The challenges and possibilities of public access defibrillation.

Out-of-hospital cardiac arrest (OHCA) is a major health problem that affects approximately four hundred and thousand patients annually in the United States alone. It is a major challenge for the emergency medical system as decreased survival rates are directly proportional to the time delay from collapse to defibrillation. Historically, defibrillation has only been performed by physicians and in-hospital. With the development of automated external defibrillators (AEDs), rapid defibrillation by nonmedical professionals and subsequently by trained or untrained lay bystanders has become possible. Much hope has been put to the concept of Public Access Defibrillation with a massive dissemination of public available AEDs throughout most Western countries. Accordingly, current guidelines recommend that AEDs should be deployed in places with a high likelihood of OHCA. Despite these efforts, AED use is in most settings anecdotal with little effect on overall OHCA survival. The major reasons for low use of public AEDs are that most OHCAs take place outside high incidence sites of cardiac arrest and that most OHCAs take place in residential settings, currently defined as not suitable for Public Access Defibrillation. However, the use of new technology for identification and recruitment of lay bystanders and nearby AEDs to the scene of the cardiac arrest as well as new methods for strategic AED placement redefines and challenges the current concept and definitions of Public Access Defibrillation. Existing evidence of Public Access Defibrillation and knowledge gaps and future directions to improve outcomes for OHCA are discussed. In addition, a new definition of the different levels of Public Access Defibrillation is offered as well as new strategies for increasing AED use in the society.

Implementation and effectiveness of a video-based debriefing programme for neonatal resuscitation.

BACKGROUND: Approximately 5%-10% of newly born babies need intervention to assist transition from intra- to extrauterine life. All providers in the delivery ward are trained in neonatal resuscitation, but without clinical experience or exposure, training competency is transient with a decline in skills within a few months. The aim of this study was to evaluate whether neonatal resuscitations skills and team performance would improve after implementation of video-assisted, performance-focused debriefings. METHODS: We installed motion-activated video cameras in every resuscitation bay capturing consecutive compromised neonates. The videos were used in debriefings led by two experienced facilitators, focusing on guideline adherence and non-technical skills. A modification of Neonatal Resuscitation Performance Evaluation (NRPE) was used to score team performance and procedural skills during a 7 month study period (2.5, 2.5 and 2 months pre-, peri- and post-implementation) (median score with 95% confidence interval). RESULTS: We compared 74 resuscitation events pre-implementation to 45 events post-implementation. NRPE-score improved from 77% (75, 81) to 89% (86, 93), P < 0.001. Specifically, the sub-categories "group function/communication", "preparation and initial steps", and "positive pressure ventilation" improved (P < 0.005). Adequate positive pressure ventilation improved from 43% to 64% (P = 0.03), and pauses during initial ventilation decreased from 20% to 0% (P = 0.02). Proportion of infants with heart rate > 100 bpm at 2 min improved from 71% pre- vs. 82% (P = 0.22) post-implementation. CONCLUSION: Implementation of video-assisted, performance-focused debriefings improved adherence to best practice guidelines for neonatal resuscitation skill and team performance.

Effectiveness of ultraportable automated external defibrillators: A scoping review.

Background: Ultraportable automated external defibrillators (AEDs) are a new generation of defibrillators that are small, lightweight, easy to carry on one's person, and affordable for personal and home use. They offer the opportunity to increase AED availability in case of out-of-hospital cardiac arrest (OHCA) and therefore improve outcomes.We aimed to review evidence supporting the potential effect on outcomes and the performance of these ultraportable AEDs. Methods: We searched Ovid Medline, Embase and Cochrane databases from 2012 to July 4th, 2024 to identify any studies related to ultraportable AED. The population was adult and children with OHCA who were treated with an ultra-portable AED. All outcomes were accepted. We limited study designs to randomized controlled trials and non-randomized studies. Data charting was done by the primary author using standardized data abstraction forms. Results: The search strategy identified 54 studies (Pubmed = 26, Embase = 28, with 19 duplicates). We included three articles in the final review. One study was a medico-economic simulation study including 600,000 simulated patients, one is the study protocol of cluster randomized trial of providing ultraportable AEDs to first responders and one is an abstract with preliminary results of this trial reporting 1805 community responders recruited, 903 allocated to ultraportable AED. No studies to date have reported patient outcomes. Conclusion: This review found no evidence of ultraportable AED device performance, clinical or safety outcomes. There is an urgent need for further research to determine the safety and effectiveness of ultraportable AEDs.

A randomized trial on elderly laypersons' CPR performance in a realistic cardiac arrest simulation.

BACKGROUND: Bystander cardiopulmonary resuscitation (CPR) is important for survival after cardiac arrest. We hypothesized that elderly laypersons would perform CPR poorer in a realistic cardiac arrest simulation, compared to a traditional test. METHODS: Sixty-four lay rescuers aged 50-75 were randomized to realistic or traditional test, both with ten minutes of telephone assisted CPR. Realistic simulation started suddenly without warning, leaving the test subject alone in a confined and noisy apartment. Traditional test was conducted in a spacious and calm classroom with a researcher present. CPR performance was recorded with a manikin with human like chest properties. Heart rate and self-reported exhaustion were registered. RESULTS: CPR quality was not different in the two groups: compression depth, 43 mm ± 7 versus 43 ± 4, P = 0.72; compressions rate, 97 min(-1) ± 11 versus 93 ± 15, P = 0.26; ventilation rate, 2.4 min(-1) ± 1.7 versus 2.8 ± 1.1, P = 0.35; and hands-off time 273 s ± 50 versus 270 ± 66, P = 0.82; in realistic (n = 31) and traditional (n = 33) groups, respectively. No fatigue was evident in the repeated measures analysis of variance. Work load was not different between the groups; attained percentage of age predicted maximum heart rate, 73% ± 9 and 76 ± 11, P = 0.37, reported exhaustion 43 ± 21 (scale: 0 to 100) and 37 ± 19, P = 0.24. CONCLUSIONS: Elderly lay people are capable of performing chest compressions with acceptable quality for ten minutes in a realistic cardiac arrest simulation. Ventilation quality and hands-off time were not adequate in either group.

European Resuscitation Council COVID-19 guidelines executive summary.

Coronavirus disease 2019 (COVID-19) has had a substantial impact on the incidence of cardiac arrest and survival. The challenge is to find the correct balance between the risk to the rescuer when undertaking cardiopulmonary resuscitation (CPR) on a person with possible COVID-19 and the risk to that person if CPR is delayed. These guidelines focus specifically on patients with suspected or confirmed COVID-19. The guidelines include the delivery of basic and advanced life support in adults and children and recommendations for delivering training during the pandemic. Where uncertainty exists treatment should be informed by a dynamic risk assessment which may consider current COVID-19 prevalence, the person's presentation (e.g. history of COVID-19 contact, COVID-19 symptoms), likelihood that treatment will be effective, availability of personal protective equipment (PPE) and personal risks for those providing treatment. These guidelines will be subject to evolving knowledge and experience of COVID-19. As countries are at different stages of the pandemic, there may some international variation in practice.

Standard basic life support vs. continuous chest compressions only in out-of-hospital cardiac arrest.

BACKGROUND: The importance of ventilations after cardiac arrest has been much debated recently and eliminating mouth-to-mouth ventilations for bystanders has been suggested as a means to increase bystander cardiopulmonary resuscitation (CPR). Standard basic life support (S-BLS) is not documented to be superior to continuous chest compressions (CCC). METHODS: Retrospective, observational study of all non-traumatic cardiac arrest patients older than 18 years between May 2003 and December 2006 treated by the community-run emergency medical service (EMS) in Oslo. Outcome for patients receiving S-BLS was compared with patients receiving CCC. All Utstein characteristics were registered for both patient groups as well as for patients not receiving any bystander CPR by reviewing Ambulance run sheets, Utstein forms and hospital records. Method of bystander CPR as well as dispatcher instruction was registered by first-arriving ambulance personnel. RESULTS: Six-hundred ninety-five out of 809 cardiac arrests in our EMS were included in this study. Two-hundred eighty-one (40%) received S-CPR and 145 (21%) received CCC. There were no differences in outcome between the two patient groups, with 35 (13%) discharged with a favourable outcome for the S-BLS group and 15 (10%) in the CCC group (P=0.859). Similarly, there was no difference in survival subgroup analysis of patients presenting with initial ventricular fibrillation/ventricular tachycardia after witnessed arrest, with 32 (29%) and 10 (28%) patients discharged from hospital in the S-BLS and CCC groups, respectively (P=0.972). CONCLUSIONS: Patients receiving CCC from bystanders did not have a worse outcome than patients receiving standard CPR, even with a tendency towards a higher distribution of known negative predictive features.

Treatment of asystole and PEA.

Recent reports consistently point to a substantial decline in the incidence of ventricular fibrillation (VF) as the initial rhythm observed by Emergency Medical Service (EMS) responders and a complementary increase in pulseless electrical activity (PEA) and asystole. Historically, efforts at improving survival have focused primarily on patients found in VF. Consequently, the approach for other patients has included frequent pauses in cardiopulmonary resuscitation (CPR) to check for VF followed by shock when VF is observed. However, the "yield" of survivors comes largely from the non-shocked patients. Therefore, it is critical that we start evaluating treatments specifically for the PEA and asystole groups.

Misplaced and dislodged endotracheal tubes may be detected by the defibrillator during cardiopulmonary resuscitation.

We present two cases of unrecognized endotracheal tube misplacements in out-of-hospital cardiopulmonary resuscitation recognized by the analysis of transthoracic impedance. In Case 1, ventilation-induced changes in transthoracic impedance disappeared after an intubation attempt corresponding to oesophageal intubation. This was clinically recognized after several minutes, the endotracheal tube was repositioned and alterations in transthoracic impedance resumed. In Case 2, the initial ventilation-induced signal change following endotracheal intubation weakened after a few minutes. At that time, the defibrillator gave vocal and visual feedback to the rescuers on ventilatory inactivity, a pharyngeal air leak was discovered simultaneously and the tube was found to be dislodged. Continuous monitoring of transthoracic impedance provided by the defibrillator during cardiopulmonary resuscitation may contribute to the early detection of an initially misplaced or later dislodged endotracheal tube.