Cardiopulmonary resuscitation on television: are we miseducating the public?


Abstract

Background Out-of-hospital cardiac arrest survival rates in the UK are poor, and non-medically trained individuals have been identified to perform substandard cardiopulmonary resuscitation (CPR). Millions watch televised medical dramas and, for many, these comprise their only education on CPR. This study aims to investigate the quality of CPR portrayed on these programmes and whether this has an effect on public knowledge.

 

Methods Prospective observational study of 30 consecutive episodes of three popular medical dramas. Public knowledge of CPR and viewing habits were assessed with a survey of non-medically trained personnel.

 

Results 90 episodes were reviewed with 39 resuscitation attempts shown. Chest compression rates varied from 60 to 204 compressions per minute with a median of 122 (95% CI 113 to 132). Depth varied from 1.5 to 7.5 cm with a median of 3 (3.15–4.31). Rate and depth were significantly different from the UK Resuscitation Council Guidelines (2010) (p<0.05, t-test). Survey participants (n=160, 80% response rate) documented what they thought was the correct rate and depth of chest compressions and were scored accordingly. Those who documented watching medical dramas regularly scored significantly worse than those who watched occasionally (p<0.05, Mann-Whitney test).

 

Conclusion Televised medical dramas depict CPR inaccurately and laypersons may be less well informed about the correct technique the more they tune into these programmes. While there may be other confounding variables, given the popularity of television medical dramas, the poor depiction may be significantly contributing to poor public CPR knowledge and represent a potential new avenue of public education.

FDA Approves New CPR Device for Out-of-Hospital Cardiac Arrest


The US Food and Drug Administration (FDA) has granted premarket approval to the ResQCPR system (Zoll Medical, Chelmsford, MA), a new compression-decompression device designed to aid in the performance of cardiopulmonary resuscitation (CPR)[1].

The ResQCPR is composed of two devices. The first, known as the ResQPump, has a double-grip handle that attaches to patient’s chest with a suction cup. It is designed with a metronome and force gauge to aid in chest compressions. The timing mechanism helps responders maintain the correct compression rate while the force gauge helps assist in achieving the correct compression depth.
The second part of the device is known as the ResQPod 16.0 impedance threshold device. It fits onto a face mask or breathing tube and is designed to reduce airflow into the chest during the “decompression” phase with the ResQPump. By reducing intrathoracic pressure during the decompression phase, more blood is drawn back to the heart, and this greater volume of blood can be pumped to the body on the next compression.

In a clinical trial testing the system in patients with out-of-hospital cardiac arrest, including 813 randomized to standard CPR and 842 subjects who received CPR with the ResQCPR system, a significantly greater number of patients survived to hospital discharge with favorable neurological function. Overall, there was a 49% increase in survival to 1 year among those treated with the novel system compared with conventional CPR. In May 2014, an FDA advisory panel recommended approval of the system.

The ResQCPR system was developed by Minnesota-based Advanced Circulatory Systems, a company Zoll Medical acquired in 2015. According to Zoll, the company expects the system to be commercially available in the US by mid-2015.

Ultrasound Confirms Tube Position During Cardiopulmonary Resuscitation.


In this small study, the positive predictive value of ultrasound to confirm endotracheal tube placement during active compressions was 98.8%.
Confirming correct endotracheal tube (ETT) placement during cardiopulmonary resuscitation (CPR) can be challenging. In a prospective observational study, researchers in Taiwan assessed the accuracy of real-time tracheal ultrasonography in 89 cardiac arrest patients (age range, 24–98 years) receiving emergency intubation during CPR. Patients with severe neck trauma, neck tumors, or history of neck surgery (including tracheotomy) were excluded. The gold standard for correct ETT placement was defined as bilateral auscultated breath sounds with good capnography waveform and exhaled carbon dioxide >4 mm Hg after at least 5 breaths.

Three senior emergency medicine residents supervised by experienced faculty performed tracheal ultrasonography during and immediately after ETT insertion, with most scans taking 10 seconds or less. Observation of a single air-mucosa interface with comet-tail artifact confirmed tracheal placement. Seven patients (7.8%) had esophageal intubations. Sensitivity, specificity, and positive and negative predictive values of tracheal ultrasound for identifying ETT position were 100%, 86%, 99%, and 100%, respectively.

COMMENT

Aspiration devices are the current standard for confirmation of tracheal tube placement during CPR when end-tidal CO2 is not detectable. Ultrasound shows promise in this setting, but the failure to identify 1 in 7 esophageal intubations is concerning. The key to establishing the value of ultrasound for tracheal tube confirmation lies in demonstration of its ability to detect 100% of esophageal intubations. We are not there yet.

Source: NEJM

Vasopressin, Steroids, and Epinephrine and Neurologically Favorable Survival After In-Hospital Cardiac Arrest.


A Randomized Clinical Trial

 

Importance  Among patients with cardiac arrest, preliminary data have shown improved return of spontaneous circulation and survival to hospital discharge with the vasopressin-steroids-epinephrine (VSE) combination.

Objective  To determine whether combined vasopressin-epinephrine during cardiopulmonary resuscitation (CPR) and corticosteroid supplementation during and after CPR improve survival to hospital discharge with a Cerebral Performance Category (CPC) score of 1 or 2 in vasopressor-requiring, in-hospital cardiac arrest.

Design, Setting, and Participants  Randomized, double-blind, placebo-controlled, parallel-group trial performed from September 1, 2008, to October 1, 2010, in 3 Greek tertiary care centers (2400 beds) with 268 consecutive patients with cardiac arrest requiring epinephrine according to resuscitation guidelines (from 364 patients assessed for eligibility).

Interventions  Patients received either vasopressin (20 IU/CPR cycle) plus epinephrine (1 mg/CPR cycle; cycle duration approximately 3 minutes) (VSE group, n = 130) or saline placebo plus epinephrine (1 mg/CPR cycle; cycle duration approximately 3 minutes) (control group, n = 138) for the first 5 CPR cycles after randomization, followed by additional epinephrine if needed. During the first CPR cycle after randomization, patients in the VSE group received methylprednisolone (40 mg) and patients in the control group received saline placebo. Shock after resuscitation was treated with stress-dose hydrocortisone (300 mg daily for 7 days maximum and gradual taper) (VSE group, n = 76) or saline placebo (control group, n = 73).

Main Outcomes and Measures  Return of spontaneous circulation (ROSC) for 20 minutes or longer and survival to hospital discharge with a CPC score of 1 or 2.

Results  Follow-up was completed in all resuscitated patients. Patients in the VSE group vs patients in the control group had higher probability for ROSC of 20 minutes or longer (109/130 [83.9%] vs 91/138 [65.9%]; odds ratio [OR], 2.98; 95% CI, 1.39-6.40; P = .005) and survival to hospital discharge with CPC score of 1 or 2 (18/130 [13.9%] vs 7/138 [5.1%]; OR, 3.28; 95% CI, 1.17-9.20; P = .02). Patients in the VSE group with postresuscitation shock vs corresponding patients in the control group had higher probability for survival to hospital discharge with CPC scores of 1 or 2 (16/76 [21.1%] vs 6/73 [8.2%]; OR, 3.74; 95% CI, 1.20-11.62; P = .02), improved hemodynamics and central venous oxygen saturation, and less organ dysfunction. Adverse event rates were similar in the 2 groups.

Conclusion and Relevance  Among patients with cardiac arrest requiring vasopressors, combined vasopressin-epinephrine and methylprednisolone during CPR and stress-dose hydrocortisone in postresuscitation shock, compared with epinephrine/saline placebo, resulted in improved survival to hospital discharge with favorable neurological status.

Source: JAMA

Paralyzing Comatose Cardiac Arrest Survivors Improves Outcomes.


Neuromuscular blockade for at least 24 hours improved in-hospital survival rate.
The 2010 American Heart Association guidelines recommend limiting neuromuscular blockade (NMB) in patients with return of spontaneous circulation (ROSC) because it could be harmful. However, NMB is often used to prevent shivering in post–cardiac arrest patients receiving therapeutic hypothermia. Researchers performed a post-hoc analysis of a prospective, observational study of comatose adults with nontraumatic out-of-hospital cardiac arrest who had sustained ROSC (palpable pulses for ≥20 minutes) and were transported to four centers over a 9-month period.

Of 111 patients, 18 received NMB for at least 24 hours after ROSC (sustained NMB), 59 received NMB for less than 24 hours, and 34 received no NMB. In-hospital survival was higher in patients who received NMB at any point than in those who received no NMB (52% vs. 35%). Patients who received sustained NMB were more likely to survive than the other two groups combined (78% vs. 41%). Fifty percent of those who received sustained NMB and 28% of the other two groups had favorable neurologic outcomes (not a significant difference). The sustained-NMB group had similar prognostic scores but shorter time from collapse to ROSC, higher baseline blood pH, and lower incidence of chronic obstructive pulmonary disease than the other two groups combined. Multivariable analysis showed that sustained NMB was independently associated with survival (adjusted odds ratio, 7.23) and improvement in lactic acidosis.

The authors postulate that NMB reduces metabolic demand and global oxygen consumption, improves pulmonary gas exchange, and prevents ventilator dyssynchrony, thereby protecting against episodic rises in intracranial pressure.

COMMENT

Although some studies have suggested that long-term neuromuscular blockade may lead to critical illness, polyneuropathy, or generalized muscle weakness, this study suggests it may have benefit in post–cardiac arrest patients. A note of caution, however: Be sure that any patient with a chance of awareness is adequately sedated before paralysis!

 

 

 

Man vs. Machine for CPR.


In this meta-analysis, return of spontaneous circulation was more likely when chest compressions were delivered by a mechanical device than manually.

When applied properly, mechanical devices provide consistent and effective chest compressions; no risk for provider fatigue; and the opportunity for concurrent defibrillation, thereby reducing time to shock. Investigators performed a meta-analysis of controlled (randomized, historical, or case-control) trials in humans to compare prehospital cardiopulmonary resuscitation (CPR) using a mechanical chest compression device versus manual compressions.

Of 12 studies meeting entry criteria, 8 involved load-distributing band CPR and 4 used piston-driven CPR, with a total of 6538 patients and 1824 instances of return of spontaneous circulation (ROSC). ROSC was defined as a measurable blood pressure sustained for at least 1 minute. Use of a mechanical device was superior to manual compressions for achieving ROSC (odds ratio, 1.53 overall, 1.62 for load-distributing band CPR, and 1.25 for piston-driven CPR).

Comment: Compression devices have become more lightweight and portable, making them a more attractive option for prehospital resuscitation, where it may be more difficult to achieve consistently adequate manual compressions. Such devices can be expected to similarly outperform humans in the emergency department and hospital settings, too, making a convincing argument for their routine use during resuscitation.

 

Source: Journal Watch Emergency Medicine

Routine Propofol Sedation Increases Risk During Colonoscopy In a large database study, anesthesia assistance was associated with an elevated risk for perforation, splenic injury, or aspiration pneumonia. The use of anesthesiologist-administered propofol sedation for colonoscopy is increasing in the U.S. (JW Gastroenterol April 13 2012 and JW Gastroenterol Feb 17 2012). Propofol use during colonoscopy is associated with shorter recovery time and higher patient satisfaction but also an estimated 20% increase in health care costs. Whereas most studies on the use of propofol sedation during colonoscopy have focused on its economic cost, researchers now explore another possible disadvantage — increased risk for complications. Using a database of linked U.S. Medicare and cancer registry data, investigators identified patients without cancer who underwent diagnostic colonoscopy between 2000 and 2009, assessed whether they received anesthesiology services, and determined whether they were hospitalized during the 30 days following colonoscopy for perforation, splenic injury, or aspiration pneumonia. Data on the type of anesthetic agent used were unavailable, but investigators assumed that anesthesiologist-administered propofol was used most often. Of 165,527 colonoscopy examinations in 100,359 patients, 35,128 procedures (21.2%) were performed with anesthesia assistance. Complications of aspiration, perforation, or splenic injury occurred more frequently in patients who received anesthesia assistance than in those who did not (0.22% vs. 0.16%, P<0.001; odds ratio, 1.46; 95% confidence interval, 1.09–1.94). This difference was mostly attributable to the difference in risk for aspiration (0.14% vs. 0.10%; P=0.02). The risks for perforation and splenic injury were similar between groups. Other independent risk factors for these complications were older age, male sex, increased comorbidity, and undergoing the procedure in a hospital. Comment: Although the overall rate of complications was very low, the use of anesthesia services for diagnostic colonoscopy resulted in a higher risk for complications. These findings might result in part from confounding if patients who received anesthesia assistance were sicker or more prone to complications and were chosen to receive anesthesia for those reasons. Also, the data were from a period when propofol was sometimes administered by trained nurses rather than anesthesiologists, and the relative safety of this approach compared to anesthesia-administered services cannot be determined. Finally, these findings might be more pronounced in the types of patients included in this trial ( 65 years old), and whether the observed increased risk is present in younger or more healthy patients remains to be determined.


In a simulation study, percent adequate chest compressions performed by in-hospital providers fell below 70% within 120 seconds in child and adult manikins.

 

The American Heart Association defines effective chest compression during cardiopulmonary resuscitation (CPR) as >100 compressions per minute at a depth >38 mm. In a prospective randomized crossover study, investigators compared quality of compressions and the work required to perform them on a 5-year old manikin and an adult manikin. Forty-five in-hospital healthcare providers performed single-rescuer continuous compressions for up to 10 minutes on both the child and adult manikins. A HeartStart MRx Monitor/Defibrillator was used to quantify compression rate and compression depth at 30-second intervals.

Mean chest compression rate remained above 100 per minute for both manikins. Mean compression depth decreased over the 10-minute period for both the child (41 to 34 mm) and adult (42 to 36 mm) manikins. Measured energy expended during CPR was comparable to that expended during running or swimming, and was about 15% greater for the adult than the child manikin. Over the 10-minute period, the percentage of adequate compressions fell from 85% to less than 40% for both manikins. Fewer than 70% of compressions were adequate by 90 seconds in the child and 120 seconds in the adult. Self-reported fatigue during the first 2 minutes was low in comparison to the decrease in compression quality.

Comment: Whether due to fatigue, declining vigilance, or other causes, providers perform high-quality CPR for only a brief period of time. These data support switching the person providing chest compressions every 2 minutes during resuscitation in adults and children.

 

Source: Journal Watch Emergency Medicine

 

Family-Witnessed CPR Associated with Better Psychological Outcomes.


Giving family members the choice to observe out-of-hospital cardiopulmonary resuscitation on a loved one might reduce psychological stress, according to a New England Journal of Medicinestudy.

Nearly 600 family members of people undergoing out-of-hospital CPR in France were either routinely asked (intervention) or not asked (control) if they wanted to be present during CPR. At 90 days, the control group had a higher prevalence of PTSD-related symptoms than the intervention group (37% vs. 27%). Interference by family members was rare, and there were no lawsuits.

Editorialists, noting that the intervention included a well-scripted protocol, conclude: “It would be imprudent to adopt this strategy into clinical practice without a similar commitment to training and staffing emergency response teams and without an understanding of the cost-effectiveness.”

Source: NEJM 

 

 

 

 

Benefits of Early Sepsis Interventions.


Use of the 6-hour sepsis resuscitation bundle was associated with reductions in mortality and hospital costs.

As part of a continuous quality improvement initiative, investigators analyzed data from 5 community and 6 tertiary hospitals in the U.S. that implemented an evidence-based, 6-hour sepsis resuscitation bundle for patients with suspected sepsis:

1) Measure serum lactate

2) Obtain blood cultures before antibiotic administration

3) Administer broad-spectrum antibiotic within 3 hours of emergency department (ED) admission and within 1 hour of non-ED intensive care unit admission

4) In the event of hypotension, serum lactate 4 mmol/L, or both:

  • Administer an initial minimum of 20 mL/kg of crystalloid or an equivalent
  • If hypotension does not respond to initial fluid resuscitation, administer vasopressors to maintain mean arterial pressure >65 mm Hg

5) In the event of persistent hypotension despite fluid resuscitation (septic shock), serum lactate 4 mmol/L, or both:

  • Achieve central venous pressure 8 mm Hg
  • Achieve central venous oxygen saturation 70%

In an analysis of 952 patients treated before and 4109 patients treated after implementation of the bundle at 8 hospitals, in-hospital mortality was significantly higher in the before group (43% vs. 29%). In an analysis of 1294 patients treated at 3 different hospitals after implementation of the bundle, mortality was significantly higher among the 602 patients who did not receive the full bundle than among the 692 patients who did (42% vs. 27%). In a combined analysis, hospital stay was 5.1 days shorter and 24-hour APACHE-II and SOFA scores were significantly lower in the treatment group (the 4109 patients treated after implementation and the 692 patients who received the full bundle) than in the control group (the 952 patients treated before implementation and the 602 patients who did not receive the full bundle).

The authors conclude that use of the sepsis resuscitation bundle is associated with significant reductions in hospital length of stay and mortality, with one life saved for every seven patients treated.

Comment: This observational study supports implementation of a sepsis resuscitation bundle in both community and tertiary hospitals and broad application of the bundle to all patients with suspected sepsis.

Source: Journal Watch Emergency Medicine

 

No Return of Pulses in the Field Portends Dismal Survival.


This study’s findings support use of prehospital termination-of-resuscitation protocols.

Prehospital cardiac arrest patients who do not achieve return of spontaneous circulation (ROSC) continue to be transported to the hospital despite the existence of prehospital termination-of-resuscitation protocols (JW Emerg Med Oct 17 2008). To determine survival rates in such patients, researchers analyzed data from two urban emergency medical service systems for patients who experienced cardiac arrest presumed to be of medical etiology from 2008 to 2010.

Among 2483 patients in whom resuscitation was attempted, survival to hospital discharge was 6.6%. ROSC in the field occurred in 36% of patients. Survival rates were 17.2% in patients with ROSC in the field versus 0.7% in those without ROSC. None of the 11 patients who survived without ROSC in the field had an initial rhythm of asystole.

Comment: If termination-of-resuscitation protocols that are based on ROSC had been followed in this study, the transport rate would have been halved. Although the authors’ recommendation for no transport of patients without field ROSC or shockable rhythm would save critical resources and reduce risks to prehospital providers and the public from collisions, nonmedical indications such as family wishes sometimes mandate transport of nonviable patients. When such patients are transported, these data are useful for receiving-hospital emergency physicians to determine whether to continue resuscitative efforts on arrival.

Source: Journal Watch Emergency Medicine .