Michael Baubin

European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators.

Basic life support (BLS) refers to maintaining airway patency and supporting breathing and the circulation, without the use of equipment other than a protective device.(1) This section contains the guidelines for adult BLS by lay rescuers and for the use of an automated external defibrillator (AED). It also includes recognition of sudden cardiac arrest, the recovery position and management of choking (foreign-body airway obstruction). Guidelines for in-hospital BLS and the use of manual defibrillators may be found in Sections 3 and 4b.

Recombinant tissue plasminogen activator during cardiopulmonary resuscitation in 108 patients with out-of-hospital cardiac arrest

BACKGROUND Thrombolytic therapy during cardiopulmonary resuscitation (CPR) is a controversial issue in emergency medicine practice. This study was conducted to determine whether administration of recombinant tissue plasminogen activator (rt-PA) in out-of-hospital cardiac arrest of non-traumatic aetiology improves CPR outcome. METHODS AND RESULTS A retrospective chart review of 401 patients with out-of-hospital cardiac arrest who were resuscitated by the emergency medical services (EMS) during a 6 year period was performed. A total of 108 patients received rt-PA during CPR and were compared to 216 controls, closely matched according to baseline characteristics, arrival status and ECG findings. Administration of rt-PA was optional. Return of spontaneous circulation (ROSC) occurred in 76 patients under rt-PA treatment (70.4 vs. 51.0% in controls; P=0.001). Fifty-two patients from the lysis group survived the first 24 h (48.1 vs. 32.9% in controls; P=0.003), while 27 (25.9%) survived to discharge. Autopsy reports revealed major bleeding complications in six patients receiving rt-PA treatment. Fulminant intracranial haemorrhage was observed in one patient who received rt-PA and in two cases from the control group. CONCLUSIONS Thrombolytic therapy may improve frequency of return of spontaneous circulation substantially and increase primary survival in patients with non-traumatic cardiac arrest. Serious bleeding complications are not frequently observed under rt-PA treatment.

Chest injuries after active compression–decompression cardiopulmonary resuscitation (ACD-CPR) in cadavers

In a prospective study of 38 cadavers of patients older than 18 without previous chest injury or cardiopulmonary resuscitation (CPR), active compression-decompression (ACD) resuscitation manoeuvres were performed to determine possible factors influencing sternal and/or rib fractures. ACD was performed for 60 s, with compression and decompression forces being continuously recorded. A stepwise logistic regression analysis was applied. Factors analyzed were age, gender, use of a compression cushion beneath the piston of the ACD device (Ambu CardioPump), and maximal compression and decompression forces. After ACD, the cadavers were autopsied and thoracic injuries were assessed. There was a significant correlation between sternal fractures and gender (P = 0.008), and between rib fractures and age (P = 0.008). Women were found to have a higher risk for sternal fractures, whereas older patients had a higher risk for rib fractures. Maximal compression force was another factor in sternal and/or rib fracture (P = 0.048). Even though a significantly higher incidence of sternal fractures was observed when the compression cushion was used (P = 0.045), inclusion of this variable in the regression analysis only marginally improved the prediction for correct classification of sternal fractures. In conclusion, when well controlled ACD-CPR is performed in cadavers, age is the most important factor determining the incidence of rib fracture. Sternal fractures were more common in female cadavers.

Increased frequency of thorax injuries with ACD-CPR ☆

A prospective, randomised out-of-hospital study in a two-tiered system with active compression-decompression (ACD) cardiopulmonary resuscitation (CPR) versus standard (STD) CPR in patients following non-traumatic cardiac arrest was planned to test the hypothesis that ACD-CPR by the first tier may increase the occurrence of ventricular fibrillation as compared with STD-CPR. Furthermore, in a later phase of the study, sternal and rib fractures induced by both CPR methods were determined by extensive autopsy. After enrolling 90 patients the study was terminated because of a high frequency of chest injuries found at autopsy. Forty-two patients received STD-CPR from the first tier and ACD-CPR from the second tier. Thirty-three patients received ACD-CPR only by the first and the second tier, while 15 patients received STD-CPR only from the first and second tiers. In order to obtain a sufficiently large control group for autopsy findings after STD-CPR, STD-CPR was performed in an additional 33 patients within a second period of 4 months. There was no improvement in the number of patients found in ventricular fibrillation after ACD-CPR as compared to STD-CPR performed by the first tier. In patients undergoing autopsy (n = 35) there were significantly more sternal fractures with ACD-CPR versus STD-CPR (14/15 vs. 6/20; P <0.005) and rib fractures (13/15 vs. 11/20; P < 0.05) In conclusion, ACD-CPR appears to cause more CPR-related injuries than does standard CPR, but as a result of a number of limitations on this study, this fact cannot be proven beyond doubt.

Vasopressin decreases endogenous catecholamine plasma concentrations during cardiopulmonary resuscitation in pigs

Objective: The purpose of this study was to evaluate the effect of vasopressin vs. saline placebo on catecholamine plasma concentrations during cardiopulmonary resuscitation (CPR). Design: Prospective, randomized laboratory investigation by using an established procine CPR model with instrumentation for measurement of hemodynamic variables, vital organ blood flow, and return of spontaneous circulation. Setting: University hospital laboratory. Subjects: Sixteen domestic pigs. Interventions: After 15 mins of untreated cardiac arrest and 3 mins of CPR, 16 pigs were randomized to be treated with either 0.8 U/kg vasopressin (n = 8) or placebo (normal saline; n = 8). Arterial epinephrine and norepinephrine plasma concentrations were sampled at prearrest, after 1.5 mins of chest compressions, and at 1.5 mins and 5 mins after drug administration during CPR. Measurements and Main Results: In comparison with placebo pigs at 1.5 and 5 mins after drug administration, animals resuscitated with vasopressin had significantly (p < .01) higher mean ± SEM left ventricular myocardial (131 ± 27 vs. 10 ± 1 mL·mins−1·100 g−1 and 62 ± 13 vs. 9 ± 2 mL·mins−1·100 g−1); total cerebral (90 ± 8 vs. 14 ± 3 mL·mins−1·100 g−1 and 51 ± 4 vs. 12 ± 2 mL·mins−1·100 g−1); and adrenal gland perfusion (299 ± 36 vs. 38 ± 7 mL·mins−1·100 g−1 and 194 ± 23 vs. 29 ± 5 mL·mins−1·100 g−1). Significantly lower mean ± SEM epinephrine concentrations in the vasopressin pigs compared with the placebo group were measured 1.5 mins and 5 mins after drug administration, (24167 ± 7919 vs. 80223 ± 19391 pg/mL [p < .01] and 8346 ± 1454 vs. 71345 ± 10758 pg/mL [p < .01]). Mean ± SEM norepinephrine plasma concentrations in the vasopressin animals in comparison with placebo were at 1.5 and 5 mins after drug administration significantly lower (41729 ± 13918 vs. 82756 ± 9904 pg/mL [p = .01] and 10642 ± 3193 vs. 62170 ± 8797 pg/mL [p < .01]). Conclusions: Administration of vasopressin during CPR resulted in significantly superior vital organ blood flow, but significantly decreased endogenous catecholamine plasma concentrations when compared with placebo.

The beneficial effect of basic life support on ventricular fibrillation mean frequency and coronary perfusion pressure

BACKGROUND AND OBJECTIVE Chest compressions before initial defibrillation attempts have been shown to increase successful defibrillation. This animal study was designed to assess whether ventricular fibrillation mean frequency after 90 s of basic life support cardiopulmonary resuscitation (CPR) may be used as an indicator of coronary perfusion and mean arterial pressure during CPR. METHODS AND RESULTS After 4 min of ventricular fibrillation cardiac arrest in a porcine model, CPR was performed manually for 3 min. Mean ventricular fibrillation frequency and amplitude, together with coronary perfusion and mean arterial pressure were measured before initiation of chest compressions, and after 90 s and 3 min of basic life support CPR. Increases in fibrillation mean frequency correlated with increases in coronary perfusion and mean arterial pressure after both 90 s (R=0.77, P<0.0001, n=30; R=0.75, P<0.0001, n=30, respectively) and 3 min (R=0.61, P<0.001, n=30; R=0.78, P<0.0001, n=30, respectively) of basic life support CPR. Increases in fibrillation mean amplitude correlated with increases in mean arterial pressure after both 90 s (R=0.46, P<0.01; n=30) and 3 min (R=0.42, P<0.05, n=30) of CPR. Correlation between fibrillation mean amplitude and coronary perfusion pressure was not significant both at 90 s and 3 min of CPR. CONCLUSIONS In this porcine laboratory model, 90 s and 3 min of CPR improved ventricular fibrillation mean frequency, which correlated positively with coronary perfusion pressure, and mean arterial pressure.

Removal of CPR Artifacts From the Ventricular Fibrillation ECG by Adaptive Regression on Lagged Reference Signals

Removing cardiopulmonary resuscitation (CPR)-related artifacts from human ventricular fibrillation (VF) electrocardiogram (ECG) signals provides the possibility to continuously detect rhythm changes and estimate the probability of defibrillation success. This could reduce ldquohands-offrdquo analysis times which diminish the cardiac perfusion and deteriorate the chance for successful defibrillations. Our approach consists in estimating the CPR part of a corrupted signal by adaptive regression on lagged copies of a reference signal which correlate with the CPR artifact signal. The algorithm is based on a state-space model and the corresponding Kalman recursions. It allows for stochastically changing regression coefficients. The residuals of the Kalman estimation can be identified with the CPR-filtered ECG signal. In comparison with ordinary least-squares regression, the proposed algorithm shows, for low signal-to-noise ratio (SNR) corrupted signals, better SNR improvements and yields better estimates of the mean frequency and mean amplitude of the true VF ECG signal. The preliminary results from a small pool of human VF and animal asystole CPR data are slightly better than the results of comparable previous studies which, however, not only used different algorithms but also different data pools. The algorithm carries the possibility of further optimization.

The prognostic significance of coma-rating, duration of anoxia and cardiopulmonary resuscitation in out-of-hospital cardiac arrest

Abstract Early determination of outcome after successful prehospital cardiopulmonary resuscitation (CPR) is a common problem with great ethical, economic, social, and legal consequences. We prospectively investigated 112 adult patients who had been resuscitated after out-of-hospital cardiac arrest (CA). The aim of our study was to determine whether coma rating by the mobile intensive care unit (MICU) is a useful tool for outcome prediction. For neurological assessment the Innsbruck Coma Scale (ICS) was used initially and after return of spontaneous circulation (ROSC) or 20–30 min after the start of CPR, before any sedating drugs were given. The duration of anoxia and CPR were determined with the automatically recorded emergency call protocol of the dispatch centre and the protocol of the MICU. For estimation of cerebral outcome at the time of discharge from hospital we used the Glasgow-Pittsburgh Cerebral Performance Categories (CPC). Restoration of spontaneous circulation was achieved in 42 patients (37%), and 15 (13%) were discharged from hospital. The first coma rating performed immediately at the time of arrival on scene had no significant prognostic value for prediction of neurological outcome (P = 0.204) and survival (P = 0.103). The second coma rating (performed after ROSC or 20–30 min after the start of CPR), however, demonstrated a significant correlation with neurological outcome (P = 0.0000) and survival (P = 0.0000), a correlation which was comparable to both duration of anoxia and duration of CPR. In patients with out-of-hospital cardiac arrest prognostic information could be obtained with the ICS as early as 20– 30 min after the start of cardiopulmonary resuscitation.

Forward blood flow during cardiopulmonary resuscitation in patients with severe accidental hypothermia: An echocardiographic study

Background: The mechanism responsible for the forward blood flow associated with external chest compression is still controversial. Evidence for both blood flow caused by direct cardiac compression and blood flow generated by a general increase in intrathoracic pressure has been found in experimental as well as clinical studies. No data are available concerning the mechanism causing forward blood flow in hypothermic patients undergoing cardiopulmonary resuscitation. Therefore, echocardiographic findings during external chest compression in seven hypothermic arrest victims are reported.

Review of active compression-decompression cardiopulmonary resuscitation (ACD-CPR) Analysis of iatrogenic complications and their biomechanical explanation

Our review takes a critical look at the active compression-decompression technique (ACD) for cardiopulmonary resuscitation (CPR). ACD-CPR was developed following a report of successful resuscitation performed by a medical amateur using a household plunger. The efficacy of the principle of active decompression has been demonstrated by animal and human studies. Potential iatrogenic complications from the CardioPump were evaluated only when large clinical trials were already underway. Our prospective analysis of autopsy patients and systematic randomised studies in corpses prove that ACD-CPR using the CardioPump considerably increases the rate of iatrogenic complications and especially of sternum fractures. The experimental use of the CardioPump in corpses and the analysis of a variety of different parameters, especially of the rubber cushion pads mounted in the silicone cup to prevent skin abrasions, revealed a statistically significant correlation between sternum fractures and female sex (P < 0.01) and usage of the rubber cushion pad (P = 0.045). Biomechanical studies showed that the transmission of forces from the CardioPump is greatly dependent on chest shape. The lower the sternum is sunken compared with the surrounding structures, the higher the force which is transmitted via the central area of the device onto the sternum. The rubber cushion pad shortens the distance between CardioPump and sternum by 5 mm and therefore increases the sternal loading. Sex differences in the shape of the sternum and especially the thickness may account for the significant correlation between sternum fractures and female sex.