Prolonged Cardiopulmonary Resuscitation Research Articles

Oxygenation and ventilation during prolonged experimental cardiopulmonary resuscitation with either continuous or 30:2 compression-to-ventilation ratios together with 10 cmH20 positive end-expiratory pressure

BackgroundIn refractory out-of-hospital cardiac arrest, the patient is commonly transported to hospital with mechanical continuous chest compressions (CCC). Limited data are available on the optimal ventilation strategy. Accordingly, we compared arterial oxygenation and haemodynamics during manual asynchronous continuous ventilation and compressions with a 30:2 compression-to-ventilation ratio together with the use of 10 cmH2O positive end-expiratory pressure (PEEP).MethodsIntubated and anaesthetized landrace pigs with electrically induced ventricular fibrillation were left untreated for 5 min (n = 31, weight ca. 55 kg), after which they were randomized to either the CCC group or the 30:2 group with the the LUCAS® 2 piston device and bag-valve ventilation with 100% oxygen targeting a tidal volume of 8 ml/kg with a PEEP of 10 cmH2O for 35 min. Arterial blood samples were analysed every 5 min, vital signs, near-infrared spectroscopy and electrical impedance tomography (EIT) were measured continuously, and post-mortem CT scans of the lungs were obtained.ResultsThe arterial blood values (median + interquartile range) at the 30-min time point were as follows: PaO2: 180 (86–302) mmHg for the 30:2 group; 70 (49–358) mmHg for the CCC group; PaCO2: 41 (29–53) mmHg for the 30:2 group; 44 (21–67) mmHg for the CCC group; and lactate: 12.8 (10.4–15.5) mmol/l for the 30:2 group; 14.7 (11.8–16.1) mmol/l for the CCC group. The differences were not statistically significant. In linear mixed models, there were no significant differences between the groups. The mean arterial pressures from the femoral artery, end-tidal CO2, distributions of ventilation from EIT and mean aeration of lung tissue in post-mortem CTs were similar between the groups. Eight pneumothoraces occurred in the CCC group and 2 in the 30:2 group, a statistically significant difference (p = 0.04).ConclusionsThe 30:2 and CCC protocols with a PEEP of 10 cmH2O resulted in similar gas exchange and vital sign outcomes in an experimental model of prolonged cardiac arrest with mechanical compressions, but the CCC protocol resulted in more post-mortem pneumothoraces.

Prognostic effects of cardiopulmonary resuscitation (CPR) start time and the interval between CPR to extracorporeal cardiopulmonary resuscitation (ECPR) on patient outcomes under extracorporeal membrane oxygenation (ECMO): a single-center, retrospective observational study

BackgroundThe impact of the chronological sequence of events, including cardiac arrest (CA), initial cardiopulmonary resuscitation (CPR), return of spontaneous circulation (ROSC), and extracorporeal cardiopulmonary resuscitation (ECPR) implementation, on clinical outcomes in patients with both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA), is still not clear. The aim of this study was to investigate the prognostic effects of the time interval from collapse to start of CPR (no-flow time, NFT) and the time interval from start of CPR to implementation of ECPR (low-flow time, LFT) on patient outcomes under Extracorporeal Membrane Oxygenation (ECMO).MethodsThis single-center, retrospective observational study was conducted on 48 patients with OHCA or IHCA who underwent ECMO at Hamad General Hospital (HGH), the tertiary governmental hospital of Qatar, between February 2016 and March 2020. We investigated the impact of prognostic factors such as NFT and LFT on various clinical outcomes following cardiac arrest, including 24-hour survival, 28-day survival, CPR duration, ECMO length of stay (LOS), ICU LOS, hospital LOS, disability (assessed using the modified Rankin Scale, mRS), and neurological status (evaluated based on the Cerebral Performance Category, CPC) at 28 days after the CA.ResultsThe results of the adjusted logistic regression analysis showed that a longer NFT was associated with unfavorable clinical outcomes. These outcomes included longer CPR duration (OR: 1.779, 95%CI: 1.218–2.605, P = 0.034) and decreased survival rates for ECMO at 24 h (OR: 0.561, 95%CI: 0.183–0.903, P = 0.009) and 28 days (OR: 0.498, 95%CI: 0.106–0.802, P = 0.011). Additionally, a longer LFT was found to be associated only with a higher probability of prolonged CPR (OR: 1.818, 95%CI: 1.332–3.312, P = 0.006). However, there was no statistically significant connection between either the NFT or the LFT and the improvement of disability or neurologically favorable survival after 28 days of cardiac arrest.ConclusionsBased on our findings, it has been determined that the NFT is a more effective predictor than the LFT in assessing clinical outcomes for patients with OHCA or IHCA who underwent ECMO. This understanding of their distinct predictive abilities enables medical professionals to identify high-risk patients more accurately and customize their interventions accordingly.

Impact of prolonged cardiopulmonary resuscitation on outcomes in heart transplantation with higher risk donor heart.

To evaluate the influence of prolonged cardiopulmonary resuscitation (CPR) on outcomes in heart transplantation with higher risk donor hearts (HRDHs). Patients transplanted in our hospital between May 2006 and December 2019 were divided into 2 groups, HRDH recipients and non HRDH recipients. HRDH was defined as meeting at least one of the following criteria: (1) donor left ventricular ejection fraction ≤ 50%, (2) donor-recipient predicted heart mass ratio < 0.8 or > 1.2, (3) donor age ≥ 55years, (4) ischemic time > 4h and (5) catecholamine index > 20. Recipients of HRDHs were divided into 3 groups according to the time of CPR (Group1: non-CPR, Group 2: less than 30min-CPR, and Group 3: longer than 30min CPR). A total of 125 recipients were enrolled in this study, composing of HRDH recipients (n = 97, 78%) and non HRDH recipients (n = 28, 22%). Overall survival and the rate of freedom from cardiac events at 10years after heart transplantation were comparable between two groups. Of 97 HRDH recipients, 54 (56%) without CPR, 22 (23%) with CPR < 30min, and 21 (22%) with CPR ≥ 30min were identified. One-year survival rates were not significantly different among three groups. The 1-year rate of freedom from cardiac events was not also statistically different, excluding the patients with coronary artery disease found in early postoperative period, which was thought to be donor-transmitted disease. Multivariate logistics regression for cardiac events identified that the CPR duration was not a risk factor even in HRDH-recipients. The CPR duration did not affect the outcomes after heart transplantation in HRDH recipients.

Coagulofibrinolytic effects of recombinant soluble thrombomodulin in prolonged porcine cardiac arrest

AimTo evaluate coagulofibrinolytic abnormalities and the effects of ART-123 (recombinant human thrombomodulin alpha) in a porcine model of cardiac arrest and prolonged cardiopulmonary resuscitation (CA/CPR). MethodsFifteen pigs (n = 5 per group) underwent 8 minutes of no-flow CA followed by 50 minutes of mechanical CPR, while 2 pigs underwent sham arrest. CA/CPR animals were randomized to receive saline or 1 mg/kg ART-123 pre-arrest (5 minutes prior to ventricular fibrillation) or post-arrest (2 minutes after initiation of CPR). Arterial and venous blood samples were drawn at multiple time points for blood gas analysis and measurement of plasma and whole blood markers of coagulation and fibrinolysis. ResultsIn saline-treated CA/CPR, but not sham animals, robust and persistent activation of coagulation and fibrinolysis was observed throughout resuscitation. After 50 minutes of CPR, plasma tests and thromboelastography indicated a mix of hypercoagulability and consumptive coagulopathy. ART-123 had a robust anticoagulant effect, reducing both thrombin-antithrombin (TAT) complexes and d-dimer (p < 0.05 for each). The duration of anticoagulant effect varied depending on the timing of ART-123 administration. Similarly, ART-123 when given prior to cardiac arrest was found to have pro-fibrinolytic effects, increasing free tissue plasminogen activator (tPA, p = 0.02) and decreasing free plasminogen activator inhibitor-1 (PAI-1, p = 0.04). ConclusionA porcine model of prolonged CA/CPR reproduces many of the coagulofibrinolytic abnormalities observed in human cardiac arrest patients. ART-123 demonstrates a combination of anticoagulant and profibrinolytic effects, depending on the timing of its administration relative to cardiac arrest.

CPR quality with rotation of every 1 versus 2 minutes as characteristics of rescuers: A randomized crossover simulation study.

Fatigue and rotation time are key factors affecting the quality of cardiopulmonary resuscitation (CPR). This study aimed to investigate the effects of rotation time on CPR duration, and sex on chest compression quality. In this randomized crossover simulation study, we enrolled 100 paramedic students stratified by sex and randomly grouped into 28 male and 22 female pairs. In the 2- and 1-minute scenarios, 2 participants performed CPR for 20 minutes with a rotation cycle of 2 minutes and 1 minute, respectively. After taking a break, they changed over and performed CPR again for 20 minutes. The switching of roles was performed with the students positioned on opposite sides of the mannequin. For chest compression quality, a set was defined as CPR performed by 1 pair in a 2-minute scenario for 4 minutes. The quality of CPR in each set was compared between the 2 groups. The 1-minute group showed significantly higher chest compression depth than the 2-minute group (54.0 [51.5-57.0] vs 52.5 [48.5-56.5] mm, P = .001, respectively). The female 2-minute group showed decreased chest compression depth over time, and the 1-minute group showed significantly increased chest compression depth during all sets except the 2nd set (54.0 [51.9-55.1] vs 50.5 [48.5-53.8] mm [P = .030], 52.3 [49.4-54.5] vs 50.8 [47.0-53.1] mm [P = .080], 52.8 [49.8-54.5] vs 48.8 [45.4-51.6] mm [P = .002], 51.5 [48.5-53.3] vs 48.3 [44.5-50.6] mm [P = .004], and 50.8 [48.9-54.1] vs 47.5 [44.6-50.1] mm [P = .001], respectively). The fatigue scores in the 2-minute group were significantly higher during sets 4 and 5 than those in the 1-minute group. When rescuer fatigue increases during prolonged CPR owing to their physical strength and skill levels, the rotation of rescuers every minute would be helpful in maintaining high-quality CPR.

Iatrogenic-induced Peripheral Gangrene: From Multiple Limb Amputations to Prosthetic Restoration

Objectives: Multiple limb amputations are an uncommon complication from inotrope-induced peripheral gangrene. Case Presentation: A 20-year-old lady with valvular heart disease had septic shock secondary to infective endocarditis and required prolonged cardiopulmonary resuscitation. Despite aggressive fluid resuscitation, the patient had triple strength intravenous noradrenaline to maintain hemodynamic stability. On day 5 of post-shock, dry gangrene occurred in distal parts of all limbs, and inotrope was stopped. Although the gangrenous changes were non-progressive, she required a significant degree of assistance with mobility and daily function performance. The patient was counseled for multiple limb amputations to promote walking and hand function through prosthetic restoration. Five months after the event, she had a right transtibial amputation, left Chopart amputation, left wrist disarticulation, and right second, third, fourth, and fifth fingers amputation. Three specific goals for inpatient rehabilitation were independent short-distance ambulation with prostheses, performing basic activities of daily living with adaptive devices, and independent wheelchair propulsion for long-distance mobility using a right-sided transtibial prosthesis, left-sided Syme's prosthesis with Kingsley's foot, right-sided silicone-based cosmetic glove and left-sided body-powered transradial prosthesis. Discussion: Although an uncommon complication, inotrope may lead to multiple limb amputations secondary to peripheral gangrene. Following amputation, the ultimate rehabilitative goal is to restore the mobility and capacity to perform daily functions through prosthetic restoration, whether walking for lower amputees or functioning hand for upper limb amputees. Prescribing prosthesis in a single limb loss is relatively straightforward, but restoring multiple limb amputations bears many challenges toward successful recovery of walking and functions.

Pediatric Extracorporeal Cardiopulmonary Resuscitation: Development of a Porcine Model and the Influence of Cardiopulmonary Resuscitation Duration on Brain Injury.

Background The primary objective was to develop a porcine model of prolonged (30 or 60 minutes) pediatric cardiopulmonary resuscitation (CPR) followed by 22- to 24-hour survival with extracorporeal life support, and secondarily to evaluate differences in neurologic injury. Methods and Results Ten-kilogram, 4-week-old female piglets were used. First, model development established the technique (n=8). Then, a pilot study was conducted (n=15). After 80% survival was achieved in the final 5 pilot animals, a proof-of-concept randomized study was completed (n=11). Shams (n=6) underwent anesthesia only. Severe neurological injury was determined by a composite score of mitochondrial function, neuropathology, and cerebral metabolism: scale of 0-6 (severe: >3). Among 15 piglets in the pilot study, overall survival was 10 (67%); of the final 5, overall survival was 4 (80%). Eleven piglets were then randomized to 60 (CPR60, n=5) or 30 minutes of CPR (CPR30, n=5); 1 animal was excluded from prerandomization for intra-abdominal hemorrhage (10/11, 91% survival). Three of 5 animals in the CPR60 group had severe neurological injury scores versus 1 of 5 in the CPR30 group (P=0.52). During ECMO, CPR60 animals had lower pH (CPR60: 7.4 [IQR 7.4-7.4] versus CPR30: 7.5 [IQR 7.4-7.5], P=0.022), higher lactate (CPR60: 6.8 [IQR 6.8-11] versus CPR30: 4.2 [IQR 4.1-4.3] mmol/L; P=0.012), and higher ICP (CPR60: 19.3 [IQR 11.7-29.3] versus CPR30: 7.9 [IQR 6.7-9.3] mm Hg; P=0.037). Both groups had greater mitochondrial injury than shams (CPR60: P<0.001; CPR30: P<0.001). CPR60 did not differ from CPR30 in mitochondrial respiration, neuropathology, or cerebral metabolism. Conclusions A pediatric porcine model of extracorporeal cardiopulmonary resuscitation after 60 and 30 minutes of CPR consistently resulted in 24-hour survival with more severe lactic acidosis in the 60-minute cohort.

Ventilation during continuous compressions or at 30:2 compression-to-ventilation ratio results in similar arterial oxygen and carbon dioxide levels in an experimental model of prolonged cardiac arrest

BackgroundIn refractory out-of-hospital cardiac arrest, transportation to hospital with continuous chest compressions (CCC) from a chest compression device and ventilation with 100% oxygen through an advanced airway is common practice. Despite this, many patients are hypoxic and hypercapnic on arrival, possibly related to suboptimal ventilation due to the counterpressure caused by the CCC. We hypothesized that a compression/ventilation ratio of 30:2 would provide better ventilation and gas exchange compared to asynchronous CCC during prolonged experimental cardiopulmonary resuscitation (CPR).MethodsWe randomized 30 anaesthetized domestic swine (weight approximately 50 kg) with electrically induced ventricular fibrillation to the CCC or 30:2 group and bag-valve ventilation with a fraction of inspired oxygen (FiO2) of 100%. We started CPR after a 5-min no-flow period and continued until 40 min from the induction of ventricular fibrillation. Chest compressions were performed with a Stryker Medical LUCAS® 2 mechanical chest compression device. We collected arterial blood gas samples every 5 min during the CPR, measured ventilation distribution during the CPR using electrical impedance tomography (EIT) and analysed post-mortem computed tomography (CT) scans for differences in lung aeration status.ResultsThe median (interquartile range [IQR]) partial pressure of oxygen (PaO2) at 30 min was 110 (52–117) mmHg for the 30:2 group and 70 (40–171) mmHg for the CCC group. The median (IQR) partial pressure of carbon dioxide (PaCO2) at 30 min was 70 (45–85) mmHg for the 30:2 group and 68 (42–84) mmHg for the CCC group. No statistically significant differences between the groups in PaO2 (p = 0.40), PaCO2 (p = 0.79), lactate (p = 0.37), mean arterial pressure (MAP) (p = 0.47) or EtCO2 (p = 0.19) analysed with a linear mixed model were found. We found a deteriorating trend in PaO2, EtCO2 and MAP and rising PaCO2 and lactate levels through the intervention. There were no differences between the groups in the distribution of ventilation in the EIT data or the post-mortem CT findings.ConclusionsThe 30:2 and CCC protocols resulted in similar gas exchange and lung pathology in an experimental prolonged mechanical CPR model.

Using Sodium Bicarbonate During Prolonged Cardiopulmonary Resuscitation in Prehospital Setting; a Retrospective Cross-sectional Study.

Although the 2020 American Heart Association (AHA) guidelines recommend that sodium bicarbonate (SB) be avoided during routine cardiopulmonary resuscitation (CPR) a limited number of studies have examined the effects of SB injection during prolonged CPR (>15 min) in prehospital setting. The present study aimed to examine the effects of prehospital SB use during prolonged CPR on patients' outcome. In this retrospective cross-sectional study adult patients aged >18 years who experienced a non-traumatic, out-of-hospital cardiac arrest (OHCA) were compared regarding three outcomes, namely return of spontaneous circulation (ROSC), ROSC > 20 minute, and survival to discharge, based on receiving or not-receiving SB during CPR. 330 patients were divided into two equal groups of 165. The two groups had similar conditions regarding gender distribution (p = 0.729); mean age (p = 0.741); underlying diseases (p = 0.027); etiology of arrest (p = 0.135); the initial rhythm (p = 0.324); receiving normal saline solution (p = 1.000), epinephrine (p = 0.848), and atropine during CPR (p = 0.054); and using defibrillation (p = 0.324). Those who received SB had 0.80 times greater likelihood for sustained ROSC (adjusted odds ratio (OR) = 0.80, 95% CI: 0.47-1.37, p = 0.415), 0.93 times greater likelihood for ROSC at the scene (adjusted OR = 0.93, 95% CI: 0.55-1.59, p = 0.798), and 0.34 times greater likelihood for survival to discharge (adjusted OR = 0.34, 95% CI: 0.10-1.17, p = 0.087). The present study demonstrated that prehospital SB use by EMS during prolonged CPR did not improve ROSC rate at the scene, sustained ROSC, and survival to discharge.

Salvage of venoarterial extracorporeal membrane oxygenation following prolonged cardiopulmonary resuscitation and failure of catheter-directed thrombectomy for massive pulmonary embolism in a young patient.

Salvage of venoarterial extracorporeal membrane oxygenation following prolonged cardiopulmonary resuscitation and failure of catheter-directed thrombectomy for massive pulmonary embolism in a young patient.

542: AWAKENING AFTER EXTRACORPOREAL LIFE SUPPORT: ASSESSING AWARENESS IN UNRESPONSIVE WAKEFULNESS

Introduction: Emergence from coma have many stages. Patients enter unresponsive wakefulness (UW) from coma when they open eyes with only reflexive motor responses. The development of voluntary responses to stimuli indicates a minimally conscious state (MCS). The addition of functional communication or object use signifies emergence from MCS. Cognitive motor dissociation has been reported in unresponsive patients with evidence of appropriate brain activation. We present a pediatric case where we detected awareness with bedside electroencephalogram (EEG) and the patient showed eventual emergence from UW. Description: A depressed teenage girl was admitted after suicidal attempt with fluoxetine and lamotrigine ingestion with subsequent cardiopulmonary arrest. After prolonged cardiopulmonary resuscitation, she was cannulated on veno-arterial extracorporeal membrane oxygenation. Initial head computed tomography showed preserved gray-white differentiation. On post-arrest day 5, she was successfully decannulated but remained in an unresponsive wakefulness state. Brain magnetic resonance imaging showed diffuse cerebral microhemorrhages. To assess preserved awareness, we performed protocolized stimulation with EEG. Consistent reactivity with increased frequency and amplitude were observed after both nociceptive and auditory stimulation, with greater response to stimuli from her parent. After slow improvement she emerged from UW on post-arrest day 35 and showed consistent appropriate responses. She was discharged to inpatient rehabilitation on post-arrest day 50. Discussion: Analysis of quantitative EEG data often requires advanced machine learning algorithms that were not readily available to bedside providers. Assessing EEG reactivity with protocolized stimulation is an effective alternative to assess preserved awareness. Our case adds to limited pediatric literature on emergence from coma and detection of preserved awareness early after brain injury. Clinically she was unresponsive to external stimuli but demonstrated signs of arousal to nociceptive and auditory stimuli on EEG, especially when from her parents. Our case demonstrates the feasibility of assessing preserved awareness at bedside via protocolized stimulation with EEG, which may assist in prognosis.

Abstract 11244: Active Decompression During Device Assisted Elevation of the Head and Thorax, an Impedance Threshold Device, and Active Compression Decompression Cardiopulmonary Resuscitation is Needed for Sustained Hemodynamic Benefit in a Porcine Model of Prolonged Cardiac Arrest

Introduction: Active compression decompression cardiopulmonary resuscitation (CPR), an impedance threshold device (ITD), and automated device-assisted controlled head up positioning, collectively termed AHUP CPR, work synergistically to lower intracranial pressure, augment venous return to the heart and significantly improve neurological survival versus conventional (C)-CPR in animals and patients in cardiac arrest. The current study focused on the role of active decompression (AD) during prolonged AHUP CPR, since AD can be difficult to perform manually for an extended period. Hypothesis: Full AD is needed to optimize hemodynamics during prolonged AHUP CPR Methods: Six female and male farm pigs (~40 kg) were sedated, intubated, anesthetized, and monitored. After 8 min of untreated ventricular fibrillation followed by ≥ 30 min of AHUP CPR with an automated device, AHUP CPR was continued except that AD was intentionally reduced from an average of 3.33 ± 0.37 cm of lift to 0 cm lift above the resting neutral position as this is the amount of decompression that occurs with C-CPR and passive chest wall recoil. After 1 min of AHUP CPR with 0 cm lift, AD was progressively increased back to 3 cm of lift over 3 min. Hemodynamics (mean ± SD) were compared using Student’s t test, where p&lt;0.05 was considered statistically significant. Results Coronary perfusion pressure (CorPP) (p&lt;0.005), cerebral perfusion pressure (CerPP) (p&lt;0.001), and ETCO2 (p&lt;0.0001) significantly decreased after AD was discontinued (Fig.1). With restoration of AD to 3 cm, CorPP (p&lt;0.009) and ETCO2 (p&lt;0.001) significantly improved and CerPP trended higher (p=0.084). Conclusion During prolonged (≥ 30 min) AHUP CPR in pigs, active lift of the chest wall is essential to maintain stable hemodynamics. Hemodynamics deteriorated rapidly with intentional loss of AD, but could be partially restored with resumption of AD.

Abstract 15563: Analysis of the Ventricular Fibrillation Waveform Can Guide Resuscitation in Cardiac Arrest by Identifying the Precipitating Cause and Estimating the Underlying Hemodynamics

Background: Patients presenting with out of hospital cardiac arrest (OHCA) and prolonged (&gt;30 min) cardiopulmonary resuscitation (CPR) face nearly 100% mortality. In patients presenting with ventricular fibrillation (VF), coronary ischemia is thought to be the cause in up to 60%. As conventional CPR does not reverse a coronary ischemia, CPR often must be done until a patient can be brought to a cardiac catheterization laboratory (CCL) where the underlying cause (acute ischemia) can be treated. In a porcine model of cardiac arrest, we have previously demonstrated that machine learning (ML) targeting invasive hemodynamic monitoring, could significantly improve CPR quality. To advance the clinical relevance of the machine-controlled CPR methods, we developed ML algorithms that can diagnose coronary ischemia during VF, and infer the underlying hemodynamics while performing CPR. Methods: In a porcine model of cardiac arrest, VF was induced via high-grade coronary occlusion (ischemia) or electrical stimulation (dysrhythmia). The animals (n = 72) were left in VF for 3 minutes prior to intervention and the ECG waveform was collected. The VF signal was converted to the frequency domain using a fast-fourier transformation and an ensemble classifier was developed to detect underlying ischemia. CPR was then initiated and the VF waveform was continuously monitored along with the coronary perfusion pressure (CPP). We then developed a 20-layer convolutional neural network (CNN) to non-invasively infer the CPP from a 10-second VF waveform. Results: Animal studies were split into training and test sets. When using the developed ML technique to detect ischemia from the VF waveform, evaluation of the test set yielded an area under the curve (AUC) of 0.81 on a ROC. When we used the CNN to infer the underlying hemodynamics, we demonstrated a high correlation between measured and predicted CPP in the test set. The AUC for the ROC when predicting a CPP of &gt;15 mmHg was 0.85. Conclusion: Survival for patients with OHCA secondary to coronary ischemia will improve with rapid diagnosis and high quality CPR. Our results demonstrate the proof-of-concept that the VF waveform contains features that can guide resuscitation for cause identification and hemodynamic improvement.

Abstract 131: Perceived Exertion And Physical Demand Of Performing 10-minutes Of Compression-only CPR

Cardiopulmonary resuscitation (CPR) is physically demanding and must also be performed under emotional distress. Most cardiac arrests (CA) occur at home, making it likely that only one rescuer is available to perform CPR until emergency medical services (EMS) or other lay rescuers arrive. We performed a study to quantify the physical exertion required of lay-providers performing compression-only CPR for 10 minutes both with (WFB) and without (WOFB) real-time CPR quality feedback. We recruited healthy, CPR certified lay individuals to perform 10-minute rounds of CPR on two occasions: once WFB and once WOFB. We collected heart rate (HR), oxygen consumption (VO 2 ), and rating of perceived exertion (RPE) at baseline and throughout each round of CPR and collected capillary lactate and blood pressures pre- and post-CPR. We used Kruskal Wallis, Wilcoxon signed rank and rank sum tests to compare changes in measures during CPR. Participants were 15 females and 11 males, age 25 (IQR 22-37). All measures except for diastolic blood pressure, significantly changed over time. Systolic blood pressure increased both WFB (mean difference (MD) 8mmHg; 95% CI 12-5) and WOFB (MD 8mmHg; 95% CI 12-3). VO 2 and HR increased over time, but peak VO 2 and HR did not differ by group. RPE significantly increased WFB and WOFB (WFB MD 8; 95% CI 10-7; WOFB MD 8; 95% CI 9-7) WFB and WOFB, with females reporting a higher RPE immediately post-CPR WFB than males (MD 2; 95% CI 5-1). Lactate increased from baseline immediately post (WFB MD 2.3mmol/L; 95% CI 0.9-3.7; WOFB MD 1.8mmol/L; 95%CI 2.6-1) and 5-minutes post CPR (WFB MD 0.8mmol/L; 95% CI 2.3-0.7; WOFB MD2.1 mmol/L; 95% CI 0.9-3.3). CPR produces subjective and objective signs of strenuous exertion in both men and women. The presence of feedback does not alter physiologic response to prolonged CPR. However, females reported higher RPEs when performing CPR WFB, despite no significant difference in physiologic response.

6-Year-Old Male Drowning Complicated by Cardiac Arrest and Ensuing Metabolic and Respiratory Acidosis: Should Presence of Pulses Lead Clinicians to Pursue Prolonged Cardiopulmonary Resuscitation?

BackgroundDrowning is one of the leading causes of death in the pediatric population. Patients arriving to the emergency department (ED) with submersion injuries are often asymptomatic and well-appearing, but can sometimes present critically ill and require prolonged resuscitation. The question of how long to continue resuscitation of a pediatric patient with a submersion injury is a difficult question to answer. Case ReportWe present a case of 6-year-old boy was found by his friends submerged in sea water for 10–15 min. The patient was rescued by lifeguards and evaluated by emergency medical personnel, who found him breathing spontaneously but unresponsive. En route to hospital, the patient became apneic, cardiopulmonary resuscitation (CPR) was started, and the patient was intubated. The patient arrived to the ED in cardiopulmonary arrest, CPR was continued and epinephrine was administered. Return of spontaneous circulation was achieved after 42 min in the ED. Initial laboratory test results showed severe acidosis and chest x-ray study showed diffuse interstitial edema. Ventilator settings were adjusted in accordance with lung protective ventilation strategies and the acidosis began to improve. Over the next several days, the patient was weaned to noninvasive ventilation modalities and eventually made a complete neurologic recovery and continued to be a straight-A student.Why Should an Emergency Physician Be Aware of This?We make the case that, in select drowning patients, duration of CPR longer than 30 min can potentially result in favorable neurologic outcomes. Prolonged CPR should be especially strongly considered in patients with a pulse at any point during evaluation. With the combination of prolonged CPR and judicious use of lung protective mechanical ventilation strategies, we were able to successfully treat the patient in our case.

IMPACT OF DIFFERENT VENTILATION STRATEGIES ON GAS EXCHANGES AND CIRCULATION DURING PROLONGED MECHANICAL CARDIO-PULMONARY RESUSCITATION IN A PORCINE MODEL.

Background: Optimal ventilation during cardio-pulmonary resuscitation (CPR) is still controversial. Ventilation is expected to provide sufficient arterial oxygen content and adequate carbon dioxide removal, while minimizing the risk of circulatory impairment. The objective of the present study was to compare three ventilation strategies in a porcine model during mechanical continuous chest compressions (CCC) according to arterial oxygenation and hemodynamic impact. Method: Ventricular fibrillation was induced and followed by five no-flow minutes and thirty low-flow minutes resuscitation with mechanical-CCC without vasopressive drugs administration. Three groups of eight Landras pig were randomized according to the ventilation strategy: 1. Standard nonsynchronized volume-control mode (SD-group); 2. synchronized bilevel pressure-controlled ventilation (CPV-group); 3. continuous insufflation with Boussignac Cardiac-Arrest Device (BC-group). We assessed 1. arterial blood gases, 2. macro hemodynamics, 3. tissular cerebral macro and micro-circulation and 4. airway pressure, minute ventilation at baseline and every 5 minutes during the protocol. Results: Arterial PaO2 level was higher at each measurement time in SD-group (>200 mm Hg) compare to CPV-group and BC-group ( P < 0.01). In BC-group, arterial PaCO2 level was significantly higher (>90mm Hg) than in SD and CPV groups ( P < 0.01). There was no difference between groups concerning hemodynamic parameters, cerebral perfusion and microcirculation. Conclusion: Ventilation modalities in this porcine model of prolonged CPR influence oxygenation and decarboxylation without impairing circulation and cerebral perfusion. Synchronized bi-level pressure-controlled ventilation' use avoid hyperoxia and was as efficient as asynchronized volume ventilation to maintain alveolar ventilation and systemic perfusion during prolonged CPR.

Extracorporeal Life Support and Temporary CentriMag Ventricular Assist Device to Salvage Cardiogenic-Shock Patients Suffering from Prolonged Cardiopulmonary Resuscitation.

Background: The extracorporeal life support (ECLS) and temporary bilateral ventricular assist device (t-BiVAD) are commonly applied in patients with cardiogenic shock. Prolonged cardiopulmonary resuscitation (CPR) has poor prognosis. Herein, we report our findings on a combined ECLS and t-BiVAD approach to salvage cardiogenic-shock patients with CPR for more than one hour. Methods: Fifty-nine patients with prolonged CPR and rescued by ECLS and subsequent t-BiVAD were retrospectively collected between January 2015 and December 2019. Primary diagnoses included ischemic, dilated cardiomyopathy, acute myocardial infarction, post-cardiotomy syndrome, and fulminant myocarditis. The mean LVEF was 16.9% ± 6.56% before t-BiVAD. The median ECLS-to-VAD interval is 26 h. Results: A total of 26 patients (44%) survived to weaning, including 13 (22%) bridged to recovery, and 13 (22%) bridged to transplantation. Survivors to discharge demonstrated better systemic perfusion and hemodynamics than non-survivors. The CentriMag-related complications included bleeding (n = 22, 37.2%), thromboembolism (n = 5, 8.4%), and infection (n = 4, 6.7%). The risk factors of mortality included Glasgow Coma Scale (Motor + Eye) ≤ 5, and lactate ≥ 8 mmol/L at POD-1, persistent ventricular rhythm or asystole, and total bilirubin ≥ 6 mg/dL at POD-3. Mortality factors included septic shock (n = 11, 18.6%), central failure (n = 10, 16.9%), and multiple organ failure (n = 12, 20.3%). Conclusions: Combined ECLS and t-BiVAD could be a salvage treatment for patients with severe cardiogenic shock, especially for those already having prolonged CPR. This combination can correct organ malperfusion and allow sufficient time to bridge patients to recovery and heart transplantation, especially in Asia, where donation rates are low, as well as intracorporeal VAD or total artificial heart being seldom available.

A Comparison between Three Different Techniques Considering Quality Skills, Fatigue and Hand Pain during a Prolonged Infant Resuscitation: A Cross-Over Study with Lifeguards.

The aim of the study was to compare the quality of CPR (Q-CPR), as well as the perceived fatigue and hand pain in a prolonged infant cardiopulmonary resuscitation (CPR) performed by lifeguards using three different techniques. A randomized crossover simulation study was used to compare three infant CPR techniques: the two-finger technique (TF); the two-thumb encircling technique (TTE) and the two-thumb-fist technique (TTF). 58 professional lifeguards performed three tests in pairs during a 20-min period of CPR. The rescuers performed compressions and ventilations in 15:2 cycles and changed their roles every 2 min. The variables of analysis were CPR quality components, rate of perceived exertion (RPE) and hand pain with numeric rating scale (NRS). All three techniques showed high Q-CPR results (TF: 86 ± 9%/TTE: 88 ± 9%/TTF: 86 ± 16%), and the TTE showed higher values than the TF (p = 0.03). In the RPE analysis, fatigue was not excessive with any of the three techniques (values 20 min between 3.2 for TF, 2.4 in TTE and 2.5 in TTF on a 10-point scale). TF reached a higher value in RPE than TTF in all the intervals analyzed (p < 0.05). In relation to NRS, TF showed significantly higher values than TTE and TTF (NRS minute 20 = TF 4.7 vs. TTE 2.5 & TTF 2.2; p < 0.001). In conclusion, all techniques have been shown to be effective in high-quality infant CPR in a prolonged resuscitation carried out by lifeguards. However, the two-finger technique is less efficient in relation to fatigue and hand pain compared with two-thumb technique (TF vs. TTF, p = 0.01).

Honey bee venom re-challenge during specific immunotherapy: prolonged cardio-pulmonary resuscitation allowed survival in a case of near fatal anaphylaxis

BackgroundSpecific immunotherapy for patients with honey bee hypersensitivity is commonly applied. Re-challenge with venom is performed to prove protection in individual cases.Case presenationWe report a case of near fatal anaphylaxis with asystole for 24 min in a 35-years-old patient with mastocytosis after honey bee sting challenge, despite 5-years of specific immunotherapy. Successful cardio-pulmonary resuscitation was applied for 32 min.ConclusionThis intervention demonstrates, that in anaphylaxis with cardio-vascular arrest, prolonged cardio-pulmonary resuscitation for up to 40 min may be appropriate to overcome the half-life of massively released histamine. Failure of specific immunotherapy was possibly due to sensitization to the allergen Api m10, potentially underrepresented in commercial honey bee venom extracts. Molecular analyses may provide additional clues to the potentially unsuccessful outcome of venom specific immunotherapy, especially in high-risk patients such as mastocytosis.

A Century With Craniopagus Twin Separation Surgeries: Nihilism to Optimism.

Craniopagus conjoined twins are extremely rare, reported 1 in 2.5 million live births. To date, 62 separation attempts in 69 well-documented cases of craniopagus twins have been made. Of these, 34 were performed in a single-stage approach, and 28 were attempted in a multistage approach. One or both twins died of massive intraoperative blood loss and cardiac arrest in 14 cases. We report our surgical experience with conjoined craniopagus twins (JB) with type III total vertical joining and shared circumferential/circular sinus with left-sided dominance. A brief review of the literature is also provided. In our twins, the meticulous preoperative study and planning by the multidisciplinary team consisting of 125-member, first-staged surgical separation consisted of creation of venous conduit to bypass part of shared circumferential sinus and partial hemispheric disconnection. Six weeks later, twin J manifested acute cardiac overload because of one-way fistula development from blocked venous bypass graft necessitating emergency final separation surgery. Unique perioperative issues were abnormal anatomy, hemodynamic sequelae from one-way fistula development after venous bypass graft thrombosis, cardiac arrest after massive venous air embolism requiring prolonged cardiopulmonary resuscitation, and return of spontaneous circulation at 15 minutes immediately after separation. This is the first Indian craniopagus separation surgery in a complex total vertical craniopagus twin reported by a single-center multidisciplinary team. Both twins could be sent home, but one remained severely handicapped. Adequate perioperative planning and multidisciplinary team approach are vital in craniopagus twin separation surgeries.