Providing Chest Compressions Research Articles

A Realistic, Low-Cost Simulated Automated Chest Compression Device.

This simulated automated chest compression device was designed for use in simulation cardiac arrest cases involving emergency medicine residents, but it would be applicable to other learners such as nurses, pharmacists, and medical students. Automated chest compression devices (ACCD) are commonly utilized in cardiac arrest in the emergency department and by emergency medical services (EMS) as patients arrive in the ED.1 Prolonged simulated cardiac arrest can be challenging to maintain proper chest compression depth and technique.2 Resident learning may be enhanced during cardiac arrest in the simulation environment by implementing the use of a simulated ACCD. By the end of this educational session using a resuscitation trainer or high-fidelity manikin, learners should be able to:Recognize appropriate application of simulated ACCD to an ongoing resuscitation caseDemonstrate proper positioning of simulated ACCD in manikin modelIntegrate simulated ACCD to provide compressions appropriately throughout cardiac arrest scenario. We developed a cost-effective simulated ACCD for use in resuscitation simulation cases. An initial pilot session identified components of fidelity that were used to model the simulated ACCD after those utilized in clinical situations. Three simulated devices were created and then tested for efficacy during high-fidelity simulation with 25 emergency medicine residents. Visual analog scales were used to explore how the simulated ACCD affected perceived realism and stress level during the cardiac arrest simulation. Qualitative data were collected through open-ended learner feedback comments. The institutional review board at our institution reviewed this project and determined that it was exempt. With inclusion of the simulated ACCD device, learners rated the simulation "more realistic" with an average rating of 74/100 and "less stressful" with an average rating of 69/100 on the visual analog scales. Learner comments noted that the use of the ACCD in simulation resulted in better resource availability and accurate environmental noise. The simulated ACCD presented here was found to be effective, realistic, and practical for use by learners in a resuscitation curriculum. Our results suggest that implementating a cost-effective simulated ACCD ($98 for supplies) in high-fidelity simulation cardiac arrest cases enhances the perceived realism of the environment and offers physician learners a low-stress opportunity to practice the clinical application of ACCD in cardiac arrest resuscitation. Additionally, the use of the simulated ACCD, specifically in a prolonged resuscitation, eliminated the need for physically demanding manual chest compressions. Anecdotally, in simulated environments we have observed poor-quality manual chest compressions due to an understanding that the manikin is "not real," leading to decreased psychological fidelity from the shared acceptance of the poor-quality compressions. Thus, the presence of a simulated clinical device providing chest compressions could have increased the feel of realism through improved psychological fidelity. Additionally, we note that the physical and psychological fidelity of this simulated device was sufficient for physicians to perceive clinical implementation, but may be suboptimal for assistive staff, who are focused on the specific functionality and may benefit from training on the physical device in clinical use. Finally, our simulated ACCD resembles the clinical device our department uses; we advise modifications as appropriate to allow a simulated ACCD created for other learners to also resemble their clinically used ACCD. Automated chest compression device, ACLS, improvised equipment, high fidelity simulation.

Comparison Between the Advanced Cardiac Life Support and Adult Advanced Life Support Protocols: A Simulation-Based Pilot Study.

Introduction: Cardiac arrest is a public health concern associated with unfavorable disease outcomes. Cardiopulmonary resuscitation (CPR) of optimal quality is widely acknowledged as an indispensable technique in restoring spontaneous circulation. In order to perform advanced cardiac life support (ACLS), chest compression must be paused twice: once to assess the rhythm and again to administer the shock. Australian advanced life support (ALS) recommends that the defibrillator needs to be precharged in order to administer the shock during a solitary interval in chest compressions. While performing chest compressions, precharging defibrillators can decrease hands-off time without posing a risk of injury. Aim: To compare chest compression fraction (CCF)-which is the cumulative time spent providing chest compressions divided by the total time taken for the entire resuscitation-by calculating the hands-off time duration in cardiac arrest between the Australian Resuscitation Council (ARC) and American Heart Association (AHA) protocols for CPR. Methods: A simulation-based pilot study was designed using a Laerdal Resusci Anne mannequin and a LIFEPACK 20 defibrillator. The study included six participants recruited from King Khalid University Hospital in Riyadh, Saudi Arabia, where three participants were certified ACLS providers and there were certified ALS providers. Participants were divided into two groups, ALS and ACLS, each following one protocol. For each scenario, a random job was assigned to each participant, regardless of their role as assistant, team leader, or performer of CPR. Each case's shockable and nonshockable rhythms were hidden from the team leader and the chest compressor. Ten trials of CPR were performed, each for four cycles with a total time of 8 min. The simulation was video recorded for hands-off time counting. Comparison between CCF (seconds) per cycle between the two protocols was performed using an independent sample t-test. A p value of 0.05 was used to measure statistical significance. Results: Comparing CCF in shockable rhythms between ARC and AHA protocols, it was observed that the CCF of ALS-ARC was significantly higher than ACLS-AHA in all cycles; the first cycle: t = 3.782, p=0.004; the second cycle: t = 3.380, p=0.007; the third cycle: t = 3.803, p=0.003; and the fourth cycle: t = 4.341, p=0.001. Conclusion: Precharging a defibrillator before a rhythm check during chest compression, in anticipation of a potentially shockable rhythm, reduces the time required for defibrillation and limits interruptions in chest compression during CPR. This practice effectively enhances the CCF. Enhancing the continuity of chest compressions can potentially improve survival rates in ARC.

Manual vs Mechanical Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest on a Ski Slope: A Pilot Study.

The quality of cardiopulmonary resuscitation (CPR) is critical in increasing the probability of survival with a good neurologic outcome after out-of-hospital cardiac arrest. In an austere environment with a potentially salvageable patient, bystanders or first responders may need to provide chest compressions for a prolonged duration or during physically challenging transportation scenarios. Consequently, they may be at risk of fatigue or injury, and chest compression quality may deteriorate. The study sought to assess whether or not access to and utilization of a mechanical compression device (Lund University Cardiopulmonary Assist System) was feasible and not inferior to manual compressions while extricating and transporting a patient from a ski slope. Variable 3-person ski patrol teams responded to a simulated patient with out-of-hospital cardiac arrest in a nonshockable rhythm. Using a mannequin and CPR quality monitor, performance during manual CPR was compared with that of a mechanical compression device. This is a prospective, crossover analysis of CPR quality during extrication from a ski slope. Across 8 total runs, chest compression fraction, which is the proportion of time without spontaneous circulation during which compressions occurred, and high-quality CPR, as measured by appropriate rate and depth, were compared between the 2 groups. Extrication times between the 2 groups were also measured. There was no difference in compression fraction between the manual (91.4%; 95% CI [86.8-96.1]) and mechanical arms (92.8%; 95% CI [88.8-96.8]) (P=0.67). There was an increase in the time performing high-quality CPR in the mechanical group (58.5%; 95% CI [45.8-71.2]) vs that in the manual group (25.6%; 95% CI [13.5-37.8]) (P<0.001). There was a statistically significant difference in the extrication times between the 2 groups, 7.6 ± 0.5 min in the manual group vs 8.6 ± 0.4 min in the mechanical group (P=0.014). Mechanical CPR devices are noninferior for use in ski areas during initial resuscitation and transportation. Compared with manual CPR, mechanical CPR would likely improve the fraction of time performing high-quality CPR.

What are ambulance crews' experiences of using a mechanical chest compression device for out-of-hospital resuscitation? A constructivist qualitative study utilising online focus groups.

Mechanical chest compression devices (MCCDs) provide chest compressions mechanically to a person in cardiac arrest. Those chest compressions would usually be provided manually. Previous studies into the use of MCCDs have focused on the quantitative outcomes, with little emphasis on the qualitative experiences of those using MCCDs. To collect and report ambulance crews' experiences of using MCCDs for out-of-hospital resuscitation attempts. The philosophical approach was constructivist, the methodology qualitative and the data collection method online focus groups. Convenience sampling was used to recruit participants who met the inclusion criteria, which broadly were to have experience of using MCCDs for out-of-hospital resuscitation. There have been two types of MCCD used locally. Participants were included regardless of which type of device they had experience of. Similarly, participants were included whether they had active or passive experience of the devices. The focus groups were recorded, fully transcribed and then analysed using constant comparison. Four selective codes emerged. These were factors directly affecting ambulance crew members; practicalities of a resuscitation attempt; ambulance crew members' perceptions, experiences and thoughts; negatives of MCCDs. The main perceptions arising from the participants' discussion in this work were that MCCD use could potentially provide psychological protection to ambulance crew members when reflecting on resuscitation attempts, and participants felt there is an overall reduction of cognitive load for ambulance crew members when using MCCDs for resuscitation attempts. There were particularly timely benefits expressed of MCCDs easing the physical fatigue of a resuscitation attempt when responding wearing personal protective equipment, as has been required during the COVID-19 pandemic. MCCDs were felt to be of benefit when transporting a patient in cardiac arrest but differences were expressed as to whether the LUCAS-2 in particular helps or hinders extrication of a patient.

Compression Device-Assisted Extracorporeal Cardiopulmonary Resuscitation Cannulation in Pediatric Patients-A Simulation Study.

Background: Surgical neck cannulation for pediatric extracorporeal cardiopulmonary resuscitation (ECPR) requires multiple interruptions of manual chest compressions to facilitate the procedure. Effective uninterrupted CPR is essential to prevent neurological injury. We hypothesized that an automated chest compression device can be used to provide effective and uninterrupted chest compressions during pediatric neck ECPR cannulation. The feasibility of surgically cannulating the right carotid artery and right internal jugular vein in an infant during ongoing automated chest compressions was tested in a simulation study. Methods: A working prototype of a pediatric chest compression device was designed to provide automated chest compressions on an infant CPR manikin at the rate of 120 compressions/minute. A feedback device attached to the manikin was used to monitor the effectiveness of CPR. A synthetic artery, vein along with carotid sheath and skin was utilized to simulate surgical neck exploration. ECPR simulation was conducted using the compression device to provide chest compressions. Results: Four ECPR simulations were conducted during which vessel sparing (n = 2) and non-vessel sparing (n = 2) cannulation of the right internal carotid artery and right internal jugular vein were performed during ongoing mechanical chest compressions. All four cannulations were successfully performed without the need to interrupt chest compressions. Conclusions: In a simulated environment, pediatric ECPR neck cannulation with uninterrupted chest compressions may be accomplished using an automated chest compression device. The strategy of compression device-assisted ECPR cannulation requires further study and could potentially reduce the neurological complications of ECPR.

Chest Compression Fraction and Factors influencing it.

Introduction:Chest compression fraction (CCF) is the cumulative time spent providing chest compressions divided by the total time taken for the entire resuscitation. Targeting a CCF of at least 60% is intended to limit interruptions in compressions and maximize coronary perfusion during resuscitation. We aimed to identify the mean CCF and its relationship with various factors affecting it.Methods:Patients presenting to the emergency department in cardiac arrest at a single center were prospectively included in this study. Resuscitation was provided by trained health-care providers. The feedback device Cprmeter2™ was placed on the patient's sternum at the beginning of resuscitation. The total time taken for the entire resuscitation was noted by the device and CCF calculated.Results:The mean CCF was analyzed using descriptive statistics and was found to be 71.60% ± 7.52%. The total duration of resuscitation (R = −0.55, P = < 0.001, min-max, 2.02–34.31, mean 12.25 ± 6.54), number of people giving chest compressions (R = −0.48, P = < 0.001, min-max, 1–6, mean 4.04 ± 1.12), and total number of team members in resuscitation (R = −0.50, P = < 0.001, min-max, 4–10, mean 6.65 ± 1.32) had negative correlation with CCF. Diurnal variation (day, n = 35; mean 69.20% ± 7% and night, n = 20; mean 75.80% ± 5.6%, P = 0.001) and patients receiving defibrillation (receiving n = 10 mean 67.00% ± 4.11% and not receiving n = 45 mean 72.62 ± 7.42%, P = 0.005) were found to significantly affect CCF.Conclusion:The mean CCF for cardiac arrest patients was well within the targets of guideline recommendation. CCF decreased when resuscitation lasted longer, during daytime when the defibrillator was used, the total team members increased, and also when the number of people giving chest compressions increased. CCF during resuscitation may improve if there is a focus on improving these factors and requires validation in multicentric settings.

Be the hero: Evaluation of the quality of basic life support manoeuvres by school-age children

Background: Out-of-Hospital Cardiac Arrest (OHCA) is the third leading cause of death in developed countries, with a survival rate less than 10%. Actually, although 70% of OHCA episodes are witnessed by laypeople only a third receive Basic Life Support (BLS). In Portugal, bystander-performed Cardiopulmonary Resuscitation (CPR) rate is still below 17%, with a survival rate of 4%. One of the most effective ways to increase bystander CPR is by training school-age children in BLS and Automated External Defibrillator (AED). Aims: Evaluate the capacity to learn and the quality of BLS maneuvers performed by school-age children. Methods: During a four-month period (interruption due to SARS-CoV-2 pandemic), BLS-AED teaching sessions were provided across schools in Oeiras, Portugal. It is considered that children older than 14 years old are able to perform quality chest compressions. Thus, classes from 14 to 18 years old were selected. Each session lasted 100 mins and was provided by nurses, with a ratio of one nurse to six students. Laerdal Medical's QCPR® software was used to measure and collect data of the quality of chest compressions. According to QCPR®, CPR is considered high quality if the final score is higher than 84%. A p-value of less than 0.05 was considered statistically significant. Results: A total of 734 young people were trained, with a median score of 97% (89–99) on the final QCPR® score. All students were able to provide chest compressions with the appropriate depth (>5 cm), 82% (44–96) provided chest compress at the recommended rate (100–120 bpm), and median compression rate of 112 (106–119) cpm. Male students performed deeper and more successful compressions but with less recoil than female students. Conclusions: School-age children aged 14–18 years old were able to learn and perform high-quality BLS maneuvers. We consider these results can have relevant public-health implications.

CPR Compression Rotation Every One Minute Versus Two Minutes: A Randomized Cross-Over Manikin Study

Background The current basic life support guidelines recommend two-minute shifts for providing chest compressions when two rescuers are performing cardiopulmonary resuscitation. However, various studies have found that rescuer fatigue can occur within one minute, coupled with a decay in the quality of chest compressions. Our aim was to compare chest compression quality metrics and rescuer fatigue between alternating rescuers in performing one- and two-minute chest compressions. Methods This prospective randomized cross-over study was conducted at Songklanagarind Hospital, Hat Yai, Songkhla, Thailand. We enrolled sixth-year medical students and residents and randomly grouped them into pairs to perform 8 minutes of chest compression, utilizing both the one-minute and two-minute scenarios on a manikin. The primary end points were chest compression depth and rate. The secondary end points included rescuers' fatigue, respiratory rate, and heart rate. Results One hundred four participants were recruited. Compared with participants in the two-minute group, participants in the one-minute group had significantly higher mean (standard deviation, SD) compression depth (mm) (45.8 (7.2) vs. 44.5 (7.1), P=0.01) but there was no difference in the mean (SD) rate (compressions per min) (116.1 (12.5) vs. 117.8 (12.4), P=0.08), respectively. The rescuers in the one-minute group had significantly less fatigue (P < 0.001) and change in respiratory rate (P < 0.001), but there was no difference in the change of heart rate (P=0.59) between the two groups. Conclusion There were a significantly higher compression depth and lower rescuer fatigue in the 1-minute chest compression group compared with the 2-minute group. This trial is registered with TCTR20170823001.

Rescuer Exertion and Fatigue Using Two-Thumb vs. Two-Finger Method During Simulated Neonatal Cardiopulmonary Resuscitation.

Background: Rescuer fatigue during neonatal CPR can affect CPR quality leading to reduced cerebral and myocardial perfusion.Aim: To investigate rescuer fatigue during simulated neonatal CPR using both objective (heart rate and cardiac output) and subjective measures.Methods: A randomized crossover manikin study performed. Nineteen doctors working in neonatology were randomized to (a) two-thumb term, (b) two-finger term, (c) two-thumb preterm, or (d) two-finger preterm group. Cardiac output and heart rate were measured with a non-invasive cardiac output monitor. A Likert scale assessed participants' level of perceived exertion.Results: In the preterm group, the mean change in HR from rest to 5 min in the TT group was 11.58 bpm (SD 6.22) vs. 9.94 bpm (SD 8.48), (p-value 0.36). There was no difference in change in CO, 2.10 (SD 1.15) in the TT group vs. 1.39 (SD 1.63) in TF group (p value 0.23). There was no difference in BORG RPE rating. In the term group, the mean change in HR from rest to 5 min was 15 bpm (SD 8.40) in TT group and 13 bpm (SD 7.86) in TF group, (p-value 0.416). The median change in CO from rest to 5 min was 1.50 (0.78 to 2.42 IQR) in TT group vs. 1.60 (0.65 to 3.0 IQR) in TF group.Conclusion: Providing chest compressions is associated with an increase in both heart rate and cardiac output. We did not identify difference between objective and subjective measures of fatigue between either technique in a preterm or term model.

Abstract 20: Peripheral Intravenous Analysis Detects Return of Spontaneous Circulation Without Interruption of Chest Compressions in a Rat Model of Cardiopulmonary Resuscitation

Introduction: A higher chest compression fraction (CCF) or percentage of time providing chest compressions is associated with improved survival after cardiac arrest (CA). Pauses in chest compression duration during cardiopulmonary resuscitation (CPR) to palpate a pulse can reduce the CCF. Peripheral Intravenous Analysis (PIVA) is a novel method for determining cardiac and volume status using waveforms from a standard peripheral intravenous (IV) line. We hypothesize that PIVA will demonstrate the onset of return of spontaneous circulation (ROSC) without interruption of CPR. Methods: Eight Zucker Diabetic Fatty (ZDF) rats (4 lean, 4 diabetic) were intubated, ventilated, and cannulated with a 24g IV in the tail vein and a 22g IV in the femoral artery, each connected to a TruWave pressure transducer. Mechanical ventilation was discontinued to achieve CA. After 8 minutes, CPR began with mechanical ventilation, IV epinephrine, and chest compressions using 1.5 cm at 200 times per minute until mean arterial pressure (MAP) increased to 120 mmHg per arterial line. All waveforms were recorded and analyzed in LabChart. PIVA was measured using a Fourier transform of the peripheral venous waveform. Data are mean ± SD. Statistics: Unpaired student’s t-test (two-tailed), α = 05. Results: CA and ROSC were achieved in all 8 rats. Within 1 minute of CPR, there was a 70 ± 35 fold increase/decrease in PIVA during CPR that was temporally associated with ROSC. Within 8 ± 13 seconds of a reduction in PIVA, there was a rapid increase in end-tidal CO 2 . In all rats, ROSC occurred within 38 ± 9 seconds of the maximum PIVA value. Peripheral venous pressure decreased by 1.2 ± 0.9 mmHg during resuscitation and ROSC, which was not significant different at p=0.05. Conclusion: In this pilot study, PIVA detected ROSC without interrupting CPR. Use of PIVA may obviate the need pause CPR for pulse checks, and may result in a higher CCF and survival. Future studies will focus on PIVA and CPR efficacy.

Abstract 449: Cost Analysis of a Contextualized Cardiopulmonary Resuscitation Training for Orderlies Participating in In-Hospital Cardiac Arrests

Introduction: Basic life support (BLS) training poses challenges for healthcare organizations. It requires numerous resources, complicates scheduling and is expensive. Orderlies typically provide chest compressions during in-hospital cardiac arrests, and are therefore recertified in cardiopulmonary resuscitation (CPR) every 2 years. However, such time lapse between CPR certifications induces skills decay. Hypothesis: Based on the American Heart Association statement on resuscitation education science published in 2018, we aimed to train all orderlies (n= 900) in less than 1 year, in order to reach proficiency in chest compressions, at a fraction of the cost. Method: A shortened (20 minutes), and adapted version of CPR training was created. This training specifically addressed high quality chest compressions, the cornerstone skill relevant to the scope of practice of orderlies in CPR. It was delivered in situ during working hours, as a mass training program that spanned over a period of 1 week. The training was provided through Mastery Learning and Deliberate Practice with direct feedback and live coaching. The cost analysis aimed to compare the costs of the new approach as compared to BLS training. Results: With this innovative approach, 30 trainers were able to train 600 employees in only 5 days. Preliminary results suggest most were able to perform high quality compressions after training. The total cost of the activity was 2 347.21 $CAD which represents 3% (2 347 of 76 200) of what it would take to train 600 people in BLS (76 200$CAD), and 13% (2 347 of 18 000) of the budget planned per year for orderlies’ BLS training at our institution (~18 000$CAD). The individual cost of our initiative was 4.13$CAD per employee. This method allowed to train employees around the clock, to cover all working shifts, thereafter preventing the removal of employees from the rolling schedule. Also, this solution allows us to repeat the experience another time this year, to train all orderlies. Conclusions: Although further research is needed to assess if skills are sustained over time and comparable based on performance outcomes, our inquiry is an innovative, sustainable and cost-effective way to train specific CPR skills to large groups.

Smartwatch feedback device for high-quality chest compressions by a single rescuer during infant cardiac arrest: a randomized, controlled simulation study.

ObjectiveAccording to the guidelines, rescuers should provide chest compressions (CC) ~1.5 inches (40 mm) for infants. Feedback devices could help rescuers perform CC with adequate rates (CCR) and depths (CCD). However, there is no CC feedback device for infant cardiopulmonary resuscitation (CPR). We suggest a smartwatch-based CC feedback application for infant CPR.Participants and methodsWe created a smartwatch-based CC feedback application. This application provides feedback on CCD and CCR by colour and text for infant CPR. To evaluate the application, 30 participants were divided randomly into two groups on the basis of whether CC was performed with or without the assistance of the smartwatch application. Both groups performed continuous CC-only CPR for 2 min on an infant mannequin placed on a firm table. We collected CC parameters from the mannequin, including the proportion of correct depth, CCR, CCD and the proportion of correct decompression depth.ResultsDemographics between the two groups were not significantly different. The median (interquartile range) proportion of correct depth was 99 (97–100) with feedback compared with 83 (58–97) without feedback (P = 0.002). The CCR and proportion of correct decompression depth were not significantly different between the two groups (P = 0.482 and 0.089). The CCD of the feedback group was significantly deeper than that of the control group [feedback vs. control: 41.2 (39.8–41.7) mm vs. 38.6 (36.1–39.6) mm; P=0.004].ConclusionRescuers who receive feedback of CC parameters from a smartwatch could perform adequate CC during infant CPR.

2017 American Heart Association Focused Update on Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This focused update to the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care follows the Pediatric Task Force of the International Liaison Committee on Resuscitation evidence review. It aligns with the International Liaison Committee on Resuscitation's continuous evidence review process, and updates are published when the International Liaison Committee on Resuscitation completes a literature review based on new science. This update provides the evidence review and treatment recommendation for chest compression-only CPR versus CPR using chest compressions with rescue breaths for children <18 years of age. Four large database studies were available for review, including 2 published after the "2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care." Two demonstrated worse 30-day outcomes with chest compression-only CPR for children 1 through 18 years of age, whereas 2 studies documented no difference between chest compression-only CPR and CPR using chest compressions with rescue breaths. When the results were analyzed for infants <1 year of age, CPR using chest compressions with rescue breaths was better than no CPR but was no different from chest compression-only CPR in 1 study, whereas another study observed no differences among chest compression-only CPR, CPR using chest compressions with rescue breaths, and no CPR. CPR using chest compressions with rescue breaths should be provided for infants and children in cardiac arrest. If bystanders are unwilling or unable to deliver rescue breaths, we recommend that rescuers provide chest compressions for infants and children.

Perinatal practice in extreme premature delivery: variation in Dutch physicians' preferences despite guideline.

Decisions at the limits of viability about initiating care are challenging. We aimed to investigate physicians’ preferences on treatment decisions, against the background of the 2010 Dutch guideline offering active care from 24+0/7 weeks of gestational age (GA). Obstetricians’ and neonatologists’ opinions were compared. An online survey was conducted amongst all perinatal professionals (n = 205) of the 10 Dutch level III perinatal care centers. Response rate was 60 % (n = 122). Comfort care was mostly recommended below 24+0/7 weeks and intensive care over 26+0/7 weeks. The professional views varied most at 24 and 25 weeks, with intensive care recommended but comfort care at parental request optional being the median. There was a wide range in perceived lowest limits of GA for interventions as a caesarian section and a neonatologist present at birth. Obstetricians and neonatologists disagreed on the lowest limit providing chest compressions and administering epinephrine for resuscitation. The main factors restricting active treatment were presence of congenital disorders, “small for gestational age” fetus, and incomplete course of corticosteroids.Conclusion: There was a wide variety in individually preferred treatment decisions, especially when aspects were not covered in the Dutch guideline on perinatal practice in extreme prematurity. Furthermore, obstetricians and neonatologists did not always agree. What is known: • Cross-cultural differences exists in the preferred treatment at the limits of viability • In the Netherlands since 2010, intensive care can be offered starting at 24 +0/7 weeks gestation What is new: • There was a wide variety in preferred treatment decisions at the limits of viability especially when aspects were not covered in the Dutch national guideline on perinatal practice in extreme prematurity.

Barriers in the implementation of the Resuscitation Guidelines: European survey of defibrillation techniques.

BackgroundThe European Resuscitation Council (ERC) Guidelines recommend providing chest compressions during defibrillator charging and using adhesive pads for defibrillation to increase the effectiveness of resuscitation. However, the most common defibrillation technique in each European country is unknown, as are the potential barriers in implementation of the guidelines. The aim of this study was to assess the techniques of defibrillation procedures performed by professional European healthcare providers and to estimate how frequently adhesive pads are used.MethodsWe sent an online questionnaire to the ERC National Representatives that contained 12 questions regarding the techniques of defibrillation and monitoring heart rhythm during cardiac arrest. We also evaluated the frequency and indications of manual paddles use.ResultsWe collected questionnaires from 27 out of 33 invited ERC member countries. The response rate was 82 %. Seventeen (17/27; 63 %) declared the use of adhesive pads. The leading cause for not using adhesive pads was economic reason (9/17; 53 %). Some respondents declared resistance to using adhesive pads by healthcare providers or tradition connected with manual paddles use. We found three leading techniques of defibrillation with manual paddles: Charging paddles keeping them on the defibrillator during chest compressions being delivered (9/21; 43 %), Charging paddles keeping them on the patient chest during chest compressions being delivered (6/21; 29 %), Charging paddles on the patient chest without chest compressions (5/21; 24 %). Respondents from 11 countries declared the use of gel or electrode pastes during defibrillation with manual paddles.DiscussionThis study collected preliminary data showing how defibrillation is performed in Europe. It revealed the recommeded techniques underuse and identyfied barriers in the Resuscitation Guidelines implementation. The survey should be open to a wider group of respondents. in each country in future.ConclusionsThere are limitations and barriers in the implementation of the defibrillation technique guidelines. There are still countries where the use of adhesive pads is low due to economic and traditional reasons. There is a need for further efforts focused on guidelines implementation.

Feedback on the Rate and Depth of Chest Compressions during Cardiopulmonary Resuscitation Using Only Accelerometers.

BackgroundQuality of cardiopulmonary resuscitation (CPR) is key to increase survival from cardiac arrest. Providing chest compressions with adequate rate and depth is difficult even for well-trained rescuers. The use of real-time feedback devices is intended to contribute to enhance chest compression quality. These devices are typically based on the double integration of the acceleration to obtain the chest displacement during compressions. The integration process is inherently unstable and leads to important errors unless boundary conditions are applied for each compression cycle. Commercial solutions use additional reference signals to establish these conditions, requiring additional sensors. Our aim was to study the accuracy of three methods based solely on the acceleration signal to provide feedback on the compression rate and depth.Materials and MethodsWe simulated a CPR scenario with several volunteers grouped in couples providing chest compressions on a resuscitation manikin. Different target rates (80, 100, 120, and 140 compressions per minute) and a target depth of at least 50 mm were indicated. The manikin was equipped with a displacement sensor. The accelerometer was placed between the rescuer’s hands and the manikin’s chest. We designed three alternatives to direct integration based on different principles (linear filtering, analysis of velocity, and spectral analysis of acceleration). We evaluated their accuracy by comparing the estimated depth and rate with the values obtained from the reference displacement sensor.ResultsThe median (IQR) percent error was 5.9% (2.8–10.3), 6.3% (2.9–11.3), and 2.5% (1.2–4.4) for depth and 1.7% (0.0–2.3), 0.0% (0.0–2.0), and 0.9% (0.4–1.6) for rate, respectively. Depth accuracy depended on the target rate (p < 0.001) and on the rescuer couple (p < 0.001) within each method.ConclusionsAccurate feedback on chest compression depth and rate during CPR is possible using exclusively the chest acceleration signal. The algorithm based on spectral analysis showed the best performance. Despite these encouraging results, further research should be conducted to asses the performance of these algorithms with clinical data.

The role of pulse oximetry plethysmographic waveform monitoring as a marker of restoration of spontaneous circulation:a pilot study

To investigate the feasibility of using pulse oximetry plethysmographic waveform (POP) to identify the restoration of spontaneous circulation (ROSC) during cardiopulmonary resuscitation (CPR). An observational research was conducted. A porcine model of ventricular fibrillation (VF) arrest was reproduced. After 3 minutes of untreated VF, animals received CPR according to the latest CPR guidelines, providing chest compressions to a depth of 5 cm with a rate of 105 compressions per minute and instantaneous mechanical ventilation. After 2 minutes of CPR, animals were defibrillated with 100 J biphasic, followed by continuous chest compressions. Data of hemodynamic parameters, partial pressure of end-tidal carbon dioxide (PETCO₂) and POP were collected. The change in POP was observed, and the characteristics of changes of the waves were recorded during the peri-CPR period using the time and frequency domain methods. VF was successfully induced in 6 pigs, except 1 death in anesthesia induction period. (1) After VF, invasive blood pressure waveform and POP of the animals disappeared. PETCO₂was (18.83 ± 2.71) mmHg (1 mmHg=0.133 kPa), and diastolic arterial pressure was (23.83 ± 5.49) mmHg in compression stage. Animals attained ROSC within 1 minute after defibrillation, with PETCO₂[(51.83 ± 9.35) mmHg] and diastolic arterial pressure [(100.67 ± 10.97) mmHg] elevated significantly compared with that of compression stage (t1 = 8.737, t2 = 25.860, both P = 0.000), with appearance of arterial blood pressure waveform.(2) Characteristic changes in POP were found in all experimental animals. During the stages of induced VF, compression, ROSC, and compression termination, POP showed characteristic waveform changes. POP showed disappearance of waveform, regular compression wave, fluctuation hybrid and stable pulse wave in time domain method; while in the frequency domain method waveform disappearance, single peak of compression, double or fusion peak and single peak of pulse were observed. Analysis of POP using time and frequency domain methods could not only quickly detect cardiac arrest, but also show a role as a feasible, non-invasive marker of ROSC during CPR.

Abstract 283: Hands-off Time During Lay Rescuer Basic Life Support Remains High After a Standard Basic Life Support Course

The current international guidelines for resuscitation recommend high quality chest compressions with minimal interruptions as important prerequisite for optimal survival after cardiac arrest. During the standard four hours BLS course of the European Resuscitation Council (ERC) the participants learn to provide chest compressions, ventilations and to use an automated external defibrillator. We know that lay rescuers are able to learn these skills. However, it is unclear whether lay rescuers manage to minimize interruptions of chest compressions. Objective: To evaluate the no-flow fraction (NFF) during lay rescuer BLS including chest compressions, ventilation and the use of an AED. Methods: 24 participants of a BLS/ AED course were assessed before (T1) and after (T2) the BLS training in a standardized scenario in pairs of 2 rescuers. We used a Resusci Anne Simulator manikin (Laerdal, Norway) and a Lifepak 1000 AED trainer device for the assessment. The scenario was an adult patient with cardiac arrest and persistent ventricular fibrillation (VF), duration of the scenario was 5 minutes. 28 lay persons served as control group and were assessed in pairs of 2 rescuers twice at the same day. Two-sided t-test was used to test differences between groups and between test scenarios (T1 vs. T2), p&lt;.05 was considered significant. Results: The NFF decreased from 0.68 ± 0.1 (before the course) to 0.5 ± 0.07 (after the course), p=.000. In the control group the NFF was 0.63 ± 0.1 (scenario 1) and 0.59 ± 0.14 (second scenario), p=.244. Conclusion: A standard BLS course reduces the interruptions of chest compressions during lay rescuer CPR. However, 50% of the scenario no chest compressions are given. Interruptions are mainly due to ventilations or related to the use of the AED. Further research is necessary to improve the BLS algorithm regarding reduction of interruptions.

Can mass education and a television campaign change the attitudes towards cardiopulmonary resuscitation in a rural community?

BackgroundSurvival after out-of-hospital cardiac arrest (OHCA) is improved when bystanders provide Basic Life Support (BLS). However, bystander BLS does not occur frequently. The aim of this study was to assess the effects on attitudes regarding different aspects of resuscitation of a one-year targeted media campaign and widespread education in a rural Danish community. Specifically, we investigated if the proportion willing to provide BLS and deploy an automated external defibrillator (AED) increased.MethodsBLS and AED courses were offered and the local television station had broadcasts about resuscitation in this study community. A telephone enquiry assessed the attitudes towards different aspects of resuscitation among randomly selected citizens before (2008) and after the project (2009).ResultsFor responses from 2008 (n = 824) to 2009 (n = 815), there was a significant increase in the proportions who had participated in a BLS course within the past 5 years, from 34% to 49% (p = 0.0001), the number willing to use an AED on a stranger (p < 0.0001), confident at providing chest compressions (p = 0.03), and confident at providing mouth-to-mouth ventilations (MMV) (p = 0.048). There was no significant change in the proportions willing to provide chest compressions (p = 0.15), MMV (p = 0.23) or confident at recognizing a cardiac arrest (p = 0.09). The most frequently reported reason for not being willing to provide chest compressions, MMV and use an AED was insecurity about how to perform the task.ConclusionA targeted media campaign and widespread education can significantly increase the willingness to use an AED, and the confidence in providing chest compressions and MMV. The willingness to provide chest compressions and MMV may be less influenced by a targeted campaign.

Abstract 190: Cardiopulmonary Resuscitation with Rescue Breathing Is Superior to Hands-Only Cardiopulmonary Resuscitation for Children and Infants: Results of a Systematic Review

Introduction: Evidence supports teaching hands-only CPR for the initial treatment of cardiac arrest in adults. Unlike adults, however, children and infants with cardiac arrest are more likely to have non-cardiac causes. Hypothesis: The objective of this project was to conduct a structured literature review to answer the question, “In children and infants with cardiac arrest treated in an out-of-hospital setting, does compression-only CPR, alone or with supplemental oxygen, compared to CPR with rescue breathing lead to improved outcomes?” Methods: We performed a MEDLINE search (“compression only”[Title/Abstract]) AND cardiopulmonary resuscitation[MeSH Terms] with limits children (ages 0 -18). We also performed a search in the Cochrane database for systematic reviews, the Central Register of Controlled Trials, and EMBASE using similar search terms. We also searched applicable bibliographies and used the ‘Cited By’ function in Google Scholar. The study included papers if they evaluated the difference between compression only CPR and CPR with rescue breathing in infants or children. Papers that reported results from studies that used procedures that were beyond the basic life support level were excluded. Each paper was evaluated using specific criteria to determine the level of evidence. Results: Sixty-nine records were identified and screened. Fifty-four of these did not meet inclusion/exclusion criteria, leaving fifteen full-text articles that we assessed for eligibility. Eleven of these did not meet inclusion/exclusion criteria, leaving four that we included in the qualitative synthesis. Of these, one good quality study with level of evidence (LOE) 2a and 3 other studies (LOE 4) all opposed the hypothesis. There is a relative paucity of published data on this subject. The majority of the papers published describe evidence from animal models. Conclusions : In conclusion, rescuers should provide chest compressions with rescue breathing to children and infants in cardiac arrest; rescuers unwilling or unable to provide compressions with rescue breathing may provide chest compressions alone for these patients.