Enrico Baldi

Complete chest recoil during laypersons' CPR: Is it a matter of weight? ☆

Introduction: Chest compressions depth and complete chest recoil are both important for high‐quality Cardio‐Pulmonary Resuscitation (CPR). It has been demonstrated that anthropometric variables affect chest compression depth, but there are no data about they could influence chest recoil. The aim of this study was to verify whether physical attributes influences chest recoil in lay rescuers. Methods: We evaluated 1 minute of compression‐only CPR performed by 333 laypersons immediately after a Basic Life Support and Automated External Defibrillation (BLS/AED) course. The primary endpoint was to verify whether anthropometric variables influence the achievement a complete chest recoil. Secondary endpoint was to verify the influence of anthropometric variables on chest compression depth. Results: We found a statistically significant association between weight and percentage of compressions with correct release (p ≤ 0.001) and this association was found also for height, BMI and sex. People who are heavier, who are taller, who have a greater BMI and who are male are less likely to achieve a complete chest recoil. Regarding chest compressions depth, we confirm that the more a person weighs, the more likely the correct depth of chest compressions will be reached. Conclusions: Anthropometric variables affect not only chest compression depth, but also complete chest recoil. CPR instructors should tailor their attention during training on different aspect of chest compression depending on the physical characteristics of the attendee.

End-tidal carbon dioxide and defibrillation success in out-of-hospital cardiac arrest

PURPOSE Basing on the relationship between the quality of cardiopulmonary resuscitation (CPR) and the responsiveness of VF to the defibrillation we aimed to assess whether the values of ETCO2 in the minute before defibrillation could predict the effectiveness of the shock. MATERIALS AND METHODS We retrospectively evaluated the reports generated by the manual monitor/defibrillator (Corpuls by GS Elektromedizinische Geräte G. Stemple GmbH, Germany) used for cases of VF cardiac arrest from January 2015 to December 2016. The mean ETCO2 value of the minute preceding the shock (METCO260) was computed. A blind evaluation of the effectiveness of each shock was provided by three cardiologists. RESULTS A total amount of 207 shocks were delivered for 62 patients. When considering the three tertiles of METCO260 (T1:METCO260 ≤ 20mmHg; T2: 20mmHg < METCO260 ≤ 31mmHg and T3: METCO260 > 31mmHg) a statistically significant difference between the percentages of shock success was found (T1: 50%; T2: 63%; T3: 78%; Chi square p=0.003; p for trend <0.001). When the METCO260 was lower than 7mmHg no shock was effective and when the METCO260 was higher than 45mmHg no shock was ineffective. Shocks followed by ROSC were preceded by higher values of METCO260 as compared either to ineffective shocks or effective ones without ROSC. CONCLUSIONS This is the first demonstration of the relation between ETCO2 and defibrillation effectiveness. Our findings stress the pivotal role of High Quality CPR, monitored via ETCO2, and suggest ETCO2 monitoring as an additional weapon to guide defibrillation.

Is it time to consider visual feedback systems the gold standard for chest compression skill acquisition

High-quality chest compressions are pivotal for improving survival from cardiac arrest. The rate and depth of compressions, chest recoil and hand position are important parameters affecting the overall quality of chest compressions, which is correlated with blood flow and oxygen delivery to the heart and brain and, consequently, with rate of ROSC and neurologically intact survival at hospital discharge [1]. During the last decade, some automated feedback devices have been investigated to improve CPR performance during cardiac arrest [2]. However, the applicability of these systems on a large scale is questionable and more attention has been focused on FS for training with unclear effects [3]. Two recently published RCTs brought new highquality evidence on this topic. Both RCTs evaluated the effect of an automated computerized real-time FS (Laerdal QCPR®) able to measure CPR quality, which can be connected wirelessly to a training mannequin and displayed on pads or laptops (Additional file 1). Baldi et al. [4] randomized 450 laypersons of various age participating in BLS courses in a three-arm study. The authors demonstrated that both a 1-minute training or a 10-minute training with the FS was superior to a standard course in terms of the percentage of compressions with correct depth, with complete chest recoil and with correct hand position. In this trial, assessment of the chest compression skill acquisition was performed at the end of the course. Cortegiani et al. [5] randomized 144 trainers in a twoarm study comparing a standard course plus a 2-minute chest compressions training with the FS versus instructorbased feedback only. The intervention group demonstrated a significantly higher overall quality and percentage of correctly released chest compressions and a more appropriate compression rate. Interestingly, in this trial, outcomes assessment was performed 7 days after the course. The median age of participants was lower than for the other trial (17 years for both groups) because it specifically focused on secondary school students. There is now high-grade evidence to support the effect of a visual FS in terms of chest compression skill acquisition for laypersons. Further research should evaluate the effect of a visual FS at longer time points and for training (and retraining) of healthcare personnel, focusing on patient-centered outcomes. Moreover, high-quality studies comparing different FSs are needed.

A wearable remote monitoring system for the identification of subjects with a prolonged QT interval or at risk for drug-induced long QT syndrome

BACKGROUND A correct measurement of the QT interval in the out-of-hospital setting is important whenever the long QT syndrome (LQTS) is suspected or a therapy might lead to drug-induced LQTS (diLQTS) because QT interval monitoring in the initial days of therapy could alert to dangerous QT prolongation. We explored whether automated QTc measurements (BGM) by BodyGuardian™ (BG), a wearable remote monitoring system, are sufficiently reliable compared to our own manual measurements (MM) performed on the same beats during 12‑lead Holter recordings in LQTS patients (pts) and in healthy controls. METHODS We performed 351 measurements in 20 LQTS pts and 16 controls. MM and BGM were compared by a Bland-Altman plot (BAp). High values of BAp indicate large differences between measurements. RESULTS In all 36 subjects QTc was 446 ± 41 and 445 ± 47 ms in MM and BGM, respectively. The mean ± SE BAp was -1.4 ± 1.8 ms for QTc in all subjects, 8.3 ± 2.3 and -7.2 ± 2.5 ms respectively in controls and LQTS. The disagreement between BGM and MM <15 ms in all, in controls, and in LQTS was respectively 57%, 63% and 54%. Among controls, there were only 3/132 false positive measurements (BGM QTc >470 ms when MM QTc <440 ms) in 3 different subjects. Among LQTS, there were 10/219 false negative measurements (BGM QTc <440 ms when MM QTc >470 ms) in 6 pts, but only two had multiple false negative values. CONCLUSIONS This wearable monitoring system reliably identifies a prolonged QT interval and probably also subjects at risk for diLQTS.

Real-time feedback systems for cardiopulmonary resuscitation training: time for a paradigm shift

Among the new tools to improve the quality of cardiopulmonary resuscitation (CPR), real-time feedback systems (FS) have been largely studied during the last decade (1). These systems permit the real-time analysis of CPR.

Protocol of a multicenter international randomized controlled manikin study on different protocols of cardiopulmonary resuscitation for laypeople (MANI-CPR)

Introduction Out-of-hospital cardiac arrest is one of the leading causes of death in industrialised countries. Survival depends on prompt identification of cardiac arrest and on the quality and timing of cardiopulmonary resuscitation (CPR) and defibrillation. For laypeople, there has been a growing interest on hands-only CPR, meaning continuous chest compression without interruption to perform ventilations. It has been demonstrated that intentional interruptions in hands-only CPR can increase its quality. The aim of this randomised trial is to compare three CPR protocols performed with different intentional interruptions with hands-only CPR. Methods and analysis This is a prospective randomised trial performed in eight training centres. Laypeople who passed a basic life support course will be randomised to one of the four CPR protocols in an 8 min simulated cardiac arrest scenario on a manikin: (1) 30 compressions and 2 s pause; (2) 50 compressions and 5 s pause; (3) 100 compressions and 10 s pause; (4) hands-only. The calculated sample size is 552 people. The primary outcome is the percentage of chest compression performed with correct depth evaluated by a computerised feedback system (Laerdal QCPR). Ethics and dissemination . Due to the nature of the study, we obtained a waiver from the Ethics Committee (IRCCS Policlinico San Matteo, Pavia, Italy). All participants will sign an informed consent form before randomisation. The results of this study will be published in peer-reviewed journal. The data collected will also be made available in a public data repository. Trial registration number NCT02632500.

Post ROSC pulse-oximetry derived perfusion index and thirty days survival after out-of-hospital cardiac arrest. New insights from the Pavia CARe (Pavia Cardiac Arrest Registry)

The perfusion index (PI) is the ratio of the pulsatile blood flow o the nonpulsatile or static blood in peripheral tissue thus it repesents a noninvasive measure of peripheral perfusion that can be ontinuously and noninvasively obtained from a pulse oximeter. eripheral PI has been proposed for different clinical uses with ome applications in critical patients [1–3]. No data are available bout cardiac arrest survivors, however It is likely that a good eripheral perfusion after the return of spontaneous circulation ROSC) could increase the chance of survival at least in the short erm. Our aim was to assess whether peripheral PI measured after OSC could predict thirty days survival after an out-of-hospital ardiac arrest (OHCA). To address our aim the reports from those atients who achieved ROSC generated by the manual monior/defibrillator (Corpuls by GS Elektromedizinische Geräte G. temple GmbH, Germany) after every case of OHCA were retropectively evaluated. The mean values of PI were automatically rovided in the report every minute from the ROSC onwards and he mean value of 30 min of monitoring (MPI30) was calculated. From January 2015 to December 2016 1501 patients have een enrolled in our OHCA registry (Pavia CARe); in 931 patients ardiopulmonary resuscitation was attempted and 156 patients howed a prehospital ROSC. Among these patients with prehospi-

Are final year medical students ready to save lives in Italy? Not yet

We read with interest the paper by Perkins GD and colleagues on a series of initiatives to improve outcomes from out-of-hospital cardiac arrest in which teaching cardiopulmonary resuscitation (CPR) to schoolchildren play a key role.1 Evidence in the literature confirms that teaching CPR in school saves lives.2 If even schoolchildren know CPR, even more so a young doctor should know how to treat a cardiac arrest. However, since we …

When an old pacemaker misleads a new automated external defibrillator. A case from the Pavia CARe (Cardiac Arrest Registry)

The use of the automatic external defibrillators (AEDs) in an outf-hospital cardiac arrest (OHCA) it’s ever more widespread and the prompt use of these devices, integrated in the chain of survival, has been demonstrated to increase the survival after an OHCA.1 An AED, according to the AHA consensus,2 should have a recommended sensitivity in recognizing a shockable rhythm more than 90%, thus, over the years, manufacturers have reached a sensitivity about 99%. However, a misdiagnosis of non-shockable rhythm is still possible and a shockable rhythm obscured by a pacemaker had been shown to be the most frequent event with an incidence of