Automatic chest compression devices--when do they make sense?

The current resuscitation guidelines of the European Resuscitation Council do not include automatic chest compression devices (ACDs) as standard equipment to support cardiopulmonary resuscitation attempts. One possible reason could be the lack of a list of indications and contraindications for the use of ACD systems. This review should give a summary of current studies and developments according to ACD systems and deliver a list of possible applications. Furthermore, we discuss some ethical problems with cardiopulmonary resuscitation attempts and, in particular, with ACD systems. The use of ACDs occurs instead of manual chest compression. Because of this, there is no reason for changing the current guidelines, especially termination recommendations while using ACD systems. From our point of view, ACDs are a very good supplement to the current standard of resuscitation according to the European Resuscitation Council guidelines.

Cardiopulmonary resuscitation guidance improves medical students' adherence to guidelines in simulated cardiac arrest: a randomised cross-over study.

BACKGROUND: The 2010 Resuscitation Guidelines require high-quality chest compression and rapid defibrillation for patients with ventricular fibrillation with rhythm analysis and defibrillation repeated every 2 min. A lack of adherence to the guidelines by medical students was observed during simulated resuscitation training. OBJECTIVES: To assess whether real-time cardiopulmonary resuscitation guidance, including an audiovisual countdown timer, a metronome, a display of the chest compression quality and voice prompts, might improve adherence to the guidelines by medical students. DESIGN: Randomised cross-over simulation study. SETTING: Studienhospital Münster, Faculty of Medicine University Münster, Germany PARTICIPANTS: One hundred and forty-one medical students (fifth year) in 47 teams. INTERVENTION: Simulated resuscitation with and without real-time cardiopulmonary resuscitation guidance. MAIN OUTCOME MEASURES: The preshock pause, postshock pause, fraction of time without chest compression and defibrillation intervals. Observed quality parameters were chest compression depth and chest compression rate. RESULTS: With real-time cardiopulmonary resuscitation guidance, there were improved mean (SD) chest compression rates (105 ±â€Š8 vs. 121 ±â€Š12 bpm; P < 0.005), fewer inappropriate shock intervals [median (interquartile range) 0 (1 to 5) vs. 4 (1 to 7); P < 0.005], a smaller fraction of time without chest compression (18.9 ±â€Š4.4 vs. 22.5 ±â€Š7.0%; P < 0.005) and shorter postshock pauses (2.3 ±â€Š0.9 vs. 3.4 ±â€Š1.2 s; P < 0.005). CONCLUSION: Real-time cardiopulmonary resuscitation guidance significantly increased adherence to the guidelines by medical students treating simulated out-of-hospital cardiac arrest. Using a simple tool such as a countdown timer makes it possible to reduce the number of inappropriate shock intervals and time without chest compression.

Primary trigeminal afferents are the main source for stimulus-induced CGRP release into jugular vein blood and CSF.

BACKGROUND: Administration of inflammatory soup (IS) leads to a significant release of calcitonin gene-related peptide (CGRP). Whether IS-induced CGRP release originates in primary or secondary neurons of the trigeminovascular system has not been clarified. METHODS: We determined CGRP release into the external jugular vein and in cerebrospinal fluid (CSF) following intracisternal IS administration using an in vivo rat model. We further performed polymerase chain reaction (PCR) and immunohistochemistry of the trigeminal ganglion and brainstem (trigeminal nucleus caudalis). To further elucidate a primary vs. secondary origin, experiments were repeated after neonatal capsaicin treatment (NCT) as this treatment destroys primary trigeminal afferents. RESULTS: IS-induced CGRP release into the external jugular vein and CSF were significantly reduced after NCT in both compartments but inhibition was more pronounced in jugular vein blood than in CSF. Baseline CGRP levels were not affected by NCT. PCR results show that following NCT, CGRP mRNA was significantly reduced in the trigeminal ganglion but not in the brainstem. Immunohistochemistry of the TG and brainstem support these results. CONCLUSIONS: We conclude that resting state CGRP levels can be maintained after trigeminal denervation of the meninges. However, for functional purposes primary trigeminal afferents are mandatory as they are the major source for stimulus-induced CGRP release.

Risk adapted dose-intensified postoperative radiation therapy in prostate cancer patients using a simultaneous integrated boost technique applied with helical Tomotherapy.

BACKGROUND: Postoperative adjuvant radiation therapy (ART) in T3 and R1 prostate cancer as well as salvage radiation therapy (SRT) in case of postoperative biochemical failure (BF) are established treatments. Dose-intensified postoperative radiation therapy (RT) schemes have shown superior biochemical control accompanied by increased toxicity rates. In our study we evaluate a novel risk adapted dose-intensified postoperative RT scheme. METHODS: A consecutive series of prostate cancer patients receiving postoperative RT after radical prostatectomy using helical Tomotherapy between 04/2012 and 04/2015 was analyzed retrospectively. RT was administered using a simultaneous integrated boost (SIB) to the area at risk (37 fractions of 1.9 Gy, total dose: 70.3 Gy) being defined based on histopathological findings (T3/R1 region) and in few cases according to additional diagnostic imaging. The whole prostate bed was treated with a dose of 66.6 Gy (37 fractions of 1.8 Gy). Primary endpoints were acute and late genitourinary (GU) and gastrointestinal (GI) toxicities. Secondary endpoints included patient reported outcome as assessed by the International Prostate Symptom Score (IPSS), the International Consultation on Incontinence questionnaire (ICIQ) and prostate cancer specific Quality of Life questionnaire QLQ-PR25, as well as rates of BF. RESULTS: A total of 69 patients were analyzed. Sixteen patients underwent ART and 53 patients SRT, respectively. The median follow-up was 20 months (range, 8-41 months). Seven (10.1%) and four (5.8%) patients experienced acute grade 2 GU and GI toxicity. Two patients (2.9%) had late grade 2 GU toxicity, whereas no late grade 2 GI nor any grade 3 acute or late GU or GI events were observed. When compared to the baseline IPSS scores (p = 1.0) and ICIQ scores (p = 0.87) were not significantly different at the end of follow-up. Patient reported Quality of life (QoL) showed also no significant difference. A total of seven patients (10.1%) experienced a biochemical recurrence with the 2-year biochemical progression-free survival (bPFS) being 91%. CONCLUSIONS: Postoperative RT for prostate cancer patients with a risk adapted dose-intensified SIB using helical tomotherapy is feasible and associated with favorable acute and late GU and GI toxicity rates, no significant change of IPSS-, ICIQ scores and patient reported QoL and results in promising bPFS rates.

Role of Dose Intensification for Salvage Radiation Therapy after Radical Prostatectomy.

For primary radiation therapy (RT) of prostate cancer, dose intensification is established as standard of care. Less is known on the role of dose intensification in the postprostatectomy setting for salvage RT. Thus, we aimed to identify and summarize the existing literature. In retrospective analyses, dose-intensified salvage RT showed a superior biochemical control compared to standard dose salvage radiation with favorable acute and late gastrointestinal and genitourinary toxicity rates, especially when modern radiation techniques such as intensity modulated RT were applied. We identified one randomized phase III trial addressing the potential benefits of dose-intensified salvage RT (SAKK 09/10). Recently, acute gastrointestinal and genitourinary toxicities and early quality of life data of this trial were reported, and no significant difference in acute toxicities between both treatment arms were found; however, a significant worsening of genitourinary quality of life was noted in the dose-intensified treatment arm. Whereas dose-intensified salvage RT appears to be feasible and well tolerated, the improved biochemical control rates using dose intensified RT as suggested by retrospective analyses have yet to be validated by prospective trials.

The addition of voice prompts to audiovisual feedback and debriefing does not modify CPR quality or outcomes in out of hospital cardiac arrest--a prospective, randomized trial.

AIMS: Chest compression quality is a determinant of survival from out-of-hospital cardiac arrest (OHCA). ERC 2005 guidelines recommend the use of technical devices to support rescuers giving compressions. This prospective randomized study reviewed influence of different feedback configurations on survival and compression quality. MATERIALS AND METHODS: 312 patients suffering an OHCA were randomly allocated to two different feedback configurations. In the limited feedback group a metronome and visual feedback was used. In the extended feedback group voice prompts were added. A training program was completed prior to implementation, performance debriefing was conducted throughout the study. RESULTS: Survival did not differ between the extended and limited feedback groups (47.8% vs 43.9%, p = 0.49). Average compression depth (mean ± SD: 4.74 ± 0.86 cm vs 4.84 ± 0.93 cm, p = 0.31) was similar in both groups. There were no differences in compression rate (103 ± 7 vs 102 ± 5 min(-1), p=0.74) or hands-off fraction (16.16% ± 0.07 to 17.04% ± 0.07, p = 0.38). Bystander CPR, public arrest location, presenting rhythm and chest compression depth were predictors of short term survival (ROSC to ED). CONCLUSIONS: Even limited CPR-feedback combined with training and ongoing debriefing leads to high chest compression quality. Bystander CPR, location, rhythm and chest compression depth are determinants of survival from out of hospital cardiac arrest. Addition of voice prompts does neither modify CPR quality nor outcome in OHCA. CC depth significantly influences survival and therefore more focus should be put on correct delivery. Further studies are needed to examine the best configuration of feedback to improve CPR quality and survival. REGISTRATION: ClinicalTrials.gov (NCT00449969), http://www.clinicalTrials.gov.