Potential impacts of a novel integrated extracorporeal-CPR workflow using an interventional radiology and immediate whole-body computed tomography system in the emergency department.

Extracorporeal cardiopulmonary resuscitation (ECPR) can be associated with increased survival and neurologic benefits in selected patients with out-of-hospital cardiac arrest (OHCA). However, there remains insufficient evidence to recommend the routine use of ECPR for patients with OHCA. A novel integrated trauma workflow concept that utilizes a sliding computed tomography (CT) scanner and interventional radiology (IR) system, named a hybrid emergency room system (HERS), allowing emergency therapeutic interventions and CT examination without relocating trauma patients, has recently evolved in Japan. HERS can drastically shorten the ECPR implementation time and more quickly facilitate definitive interventions than the conventional advanced cardiovascular life support workflow. Herein, we discuss our novel workflow concept using HERS on ECPR for patients with OHCA.

Treatment Effect or Effective Treatment? Cardiac Compression Fraction and End-tidal Carbon Dioxide Are Higher in Patients Resuscitative Endovascular Balloon Occlusion of the Aorta Compared with Resuscitative Thoracotomy and Open-Chest Cardiac Massage.

The purpose of this study is to compare end-tidal carbon dioxide (EtCO2) during resuscitation of open-chest cardiac massage (OCCM) with aortic cross-clamp (ACC) versus receiving resuscitative endovascular balloon occlusion of the aorta (REBOA) with closed-chest compressions (CCCs). Patients who received REBOA were compared with patients receiving OCCM for traumatic arrest using continuous vital sign monitoring and videography. Thirty-three patients were enrolled in the REBOA group and 18 patients were enrolled in the OCCM group. Of the total patients, 86.3 per cent were male with a mean age of 36.2 ± 13.9 years. Ninety-four percent of patients suffered penetrating trauma in the OCCM group compared with 30.3 per cent of the REBOA group (P = <0.001). Before aortic occlusion (AO), there was no difference in initial EtCO2 values, but mean, median, peak, and final EtCO2 values were lower in OCCM (P < 0.005). During CPR after AO, the initial, mean, and median values were higher with REBOA (P = 0.015, 0.036, and 0.038). The rate of return of spontaneous circulation was higher in REBOA versus OCCM (20/33 [60.1%] vs 5/18 [33.3%]; P = 0.04), and REBOA patients survived to operative intervention more frequently (P = 0.038). REBOA patients had greater total cardiac compression fraction (CCF) before AO than OCCM (85.3 ± 12.7% vs 35.2 ± 18.6%, P < 0.0001) and after AO (88.3 ± 7.8% vs 71.9 ± 24.4%, P = 0.0052). REBOA patients have higher EtCO2 and cardiac compression fraction before and after AO compared with patients who receive OCCM.

Status of and problems concerning neonatal resuscitation in Japan in 2015.

BACKGROUND: The International Liaison Committee on Resuscitation (ILCOR) published Consensus 2015 in October 2015. Thereafter, the Japanese version of neonatal cardiopulmonary resuscitation programs was revised. Prior to the revision, we re-conducted questionnaire surveys in three types of medical facilities in January 2015. METHODS: Targeted groups included (i) 277 training hospitals authorized by the Japanese Society of Perinatal/Neonatal Medicine for training of physicians specialized in perinatal care (neonatology) in January 2015 (training hospitals; response rate, 70.8%); (ii) 459 obstetric hospitals/clinics (response rate, 63.6%); and (iii) 453 midwife clinics (response rate, 60.9%). The survey included systems of neonatal resuscitation, medical equipment and practices, and education systems. The results were compared with that of similar surveys conducted in 2005, 2010 and 2013. RESULTS: Almost all results were generally improved compared with past surveys. In training hospitals, however, the use of oxygen blenders or manometers was not widespread. Only 35% of institutions used continuous positive airway pressure systems frequently, and expert neonatal resuscitation doctors attended all deliveries in only 6% of training centers. In addition, only 71% of training hospitals had brain therapeutic hypothermia facilities. Not all obstetric hospitals/clinics prepared pulse oximeters, and only a few used manometers frequently. Some midwife clinics did not keep warming equipment, and few midwife clinics were equipped with pulse oximeters. In addition, some midwife clinics did not prepare ventilation bags (masks). CONCLUSIONS: The equipment in Japanese delivery rooms is variable. Further efforts need to be made in the distribution of neonatal resuscitation devices and the dissemination of techniques.

Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device.

BACKGROUND: A recent out-of-hospital cardiac arrest (OHCA) clinical trial showed improved survival to hospital discharge (HD) with favorable neurologic function for patients with cardiac arrest of cardiac origin treated with active compression decompression cardiopulmonary resuscitation (CPR) plus an impedance threshold device (ACD+ICD) versus standard (S) CPR. The current analysis examined whether treatment with ACD+ITD is more effective than standard (S-CPR) for all cardiac arrests of non-traumatic origin, regardless of the etiology. METHODS: This is a secondary analysis of data from a randomized, prospective, multicenter, intention-to-treat, OHCA clinical trial. Adults with presumed non-traumatic cardiac arrest were enrolled and followed for one year post arrest. The primary endpoint was survival to hospital discharge (HD) with favorable neurologic function (Modified Rankin Scale score ≤ 3). RESULTS: Between October 2005 and July 2009, 2738 patients were enrolled (S-CPR=1335; ACD+ITD=1403). Survival to HD with favorable neurologic function was greater with ACD+ITD compared with S-CPR: 7.9% versus 5.7%, (OR 1.42, 95% CI 1.04, 1.95, p=0.027). One-year survival was also greater: 7.9% versus 5.7%, (OR 1.43, 95% CI 1.04, 1.96, p=0.026). Nearly all survivors in both groups had returned to their baseline neurological function by one year. Major adverse event rates were similar between groups. CONCLUSIONS: Treatment of out-of-hospital non-traumatic cardiac arrest patients with ACD+ITD resulted in a significant increase in survival to hospital discharge with favorable neurological function when compared with S-CPR. A significant increase survival rates was observed up to one year after arrest in subjects treated with ACD+ITD, regardless of the etiology of the cardiac arrest.

Hyperinvasive approach to out-of hospital cardiac arrest using mechanical chest compression device, prehospital intraarrest cooling, extracorporeal life support and early invasive assessment compared to standard of care. A randomized parallel groups comparative study proposal. "Prague OHCA study".

BACKGROUND: Out of hospital cardiac arrest (OHCA) has a poor outcome. Recent non-randomized studies of ECLS (extracorporeal life support) in OHCA suggested further prospective multicenter studies to define population that would benefit from ECLS. We aim to perform a prospective randomized study comparing prehospital intraarrest hypothermia combined with mechanical chest compression device, intrahospital ECLS and early invasive investigation and treatment in all patients with OHCA of presumed cardiac origin compared to a standard of care. METHODS: This paper describes methodology and design of the proposed trial. Patients with witnessed OHCA without ROSC (return of spontaneous circulation) after a minimum of 5 minutes of ACLS (advanced cardiac life support) by emergency medical service (EMS) team and after performance of all initial procedures (defibrillation, airway management, intravenous access establishment) will be randomized to standard vs. hyperinvasive arm. In hyperinvasive arm, mechanical compression device together with intranasal evaporative cooling will be instituted and patients will be transferred directly to cardiac center under ongoing CPR (cardiopulmonary resuscitation). After admission, ECLS inclusion/exclusion criteria will be evaluated and if achieved, veno-arterial ECLS will be started. Invasive investigation and standard post resuscitation care will follow. Patients in standard arm will be managed on scene. When ROSC achieved, they will be transferred to cardiac center and further treated as per recent guidelines. PRIMARY OUTCOME: 6 months survival with good neurological outcome (Cerebral Performance Category 1-2). Secondary outcomes will include 30 day neurological and cardiac recovery. DISCUSSION: Authors introduce and offer a protocol of a proposed randomized study comparing a combined "hyperinvasive approach" to a standard of care in refractory OHCA. The protocol is opened for sharing by other cardiac centers with available ECLS and cathlab teams trained to admit patients with refractory cardiac arrest under ongoing CPR. A prove of concept study will be started soon. The aim of the authors is to establish a net of centers for a multicenter trial initiation in future. ETHICS AND REGISTRATION: The protocol has been approved by an Institutional Review Board, will be supported by a research grant from Internal Grant Agency of the Ministry of Health, Czech Republic NT 13225-4/2012 and has been registered under ClinicalTrials.gov identifier: NCT01511666.

Manual versus mechanical cardiopulmonary resuscitation. An experimental study in pigs.

BACKGROUND: Optimal manual closed chest compressions are difficult to give. A mechanical compression/decompression device, named LUCAS, is programmed to give compression according to the latest international guidelines (2005) for cardiopulmonary resuscitation (CPR). The aim of the present study was to compare manual CPR with LUCAS-CPR. METHODS: 30 kg pigs were anesthetized and intubated. After a base-line period and five minutes of ventricular fibrillation, manual CPR (n = 8) or LUCAS-CPR (n = 8) was started and run for 20 minutes. Professional paramedics gave manual chest compression's alternating in 2-minute periods. Ventilation, one breath for each 10 compressions, was given to all animals. Defibrillation and, if needed, adrenaline were given to obtain a return of spontaneous circulation (ROSC). RESULTS: The mean coronary perfusion pressure was significantly (p < 0.01) higher in the mechanical group, around 20 mmHg, compared to around 5 mmHg in the manual group. In the manual group 54 rib fractures occurred compared to 33 in the LUCAS group (p < 0.01). In the manual group one severe liver injury and one pressure pneumothorax were also seen. All 8 pigs in the mechanical group achieved ROSC, as compared with 3 pigs in the manual group. CONCLUSIONS: LUCAS-CPR gave significantly higher coronary perfusion pressure and significantly fewer rib fractures than manual CPR in this porcine model.

Effects of audio tone guidance on performance of CPR in simulated cardiac arrest with an advanced airway.

THE AIM OF THE STUDY: Despite the emphasis of cardiopulmonary resuscitation (CPR) quality, the performance of on-site CPR is reported to be frequently unsuccessful. In order to improve CPR quality, various feedback systems have been developed, but they have not yet been widely used on site due to low economic efficiency. The present study was attempted to determine whether CPR quality can be improved using audio tone guidance. THE METHODS: A total of 80 seniors at our medical school and college of nursing participated in the study. After they were trained in CPR according to the 2005 guidelines, they performed CPR using a cardiac arrest model with an advanced airway. The participants were organized into 40 groups. After they took Test 1 without any feedback for 2 min, they were randomly assigned to the feedback and control groups and took Test 2 for 2 min. In the feedback group, a low-pitched sound was delivered every 0.6 s for the guidance of chest compression and a high-pitched sound was simultaneously delivered every 10 deliveries of a low-pitched sound for the guidance of ventilation at 6s intervals. THE RESULTS: In the feedback group the mean compression rate significantly improved in accuracy from 111.5+/-13.7/min to 100.1+/-3.2/min (P<0.01), and ventilation counts significantly improved in accuracy from 7.4+/-1.8/min to 9.9+/-0.3/min (P<0.01). However, the mean compression depth significantly decreased from 39.3+/-9.5 mm to 35.8+/-8.2 mm (P<0.01). THE CONCLUSION: Audio tone guidance ensures better chest compression rate and ventilation rate but this does not necessarily result in a better CPR quality.

A comparison of transoesophageal cardiac pacing and epinephrine for cardiopulmonary resuscitation.

The use of cardiac pacing to deal with bradycardia is well established. There is debate as to the benefits during cardiopulmonary resuscitation (CPR). This study was performed to compare the effects of transoesophageal cardiac pacing and high-dose epinephrine on the benefits of cardiopulmonary resuscitation after asphyxial cardiac arrest in rats. Thirty Sprague-Dawley rats of both sexes were randomly selected to a saline group (Sal-gro, treated with normal saline 1 mL IV, n = 10), an epinephrine group (Epi-gro, treated with epinephrine 0.4 mg/kg IV, n = 10), or a pacing group (Pac-gro, treated with normal saline 1 mL IV combined with transoesophageal cardiac pacing, n = 10) in a blinded fashion during resuscitation after 10 minutes of asphyxial cardiac arrest. Manual chest compression was in all cases performed using the same methodology by the same personnel who was blinded to hemodynamic monitor tracings. The rate of restoration of spontaneous circulation was 1 (10%), 7 (70%), and 8 (80%) of 10 in Sal-gro, Epi-gro, and Pac-gro, respectively. The rate of ventilator withdrawal within 60 minutes after resuscitation in Pac-gro was higher than that of Epi-gro (8/8 vs 1/7, respectively; P = .001); the survival rate after 2 hours in Pac-gro was significantly higher than that in Epi-gro (7/8 vs 1/7, respectively; P = .01). The data demonstrate that both epinephrine and transoesophageal cardiac pacing are effective within 10 minutes of asphyxia in rats. It is worth noting that transoesophageal cardiac pacing produced a better outcome with respiration and longer survival time compared with epinephrine after restoration of spontaneous circulation.

Treatment of out-of-hospital cardiac arrest with LUCAS, a new device for automatic mechanical compression and active decompression resuscitation.

Lund University Cardiopulmonary Assist System (LUCAS) is a new gas-driven CPR device providing automatic chest compression and active decompression. This is a report of the first 100 consecutive cases treated with LUCAS due to out-of-hospital cardiac arrest (58% asystole, 42% ventricular fibrillation (VF)). Safety aspects were also investigated and it was found that LUCAS can be used safely regarding noise levels and oxygen concentrations within the ambulance. A crash test (10G) showed no displacement of the device from the manikin. Of the 71 patients with witnessed cardiac arrest, 39% received bystander CPR. In those 28 patients where LUCAS-CPR was initiated more than 15 min after the ambulance alarm and in the 29 unwitnessed cases, none survived for 30 days. Of the 43 witnessed cases treated with LUCAS within 15 min, 24 had VF and 15 (63%) of these cases achieved a stable return of spontaneous circulation (ROSC) and 6 (25%) of them survived with a good neurological recovery after 30 days; 5 (26%) of the 19 patients with asystole achieved ROSC and 1 (5%) survived for over 30 days. One patient where ROSC could not be achieved was transported with on-going LUCAS-CPR to the catheter laboratory and after PCI for an occluded LAD a stable ROSC occurred, but the patient never regained consciousness and died 15 days later. To conclude, establishment of an adequate cerebral circulation as quickly as possible after cardiac arrest is mandatory for a good outcome. In this report patients with a witnessed cardiac arrest receiving LUCAS-CPR within 15 min from the ambulance call had a 30-day survival of 25% in VF and 5% in asystole, but if the interval was more than 15 min, there were no 30-day survivors.

Use of the infant transwarmer mattress as an external warming modality in resuscitation from hypothermia.

Normothermia must be established in drowning victims before death may be declared, as the myocardium may remain resistant to stimulation at subnormal temperatures, and complete neurological recovery from submersion associated hypothermia has been reported. A safe and effective method of external re-warming is described that may prove particularly useful in the paediatric population.

Feasibility and effects of transcutaneous phrenic nerve stimulation combined with an inspiratory impedance threshold in a pig model of hemorrhagic shock.

OBJECTIVE: Intrathoracic pressure changes are of particular importance under hypovolemic conditions, especially when central venous blood pressure is critically low. Accordingly, the purpose of this study was to assess the feasibility of transcutaneous phrenic nerve stimulation, used in conjunction with an inspiratory impedance threshold, on hemodynamic variables during hemorrhagic shock. DESIGN: Prospective, randomized laboratory investigation using a porcine model for measurement of hemodynamic variables, left and right ventricular diameter, and transmitral, transpulmonary, and transaortic blood flow employing transesophageal echo-Doppler technique. SETTING: University hospital laboratory. SUBJECTS: Thirteen female pigs weighing 28-36 kg. INTERVENTIONS: The anesthetized pigs were subjected to profound hemorrhagic shock by withdrawal of 55% of estimated blood volume over 20 mins. After a 10-min recovery period, the diaphragm was stimulated with a prototype transcutaneous phrenic nerve stimulator at a rate of ten per minute while the airway was intermittently occluded with an inspiratory threshold valve between positive pressure ventilations. Hemodynamic variables were monitored for 30 mins. MEASUREMENTS AND MAIN RESULTS: Phrenic nerve stimulation in combination with the inspiratory threshold valve significantly (p <.001) improved right and left ventricular diameter compared with hypovolemic shock values by 34 +/- 2.5% and 20 +/- 2.5%, respectively. Moreover, phrenic nerve stimulation together with the inspiratory threshold valve also increased transaortic, transpulmonary, and transmitral valve blood flow by 48 +/- 6.6%, 67 +/- 13.3, and 43 +/- 8.2%, respectively (p <.001 for comparisons within group). Mean +/- sem coronary perfusion and systolic aortic blood pressures were also significantly (p <.001) higher compared with values before stimulation (30 +/- 2 vs. 20 +/- 2 mm Hg, and 37 +/- 2 vs. 32 +/- 3 mm Hg, respectively). CONCLUSIONS: This feasibility study suggests that phrenic nerve stimulation with the inspiratory threshold valve may improve cardiac preload and, subsequently, key hemodynamic variables in porcine model of severe hemorrhagic shock.