Petter Andreas Steen

Quality of bystander cardiopulmonary resuscitation influences outcome after prehospital cardiac arrest

To evaluate the influence of quality of bystander cardiopulmonary resuscitation (CPR) on outcome in prehospital cardiac arrest we consecutively included patients with prehospital cardiac arrest treated by paramedics in a community run ambulance system in Oslo, Norway from 1985 to 1989. Good CPR was defined as palpable carotid or femoral pulse and intermittent chest expansion with inflation attempts. Outcome measure was hospital discharge rate. One hundred and forty-nine of 334 patients (45%) received bystander CPR. The discharge rate after good BCPR (23%) was higher than after no good BCPR (1%, P < 0.0005) or after no BCPR (6%, P < 0.0005). There was no difference between no good and no BCPR (P = 0.1114). There were no differences in paramedic response interval between the groups, but the mean interval from start of unconsciousness to initiation of CPR (arrest-CPR interval) was significantly shorter in the group receiving good bystander CPR (2.5 min, 95% confidence interval (CI): 1.7-3.3 min) than no good CPR (6.6 min, CI: 5.2-8.0 min) or no bystander CPR (7.8 min, CI: 7.2-8.4 min). Bystanders started CPR more frequently in public than in the patients home (58 vs. 34%, P < 0.0005). Good bystander CPR was associated with a shorter arrest-CPR interval and improved hospital discharge rate as compared to no good BCPR or no BCPR.

Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest: A Randomized Trial

CONTEXT Intravenous access and drug administration are included in advanced cardiac life support (ACLS) guidelines despite a lack of evidence for improved outcomes. Epinephrine was an independent predictor of poor outcome in a large epidemiological study, possibly due to toxicity of the drug or cardiopulmonary resuscitation (CPR) interruptions secondary to establishing an intravenous line and drug administration. OBJECTIVE To determine whether removing intravenous drug administration from an ACLS protocol would improve survival to hospital discharge after out-of-hospital cardiac arrest. DESIGN, SETTING, AND PATIENTS Prospective, randomized controlled trial of consecutive adult patients with out-of-hospital nontraumatic cardiac arrest treated within the emergency medical service system in Oslo, Norway, between May 1, 2003, and April 28, 2008. INTERVENTIONS Advanced cardiac life support with intravenous drug administration or ACLS without access to intravenous drug administration. MAIN OUTCOME MEASURES The primary outcome was survival to hospital discharge. The secondary outcomes were 1-year survival, survival with favorable neurological outcome, hospital admission with return of spontaneous circulation, and quality of CPR (chest compression rate, pauses, and ventilation rate). RESULTS Of 1183 patients for whom resuscitation was attempted, 851 were included; 418 patients were in the ACLS with intravenous drug administration group and 433 were in the ACLS with no access to intravenous drug administration group. The rate of survival to hospital discharge was 10.5% for the intravenous drug administration group and 9.2% for the no intravenous drug administration group (P = .61), 32% vs 21%, respectively, (P<.001) for hospital admission with return of spontaneous circulation, 9.8% vs 8.1% (P = .45) for survival with favorable neurological outcome, and 10% vs 8% (P = .53) for survival at 1 year. The quality of CPR was comparable and within guideline recommendations for both groups. After adjustment for ventricular fibrillation, response interval, witnessed arrest, or arrest in a public location, there was no significant difference in survival to hospital discharge for the intravenous group vs the no intravenous group (adjusted odds ratio, 1.15; 95% confidence interval, 0.69-1.91). CONCLUSION Compared with patients who received ACLS without intravenous drug administration following out-of-hospital cardiac arrest, patients with intravenous access and drug administration had higher rates of short-term survival with no statistically significant improvement in survival to hospital discharge, quality of CPR, or long-term survival. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00121524.

Recommended Guidelines for Reviewing, Reporting, and Conducting Research on In-Hospital Resuscitation: The In-Hospital ‘Utstein Style’ A Statement for Healthcare Professionals From the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Australian Resuscitation Council, and the Resuscitation Councils of Southern Africa

This scientific statement is the product of the Utstein ’95 Symposium held June 23-24, 1995, at Utstein Abbey, Island of Mosteroy, Rogaland County, Norway. Draft versions were circulated for comment to participants of the Utstein ’95 Symposium; the European Resuscitation Council Executive Committee; the Emergency Cardiac Care Committee of the American Heart Association; the Executive Committees of the Heart and Stroke Foundation of Canada, the Australian Resuscitation Council, and the Resuscitation Councils of Southern Africa; and several outside reviewers. The development of this statement was authorized by the Science Advisory and Coordinating Committee of the AHA and the Executive Committee of the European Resuscitation Council. We do not know the true effectiveness of in-hospital resuscitation. Observed results of the many published studies vary greatly. Studies originate from different settings and have different patient populations. Reports suffer from nonuniform nomenclature and variable inclusion definitions. Patients differ in the extent of comorbid conditions and interventions in place at the time of cardiac arrest. These differences prevent valid interhospital and intrahospital comparisons and make determining the effectiveness of current resuscitation techniques impossible. To develop these guidelines the task force used a consensus development process that originated with the “Utstein style” for reporting outcome data from out-of-hospital resuscitation events. Task force members performed an integrated review of published studies. An initial draft was prepared, discussed, and revised at a 2-day conference. Further drafts were revised and circulated among task force members and discussed face-to-face at three subsequent meetings. The task force defined a set of data elements that are essential or desirable for documenting in-hospital cardiac arrest. Data categories are hospital variables, patient variables, arrest variables, and outcome variables. The “In-Hospital Utstein-Style Template” was developed to summarize these data and recommendations for reporting a specific set of survival rates and outcomes. The task force …

In-hospital factors associated with improved outcome after out-of-hospital cardiac arrest. A comparison between four regions in Norway

INTRODUCTION While pre-hospital factors related to outcome after out-of-hospital cardiac arrest (OHCA) are well known, little is known about possible in-hospitals factors related to outcome. HYPOTHESIS Some in-hospital factors are associated with outcome in terms of survival. MATERIAL AND METHODS An historical cohort observational study of all patients admitted to hospital with a spontaneous circulation after OHCA due to a cardiac cause in four different regions in Norway 1995-1999: Oslo, Akershus, Østfold and Stavanger. RESULTS In Oslo, Akershus, Østfold and Stavanger 98, 84, 91 and 186 patients were included, respectively. Hospital mortality was higher in Oslo (66%) and Akershus (64%) than in Østfold (56%) and Stavanger (44%), P=0.002. By multivariate analysis the following pre-arrest and pre-hospital factors were associated with in-hospital survival: age <or=71 years, better pre-arrest overall performance, a call-receipt-start CPR interval <or=1 min, and no use of adrenaline (epinephrine). The in-hospital factors associated with survival were: no seizures, base excess >-3.5 mmol l(-1), body temperature <or=37.8 degrees C, and serum glucose <or=10.6 mmol l(-1) 1-24 h after admittance with OR (95% CI) 2.72 (1.09-8.82, P=0.033), 1.12 (1.02-1.23, P=0.016), 2.67 (1.17-6.20, P=0.019) and 2.50 (1.11-5.65, P=0.028), respectively. Pre-arrest overall function, whether adrenaline was used, body temperature, the occurrence of hypotensive episodes, and the degree of metabolic acidosis differed between the four regions in parallel with the in-hospital survival rates. CONCLUSION Both pre-arrest, pre- and in-hospital factors were associated with in-hospital survival after OCHA. It seems important also to report in-hospital factors in outcome studies of OCHA. The design of the study precludes a conclusion on causability.

European Resuscitation Council Guidelines for Resuscitation 2010 Section 10. The ethics of resuscitation and end-of-life decisions.

uccessful resuscitation attempts have brought xtended, useful and precious life to many, and appiness and relief to their relatives and loved nes. And yet, there are occasions when resuscitaion attempts have merely prolonged suffering and he process of dying. In few cases resuscitation has esulted in the ultimate tragedy—–the patient in a ersistent vegetative state. Resuscitation attempts re unsuccessful in 70—95% of cases and death ultiately is inevitable. All would wish to die with ignity. Several ethical decisions are required to ensure hat the decisions to attempt or withhold cardiopulonary resuscitation (CPR) are appropriate, and hat patients and their loved ones are treated with ignity. These decisions may be influenced by indiidual, international and local cultural, legal, traitional, religious, social and economic factors.1—10 ometimes the decisions can be made in advance, This section of the guidelines deals with ethical aspects and decisions, including

Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: The in-hospital 'Utstein style'

This scientific statement is the product of the Utstein ’95 Symposium held June 23-24, 1995, at Utstein Abbey, Island of Mosteroy, Rogaland County, Norway. Draft versions were circulated for comment to participants of the Utstein ’95 Symposium; the European Resuscitation Council Executive Committee; the Emergency Cardiac Care Committee of the American Heart Association; the Executive Committees of the Heart and Stroke Foundation of Canada, the Australian Resuscitation Council, and the Resuscitation Councils of Southern Africa; and several outside reviewers. The development of this statement was authorized by the Science Advisory and Coordinating Committee of the AHA and the Executive Committee of the European Resuscitation Council. We do not know the true effectiveness of in-hospital resuscitation. Observed results of the many published studies vary greatly. Studies originate from different settings and have different patient populations. Reports suffer from nonuniform nomenclature and variable inclusion definitions. Patients differ in the extent of comorbid conditions and interventions in place at the time of cardiac arrest. These differences prevent valid interhospital and intrahospital comparisons and make determining the effectiveness of current resuscitation techniques impossible. To develop these guidelines the task force used a consensus development process that originated with the “Utstein style” for reporting outcome data from out-of-hospital resuscitation events. Task force members performed an integrated review of published studies. An initial draft was prepared, discussed, and revised at a 2-day conference. Further drafts were revised and circulated among task force members and discussed face-to-face at three subsequent meetings. The task force defined a set of data elements that are essential or desirable for documenting in-hospital cardiac arrest. Data categories are hospital variables, patient variables, arrest variables, and outcome variables. The “In-Hospital Utstein-Style Template” was developed to summarize these data and recommendations for reporting a specific set of survival rates and outcomes. The task force …

Effects of Cardiopulmonary Resuscitation on Predictors of Ventricular Fibrillation Defibrillation Success During Out-of-Hospital Cardiac Arrest

Background—Early defibrillation is considered the most important factor for restoring spontaneous circulation in cardiac arrest patients with ventricular fibrillation. Recent studies have shown that, after prolonged ventricular fibrillation, the rates of return of spontaneous circulation (ROSC) and survival are improved if defibrillation is delayed so that CPR can be given first. To examine whether CPR improves myocardial readiness for defibrillation, we analyzed whether CPR causes changes in predictors of defibrillation success calculated from the ventricular fibrillation waveform. Methods and Results—ECG recordings were retrieved for 105 patients from an original study of 200 patients receiving CPR or defibrillation first. Altogether, 267 CPR sequences from 77 patients were identified on which the effect of CPR could be evaluated. Five predictors of ROSC (spectral flatness measure, energy, centroid frequency, amplitude spectrum relationship, and estimated probability of ROSC) were determined from a spectral analysis of the ventricular fibrillation waveform immediately before and immediately after each of the 267 sequences. CPR increased spectral flatness measure, centroid frequency, and amplitude spectrum relationship (P <0.05, P <0.001, P <0.01). In an analysis of the effect of the duration of CPR, the probability of ROSC and amplitude spectrum relationship showed a positive change for CPR sequences lasting >3 minutes (P <0.001, P <0.05). Conclusions—During resuscitation from ventricular fibrillation, changes in the predictors calculated from the ventricular fibrillation waveform indicated a positive effect of CPR on the myocardium.

Post-hypoxic hypothermia reduces cerebrocortical release of NO and excitotoxins

HYPOTHERMIA applied after hypoxia offers neuroprotection in neonatal animals, but the mechanisms involved remain unknown. Hypoxia was induced in newborn piglets and changes in excitatory amino acids (EAAs) and the citrulline:arginine ratio (CAR) were followed by microdialysis for 5 h. After the 45 min hypoxic insult, the animals were randomized to receive normothermia (39°C; n = 7) or hypothermia (35°C; n = 7). After reoxygenation, extracellular glutamate, aspartate and the excitotoxic index were significantly lower in the cerebral cortex of hypothermic animals than in normothermic animals. A progressive rise of the CAR occurred during reoxygenation in the normothermic group whereas the ratio tended to decrease in the hypothermic group. In conclusion, post-hypoxic hypothermia attenuated NO production and overflow of EAAs.

Retention of basic life support skills 6 months after training with an automated voice advisory manikin system without instructor involvement

AIM To evaluate the retention of skills 6 months after training in ventilation and chest compressions (CPR) on a manikin with computer based on-line voice advisory feedback and the possible effects of initial overtraining. METHODS Thirty five volunteers had 20 min provisional CPR training on a manikin with computer based voice advisory feedback but without an instructor. The appropriate feedback was taken from a pre-recorded list depending on performance measured by the manikin--computer system versus set limits for ventilation and compression variables. One group in addition was randomised to receive 10 similar 3 min training sessions during 1 week in the following month (overtrained group). All ventilation and compression variables were measured without feedback before and after the initial training session, with feedback immediately thereafter, and both without and with feedback 6 months after the initial training session. RESULTS The initial training improved all variables. Compressions with correct depth increased from a mean of 33 to 77%, and correct inflations from a mean of 9 to 58%. After 6 months, the results for the controls were not significantly different from pre-training, except for a higher of correct inflations (18%), while the overtrained group had better retention of skills including the correct compression depth (mean 61%) and inflations (mean 42%). When verbal feedback was added both the compressions and ventilations immediately improved both when tested immediately and 6 months after the initial training session. CONCLUSIONS The computer-based voice advisory manikin (VAM) feedback system can improve immediate performance of basic life support (BLS) skills, with better long-term retention with overtraining.

The Utstein template for uniform reporting of data following major trauma: A joint revision by SCANTEM, TARN, DGU-TR and RITG

BackgroundIn 1999, an Utstein Template for Uniform Reporting of Data following Major Trauma was published. Few papers have since been published based on that template, reflecting a lack of international consensus on its feasibility and use. The aim of the present revision was to further develop the Utstein Template, particularly with a major reduction in the number of core data variables and the addition of more precise definitions of data variables. In addition, we wanted to define a set of inclusion and exclusion criteria that will facilitate uniform comparison of trauma cases.MethodsOver a ten-month period, selected experts from major European trauma registries and organisations carried out an Utstein consensus process based on a modified nominal group technique.ResultsThe expert panel concluded that a New Injury Severity Score > 15 should be used as a single inclusion criterion, and five exclusion criteria were also selected. Thirty-five precisely defined core data variables were agreed upon, with further division into core data for Predictive models, System Characteristic Descriptors and for Process Mapping.ConclusionThrough a structured consensus process, the Utstein Template for Uniform Reporting of Data following Major Trauma has been revised. This revision will enhance national and international comparisons of trauma systems, and will form the basis for improved prediction models in trauma care.