Ashish R. Panchal

Chest compression depth and survival in out-of-hospital cardiac arrest

AIM Outcomes from out-of-hospital cardiac arrest (OHCA) may improve if rescuers perform chest compressions (CCs) deeper than the previous recommendation of 38-51mm and consistent with the 2010 AHA Guideline recommendation of at least 51mm. The aim of this study was to assess the relationship between CC depth and OHCA survival. METHODS Prospective analysis of CC depth and outcomes in consecutive adult OHCA of presumed cardiac etiology from two EMS agencies participating in comprehensive CPR quality improvement initiatives. ANALYSIS Multivariable logistic regression to calculate adjusted odds ratios (aORs) for survival to hospital discharge and favorable functional outcome. RESULTS Among 593 OHCAs, 136 patients (22.9%) achieved return of spontaneous circulation, 63 patients (10.6%) survived and 50 had favorable functional outcome (8.4%). Mean CC depth was 49.8±11.0mm and mean CC rate was 113.9±18.1CCmin(-1). Mean depth was significantly deeper in survivors (53.6mm, 95% CI: 50.5-56.7) than non-survivors (48.8mm, 95% CI: 47.6-50.0). Each 5mm increase in mean CC depth significantly increased the odds of survival and survival with favorable functional outcome: aORs were 1.29 (95% CI 1.00-1.65) and 1.30 (95% CI 1.00-1.70) respectively. CONCLUSION Deeper chest compressions were associated with improved survival and functional outcome following OHCA. Our results suggest that adhering to the 2010 AHA Guideline-recommended depth of at least 51mm could improve outcomes for victims of OHCA.

Cardiovascular response to epinephrine varies with increasing duration of cardiac arrest

OBJECTIVE Epinephrine (adrenaline) is widely used as a primary adjuvant for improving perfusion pressure and resuscitation rates during cardiopulmonary resuscitation (CPR). Epinephrine is also associated with significant myocardial dysfunction in the post-resuscitation period. We tested the hypothesis that the cardiac effects of epinephrine vary according to the duration of cardiac arrest. METHODS AND MATERIALS Cardiac arrest (CA) was induced in Sprague-Dawley rats with an IV bolus of KCl (40 microg/g). Three series of experiments were performed with CPR begun after 2, 4, or 6 min of cardiac arrest. Epinephrine (0.01 mg/kg) IV or placebo was given immediately in the 2 and 4 min CA groups. In the 6 min group, CPR was started after 6 min CA and epinephrine was given at 15 min if no return of spontaneous circulation (ROSC) occurred. Time to ROSC was recorded in all groups. Cardiac function was determined with trans-thoracic echocardiography at baseline, 5, 30 and 60 min after ROSC. RESULTS After 2 min CA, 8/8 (100%) placebo animals and 8/8 (100%) epinephrine animals attained ROSC. Cardiac index was significantly increased during the first 60 min in the epinephrine group compared with the placebo group (p<0.01). After 4 min of cardiac arrest, 14/29 (48%) placebo animals and 14/16 (88%) epinephrine animals attained ROSC (p<0.01). Cardiac index after ROSC returned to baseline in both groups, although tended to be lower in the epinephrine group. After 6 min CA, 10/31 (32%) animals attained ROSC without epinephrine and 17/21 (81%) animals with epinephrine (p<0.01). Post-ROSC depression of cardiac index was greatest in the epinephrine group (p<0.05). CONCLUSIONS As the duration of cardiac arrest increases, a paradoxical myocardial epinephrine response develops, in which epinephrine becomes increasingly more important to attain ROSC, but is increasingly associated with post-ROSC myocardial depression.

Part 3: Ethical Issues 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

The goals of resuscitation are to preserve life; restore health; relieve suffering; limit disability; and respect individuals’ decisions, rights, and privacy. Because cardiopulmonary resuscitation (CPR) efforts must be initiated immediately at the time of arrest, a rescuer may not know who the victim is, what that individual’s goals of care are, or if an advance directive exists. As a result, administration of CPR may be contrary to the individual’s desires or best interests.1–3 This Part of the 2015 American Heart Association (AHA) Guidelines Update for CPR and Emergency Cardiovascular Care provides updates to the 2010 AHA Guidelines4 for healthcare providers who are faced with the difficult decision to provide or withhold emergency cardiovascular care. Ethical, legal, and cultural factors influence decisions about resuscitation. Ideally, these decisions are guided by science, patient or surrogate preferences, local policies and legal requirements, and established ethical principles. ### Principle of Respect for Autonomy Respect for autonomy is an important social value in medical ethics and law.5 This principle is based on society’s respect for a competent individual’s ability to make decisions about his or her own health care. Adults are presumed to have decision-making capability unless they are incapacitated or declared incompetent by a court of law. Informed decisions require that individuals receive and understand accurate information about their condition and prognosis as well as the nature, risks, benefits, and alternatives of any proposed interventions. Individuals must deliberate and choose among alternatives by linking their decisions to their values and personal goals of care. When physicians strive to understand patients’ goals of care, decisions can be made based on the likelihood that together they will achieve the patients’ goals of care. The following 3-step process may assist healthcare providers in ensuring each patient understands and makes informed decisions: (1) the patient receives and understands accurate …

CPR variability during ground ambulance transport of patients in cardiac arrest.

AIM OF STUDY High-quality CPR is associated with improved outcomes from out-of-hospital cardiac arrest (OHCA). The purpose of this investigation was to compare the quality of CPR provided at the prehospital scene, during ambulance transport, and during the early minutes in the emergency department (ED). METHODS A prospective observational review of consecutive adult patients with non-traumatic OHCA was conducted between September 2008 and February 2010. Patients with initiation of prehospital CPR were included as part of a statewide cardiac resuscitation quality improvement program. A monitor-defibrillator with accelerometer-based CPR measurement capability (E-series, ZOLL Medical) was utilized. CPR quality measures included variability in chest compression (CC) depth and rate, mean depth and rate, and the CC fraction. Variability of CC was defined as the mean of minute-to-minute standard deviation in CC depth or rate. CC fraction was defined as the percent of time that CPR was being performed when appropriate throughout resuscitation. RESULTS Fifty-seven adult patients with OHCA had electronic CPR data recorded at the scene, in the ambulance, and upon arrival in the ED. Across time periods, there was increased variability in CC depth (scene: 0.20 in.; transport: 0.26 in.; ED: 0.31 in., P<0.01) and rate (scene: 18.2 CC min(-1); transport: 26.1 CC min(-1); ED: 26.3 CC min(-1), P<0.01). The mean CC depth, rate, and the CC fraction did not differ significantly between groups. CONCLUSIONS There was increased CC variability from the prehospital scene to the ED though there was no difference in mean CC depth, rate, or in CC fraction. The clinical significance of CC variability remains to be determined.

Chest compression-only cardiopulmonary resuscitation performed by lay rescuers for adult out-of-hospital cardiac arrest due to non-cardiac aetiologies

OBJECTIVE Bystander CPR improves survival in patients with out-of-hospital cardiac arrest (OHCA). For adult sudden collapse, bystander chest compression-only CPR (COCPR) is recommended in some circumstances by the American Heart Association and European Resuscitation Council. However, adults who arrest from non-cardiac causes may also receive COCPR. Because rescue breathing may be more important for individuals suffering OHCA secondary to non-cardiac causes, COCPR is not recommended for these cases. We evaluated the relationship of lay rescuer COCPR and survival after OHCA from non-cardiac causes. METHODS Analysis of a statewide Utstein-style registry of adult OHCA, during a large scale campaign endorsing COCPR for OHCA from presumed cardiac cause. The relationship between lay rescuer CPR (both conventional CPR and COCPR) and survival to hospital discharge was evaluated. RESULTS Presumed non-cardiac aetiologies of OHCA accounted for 15% of all cases, and lay rescuer CPR was provided in 29% of these cases. Survival to hospital discharge occurred in 3.8% after conventional CPR, 2.7% after COCPR, and 4.0% after no CPR (p=0.85). The proportion of patients receiving COCPR was much lower in the cohort of OHCA from respiratory causes (8.3%) than for those with presumed cardiac OHCA (18.0%; p<0.001). CONCLUSIONS In the setting of a campaign endorsing lay rescuer COCPR for cardiac OHCA, bystanders were less likely to perform COCPR on OHCA victims who might benefit from rescue breathing.

Viewing a brief chest-compression-only CPR video improves bystander CPR performance and responsiveness in high school students: A cluster randomized trial

BACKGROUND CPR training in schools is a public health initiative to improve out of hospital cardiac arrest (OHCA) survival. It is unclear whether brief video training in students improves CPR quality and responsiveness and skills retention. OBJECTIVES Determine if a brief video is as effective as classroom instruction for chest compression-only (CCO) CPR training in high school students. METHODS This was a prospective cluster-randomized controlled trial with three study arms: control (sham video), brief video (BV), and CCO-CPR class. Students were randomized and clustered based on their classrooms and evaluated using a standardized OHCA scenario measuring CPR quality (compression rate, depth, hands-off time) and responsiveness (calling 911, time to calling 911, starting compressions within 2min). Data was collected at baseline, post-intervention and 2 months. Generalized linear mixed models were used to analyze outcome data, accounting for repeated measures for each individual and clustering by class. RESULTS 179 students (14-18 years) were consented in 7 classrooms (clusters). At post-intervention and 2 months, BV and CCO class students called 911 more frequently and sooner, started chest compressions earlier, and had improved chest compression rates and hands-off time compared to baseline. Chest compression depth improved significantly from baseline in the CCO class, but not in the BV group post-intervention and at 2 months. CONCLUSIONS Brief CPR video training resulted in improved CPR quality and responsiveness in high school students. Compression depth only improved with traditional class training. This suggests brief educational interventions are beneficial to improve CPR responsiveness but psychomotor training is important for CPR quality.

Use of double sequential external defibrillation for refractory ventricular fibrillation during out-of-hospital cardiac arrest☆

INTRODUCTION Survival from out of hospital cardiac arrest (OHCA) is highest in victims with shockable rhythms when early CPR and rapid defibrillation are provided. However, a subset of individuals present with ventricular fibrillation (VF) that does not respond to defibrillation (refractory VF). One intervention that may be a possible option in refractory VF is double sequential external defibrillation (DSD). The objective of this case series was to describe the outcome of prehospital victims with refractory VF treated with DSD in the out-of-hospital setting. METHODS This evaluation is a retrospective chart review of VF patients treated with DSD in the prehospital setting from August 1st, 2010 through June 30th, 2014. Patients were excluded if less than 17 years of age. The outcomes we evaluated were the number of patients with return of spontaneous circulation, conversion from VF, survival-to-hospital discharge, and Cerebral Performance Category score. RESULTS Total of 2428 OHCA events were reviewed with twelve patients treated with DSD. Median DSD and prehospital resuscitation times were 27min (IQR 22-33) and 32 (IQR 24-38), respectively. Of the 12 patients treated, return of spontaneous circulation was achieved in three patients, nine patients were converted out of ventricular fibrillation, three patients survived to hospital discharge, and two patients (2/12, 17%) were discharged with Cerebral Performance Category scores of 1 (good cerebral performance). CONCLUSIONS Double sequential defibrillation may be another tool to improve neurologically intact survival from OHCA. Further studies are needed to demonstrate direct benefits to patient outcomes.

Effect of Geriatric-Specific Trauma Triage Criteria on Outcomes in Injured Older Adults: A Statewide Retrospective Cohort Study.

To evaluate the effect on outcomes of the Ohio Department of Public Safety statewide geriatric triage criteria, established in 2009 for emergency medical services (EMS) to use for injured individuals aged 70 and older.

Analysis of Automated External Defibrillator Device Failures Reported to the Food and Drug Administration

STUDY OBJECTIVE Automated external defibrillators are essential for treatment of cardiac arrest by lay rescuers and must determine when to shock and if they are functioning correctly. We seek to characterize automated external defibrillator failures reported to the Food and Drug Administration (FDA) and whether battery failures are properly detected by automated external defibrillators. METHODS FDA adverse event reports are catalogued in the Manufacturer and User Device Experience (MAUDE) database. We developed and internally validated an instrument for analyzing MAUDE data, reviewing all reports in which a fatality occurred. Two trained reviewers independently analyzed each report, and a third resolved discrepancies or passed them to a committee for resolution. RESULTS One thousand two hundred eighty-four adverse events were reported between June 1993 and October 2008, of which 1,150 were failed defibrillation attempts. Thirty-seven automated external defibrillators never powered on, 252 failed to complete rhythm analysis, and 524 failed to deliver a recommended shock. In 149 cases, the operator disagreed with the devices rhythm analysis. In 54 cases, the defibrillator stated the batteries were low and in 110 other instances powered off unexpectedly. Interrater agreement between reviewers 1 and 2 ranged by question from 69.0% to 98.6% and for most likely cause was 55.9%. Agreement was obtained for 93.7% to 99.6% of questions by the third reviewer. Remaining discrepancies were resolved by the arbitration committee. CONCLUSION MAUDE information is often incomplete and frequently no corroborating data are available. Some conditions not detected by automated external defibrillators during self-test cause units to power off unexpectedly, causing defibrillation delays. Backup units frequently provide shocks to patients.

Connecting Emergency Department Patients to Primary Care

Background: Inappropriate emergency department (ED) use among Medicaid enrollees is considered a problem because of cost. We developed and evaluated a system change innovation designed to remove system barriers to primary care access for Medicaid patients. Methods: Patients who presented to the ED without an identified primary care provider were randomized to the intervention (n = 72) or comparison group (n = 68) for a 12-month study designed to connect these patients to primary care offices. Evaluation was mixed quantitative/qualitative. Results: Significantly more intervention participants attended at least 1 primary care visit 3 months after the intervention (odds ratio [OR], 2.52; 95% confidence interval [CI], 1.06–6.02), though this difference was not significant by 12 months (OR, 1.74; 95% CI, 0.79–3.84). The intervention participants also did not have lower odds of returning to the ED for nonurgent reasons by the 12-month follow-up (OR, 1.27; 95% CI, 0.65–2.48). Patient-reported barriers to attending a primary care appointment were primarily social and health system–related factors. Conclusion: The intervention did not decrease ED visits nor increase primary care use over the 12 months of the study period. The qualitative results provide insight into nonurgent ED utilization by patients with Medicaid, suggesting potential future interventions.