiopulmonary resuscitation has resulted in a near flat survival rate from cardiac arrest in the past few years.