Patrick Plaisance

A comparison of standard cardiopulmonary resuscitation and active compression- decompression resuscitation for out-of-hospital cardiac arrest

Background We previously observed that short-term survival after out-of-hospital cardiac arrest was greater with active compression–decompression cardiopulmonary resuscitation (CPR) than with standard CPR. In the current study, we assessed the effects of the active compression–decompression method on one-year survival. Methods Patients who had cardiac arrest in the Paris metropolitan area or in Thionville, France, more than 80 percent of whom had asystole, were assigned to receive either standard CPR (377 patients) or active compression–decompression CPR (373 patients) according to whether their arrest occurred on an even or odd day of the month, respectively. The primary end point was survival at one year. The rate of survival to hospital discharge without neurologic impairment and the neurologic outcome were secondary end points. Results Both the rate of hospital discharge without neurologic impairment (6 percent vs. 2 percent, P=0.01) and the one-year survival rate (5 percent vs. 2 percent, P=0.03) wer...

Practical recommendations for prehospital and early in-hospital management of patients presenting with acute heart failure syndromes

Guideline recommendations for the prehospital and early in-hospital (first 6-12 hrs after presentation) management of acute heart failure syndromes are lacking. The American College of Cardiology/American Heart Association and European Society of Cardiology guidelines direct the management of these acute heart failure patients, but specific consensus on early management has not been published, primarily because few early management trials have been conducted. This article summarizes practical recommendations for the prehospital and early management of patients with acute heart failure syndromes; the recommendations were developed from a meeting of experts in cardiology, emergency medicine, and intensive care medicine from Europe and the United States. The recommendations are based on a unique clinical classification system considering the initial systolic blood pressure and other symptoms: 1) dyspnea and/or congestion with systolic blood pressure >140 mm Hg; 2) dyspnea and/or congestion with systolic blood pressure 100-140 mm Hg; 3) dyspnea and/or congestion with systolic blood pressure <100 mm Hg; 4) dyspnea and/or congestion with signs of acute coronary syndrome; and 5) isolated right ventricular failure. These practical recommendations are not intended to replace existing guidelines. Rather, they are meant to serve as a tool to facilitate guideline implementation where data are available and to provide suggested treatment approaches where formal guidelines and definitive evidence are lacking.

Benefit of Active Compression-Decompression Cardiopulmonary Resuscitation as a Prehospital Advanced Cardiac Life Support A Randomized Multicenter Study

BACKGROUND We compared short-term prognosis of active compression-decompression (ACD) and standard (STD) cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrests. METHODS AND RESULTS We randomized advanced cardiac life support (ACLS) with ACD ACLS CPR on odd days and STD ACLS CPR on even days. We measured the rates of return of spontaneous circulation (ROSC), survival at 1 hour (H1), at 24 hours (H24), and at 1 month (D30): hospital discharge (HD); neurological outcome; and complications. Mean times from collapse to basic cardiac life support CPR was 9 minutes and from collapse to ACLS CPR was 21 minutes. Compared with the STD ACLS patients (n = 258), ACD ACLS patients (n = 254) had higher survival rates (ROSC, 44.9% versus 29.8%, P = .0004; H1, 36.6% versus 24.8%, P = .003; H24, 26% versus 13.6%, P = .002; HD without neurological impairment, 5.5% versus 1.9%, P = .03) and a trend for improvement in neurological outcome at D30 (Glasgow-Pittsburgh Outcome Categories = 1.6 +/- 0.8 versus 2.3 +/- 1.1. P = .09). Sternal dislodgements (2.9% versus 0.4%, P = .03) and hemoptysis (5.4% versus 1.3%, P = .01) were more frequent in the ACD ACLS group. CONCLUSIONS Despite long time intervals, ACD significantly improved short-term survival rates in out-of-hospital cardiac arrests compared with STD CPR.

Trends in death attributed to heart failure over the past two decades in Europe

Little is known regarding temporal trends in mortality attributed to heart failure (HF) from a population perspective. The aim of this study was to assess the mortality related to HF as an underlying cause during the last 20 years in seven European countries.

Head injury: Clonidine decreases plasma catecholamines

Seven patients who had suffered head injury 3 to 5 days before the study was undertaken received clonidine (2.5 μg/kg iv over 10 min). This resulted in a reduction of plasma norepinephrine (p < .05) and in normalization of plasma epinephrine (p < .05). Neither common carotid blood flow nor diastolic blood flow as index of global cerebral perfusion as measured by pulsed Doppler changed. The reduction of sympathetic overactivity, probably due to the specific action of clonidine on α2-adrenoceptors within the rostral ventrolateral medulla, may be of interest in the management of head injury because of the maintenance of cephalic hemodynamics. (Crit Care Med 1990; 18:392)

In-hospital and long-term prognosis of elderly patients requiring endotracheal intubation for life-threatening presentation of cardiogenic pulmonary edema.

ObjectiveWe studied the in-hospital course, long-term prognosis, and functional status of elderly patients with life-threatening cardiogenic pulmonary edema requiring mechanical ventilation. DesignSemiprospective evaluation. SettingTwelve intensive care units and one emergency prehospital medical department in university hospitals. PatientsPatients, aged >75 yrs, with life-threatening cardiogenic pulmonary edema requiring invasive airway management during the prehospital phase between January 1994 and January 1999 were included. InterventionNone. Measurements and Main Results A total of 79 patients were studied, of which 55 were included in the prospective phase and 24 during the retrospective phase. The age range was 75–99 yrs, with a mean age of 82.4 ± 5.9. The male/female ratio was 35:44. The in-hospital mortality was 26.6%. The mean follow-up time for all 58 survivors was 23 months (range, 2–56 months). Among those discharged, survival at 1 yr was 69%. At 3 months after hospital discharge, 49 (87%) patients lived at home, 46 (82%) were able to bathe themselves, 35 (62%) could walk at least one block, and 34 (61%) could climb one flight of stairs. ConclusionsMortality after severe pulmonary edema requiring endotracheal intubation in a very elderly cohort has a predictably high mortality, although not related directly to the degree of presenting respiratory compromise. However, approximately 50% of the overall cohort returned to relatively good functional status, despite advanced age and a severely compromised presentation. Aggressive airway management appears, therefore, justified in this select group of patients.

Augmentation of ventricular preload during treatment of cardiovascular collapse and cardiac arrest.

Despite aggressive measures for the treatment of cardiovascular collapse and cardiac arrest, the hypotension associated with these malignant processes usually leads to profound vital-organ ischemia and death. A fundamental therapeutic challenge of such life-threatening processes is the restoration of adequate blood flow to the heart and the brain. However, to maintain adequate forward blood flow out of the heart, venous blood return must be drawn back into the heart. With the exception of administration of exogenous fluid replacement, there are limited ways to enhance blood flow back to the heart during prolonged hypotension. This article describes the potential value of a new impedance threshold valve for the treatment of cardiac arrest and hypotension. The valve was designed to create a vacuum within the thorax during the decompression phase of cardiopulmonary resuscitation or during inhalation. By transiently blocking inspiratory gas exchange during the decompression phase of cardiopulmonary resuscitation, after phrenic nerve-stimulated gasping, or during spontaneous ventilation, the impedance-valve concept may have clinical value in the treatment of patients in cardiac arrest, hemorrhagic shock, and cardiovascular collapse secondary to a number of life-threatening clinical processes.

The effects of positive end-expiratory pressure during active compression decompression cardiopulmonary resuscitation with the inspiratory threshold valve.

The use of an inspiratory impedance threshold valve (ITV) during active compression-decompression (ACD) cardiopulmonary resuscitation (CPR) improves perfusion pressures, and vital organ blood flow. We evaluated the effects of positive end-expiratory pressure (PEEP) on gas exchange, and coronary perfusion pressure gradients during ACD + ITV CPR in a porcine cardiac arrest model. All animals received pure oxygen intermittent positive pressure ventilation (IPPV) at a 5:1 compression-ventilation ratio during ACD + ITV CPR. After 8 min, pigs were randomized to further IPPV alone (n = 8), or IPPV with increasing levels of PEEP (n = 8) of 2.5, 5.0, 7.5, and 10 cm H2O for 4 consecutive min each, respectively. Mean ± sem arterial oxygen partial pressure decreased in the IPPV group from 150 ± 30 at baseline after 8 min of CPR to 110 ± 25 torr at 24 min, but increased in the PEEP group from 115 ± 15 to 170 ± 25 torr with increasing levels of PEEP (P <0.02 for comparisons within groups). Mean ± sem diastolic aortic minus diastolic left ventricular pressure gradient was significantly (P < 0.001) higher after the administration of PEEP (24 ± 0 vs 17 ± 1 mm Hg with 5 cm H2O of PEEP, and 26 ± 0 vs 17 ± 1 mm Hg with 10 cm H2O of PEEP), whereas the diastolic aortic minus right atrial pressure gradient (coronary perfusion pressure) was comparable between groups. Furthermore, systolic aortic pressures were significantly (P < 0.05) higher with 10 cm H2O of PEEP when compared with IPPV alone (68 ± 0 vs 59 ± 2 mm Hg). In conclusion, when CPR was performed with devices designed to improve venous return to the chest, increasing PEEP levels improved oxygenation. Moreover, PEEP significantly increased the diastolic aortic minus left ventricular gradient and did not affect the decompression phase aortic minus right atrial pressure gradient. These data suggest that PEEP reduces alveolar collapse during ACD + ITV CPR, thus leading to an increase in indirect myocardial compression.

Effect of the Addition of Vasopressin or Vasopressin Plus Nitroglycerin to Epinephrine on Arterial Blood Pressure during Cardiopulmonary Resuscitation in Humans

BACKGROUND Infusion of a vasopressor during cardiopulmonary resuscitation (CPR) in humans increases end decompression (diastolic) arterial blood pressure, and consequently increases vital organ perfusion pressure and survival. Several vasoactive drugs have been tested alone or in combination, but their hemodynamic effects have not been investigated clinically in humans. STUDY OBJECTIVE We tested the hypothesis that epinephrine (1 mg) co-administered with vasopressin (40 IU) ± nitroglycerin (300 μg) results in higher diastolic blood pressure than epinephrine alone. STUDY DESIGN A prospective, randomized, double-blinded controlled trial in the prehospital setting. The study included 48 patients with witnessed cardiac arrest. Patients received either epinephrine alone (E alone) or epinephrine plus vasopressin (E+V) or epinephrine plus vasopressin plus nitroglycerin (E+V+N). A femoral arterial catheter was inserted for arterial pressure measurement. OUTCOME MEASURES The primary end point was diastolic blood pressure during CPR, 15 min after the first drug administration (T = 15 min). RESULTS After exclusions, a total of 44 patients were enrolled. Diastolic blood pressures (mm Hg) at T = 15 min were not statistically different between groups (median [interquartile range]: 20 [10], 15 [6], and 15 [13] for E alone, E+V, and E+V+N, respectively. The rate of return of spontaneous circulation was 63% (n = 10) in the epinephrine group, 43% (n = 6) in the epinephrine plus vasopressin group, and 36% (n = 5) in the triple therapy group (NS). CONCLUSIONS Addition of vasopressin or vasopressin plus nitroglycerin to epinephrine did not increase perfusion blood pressure compared to epinephrine alone in humans in cardiac arrest, suggesting the absence of benefit in using these drug combination(s).

Prolonged severe hypercapnia complicating near fatal asthma in a 35-year-old woman

Objective: We describe a patient with a prolonged and severe hypercapnia occurring during an episode of status asthmaticus induced by ophthalmic instillation of carteolol. Setting: Prehospital Emergency Medical Service and Pulmonary Intensive Care Unit in a university hospital. Patient: A 35-year-old female developed an acute asthma attack while at home, which required advanced life support. Intervention: On hospital admission, arterial blood gases revealed a PaCO2 of 208 mmHg. Hypercapnia persisted with a PaCO2 of more than 190 mmHg for 10 h, with pH always less than 7.00. The patient was finally discharged after 26 days without sequelae. Conclusion: This case illustrates the cerebral and cardiovascular tolerance of severe and prolonged hypercapnia associated with major acidosis.