Utility of pre-cordial thump for treatment of out of hospital cardiac arrest: a prospective study.

BACKGROUND: Prospective data on pre-cordial thump (PT), one of the fastest possible resuscitative manoeuvres, are scant, particularly in out-of-hospital (OOH) cardiac arrest (CA). METHODS: In this study, conducted in the Pordenone-province (north-east Italy), suspected OOH-CA victims were connected to a cardiac monitor and, upon confirmation of CA, subjected to a swift PT before any other resuscitatory intervention, without notable delay in other procedures. Investigation targets were: (i) effects on heart rhythm, (ii) return of spontaneous circulation (ROSC), (iii) hospital discharge, (iv) presence of adverse effects. Outcomes were additionally grouped by presenting rhythms into ventricular tachyarrhythmias (CA(VF/VT)), pulseless electrical activity (CA(PEA)), and asystole (CA(AS)). RESULTS: Out of 144 OOH-CA cases, PT had no effect on heart rhythm in 138 patients (CA(VF/VT)-23/24; CA(PEA)-41/42; CA(AS)-74/78). In 112 of the 138 non-responders, ROSC was neither achieved by other interventions (CA(VF/VT)-13/23; CA(PEA)-38/41; CA(AS)-61/74); overall survival was 5.6% (CA(VF/VT)-16.7%; CA(PEA)-0%; CA(AS)-5.1%). PT caused ROSC in 3 patients with witnessed CA(AS) (time-to-intervention <3 min), representing one quarter of ROSC among witnessed CA victims. Survival of PT-induced ROSC patients (2/3) was certainly no worse than among PT-irresponsive ROSC patients (6 of 28). Overall, one quarter of patients, discharged from hospital, had been resuscitated by PT. No adverse effects of PT were observed. CONCLUSIONS: PT can be combined with standard resuscitatory interventions without significant time-delay or apparent side effects. PT efficacy in CA(VF/VT) and CA(PEA) is lacking. However, PT may offer potential for the increasing proportion of asystolic OOH-CA, in particular when witnessed.

Out-of-hospital cardiac arrest (OHCA) Survey in Lombardy: data analysis through prospective short time period assessment.

BACKGROUND AND AIM OF THE WORK: The results of out-of-hospital cardiac arrests (OHCA) are usually reported through data collected collected via "ad hoc"  registries, but in large populations, samples of short time periods can be used to apply the results to the entire population. We would like to describe the situation of Lombardy to provide evidence on successful procedures, which may be carried out in a larger context. METHODS: Observational, prospective, analytical, single cohort study in Lombardy population. Data of OHCA of cardiac aetiology, according to "Utstein Style", with resuscitation attempts started by the Emergency Medical Service (EMS), were collected for 40 days subdivided in 10-day-periods in all seasons 2014-15 via Operating System "Emergency Management" (EmMa). RESULTS: Of 1219 cases, 536 events of witnessed OHCA of presumed cardiac etiology were analyzed. Outcomes were: sustained Return Of Spontaneous Circulation ROSC (25.6%), Survival Event in Emergency Department (22.8%), Survival after 24 hours (21.2%) and Survival after hospital discharge at home 30 days after (11.2%). Statistically significant results were found in age, rhythm of presentation, and resuscitation by bystanders. Sex, seasonality and rescue timing did not differ statistically. CONCLUSIONS: Overall the thirty-day survival rate was similar to studies with larger databases. Our data are consistent with the concept that all emergency service should provide CPR instructions for every citizen who activate the EMS in the suspect of a SCA; further investigation should clarify how long interval could be useful for ROSC and sustained ROSC in patients resuscitated by lay people using CPR instructions.

Increased survival despite a reduction in out-of-hospital ventricular fibrillation in north-east Italy.

BACKGROUND: We have reported the epidemiology and survival rate of out-of-hospital cardiac arrest (OOH-CA) in a north-east region of Italy previously, the Friuli-Venezia-Giulia Arrest Cooperative Study (FACS). We present the results of a second observational, prospective, multicentre study on OOH-CA victims in a local area in the same geographical Italian region. METHODS AND RESULTS: The area investigated, Pordenone province, is representative of the entire region studied in 1994. In the 1994 FACS study, the heterogeneous ambulance personnel, ranging from volunteers to registered nurses and physicians, were not all trained in basic life support and early defibrillation. In 2003 all rescuers had advanced cardiac life support (ACLS) skills. Moreover, in 2003 dispatch-guided CPR was used. The time from dispatch to defibrillation of victims of OOH-CA from cardiac aetiology was comparable between 1994 and 2003. However, the rate of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) as presenting rhythm decreased significantly between 1994 and 2003 from 30.2% to 20.1% (p < 0.05). Despite this, survival to hospital discharge for VF/VT almost tripled (15.4% versus 41.0%; p < 0.05). Hospital discharge for asystole or pulseless electrical activity remained dismal (3.1% and 1.7%). CONCLUSIONS: Despite a reduction in the rate of VF/VT as presenting rhythm, survival was almost tripled. Manning all ambulances with professional emergency medical personnel and ACLS training together with dispatch-guided CPR may have contributed to the improvements observed in survival rates.

The use of laryngeal tube by nurses in out-of-hospital emergencies: preliminary experience.

In out-of-hospital emergencies, including cardiac arrest, securing the airway and providing adequate lung ventilation are of paramount importance. Tracheal intubation is perceived as the gold standard technique and it is recommended by International Guidelines, but non skilled personnel often find the procedure difficult to achieve. Supraglottic devices are a good alternative in these situations, because they are superior to a bag-valve-mask for lung ventilation and offer better protection from aspiration. We have tested the laryngeal tube (LT) in out-of-hospital emergencies by minimally trained nurses. The LT was placed in 30 patients in cardiac arrest. LT insertion was successful within two attempts in 90% of patients, and ventilation was adequate in 80% of cases. No regurgitation occurred in any patient. The laryngeal tube remained in the correct position throughout resuscitation attempts in 93.3% of cases, while in two patients (6.6%) it became dislodged. In a subjective evaluation of the manoeuvre by nurses (ease of insertion, adequacy of ventilation, protection from aspiration), 86.7% of them expressed a positive opinion. The laryngeal tube appeared to be a reliable device for nurses to manage the airway in out-of-hospital emergencies.

Isolated myocardial contusion in blunt chest trauma.

The objective of this case report was to document a rare case of isolated myocardial contusion in the setting of blunt thoracic trauma. Although demonstrated by electrocardiogram and myocardium-specific enzymes, the trauma had no clinical relevance and the patient was discharged uneventfully from the intensive care unit. The clinical significance of blunt myocardial contusion is then discussed.

Out-of-Hospital Perimortem Cesarean Section as Resuscitative Hysterotomy in Maternal Posttraumatic Cardiac Arrest.

The optimal treatment of a severe hemodynamic instability from shock to cardiac arrest in late term pregnant women is subject to ongoing studies. However, there is an increasing evidence that early "separation" between the mother and the foetus may increase the restoration of the hemodynamic status and, in the cardiac arrest setting, it may raise the likelihood of a return of spontaneous circulation (ROSC) in the mother. This treatment, called Perimortem Cesarean Section (PMCS), is now termed as Resuscitative Hysterotomy (RH) to better address the issue of an early Cesarean section (C-section). This strategy is in contrast with the traditional treatment of cardiac arrest characterized by the maintenance of cardiopulmonary resuscitation (CPR) maneuvers without any emergent surgical intervention. We report the case of a prehospital perimortem delivery by Caesarean (C) section of a foetus at 36 weeks of gestation after the mother's traumatic cardiac arrest. Despite the negative outcome of the mother, the choice of performing a RH seems to represent up to date the most appropriate intervention to improve the outcome in both mother and foetus.

Calcium administration during cardiac arrest: a systematic review.

This topic highlights the results of the literature review on calcium therapy during cardiac arrest and cardiopulmonary resuscitation according to the Patient/population, Intervention, Comparator, Outcome structure. Eligible studies were assigned to one of the five levels of evidence. Their quality was rated as either good, fair, or poor and then classified as supportive, neutral, or opposing according to the outcome benefits. Among the 48 articles retrieved, 10 articles fulfilled all the criteria for analysis for the Guidelines preparation. There is no evidence that the administration of calcium during cardiopulmonary resuscitation improves survival from cardiac arrest irrespective of the presenting rhythm. In the setting of hyperkalemia, calcium channel blocker intoxication, hypocalcemia, and hypermagnesemia, the role of calcium remains unclear because of the limited amount of evidence. The main limitation is the scarcity of data, most of which relate to anoxic cardiac arrest, accounting for no more than 25% of the causes of cardiac arrest in humans.

Electrical features of eighteen automated external defibrillators: a systematic evaluation.

AIM: Assessment and comparison of the electrical parameters (energy, current, first and second phase waveform duration) among eighteen AEDs. METHOD: Engineering bench tests for a descriptive systematic evaluation in commercially available AEDs. AEDs were tested through an ECG simulator, an impedance simulator, an oscilloscope and a measuring device detecting energy delivered, peak and average current, and duration of first and second phase of the biphasic waveforms. All tests were performed at the engineering facility of the Lombardia Regional Emergency Service (AREU). RESULTS: Large variations in the energy delivered at the first shock were observed. The trend of current highlighted a progressive decline concurrent with the increases of impedance. First and second phase duration varied substantially among the AEDs using the exponential biphasic waveform, unlike rectilinear waveform AEDs in which phase duration remained relatively constant. CONCLUSIONS: There is a large variability in the electrical features of the AEDs tested. Energy is likely not to be the best indicator for strength dose selection. Current and shock duration should be both considered when approaching the technical features of AEDs. These findings may prompt further investigations to define the optimal current and duration of the shock waves to increase the success rate in the clinical setting.