Standard cardiopulmonary resuscitation versus chest compressions only after out-of-hospital cardiac arrest: a protocol for a systematic review and meta-analysis.

INTRODUCTION: The 2020 American Heart Association guidelines encourage lay rescuers to provide chest compression-only cardiopulmonary resuscitation to simplify the process and encourage cardiopulmonary resuscitation initiation. However, recent clinical trials had contradictory results about chest compression-only cardiopulmonary resuscitation. This study will aim to compare standard and chest compressions-only cardiopulmonary resuscitation after out-of-hospital cardiac arrest. METHODS AND ANALYSIS: This study will retrieve only randomised and quasi-randomised controlled trials from the Cochrane Library, PubMed, Web of Science and Embase databases. Data on study design, participant characteristics, intervention details and outcomes will be extracted by a unified standard form. Primary outcomes to be assessed are hospital admission, discharge, and 30-day survival, and return of spontaneous circulation. The Grading of Recommendations, Assessment, Development and Evaluation framework will evaluate the quality of evidence. Cochrane's tool for assessing the risk of bias will evaluate risk deviation. If the I2 statistic is lower than 40%, the fixed-effects model will be used for meta-analysis. Otherwise, the random-effects model will be used. The search will be performed following the publication of this protocol (estimated to occur on 30 December 2024). DISCUSSION: This study will evaluate the effect of chest compression-only cardiopulmonary resuscitation after out-of-hospital cardiac arrest and provide evidence for cardiopulmonary resuscitation guidelines. ETHICS AND DISSEMINATION: No patient or public entity will be involved in this study. Therefore, the study does not need to be ethically reviewed. The results of the study will be disseminated through peer-reviewed journal publications and committee conferences. PROSPERO REGISTRATION NUMBER: CRD42021295507.

Impacts of chest compression cycle length and real-time feedback with a CPRmeter® on chest compression quality in out-of-hospital cardiac arrest: study protocol for a multicenter randomized controlled factorial plan trial.

BACKGROUND: With a survival rate of 6 to 11%, out-of-hospital cardiac arrest (OHCA) remains a healthcare challenge with room for improvement in morbidity and mortality. The guidelines emphasize the highest possible quality of cardiopulmonary resuscitation (CPR) and chest compressions (CC). It is essential to minimize CC interruptions, and therefore increase the chest compression fraction (CCF), as this is an independent factor for survival. Survival is significantly and positively correlated with the suitability of CCF targets, CC frequency, CC depth, and brief predefibrillation pause. CC guidance improves adherence to recommendations and allows closer alignment with the CC objectives. The possibility of improving CCF by lengthening the time between two CC relays and the effect of real-time feedback on the quality of the CC must be investigated. METHODS: Using a 2 × 2 factorial design in a multicenter randomized trial, two hypotheses will be tested simultaneously: (i) a 4-min relay rhythm improves the CCF (reducing the no-flow time) compared to the currently recommended 2-min relay rate, and (ii) a guiding tool improves the quality of CC. Primary outcomes (i) CCF and (ii) correct compression score will be recorded by a real-time feedback device. Five hundred adult nontraumatic OHCAs will be included over 2 years. Patients will be randomized in a 1:1:1:1 distribution receiving advanced CPR as follows: 2-min blind, 2 min with guidance, 4-min blind, or 4 min with guidance. Secondary outcomes are the depth, frequency, and release of CC; length (care, no-flow, and low-flow); rate of return of spontaneous circulation; characteristics of advanced CPR; survival at hospital admission; survival and neurological state on days 1 and 30 (or intensive care discharge); and dosage of neuron-specific enolase on days 1 and 3. DISCUSSION: This study will contribute to assessing the impact of real-time feedback on CC quality in practical conditions of OHCA resuscitation. It will also provide insight into the feasibility of extending the relay rhythm between two rescuers from the currently recommended 2 to 4 min. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03817892 . Registered on 28 January 2019.

Real-time feedback improves chest compression quality in out-of-hospital cardiac arrest: A prospective cohort study.

BACKGROUND: Current guidelines underline the importance of high-quality chest compression during cardiopulmonary resuscitation (CPR), to improve outcomes. Contrary to this many studies show that chest compression is often carried out poorly in clinical practice, and long interruptions in compression are observed. This prospective cohort study aimed to analyse whether chest compression quality changes when a real-time feedback system is used to provide simultaneous audiovisual feedback on chest compression quality. For this purpose, pauses in compression, compression frequency and compression depth were compared. METHODS: The study included 292 out-of-hospital cardiac arrests in three consecutive study groups: first group, conventional resuscitation (no-sensor CPR); second group, using a feedback sensor to collect compression depth data without real-time feedback (sensor-only CPR); and third group, with real-time feedback on compression quality (sensor-feedback CPR). Pauses and frequency were analysed using compression artefacts on electrocardiography, and compression depth was measured using the feedback sensor. With this data, various parameters were determined in order to be able to compare the chest compression quality between the three consecutive groups. RESULTS: The compression fraction increased with sensor-only CPR (group 2) in comparison with no-sensor CPR (group 1) (80.1% vs. 87.49%; P < 0.001), but there were no further differences belonging compression fraction after activation of sensor-feedback CPR (group 3) (P = 1.00). Compression frequency declined over the three study groups, reaching the guideline recommendations (127.81 comp/min vs. 122.96 comp/min, P = 0.02 vs. 119.15 comp/min, P = 0.008) after activation of sensor-feedback CPR (group 3). Mean compression depth only changed minimally with sensor-feedback (52.49 mm vs. 54.66 mm; P = 0.16), but the fraction of compressions with sufficient depth (at least 5 cm) and compressions within the recommended 5-6 cm increased significantly with sensor-feedback CPR (56.90% vs. 71.03%; P = 0.003 and 28.74% vs. 43.97%; P < 0.001). CONCLUSIONS: The real-time feedback system improved chest compression quality regarding pauses in compression and compression frequency and facilitated compliance with the guideline recommendations. Compression depth did not change significantly after activation of the real-time feedback. Even the sole use of a CPR-feedback-sensor ("sensor-only CPR") improved performance regarding pauses in compression and compression frequency, a phenomenon known as the 'Hawthorne effect'. Based on this data real-time feedback systems can be expected to raise the quality level in some parts of chest compression quality. TRIAL REGISTRATION: International Clinical Trials Registry Platform of the World Health Organisation and German Register of Clinical Trials (DRKS00009903), Registered 09 February 2016 (retrospectively registered).

Physiological demands of quality cardiopulmonary resuscitation performed at simulated 3250 meters high.

AIM: To analyse the effect of oxygen fraction reduction (O2 14%, equivalent to 3250 m) on Q-CPR and rescuers' physiological demands. METHODOLOGY: A quasi-experimental study was carried out in a sample of 9 Q-CPR proficient health care professionals. Participants, in teams of 2 people, performed 10 min CPR on a Laerdal ResusciAnne mannequin (30:2 compression/ventilation ratio and alternating roles between rescuers every 2 min) in two simulated settings: T21-CPR at sea level (FiO2 of 21%) and T14 - CPR at 3250 m altitude (FiO2 of 14%). Effort self-perception was rated from 0 (no effort) to 10 (maximum demand) points. RESULTS: Quality of chest compressions was good and similar in both conditions (T21 vs T14). However, the percentage of ventilations with adequate tidal volume was lower in altitude than at sea level conditions (35.9 ± 25.2% vs. 54.7 ± 23.2%, p = 0.035). The subjective perception of effort was significantly higher at simulated altitude (5 ± 2) than at sea level (3 ± 2) (p = 0.038). Maximum heart rate during the tests was similar in both conditions; however, mean oxygen saturation was significantly lower in altitude conditions (90.5 ± 2.5% vs. 99.3 ± 0.5%, p < 0.001). CONCLUSION: Although performing CPR under simulated hypoxic altitude conditions significantly increases the physiological demands and subjective feeling of tiredness compared to sea level CPR, trained rescuers are able to deliver good Q-CPR in such conditions, at least in the first 10 min of resuscitation.

Chest compression components (rate, depth, chest wall recoil and leaning): A scoping review.

AIM: To understand whether the science to date has focused on single or multiple chest compression components and identify the evidence related to chest compression components to determine the need for a full systematic review. METHODS: This review was undertaken by members of the International Liaison Committee on Resuscitation and guided by a specific methodological framework and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). Studies were eligible for inclusion if they were peer-reviewed human studies that examined the effect of different chest compression depths or rates, or chest wall or leaning, on physiological or clinical outcomes. The databases searched were MEDLINE complete, Embase, and Cochrane. RESULTS: Twenty-two clinical studies were included in this review: five observational studies involving 879 patients examined both chest compression rate and depth; eight studies involving 14,285 patients examined chest compression rate only; seven studies involving 12001 patients examined chest compression depth only, and two studies involving 1848 patients examined chest wall recoil. No studies were identified that examined chest wall leaning. Three studies reported an inverse relationship between chest compression rate and depth. CONCLUSION: This scoping review did not identify sufficient new evidence that would justify conducting new systematic reviews or reconsideration of current resuscitation guidelines. This scoping review does highlight significant gaps in the research evidence related to chest compression components, namely a lack of high-level evidence, paucity of studies of in-hospital cardiac arrest, and failure to account for the possibility of interactions between chest compression components.

Evaluation of the thoracic compression technique using APPs. Do they help or hinder cardiopulmonary resuscitation? / Evaluación sobre la técnica de compresiones torácicas usando APP. ¿Ayudan o entorpecen la reanimación cardiopulmonar?

OBJECTIVE: To evaluate the quality of cardiopulmonary resuscitation (CPR) by lay people when guided by a mobile phone application with real-time feedback, with the comparison of three different mobile phone applications (APPs). DESIGN: A cross-sectional quasi-experimental study was carried out. PARTICIPANTS: A sample of 113 nursing students participated in the study. INTERVENTIONS: Three hands-only CPR tests with continuous compressions were performed: (i)without external help; (ii)with the mobile phone turned off; and (iii)guided by APP. Three different APPs were randomly assigned (Pocket CPR®, CPR Pro®> and Massage cardiaque et DSA®). The mannequin Laerdal Resusci Anne QCPR (Stavanger, Norway) 2.0.0.14 software was used. VARIABLES OF PRIMARY INTEREST: APPs used. Demographic variables characterizing the study sample. INDEPENDENT VARIABLES: mean depth, mean rate, percentage of correct hand positioning, percentage of compressions with correct re-expansion, percentage of compressions with correct depth, percentage of compressions at the correct rate, and overall quality of CPR. RESULTS: Overall CPR quality was 33.3% ± 32.7 using Pocket CPR, 10.9% ± 22.72% using CPR Pro and 7.8% ± 9.2 using Massage cardiaque et DSA. None of the APPs produced a statistically significant improvement. The percentage of time that the resuscitator managed to maintain a correct compression rate improved when using all three APPs. CONCLUSIONS: Cardiopulmonary resuscitation guided by phone APPs did not improve the overall quality of compressions during resuscitation, though it improved the percentage of compressions performed at the correct rate.

Pediatric in-hospital CPR quality at night and on weekends.

INTRODUCTION: Survival after in-hospital cardiac arrest (IHCA) has been reported to be worse for arrests at night or during weekends.This study aimed to determine whether measured cardiopulmonary resuscitation (CPR) quality metrics might explain this difference in outcomes. METHODS: IHCA data was collected by the Pediatric Resuscitation Quality (pediRES-Q) collaborative for patients <18 years. Metrics of CPR quality [chest compression rate, depth and fraction] were measured using monitordefibrillator pads, and events were compared by time of day and day of week. RESULTS: We evaluated 6915 sixty-second epochs of chest compression (CC) data from 239 subjects between October 2015 and March 2019, across 18 hospitals. There was no significant difference in CPR quality metrics during day (07:00-22:59) versus night (23:00-06:59), or weekdays (Monday 07:00 to Friday 22:59) versus weekends (Friday 23:00 to Monday 06:59).There was also no difference in rate of return of circulation. However, survival to hospital discharge was higher for arrests that occurred during the day (39.1%) vs. nights (22.4%, p = 0.015), as well as on weekdays (39.9%) vs. weekends (19.1%, p = 0.003). CONCLUSIONS: For pediatric IHCA where CC metrics were obtained, there was no significant difference in CPR quality metrics or rate of return of circulation by time of day or day of week. There was higher survival to hospital discharge when arrests occurred during the day (vs. nights), or on weekdays (vs. weekends), and this difference was not related to disparities in CC quality.

Comparison of standard and alternative methods for chest compressions in a single rescuer infant CPR: A prospective simulation study.

OBJECTIVE: The aims of this study were to develop a novel three-finger chest compression technique (pinch technique; PT) and an assistive device chest compression technique (plate-assisted technique; PAT) and compare these techniques with conventional techniques. DESIGN: Prospective, crossover manikin study. SETTING: Pediatric emergency department at a tertiary care academic center. SUBJECTS: Fifty medical doctors and medical students. INTERVENTIONS: Using a manikin, fifty participants performed five different chest compression techniques-two 2-finger techniques (TFT1 and TFT2), two PTs (PT1 and PT2), and the PAT-for 2 minutes with 2 minutes of rest in a randomized sequence. MEASUREMENTS AND MAIN RESULTS: The compression depth (CD), compression rate, recoil, and finger position were recorded. At the study conclusion, each participant completed a 5-point Likert scale-based questionnaire on fatigue, satisfaction and difficulty of performing each technique. The mean CDs were 32.9 mm (TFT1), 30.3 mm (TFT2), 37.3 mm (PT1), 35.0 mm (PT2) and 40.1 mm (PAT) (p<0.001). TFT2 achieved the highest frequency of complete chest recoil, followed by PT1 and TFT1 (88.9%, 86.9%, and 81.4%, respectively, p = 0.003). The highest percentage of correct finger position was achieved by the PAT, followed by the PT1 and PT2 (93.4%, 83.1%, and 80.1%, respectively, p = 0.016). PAT use resulted in higher participant satisfaction, less fatigue, and less difficulty than the other four techniques. CONCLUSION: Our new chest compression methods using three fingers and assistive plates showed better CD results than the conventional 2-finger technique.

Chest compression release velocity factors during out-of-hospital cardiac resuscitation.

BACKGROUND: Higher chest compression release velocity (CCRV) has been associated with better outcomes after out-of-hospital cardiac arrest (OHCA), and patient factors have been associated with variations in chest wall compliance and compressibility. We evaluated whether patient sex, age, weight, and time in resuscitation were associated with CCRV during pre-hospital resuscitation from OHCA. METHODS: Observational study of prospectively collected OHCA quality improvement data in two suburban EMS agencies in Arizona between 10/1/2008 and 12/31/2016. Subject-level mean CCRV during the first 10 min of compressions was correlated with categorical variables by the Wilcoxon rank-sum test and with continuous variables by the Spearman's rank correlation coefficient. Generalized estimating equation and linear mixed-effect models were used to study the trend of CCRV over time. RESULTS: During the study period, 2535 adult OHCA cases were treated. After exclusion criteria, 1140 cases remained for analysis. Median duration of recorded compressions was 8.70 min during the first 10 min of CPR. An overall decline in CCRV was observed even after adjusting for compression depth. The subject-level mean CCRV was higher for minutes 0-5 than for minutes 5-10 (mean 347.9 mm/s vs. 339.0 mm/s, 95% CI of the difference -12.4 to -5.4, p < 0.0001). Males exhibited a greater mean CCRV compared to females [344.4 mm/s (IQR 307.3-384.6) vs. 331.5 mm/s (IQR 285.3-385.5), p = 0.013]. Mean CCRV was negatively correlated with age and positively correlated with patient weight. CONCLUSION: CCRV declines significantly over the course of resuscitation. Patient characteristics including male sex, younger age, and increased weight were associated with a higher CCRV.

The thumbs angle used in the novel infant chest compression technique (new two-thumb technique, nTTT) can influence the quality parameters of resuscitation / El ángulo de pulgares que usa una nueva técnica de masaje cardíaco en lactantes (nTTT) puede influir en los parámetros de calidad de la reanimación

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Pauses in compressions during pediatric CPR: Opportunities for improving CPR quality.

OBJECTIVE: Minimizing pauses in chest compressions during cardiopulmonary resuscitation (CPR) is recommended by the American Heart Association (AHA) and is associated with improved patient outcomes. We studied the quality of pediatric CPR performed in a tertiary pediatric emergency department (ED) with a focus on pauses in chest compressions. METHODS: We conducted an observational study of CPR quality in two pediatric EDs using video review during pediatric cardiac arrest. Events were reviewed for AHA guideline adherence. Parameters of CPR performance were described according to individual compressor segment. Pauses in compressions were analyzed for duration and pause activities. RESULTS: From a 30-month period, 81 cardiac arrests were analyzed, including 1003 individual compressor segments and 900 pauses. Median chest compression fraction was 91%, with a median pause duration of 4 s (IQR 2, 10); 22% of pauses were prolonged (>10 s). Pulse checks occurred in 23% of pauses; 62% were prolonged. Checking a single pulse site (p < 0.001) and having fingers ready pre-pause (p = 0. 001) were associated with significantly shorter pause duration. Pause duration was correlated with the number of pause tasks (r = 0.559, p < 0.001). "Coordinated pauses" (pulse check, rhythm check and compressor change) were rare (6%) and long in duration (19 s; IQR 11, 30). CONCLUSIONS: Prolonged pauses in chest compressions occurred frequently during CPR and were associated with pulse checks and multiple simultaneous tasks. Checking a single pulse site with fingers ready on the pulse site pre-pause could decrease pause duration and improve CPR quality.

Two new chest compression methods might challenge the standard in a simulated infant model.

Paediatric cardiorespiratory arrest is a rare event that requires a fast, quality intervention. High-quality chest compressions are an essential prognostic factor. The aim of this prospective, randomized and crossover study in infant manikin 2-min cardiorespiratory resuscitation scenario is to quantitatively compare the quality of the currently recommended method in infants (two-thumb-encircling hand techniques) with two new methods (the new two-thumb and the knocking-fingers techniques) using a 15:2 compression-to-ventilation ratio. Ten qualified health professionals were recruited. Variables analysed were mean rate and the ratio of compressions in the recommended rate range, mean depth and the ratio of compressions within the depth range recommendations, ratio of compressions with adequate chest release and ratio of compressions performed with the fingers in the correct position. Ratios of correct compressions for depth, rate, chest release and hand position were always above 70% regardless of the technique used. Reached mean depth and mean rate were similar to the 3 techniques. No statistically significant differences were found in any of the variables analysed.Conclusion: In an infant manikin, professionals are able to perform chest compressions with the new techniques with similar quality to that obtained with the standard method. What is Known: • Quality chest compressions are an essential prognostic factor in paediatric cardiorespiratory arrest. • It has been reported poor results when studied cardiorespiratory resuscitation quality in infants applying the recommended methods. What is New: • In a simulated scenario, quality of chest compressions performed with two new techniques (nTTT and KF) is similar to that obtained with the currently recommended method (TTHT).

Association of chest compression and recoil velocities with depth and rate in manual cardiopulmonary resuscitation.

AIM: Maximum velocity during chest recoil has been proposed as a metric for chest compression quality during cardiopulmonary resuscitation (CPR). This study investigated the relationship of the maximum velocities during compression and recoil phases with compression depth and rate in manual CPR. METHODS: We measured compression instances in out-of-hospital cardiac arrest recordings using custom Matlab programs. Each compression cycle was characterized by depth and rate, maximum compression and recoil velocities (CV and RV), and compression and recoil durations (total and effective). Mean compression and recoil velocities were computed as depth divided by compression and recoil durations, respectively. We correlated CV and RV with their corresponding mean velocities (total and effective), characterized by Pearson's correlation coefficient. RESULTS: CV/RV were strongly correlated with their corresponding mean velocities, with a median r of 0.83 (0.77-0.88)/0.82 (0.76-0.87) in per patient analysis, 0.86/0.88 for all the population. Correlation with mean effective velocities had a median r of 0.91 (0.87-0.94)/0.92 (0.89-0.94) in per-patient, 0.92/0.94 globally (p < 0.001). Total and effective compression and recoil durations were inversely proportional to compression rate. We observed similar RV values among compressions regardless of whether they were compliant with recommended depth and rate. Conversely, we observed different RV values among compressions having the same depth and rate, but presenting very distinct compression waveforms. CONCLUSION: CV and RV were highly correlated with compression depth and compression and recoil times, respectively. Better understanding of the relationship between novel and current quality metrics could help with the interpretation of CPR quality studies.

The impact of resuscitation guideline terminology on quality of dispatcher-assisted cardiopulmonary resuscitation: A randomised controlled manikin study.

BACKGROUND: Cardiopulmonary resuscitation (CPR) guidelines vary in the terminology used to describe target chest compression depth, which may impact CPR quality. We investigated the impact of using different chest compression depth instruction terminologies on CPR quality. METHODS: We conducted a parallel group, three-arm, randomised controlled manikin trial in which individuals without recent CPR training were instructed to deliver compression-only CPR for 2-min based on a standardised dispatcher-assisted CPR script. Participants were randomised in a 1:1:1 ratio to receive CPR delivery instructions that instructed them to deliver chest compressions based on the following terminologies: 'press at least 5 cm', 'press approximately 5 cm' or 'press hard and fast.' The primary outcome was compression depth, measured in millimetres. RESULTS: Between October 2017 and June 2018, 330 participants were randomised to 'at least 5 cm' (n = 109), 'approximately 5 cm' (n = 110) and 'hard and fast' (n = 111), in which mean chest compression depth was 40.9 mm (SD 13.8), 35.4 mm (SD 14.1), and 46.8 mm (SD 15.0) respectively. Mean difference in chest compression depth between 'at least 5 cm' and 'approximately 5 cm' was 5.45 (95% confidence interval (95% CI) 0.78-10.12), between 'hard and fast' and 'approximately 5 cm' was 11.32 (95% CI 6.65-15.99), and between 'hard and fast' and 'at least 5 cm' was 5.87 (95% CI 1.21-10.53). Chest compression rate and count were both highest in the 'hard and fast' group. CONCLUSIONS: The use of 'hard and fast' terminology was superior to both 'at least 5 cm' and 'approximately 5 cm' terminologies. TRIAL REGISTRATION: ISRCTN15128211.

The TrueCPR device in the process of teaching cardiopulmonary resuscitation: A randomized simulation trial.

BACKGROUND: International resuscitation guidelines emphasize the importance of high quality chest compressions, including correct chest compression depth and rate and complete chest recoil. The aim of the study was to assess the role of the TrueCPR device in the process of teaching cardiopulmonary resuscitation in nursing students. METHODS: A prospective randomized experimental study was performed among 94 first year students of nursing. On the next day, the participants were divided into 2 groups-the control group practiced chest compressions without the use of any device for half an hour, and the experimental group practiced with the use of TrueCPR. Further measurement of chest compressions was performed after a month. RESULTS: The chest compression rate achieved the value of 113 versus 126 (P < .001), adequate chest compression rate (%) was 86 versus 68 (P < .001), full chest release (%) 92 versus 69 (P = .001), and correct hand placement (%) 99 versus 99 (P, not significant) in TrueCPR and standard BLS groups, respectively. As for the assessment of the confidence of chest compression quality, 1 month after the training, the evaluation in the experimental group was statistically significantly higher (91 vs 71; P < .001) than in the control group. CONCLUSIONS: Cardiopulmonary resuscitation training with the use of the TrueCPR device is associated with better resuscitation skills 1 month after the training. The participants using TrueCPR during the training achieved a better chest compression rate and depth with in international recommendations and better full chest release percentage and self-assessed confidence of chest compression quality comparing with standard cardiopulmonary resuscitation training.

Circumstances, outcome and quality of cardiopulmonary resuscitation by lifeboat crews.

BACKGROUND: Little is known regarding circumstances, outcomes and quality of cardiopulmonary resuscitation (CPR) and the use of automated external defibrillators (AEDs) performed by operational lifeboat crews. Our aim is to evaluate circumstances, outcomes and quality of CPR performed by the Royal Dutch Lifeboat Institution (KNRM) in out-of-hospital cardiac arrest (OHCA). METHODS: The internal KNRM database has been used to identify and analyse all OHCA cases between July 2011 and December 2017. A limited set of AED data was available to study the quality of CPR. RESULTS: In 37 patients the lifeboat crew members have performed CPR, of which 29 (78.4%) occurred under hostile conditions. The median response time to arrive at the location was 15min. In 11 (29.7%) patients return of spontaneous circulation was achieved at any moment during CPR and 3 (8.1%) patients were still alive after one month. The lifeboat AED was used in 12 patients. Their recordings show a high median compression frequency (120, IQR 111-131) and prolonged median interruption periods (pre-analysis pause 11s (IQR 10-13), post-analysis pause 4s (IQR 3-8), pre-shock pause 24s (IQR 19-26), post-shock pause 6s (IQR 6-11), ventilation pause 6s (IQR 4-8) and other pauses 9s (IQR 4-17)). CONCLUSIONS: Compared to most out-of-hospital resuscitations, resuscitations by lifeboat crews have a low incidence, occur under difficult circumstances and in a younger population. AED's on lifeboats have not contributed to any of the survivals. Analysis of AED information can be used to study the quality of CPR and provide input for improving future training of lifeboat crews.

The Efficacy of Chest Compressions in the Bell 407.

OBJECTIVE: The Air Medical industry is fraught with obstacles to patient care and providers can recognize that several sub-groups of patients can provide very challenging scenarios while in flight. However, the patient experiencing cardiac arrest in flight is, by its very nature, one that poses the most severe risk to the patient and provider. This study seeks to explore the capability of a highly trained emergency medical provider to provide adequate chest compressions while in a Bell 407 helicopter. METHODS: 59 participants were evaluated in two separate scenarios. Scenario A consisted of 2 rounds of of 200 chest compressions performed on a flat, uncrowded surface. Scenario B consisted of 200 chest compressions performed in the cabin of a Bell 407. Participants performed 2 rounds of 200 chest compressions. The results were then compared to each other and to the AHA 2010 CPR guidelines. RESULTS: The findings of the study show that compressions performed in the aircraft do not meet AHA guidelines for chest compressions in regard to depth and duration of compressions. The deviation from guideline in regard to rate was found to be not statistically significant. CONCLUSION: Chest compressions performed in a Bell 407 helicopter do not meet AHA guidelines.

Using a smartwatch with real-time feedback improves the delivery of high-quality cardiopulmonary resuscitation by healthcare professionals.

AIM: Cardiopulmonary resuscitation (CPR) quality affects survival after cardiac arrest. We aimed to investigate if a smartwatch with real-time feedback can improve CPR quality by healthcare professionals. METHODS: An app providing real-time audiovisual feedback was developed for a smartwatch. Emergency Department (ED) professionals were recruited and randomly allocated to either the intervention group wearing a smartwatch with the preinstalled app, or to a control group. All participants were asked to perform a two-minute CPR on a manikin at a 30:2 compression-ventilation ratio. Primary outcomes were the mean CCR and CCD measured on the manikin. A secondary outcome was the percentage of chest compressions meeting both the guideline-recommended rate (100-120 min-1) and depth (50-60 mm) of high-quality CPR during a 2-min period. Differences between groups were evaluated with t-test, Chi-Square test, or Mann-Whitney U test depending on the distribution. RESULTS: Eighty participants were recruited. 40 people were assigned to the intervention and 40 to the control group. The compression rates (mean ± SD, min-1) were significantly faster (but above the guideline recommendation, P < 0.001) in the control (129.1 ± 14.9) than in the intervention group (112.0 ± 3.5). The compression depths (mean ± SD, mm) were significantly deeper (P < 0.001) in the intervention (50.9 ± 6.6) than in the control group (39.0 ± 8.7). The percentage (%) of high-quality CPR was significantly higher (P < 0.001) in the intervention (median 39.4, IQR 27.1-50.1) than in the control group (median 0.0, IQR 0.0-0.0). CONCLUSION: Without real-time feedback, chest compressions tend to be too fast and too shallow. CPR quality can be improved with the assistance of a smartwatch providing real-time feedback.

Key components of a community response to out-of-hospital cardiac arrest.

Out-of-hospital cardiac arrest (OHCA) remains a leading cause of death worldwide, with substantial geographical, ethnic and socioeconomic disparities in outcome. Successful resuscitation efforts depend on the 'chain of survival', which includes immediate recognition of cardiac arrest and activation of the emergency response system, early bystander cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions, rapid defibrillation, basic and advanced emergency medical services and integrated post-cardiac arrest care. Well-orchestrated telecommunicator CPR programmes can improve rates of bystander CPR - a critical link in the chain of survival. High-performance CPR by emergency medical service providers includes minimizing interruptions in chest compressions and ensuring adequate depth of compressions. Developing local, regional and statewide systems with dedicated high-performing cardiac resuscitation centres for post-resuscitation care can substantially improve survival after OHCA. Innovative digital tools for recognizing cardiac arrest where and when it occurs, notifying potential citizen rescuers and providing automated external defibrillators at the scene hold the promise of improving survival after OHCA. Improved implementation of the chain of survival can save thousands of lives each year.

How much experience do rescuers require to achieve successful tracheal intubation during cardiopulmonary resuscitation?

AIM: The cardiopulmonary resuscitation (CPR) guidelines recommend that endotracheal intubation (ETI) should be performed only by highly skilled rescuers. However, the definition of 'highly skilled' is unclear. This study evaluated how much experience with ETI is required for rescuers to perform successful ETI quickly without complications including serious chest compression interruption (interruption time <10 s) or oesophageal intubation during CPR. METHODS: This was a clinical observation study using review of CPR video clips in an urban emergency department (ED) over 2 years. Accumulated ETI experience and performance of ETI were analysed. Main outcomes were 1) 'qualified ETI': successful ETI within 60 s without complications and 2) 'highly qualified ETI': successful ETI within 30 s without complications. RESULTS: We analysed 110 ETIs using direct laryngoscopy during CPR. The success rate improved and the time to successful ETI decreased with increasing experience; however, the total interruption time of chest compression did not decrease. A 90% success rate for qualified ETI required 137 experiences of ETIs (1218 days of training). A 90% success rate for highly qualified ETI required at least 243 experiences of ETIs (1973 days of training). CONCLUSIONS: Accumulated experience can improve the ETI success rate and time to successful ETI during CPR. Because ETI must be performed quickly without serious interruption of chest compression during CPR, becoming proficient at ETI requires more experience than that required for non-arrest patients. In our analysis, more than 240 experiences were required to achieve a 90% success rate of highly qualified ETI.