Real Cardiopulmonary Resuscitation Research Articles

Relationship of Public Interest in Cardiopulmonary Resuscitation with Cardiac Arrest Epidemiology and National Socioeconomic Indicators: Exploratory Infodemiology Study.

Web-based big data analytics provides a great opportunity to measure public interest in cardiac arrest (CA) and cardiopulmonary resuscitation (CPR). This study aimed to examine associations of online interest in CPR and CA with epidemiological characteristics of out-of-hospital CA (OHCA) and national socioeconomic indicators in a set of European countries. Country-level online search popularity data for CPR and CA topics measured in relative search volume (RSV) with Google Trends (GT), published OHCA epidemiological indicators, and World Bank's socioeconomic statistics of 28 European countries for the year 2017 were analyzed for correlation using Spearman's rank correlation coefficient (r S ). Whereas OHCA incidence, bystander CPR rate, and hospital survival did not correlate with RSV for CPR or CA, the rate of return of spontaneous circulation (ROSC) demonstrated a positive correlation with RSV for CPR (r S = 0.388; P = .042). Further, RSV for CPR positively correlated with countries' gross domestic product and health expenditure (r S = 0.939 and 0.566; P ≤.002) and negatively correlated with mortality caused by road traffic injury (r S = -0.412; P = .029). For the sample of European countries, public interest in CPR or CA showed no relationship with real bystander CPR rates and therefore could not be recommended as a proxy of community readiness to attempt resuscitation. The association of RSV for CPR with the rate of ROSC and countries' socioeconomic characteristics suggests it could be used for identifying geographies with poor performance of prehospital systems in terms of managing CA, in particular where effective epidemiological surveillance for CA may be unavailable.

Development of Smart-Ring-Based Chest Compression Depth Feedback Device for High Quality Chest Compressions: A Proof-of-Concept Study

Recently, a smart-device-based chest compression depth (CCD) feedback system that helps ensure that chest compressions have adequate depth during cardiopulmonary resuscitation (CPR) was developed. However, no CCD feedback device has been developed for infants, and many feedback systems are inconvenient to use. In this paper, we report the development of a smart-ring-based CCD feedback device for CPR based on an inertial measurement unit, and propose a high-quality chest compression depth estimation algorithm that considers the orientation of the device. The performance of the proposed feedback system was evaluated by comparing it with a linear variable differential transformer in three CPR situations. The experimental results showed compression depth errors of 2.0 ± 1.1, 2.2 ± 0.9, and 1.4 ± 1.1 mm in the three situations. In addition, we conducted a pilot test with an adult/infant mannequin. The results of the experiments show that the proposed smart-ring-based CCD feedback system is applicable to various chest compression methods based on real CPR situations.

Abstract 240: Smartphone Application to Provide Real-Time Cardiopulmonary Resuscitation Quality Feedback

Introduction: Quality of cardiopulmonary resuscitation (CPR) contributes significantly to morbidity and mortality in both in-hospital and out-of-hospital cardiac arrest. Key parameters that determine the CPR quality are compression rate, compression depth, duration of interruptions, chest recoil factor and respiratory rate. Several studies have demonstrated that real-time audiovisual feedback improves CPR quality in both bystanders and hospital staff. This study aims to develop and validate a smart device (phones and wearable technology) application to provide real-time audiovisual and haptic feedback to optimize CPR quality, by calculating aforementioned chest compression parameters. Hypothesis: A mobile application using acceleration sensor data from smart devices can provide accurate real time CPR quality feedback. Methods: A mobile application was developed to track the compression depth, compression rate and pause duration in real time using the data captured from the on-device accelerometer. The mobile device was placed on an adult manikin’s chest along the midline close to the point of compressions. Data from the application was compared directly to data obtained from a validated clinical standard CPR quality tool. Results: CPR quality parameters were obtained from the app and the standard for 60, 10-second-long sessions. Bland-Altman plot analysis for compression depth showed agreement between the app measurements and standard within +/-3.5mm (Figure 1). The intraclass correlation for agreement in the measurement of compression count was 0.92 (95% CI: 0.88-0.95), indicative of very strong agreement. Conclusions: Smart device (phones and wearable technology) applications using acceleration sensor data can accurately provide real-time CPR quality feedback. With further development and validation they can provide a ubiquitous CPR feedback tool valuable for out of hospital arrests and in under-privileged areas worldwide.

Abstract 175: Evaluation of Team Performance in Video Review of Pediatric Cardiopulmonary Resuscitation

Background: Team dynamics have been a learning objective of AHA courses since 2005. Cardiopulmonary resuscitation (CPR) in a hospital setting involves a multidisciplinary team with multiple specific roles occurring simultaneously. Though evaluation of team performance in simulated resuscitation events has been studied, little information exists on the performance of teams in real CPR events. The development of a video-based resuscitation quality improvement (QI) program has allowed a route for the analysis of team performance during actual patient care. Objective: Demonstrate feasibility of team performance rating of real pediatric CPR events using video review. Methods: All pediatric resuscitations requiring cardiopulmonary resuscitation (CPR) in the emergency department of a tertiary children’s hospital are video-recorded for QI purposes. Following video review, team performance was rated by study personnel using the validated Behavioral Assessment Tool (BAT). The BAT scores 10 domains of team performance, each on a 0-4 Likert Scale (score range 0 – 40). Univariate comparison of BAT scores was done between patient age categories, event duration, location of arrest (in- vs. out-of-hospital), and chest compression fraction (CCF) below or above 80% using nonparametric methods. Results: 13 events requiring CPR occurred during the study period. Mean BAT scores were 32 (+/- 6) points. Lowest rated domains were Attention allocation , Distribution of workload, and Utilization of information. Highest rated domains across all events were Recognition of Limitations and Professional behavior. BAT scores were significantly higher in infant CPR events than older children (39 vs. 28, p=0.005) and out-of-hospital events compared with in-hospital (37 vs 27, p=0.04). There were no significant differences in BAT scores based on event duration or CCF. Conclusions: Video-based review of pediatric CPR events is a feasible method for efficient evaluation of team performance using validated tools. Quantitative assessment of team performance allows for needs assessments to determine areas in which intervention should be focused for maximum impact on CPR quality. Future work should focus on interventions to address areas of suboptimal performance.

Factors that influence the self-reported confidence of pediatric residents as team leaders during cardiopulmonary resuscitation: Anational survey.

ObjectiveThe leadership skills of pediatric residents during cardiopulmonary resuscitation (CPR) may have major impacts on their performance. These skills should be addressed during the pediatric residency training program. Therefore, we aimed to identify the perceptions of residents regarding their level of confidence in providing or leading a real pediatric CPR code, and to identify different factors that might influence their self-confidence when assuming the role of a team leader during a real CPR.Design & settingCross-sectional paper-based and online electronic surveys were conducted in February 2017, which included all Saudi pediatric residency program trainees.InterventionsA survey questionnaire was distributed to Saudi pediatric residency trainees throughout the Kingdom. The main aim was to assess their perceived level of confidence when running a real pediatric CPR code either as a team leader or as a team member.ResultsThe survey was distributed and sent by email to 1052 residents, where it was received by 640 and 231 responded (response rate = 36%). Almost one-fifth of the respondents (19.5%) did not have a valid pediatric advanced life support (PALS) certificate. The most frequently reported obstacles to life support training were lack of time (45.8%) and its financial cost (22.7%). The mean self-reported confidence as a CPR team member was reported significantly more frequently than being a CPR team leader (mean standard deviation, SD) = 7.8 (2.1) and 6.7 (2.4) respectively, P < .001). The self-reported confidence as a CPR team leader was reported significantly more frequently in males compared with female respondents (mean ± SD = 6.7 ± 2.4 and 5.9 ± 2.4, respectively; P < .013). There was a significant positive effect of recent attendance at a real CPR event on the perceived self-rated confidence of residents as a CPR team leader (P < .001). Residents who reported that they had often assumed a real CPR leadership role had significantly greater perceived self-confidence compared with those who assumed a member role (P < .05). Furthermore, residents without a valid PALS certificate had significantly less confidence in leading CPR teams than their peers who were recently certified (P < .05).ConclusionsThe self-reported confidence as team leader during CPR was higher among residents who were certified in life support courses, exposed to CPR during their training, and those who assumed the role of a team leader during CPR. Our findings suggests the need to incorporate life support training courses and simulation-based mock code programs with an emphasis on the leadership in the curriculum of the pediatric residency training program.

US-CAB protocol for ultrasonographic evaluation during cardiopulmonary resuscitation: Validation and potential impact

BackgroundWe previously developed a US-CAB protocol for evaluation of circulatory-airway-breathing status during cardiopulmonary resuscitation (CPR). This study aimed at validating its application in real CPR scenarios and the potential impact on CPR outcomes. MethodsThe US-CAB protocol was implemented at the emergency department of National Taiwan University Hospital since January 2016. The US images, initiation time and operation duration of each US-CAB procedure, and relevant CPR information were recorded for analysis. ResultsFrom January 2016 to March 2017, 177 cardiac arrest patients receiving US-CAB were included. The durations of US-C-A-B procedure were 9.0 ± 1.4, 7.5 ± 1.5, and 16.0 ± 1.9 s, respectively. Cardiac activity was identified in 47 cases (26.6%), with higher rates of return of spontaneous circulation (ROSC) (95.7% vs. 21.5%, p < .0001) and survival to hospital discharge (25.5% vs. 10.0%, p < .01). Detection of cardiac activity after 10 min of CPR exhibited 100% sensitivity, specificity, positive and negative predictive value for ROSC. Cardiac tamponade was noted in eight patients. ROSC was achieved in two (25.0%) after pericardiocentesis, and aortic dissection was diagnosed in one (12.5%). Confirmation of correct intubation was significantly faster by US than by capnography (7.4 ± 1.4 vs. 38.3 ± 110.2 s, p < .001). US detected 21 (11.9%) esophageal intubations and 3 (1.7%) one-lung intubations. All were promptly corrected. ConclusionThe US-CAB protocol is feasible in real CPR scenarios. It confers diagnostic value and prognostic implications which potentially impact the efficacy and outcomes of CPR. However, a future prospective multi-center study to validate its feasibility and indicate the need of structured training is mandated.

CPR performance in the presence of audiovisual feedback or football shoulder pads

ObjectiveThe initiation of cardiopulmonary resuscitation (CPR) can be complicated by the use of protective equipment in contact sports, and the rate of success in resuscitating the patient depends on the...

A method to differentiate between ventricular fibrillation and asystole during chest compressions using artifact-corrupted ECG alone

In recent years, numerous adaptive filtering techniques have been developed to suppress the chest compression (CC) artifact for reliable analysis of the electrocardiogram (ECG) rhythm without CC interruption. Unfortunately, the result of rhythm diagnosis during CCs is still unsatisfactory in many studies. The misclassification between corrupted asystole (ASY) and corrupted ventricular fibrillation (VF) is generally regarded as one of the major reasons for the poor performance of reported methods. In order to improve the diagnosis of VF/ASY corrupted by CCs, a novel method combining a least mean-square (LMS) filter and an amplitude spectrum area (AMSA) analysis was developed based only on the analysis of the surface of the corrupted ECG episode. This method was tested on 253 VF and 160 ASY ECG samples from subjects who experienced cardiac arrest using a porcine model and was compared with six other algorithms. The validation results indicated that this method, which yielded a satisfactory result with a sensitivity of 93.3%, a specificity of 96.3% and an accuracy of 94.8%, is superior to the other reported techniques. After improvement using the human ECG records in real cardiopulmonary resuscitation (CPR) scenarios, the algorithm is promising for corrupted VF/ASY detection with no hardware alterations in clinical practice.

ABSTRACT 835

Background and aims: There have been several studies on medication errors in children in the PED and wards, but none of them have evaluated incidence of medication errors occurring during real life CPR in the acute care set up. Aims: To evaluate the effect of informal training and technical aids on the rates of medication errors during pediatric cardiopulmonary resuscitation (CPR). Methods: In the pre-intervention period, the treatment records of all children who underwent CPR were reviewed, and the existent knowledge of the on-duty residents was assessed using pre-designed questionnaires. Following this a training session was conducted. Also use of technical aids such as Broselow tapes and CPR charts were introduced into these areas during this time. In the post-intervention period, record review and knowledge assessment of the residents was carried out in the same way as in the pre-intervention period. Results: Twenty-eight records were evaluated in the pre-intervention period, of which 15 (54%) had medication errors. Out of 15, 67% (n=10) were related to documentation and the remaining (n=5) to dosing. Of the 20 records evaluated in the post-intervention period, a total of 4 errors pertaining to documentation (not dosing) were found. The incidence of severe errors decreased from 20% (n=3) pre-training to 0% post-training.The mean (SD) knowledge scores of residents increased from 7.9 (2.9) pre-training to 13 (1.4) post-training (p=0.01). Conclusions: Rates of medication errors in pediatric CPR declined with training and the use of technical aids. Documentation errors may not be eliminated completely with only one time training.

The Effects of Flashlight Guidance on Performance for Chest Compression of Cardiopulmonary Resuscitation in a Noisy Environment

In real cardiopulmonary resuscitation (CPR) situations, noise can arise from instructional voices and from environmental sounds in places such as the battlefield, industrial, commercial shopping, and high traffic areas. The World Health Organization suggested guideline limits for community noise in specific environments. In the specific environments mentioned above, noise levels were measured to be>70 dB, which can induce annoyance and hearing impairment. A simple feedback device using flashlight stimulus was designed for overcoming noise-induced stimulus saturation during CPR.

Accuracy of a feedback device for cardiopulmonary resuscitation on a dental chair

BackgroundConflicting studies exist about the effectiveness of cardiopulmonary resuscitation (CPR) on a dental chair. In some situations, dental surgeons are obliged to perform CPR with the patient on the chair....

Reduction of CPR artifacts in the ventricular fibrillation ECG by coherent line removal

BackgroundInterruption of cardiopulmonary resuscitation (CPR) impairs the perfusion of the fibrillating heart, worsening the chance for successful defibrillation. Therefore ECG-analysis during ongoing chest compression could provide a considerable progress in comparison with standard analysis techniques working only during "hands-off" intervals.MethodsFor the reduction of CPR-related artifacts in ventricular fibrillation ECG we use a localized version of the coherent line removal algorithm developed by Sintes and Schutz. This method can be used for removal of periodic signals with sufficiently coupled harmonics, and can be adapted to specific situations by optimal choice of its parameters (e.g., the number of harmonics considered for analysis and reconstruction). Our testing was done with 14 different human ventricular fibrillation (VF) ECGs, whose fibrillation band lies in a frequency range of [1 Hz, 5 Hz]. The VF-ECGs were mixed with 12 different ECG-CPR-artifacts recorded in an animal experiment during asystole. The length of each of the ECG-data was chosen to be 20 sec, and testing was done for all 168 = 14 × 12 pairs of data. VF-to-CPR ratio was chosen as -20 dB, -15 dB, -10 dB, -5 dB, 0 dB, 5 dB and 10 dB. Here -20 dB corresponds to the highest level of CPR-artifacts.ResultsFor non-optimized coherent line removal based on signals with a VF-to-CPR ratio of -20 dB, -15 dB, -10 dB, -5 dB and 0 dB, the signal-to-noise gains (SNR-gains) were 9.3 ± 2.4 dB, 9.4 ± 2.4 dB, 9.5 ± 2.5 dB, 9.3 ± 2.5 dB and 8.0 ± 2.7 (mean ± std, n = 168), respectively. Characteristically, an original VF-to-CPR ratio of -10 dB, corresponds to a variance ratio var(VF):var(CPR) = 1:10. An improvement by 9.5 dB results in a restored VF-to-CPR ratio of -0.5 dB, corresponding to a variance ratio var(VF):var(CPR) = 1:1.1, the variance of the CPR in the signal being reduced by a factor of 8.9.DiscussionThe localized coherent line removal algorithm uses the information of a single ECG channel. In contrast to multi-channel algorithms, no additional information such as thorax impedance, blood pressure, or pressure exerted on the sternum during CPR is required. Predictors of defibrillation success such as mean and median frequency of VF-ECGs containing CPR-artifacts are prone to being governed by the harmonics of the artifacts. Reduction of CPR-artifacts is therefore necessary for determining reliable values for estimators of defibrillation success.ConclusionsThe localized coherent line removal algorithm reduces CPR-artifacts in VF-ECG, but does not eliminate them. Our SNR-improvements are in the same range as offered by multichannel methods of Rheinberger et al., Husoy et al. and Aase et al. The latter two authors dealt with different ventricular rhythms (VF and VT), whereas here we dealt with VF, only. Additional developments are necessary before the algorithm can be tested in real CPR situations.

Foreword

In recent years, numerous adaptive filtering techniques have been developed to suppress the chest compression (CC) artifact for reliable analysis of the electrocardiogram (ECG) rhythm without CC interruption. Unfortunately, the result of rhythm diagnosis during CCs is still unsatisfactory in many studies. The misclassification between corrupted asystole (ASY) and corrupted ventricular fibrillation (VF) is generally regarded as one of the major reasons for the poor performance of reported methods. In order to improve the diagnosis of VF/ASY corrupted by CCs, a novel method combining a least mean-square (LMS) filter and an amplitude spectrum area (AMSA) analysis was developed based only on the analysis of the surface of the corrupted ECG episode. This method was tested on 253 VF and 160 ASY ECG samples from subjects who experienced cardiac arrest using a porcine model and was compared with six other algorithms. The validation results indicated that this method, which yielded a satisfactory result with a sensitivity of 93.3%, a specificity of 96.3% and an accuracy of 94.8%, is superior to the other reported techniques. After improvement using the human ECG records in real cardiopulmonary resuscitation (CPR) scenarios, the algorithm is promising for corrupted VF/ASY detection with no hardware alterations in clinical practice.

Measuring forces and frequency during active compression decompression cardiopulmonary resuscitation: a device for training, research and real CPR

Active compression decompression (ACD) cardiopulmonary resuscitation (CPR) is possibly a superior alternative to standard (STD) CPR, but an optimal compression and decompression pattern has to be ensured. ACD-CPR can be evaluated during CPR training sessions using commercially available manikins; however devices for recording compression and decompression forces or frequency during real CPR are lacking. Using the Ambu CardioPump® without changing its mechanical characteristics, two force transducers were integrated into the ACD device. Using specially designed electronics and a portable computer, compression and decompression forces were measured and displayed continuously and compression frequency and the compression decompression phase are calculated on-line during real CPR action. All measured parameters were stored on a hard disk for later retrieval and analysis. Linearity of force measurement was better than 6% within a −250–+500 N range. The error in repeatability was below 5% thus outperforming the original mechanical force measurement system of the Ambu CardioPump®. Compression frequency was calculated very accurately (error<1%). The system has been successfully used during CPR training, during ACD-CPR in 37 corpses under research conditions and in five out-of-hospital CPR casualties. Simple and safe in use, our modified CardioPump® with integrated electronics provides an important, technically advanced solution for monitoring ACD-CPR on-line. It warrants quality assurance during ACD-CPR training and in real CPR scenarios and guarantees accurate recording of compression and decompression forces and compression frequency.

Targeted mass CPR training for families of cardiac patients - Experience in Taipei city

Targeted mass cardiopulmonary resuscitation(CPR)training has been suggested in previous studies, and there was no information about targeted mass CPR training in Taiwan. We designed this study to determine whether targeted mass CPR training course in Taipei City could attract families of cardiac patients to learn CPR technique. We used a targeted strategy and aggressive methods such as mailing and telephoning to invite citizens of Taipei city to join our mass CPR training course. The participants of this activity were divided into two groups according to whether they have members in their families with cardiac disease or not. Questionnaires were answered by these participants after they had finished the CPR training course. Chi-Square method was used to compare the variables of the two groups. The targeted strategy significantly attracted families of cardiac patients (60.5%) to join this activity compared to previous articles in western countries. After acquiring CPR skill, most participants of both groups have confidence and willingness to perform real CPR for their families (92.1% vs 92.9%; NS), relatives (89.0% vs 89.1%;NS), friends (87.8% vs 88.1%;NS), or even strangers (75.3% vs 74.9%;NS), Our results suggested that targeted mass CPR training program could attract families of cardiac patients in Taipei City to learn CPR setting an example for future CPR training programs in Taiwan.(Tzi Chi Med j 1997;9:273-278)