Andrea Scapigliati

Part 3: Adult Basic Life Support and Automated External Defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This review comprises the most extensive literature search and evidence evaluation to date on the most important international BLS interventions, diagnostics, and prognostic factors for cardiac arrest victims. It reemphasizes that the critical lifesaving steps of BLS are (1) prevention, (2) immediate recognition and activation of the emergency response system, (3) early high-quality CPR, and (4) rapid defibrillation for shockable rhythms. Highlights in prevention indicate the rational and judicious deployment of search-and-rescue operations in drowning victims and the importance of education on opioid-associated emergencies. Other 2015 highlights in recognition and activation include the critical role of dispatcher recognition and dispatch-assisted chest compressions, which has been demonstrated in multiple international jurisdictions with consistent improvements in cardiac arrest survival. Similar to the 2010 ILCOR BLS treatment recommendations, the importance of high quality was reemphasized across all measures of CPR quality: rate, depth, recoil, and minimal chest compression pauses, with a universal understanding that we all should be providing chest compressions to all victims of cardiac arrest. This review continued to focus on the interface of BLS sequencing and ensuring high-quality CPR with other important BLS interventions, such as ventilation and defibrillation. In addition, this consensus statement highlights the importance of EMS systems, which employ bundles of care focusing on providing high-quality chest compressions while extricating the patient from the scene to the next level of care. Highlights in defibrillation indicate the global importance of increasing the number of sites with public-access defibrillation programs. Whereas the 2010 ILCOR Consensus on Science provided important direction for the “what” in resuscitation (ie, what to do), the 2015 consensus has begun with the GRADE methodology to provide direction for the quality of resuscitation. We hope that resuscitation councils and other stakeholders will be able to translate this body of knowledge of international consensus statements to build their own effective resuscitation guidelines.

Part 3: Adult Basic Life Support and Automated External Defibrillation

This Part of the 2015 International Consensus on Cardiopul monary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science With Treatment Recommendations (CoSTR) presents the consensus on science and treatment recommendations for adult basic life support (BLS) and automated external defibrillation (AED). After the publication of the 2010 CoSTR, the Adult BLS Task Force developed review questions in PICO (population, intervention, comparator, outcome) format.1 This resulted in the generation of 36 PICO questions for systematic reviews. The task force discussed the topics and then voted to prioritize the most important questions to be tackled in 2015. From the pool of 36 questions, 14 were rated low priority and were deferred from this round of evidence evaluation. Two new questions were submitted by task force members, and 1 was submitted via the public portal. Two of these (BLS 856 and BLS 891) were taken forward for evidence review. The third question (368: Foreign-Body Airway Obstruction) was deferred after a preliminary review of the evidence failed to identify compelling evidence that would alter the treatment recommendations made when the topic was last reviewed in 2005.2 Each task force performed a systematic review using detailed inclusion and exclusion criteria, based on the recommendations of the Institute of Medicine of the National Academies.3 With the assistance of information specialists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library). Reviewers were unable to identify any relevant evidence for 3 questions (BLS 811, BLS 373, and BLS 348), and the evidence review was not completed in time for a further question (BLS 370). A revised PICO question was developed for the opioid question (BLS 891). The task force reviewed 23 PICO questions for the …

Relive: a serious game to learn how to save lives.

A recent review has provided evidence in support of new nd alternative methods for CPR training.1 Among these, are he “serious games”, which are applications developed using omputer game technologies more often associated with enterainment, but characterized by a serious purpose. Indeed, during he last decade, many serious games have been developed and sed successfully in the field of health, including training of oth technical and non-technical skills relevant to the surgical rea.2 The Italian Resuscitation Council (IRC) has implemented a erious game for the Viva! Campaign 20133 called Viva! Game http://www.viva2013.it/viva-game). Viva! Game is a serious game irected to kids and young adults. It served as a tool to create wareness on cardiac arrest and cardiopulmonary resuscitation CPR) in a soft and enjoyable way. The game has different scenaros, i.e. school, home, stadium, through which the player needs to nteract. More specifically, during the development of the story, he player finds himself in the need to perform a high quality hest compression to save another character from cardiac arrest. iva! CPR (http://www.viva2013.it/vivacpr) is an application for eal time feedback on chest compression quality created for smarthones directed to general population to increase awareness and nowledge about chest compression only manoeuvres. The numer of downloads of Viva! Game and Viva! CPR during the Viva! ampaign 2013 was around 10,000 (Table 1). For the Viva! Camaign 2014, the Italian Resuscitation Council developed a new and ore ambitious project called “Relive” game. Relive is a serious ame focusing on CPR with the main purpose of increasing kids nd young adults’ awareness on CPR and prompting them to attend PR classes and be prepared to intervene in case of cardiac arrest. elive is a first person 3D adventure taking place on planet Mars, n a near future. The game is divided into two different playing odes: a tournament mode and a story mode. The tournament ode is a ready-to-play simulated emergency scene, taken from elected game scenes, where the player faces different rescue sit-

Enoximone in cardiac arrest caused by propranolol: two case reports.

We report two clinical cases of cardiac arrest, the former due to an adverse effect of intravenous (i.v.) propranolol in a patient with systemic sclerosis, the latter from a propranolol suicidal overdose. In both cases, conventional advanced life support (ALS) was ineffective but both patients eventually responded to the administration of enoximone, a phosphodiesterase III (PDE III) inhibitor. After the arrest, both patients regained consciousness and were discharged home. The chronotropic and inotropic effects of PDE III inhibitors are due to inhibition of intracellular PDEIII and are therefore unaffected by beta‐blockers. These cases suggest that PDEIII inhibitors may be useful in restoring spontaneous circulation in cardiac arrest associated with beta‐blocker administration when standard ALS is ineffective.

Pulsatile normothermic cardiopulmonary bypass and plasma catecholamine levels

The aim of the study was to assess plasma catecholamine levels in patients undergoing myocardial revascularization and relate them to pulsatile (P) and nonpulsatile (NP) normothermic cardiopulmonary bypass (CPB). Twenty-eight patients were randomly assigned to different CPB management: 15 patients were assigned to group ‘P’, 13 patients to group ‘NP’. During normothermic extracorporeal circulation, group ‘P’ received pulsatile perfusion, while group ‘NP’ received nonpulsatile perfusion. Levels of epinephrine and norepinephrine were evaluated during the operation and in the intensive care unit (ICU), at seven time points. Haemodynamic assessment was performed at four time points in the same period. Demographic and surgical data were collected, and the postoperative course was analysed. Epinephrine levels were markedly increased during CPB in both groups, while norepinephrine increased more in group NP in comparison with group P. No significant difference was found in fluid administration, transfusion, drugs usage, or postoperative complications. Normothermic pulsatile CPB seems to achieve reduced levels of norepinephrine. A clinical beneficial effect of this finding was not demonstrated during the study.

Ultrasound artifacts mimicking pleural sliding after pneumonectomy

STUDY OBJECTIVE To determine the presence of pleural sliding on chest ultrasonography (US) in a series of patients admitted to a surgical intensive care unit (SICU). DESIGN Prospective, observational study. SETTING 16-bed SICU of a University hospital. PATIENTS 8 patients (7 men, 1 woman), aged 64 - 73 years (mean 67.5 yrs). Seven patients underwent pneumonectomy for pulmonary neoplasms; one patient underwent an atypical lung resection after having undergone a pneumonectomy one year before. INTERVENTIONS None. MEASUREMENTS Chest ultrasounds were performed during mechanical ventilation and spontaneous ventilation after endotracheal tube removal. In both examinations, pleural sliding was searched bilaterally in brightness mode (B-mode) and motion mode (M-mode) on the anterior thoracic wall in the least gravitationally dependent areas. RESULTS During mechanical ventilation, pleural sliding was always absent on the side of the pneumonectomy and present on the other side. During spontaneous ventilation, some artifacts mimicking pleural sliding were noted on the side of the pneumonectomy both in B-mode and M-mode (presence of the seashore sign) in all patients, except for the one patient who had undergone a pneumonectomy one year earlier. Those artifacts became more pronounced during deep breaths. CONCLUSIONS Ultrasound artifacts mimicking pleural sliding may be observed in the absence of the lung and may originate from the activity of intercostal muscles since they become more evident during deep breathing.

Extracorporeal Membrane Oxygenation for Resuscitation and Cardiac Arrest Management

This article reviews the potential application of extracorporeal membrane oxygenation (ECMO) technology to cardiopulmonary resuscitation for in and out-of-hospital cardiac arrest and discusses the current evidence on the subject. The possible strategies for organ protection during ECMO and the concept of ECMO networks are also reviewed.

The effect of the AED and AED programs on survival of individuals, groups and populations.

OBJECTIVE The automated external defibrillator (AED) is a tool that contributes to survival with mixed outcomes. This review assesses the effectiveness of the AED, consistencies and variations among studies, and how varying outcomes can be resolved. METHODS A worksheet for the International Liaison Committee on Resuscitation (ILCOR) 2010 science review focused on hospital survival in AED programs was the foundation of the articles reviewed. Articles identified in the search covering a broader range of topics were added. All articles were read by at least two authors; consensus discussions resolved differences. RESULTS AED use developed sequentially. Use of AEDs by emergency medical technicians (EMTs) compared to manual defibrillators showed equal or superior survival. AED use was extended to trained responders likely to be near victims, such as fire/rescue, police, airline attendants, and casino security guards, with improvement in all venues but not all programs. Broad public access initiatives demonstrated increased survival despite low rates of AED use. Home AED programs have not improved survival; in-hospital trials have had mixed results. Successful programs have placed devices in high-risk sites, maintained the AEDs, recruited a team with a duty to respond, and conducted ongoing assessment of the program. CONCLUSION The AED can affect survival among patients with sudden ventricular fibrillation (VF). Components of AED programs that affect outcome include the operator, location, the emergency response system, ongoing maintenance and evaluation. Comparing outcomes is complicated by variations in definitions of populations and variables. The effect of AEDs on individuals can be dramatic, but the effect on populations is limited.

Kids Save Lives campaign in Italy: A picture from a nationwide survey on the web

Recently, we conducted a survey on cardiac arrest knowledge in talian schoolchildren. The Italian Resuscitation Council (IRC) and he Skuola.net1 developed an online survey launched to all visiors of Skuola.net website (over 3,700,000 unique browser/months, ver 1,000,000 registered member, over 780,000 Facebook fans) for en days during October 2016. We used the data of survey for a viral eb campaign during Viva! 2016 (17th–23th October 2016) and we reated an infographic for students (Fig. 1). The survey included ten ultiple-choice questions on: CPR algorithm knowledge, informaion about AED and first aid training implementation in the school. e collected 9500 responses from young people between 11 and 25 ears old: 1% under 11 years old, 9% 11–13, 43% 14–16, 34% 17–19, % 19–25, and 4% over 25 years old. Female were 63% and male 37%. nly 43% of students would evaluate the consciousness calling and haking the victim, 41% would call the emergency medical service, 1% would slap the victim’s face, and 5% would go into the panic. or checking sign of life, 40% would use breathing looking, listening nd feeling, 33% would put his ears on the thorax to listen for hearteats, 27% would put fingers close to nose and mouth. If the victim s unconscious and not breathing, 83% would call the emergency umber, 12% would call for parents, and 5% would go into panic. egarding the Italian medical emergency number: 88% responded orrectly, i.e. 118/112, 5% would call 911 (US EMS number), and % would call 113 and 115 (police and firefighter numbers). If the MS dispatcher would ask them to try to start CPR: 58% would ot be able to start but compliant to operator instructions, 31% ould start on the basis of previous knowledge, and 11% would ot know what to do. About the victim’s position to perform CPR: 9% answered supine, 3% prone, 25% answered that was better not o move the victim in the suspect of trauma, and 3% did not know. bout chest compression rate, only 20% of students answered corectly, 100–120/min. The majority of students (84%) was not ready o use an AED. We asked about AED presence in their school: 49% id not know, 26% answered yes, 25% answered no. Finally, 74% of tudents had never participated to a CPR training course and 95% onsidered the CPR knowledge useful, while 5% did not. Most of he responders (with a peek in the 14–19 years old) agreed with mandatory teaching of first aid in schools. This survey provides realistic picture of the Italian schoolchildren education and attiude towards CPR. The information obtained depicts the staring oint of students’ CPR knowledge and is useful for designing the mplementation of Kids save lives campaign in Italy.2–4

Early postoperative obstructive prosthetic mitral valve thrombosis in a patient double heterozygous for factor V Leiden and prothrombin G20210A mutation.

Early postoperative obstructive prosthetic mitral valve thrombosis in a patient double heterozygous for factor V Leiden and prothrombin G20210A mutation -