Opting for CPR But Not Intubation May Not Be Wise

If you have an advance directive that cherry-picks the interventions you want to receive if your heart suddenly stops, you might want to rethink your choices, according to physicians writing in JAMA Internal Medicine.

As patients and families increasingly recognize the value of specifying their wishes regarding medical treatment in case they become unable to communicate, they need to better understand the implications of their decisions, the doctors say.

People who prepare for the possibility of cardiopulmonary resuscitation (CPR) by specifying selected options – “everything but intubation” or “everything but defibrillation” – don’t realize what that can mean, they warn.

Dr. Paul Rousseau of the Wake Forest School of Medicine in Winston-Salem, North Carolina describes a 77-year-old man with advanced cancer whose code status called for a “partial” code, with “no intubation.”

So while doctors were able to restart his heart, they couldn’t place a breathing tube in his lungs per his written wish. Without the breathing tube, he didn’t get enough oxygen, and as a result, he suffered severe brain damage. He remained comatose in the intensive care unit for another two weeks before he died.

Delivery of selected options during CPR attempts is a troublesome and increasingly frequent preference that often stems from good intentions among families balancing desires to save a life and limit suffering, Rousseau wrote in his paper.

Many staff, Rousseau recounts, felt that despite honoring this patient’s advance directive, they had actually harmed him. Others worried that the patient had not understood the likely outcomes.

“You do everything you can to return functioning, or you don’t,” Rousseau told Reuters Health. “If you are a baker and not using the main ingredient, the food will not come out okay.”

Rousseau would like to see partial codes banned. “When patients survive, it can often portend messy and emotional futures for families as well as physicians, not to mention financial repercussions for hospitals,” he said.

In a linked commentary, Dr. Josue Zapata and Dr. Eric Widera, both from the University of California, San Francisco, say “partial codes” are symptomatic of communication failures.

“A partial code likely represents a partial understanding by a patient or a partial assessment of their priorities by a provider,” they write.

Zapata and Widera advise doctors to ask patients what they hope their treatments will achieve.

“Providing a list of choices may in itself be misleading in that a patient may falsely believe that if a given intervention is offered as an option by a presumably expert and well-intentioned physician, there must be at least some sort of benefit,” they say.

Outcomes after partial codes in hospitals are hard to study; scant research exists. Large-scale studies show that after a full-out resuscitation effort, including intubation, 17 percent of patients live long enough to be discharged from the hospital, according to Zapata and Widera. For patients with advanced cancer, that rate is probably no higher than 5 percent.

Bioethicist Craig Klugman from DePaul University in Chicago agrees that partial codes should not be offered.

“There are many times in medicine when one thing requires a second thing, and to separate them undermines the chance of benefit,” Klugman told Reuters Health. “To offer a ‘choose your own adventure’ procedure violates the oath to do no harm.”

But Dr. Patrick Cullinan, former medical director of an intensive care unit in San Antonio, Texas, disagrees.

Cullinan told Reuters Health that when patients request a partial code without intubation, he often uses either bag masks or BiPAP (bilevel positive airway pressure), which are noninvasive breathing therapies, instead of intubation.

“Partial DNRs (Do Not Resuscitate orders) are helpful in allowing families to feel empowered and have some input,” Cullinan said. “Those staunchly ‘all’ or ‘nothing’ don’t understand subtleties in providing the most compassionate and appropriate care. By placing an unwanted tube, you steal their last opportunity to talk to their family, to tell them ‘I love you.'”

Dr. Melissa Bregger, a chief internal medicine resident at Northwestern University’s Feinberg School of Medicine in Chicago who has extensively studied CPR and advanced life support, says that while little data exists, emerging research showing improved outcomes using bag masks instead of intubation is “somewhat promising.” Among critically ill patients, however, not much evidence supports noninvasive measures.

“It depends on what caused the code, and that’s one of the hardest things to figure out during a code,” Bregger told Reuters Health. If patients code due to dangerous heart rhythms, partial codes may prove as effective as full efforts. However, such patients would be unlikely to have participated in planning discussions to request limited measures.”

“It’s a really hard question,” she said.

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.

Basic Life Support and Advanced Cardiac Life Support: Knowledge of Medical Students in New Delhi

Background: The chain of survival includes basic life support (BLS) as an important element. Knowledge of CPR is an important part of medical student’s training but there is still no routine training included in medical undergraduate teaching in developing countries like India, thus, medical graduates often face difficulty in emergency situations.
Aim: To assess BLS/ACLS knowledge among medical students from different professional years in New Delhi.
Methodology: A multi-centric study was planned as an analytical cross-sectional study with study sample drawn from medical students enrolled in various professional years and interns during the session 2012-2013 at 5 medical colleges of New Delhi. The sample was randomly drawn from each professional year and interns of 5 teaching hospitals of New Delhi. The study was conducted from May to August 2013.A predesigned self-administered objective questionnaire was distributed and15 minutes were given to each participant. Twenty questions were based on BLS while ten on ACLS.
Results: The data from 288 responders was analyzed using Microsoft Excel 2010 and Stata S.E 9.0.The mean scores of first-year students in BLS and ACLS were the lowest, 4.56 + 2.76 and 1.65 +  1.35 respectively while the mean scores of second-,third- and final-year students in BLS and ACLS were 6.28 +3.03 and 2.6 + 1.68, 7.75 + 3.34 and 3.62 + 2.47, 10.17 + 2.4 and 6.1 + 2.04 respectively. The mean scores of interns were the highest, 10.85 +1.83 in BLS and 6.35 + 2.59 respectively(p<0.001). The mean score of study sample was 7.416 + 3.55 in BLS and 3.7 + 2.66 in ACLS.
Those who received a formal training in BLS/ACLS had a mean score of 11.07+ 1.86 compared to those who had not received formal training and had a score of 6.99 + 3.43(p<0.001).
Conclusion: The study revealed that the medical undergraduates (UGs) had inadequate knowledge in BLS and ACLS. Most of them support the idea of training in BLS/ACLS to be a part of the UG curriculum. Those who were performing CPR (interns) had a significantly higher knowledge than those who didn’t. The knowledge of formally trained students is significantly higher than untrained students.
Despite important advances in prevention, cardiac arrest remains a substantial public health problem and a leading cause of death in many parts of the world.[1]In the United States and Canada, approximately 3,50,000 people per year (approximately half of them admitted in-hospitals) suffer a cardiac arrest and receive attempted resuscitation. This estimate does not include the substantial number of victims who suffer an arrest without attempted resuscitation. While attempted resuscitation is not always appropriate, there are many lives and life-years lost because appropriate resuscitation is not attempted.[2]
Cardiopulmonary resuscitation (CPR) is a series of life-saving actions that improve the chances of survival, following cardiac arrest.[3] Successful resuscitation, following cardiac arrest, requires an integrated set of coordinated actions represented by the links in the Chain of Survival. The links include the following: immediate recognition of cardiac arrest and activation of the emergency response system, early CPR with an emphasis on chest compressions, rapid defibrillation, effective advanced life support (ALS), and integrated post-cardiac arrest care.[4] The likelihood to achieveROSC increases with drug therapy, advanced airway management and physiological monitoring.
Return to a prior quality of life and functional state of health is the ultimate goal of a resuscitation system of care.In 1966 the AHA developed the first CPR guidelines which have been followed by periodic updates, the latest one being of 2010.[5]
Knowledge of CPR is an important part of medical student’s training but there is still no routine training included in the medical UG teaching in developing countries like India, thus, medical graduates when they become interns and post graduates often face difficulty in emergency situations. In this study we aimed at finding the awareness of medical students of various professional years and interns regarding BLS and ACLSwhich can be provided by either trained medical personnels,emergency medical technicians or by ordinarypeopletrained in BLS. This ability to recognize and treat a respiratory or cardiac arrest is a basic skill that all doctors are expected to have mastered. However,not many junior doctors are competent to carry out effective CPR.[6] There’s a lack of structured pattern of BLS/ACLS training in medical curriculum.[7]Thus, they are not completely confident when they suddenly face a situation of resuscitation.There are not many studies to assess the knowledge of medical students regarding resuscitation, especially in India. Hence this study was conducted to assess BLS/ACLS knowledge among them.
AIM:To assess BLS/ACLSknowledge among medical students from different professional years inNew Delhi.
Study Design: A multi-centric study was planned as an analytical cross-sectional study.
Study sample: It included medical students enrolled in various professional years and interns during the session of 2012-2013 at 5 medical colleges of New Delhi. The samplewas randomly drawn from each professional year and interns of 5 teaching hospitals of New Delhi. Permission was taken from the head of institutions (Table 1).
Study Time:The study was conducted over a 4-month period from May to August 2013.
Study Tool: A predesigned self-administered objective questionnaire was given to each participant. Twenty questions were based on BLS while ten were based on ACLS.A questionnaire was prepared by the authors that encompassed 3 domains:
1. Demography and formal training of the participants in BLS/ACLS
2. Theoretical and practical knowledge of the participants related to BLS,a set of self-prepared 20 MCQs with 4 options based on BLS For Healthcare Providers Student Manual,2010.
3.Theoretical and practical knowledge of the participants related to ACLS,a set of 10 MCQs with 4 options based on Advanced Cardiovascular
Life Support (ACLS) Provider Manual, 2010American Heart Association Guidelines for CPR and ECC.
Each student was given 15 minutes for 30 questions.
Data Analysis: The collected data were calculated using Microsoft Excel and then statistical analysis was made by Stata S.E 9.0. Student’s independent ‘t’ test was applied and p value <0.05 was considered statistically significant.
Out of 300 questionnaires filled,12 were excluded as they were incomplete and remaining 288 were included in the study. Table 1 gives us the demographic details of the participants.
Participants (96%) felt BLS and ACLS training should be a part of routine training in UG curriculum.
The mean scores of first-year students in BLS and ACLS were the lowest, 4.56 + 2.76 and 1.65 + 1.35 respectively while the mean scores of second-,third- and final years in BLS and ACLS were 6.28 +3.03 and 2.6 + 1.68, 7.75 + 3.34 and 3.62 + 2.47, 10.17 + 2.4 and 6.1 +2.04, respectively. The mean scores of interns were the highest, 10.85 + 1.83 in BLS and 6.35 + 2.59, respectively. The mean score of study sample was 7.416 + 3.55 in BLS and 3.7 + 2.66 in ACLS(Table 2).
An association was seen between the qualification of medical students/internsand their knowledge in BLS (p value <0.005) (Table 2).
Also an association was observed between the trained participants in BLS/ACLS and their mean scores(p<0.001) (Table 3).
Figures 1 and 2 show us the percentage score of the study group in BLS and ACLS respectively.Tables 4 and 5 show us theoretical and practical knowledge of the participants in BLS and ACLS respectively.
The study results showed that medical students in Delhi failed to show adequate knowledge in both BLS and ACLS (see Tables 4 and 5). Percentageof students who scored less than 50% in BLS was 65, only 2%(6) students scored 70%-79% and only 1% (3) studentsscored>80% (see Figure 1). Similar results were shown by ShantaChandrasekaran et al where none of the participants scored above 85% while 85% of participants scored less than 50%.[8]Only (48.1%) of the students from Switzerland could give correct answers on knowledge based questions.[9] Similarly low levels (54.3%, 25%) of knowledge have been reported from medical students in Poland and interns from southern India, respectively.[10],[11]
Early institution of CPR can double or triple the victim’s chances of survival fromsudden cardiac arrest.[12]However in our study only 41% had knowledge about the AED usage (see Table 5).In other study by Avabratha KS et al 37.4% of medical interns were aware of the AED usage.[13]
The newest development in the 2010 AHA Guidelines for CPR and ECC is a change in the BLS sequence ofsteps from airway, breathing, chest compressions (ABC) tochest compressions, airway, breathing (CAB) for adultsand pediatric patients (children and infants, excluding newborns) as the highest survival rates from cardiac arrest are reported among patients of all ages with witnessed arrest and a rhythm of VF or pulseless ventricular tachycardia (VT). In these patients the critical initial elements of CPR are chest compressions and early defibrillation.[5] However, in our study only 4% of the participants were able to answer all questions regarding chest compressions correctly.
Very few participants (9%) had undergone formal training in BLS and only 3.6% in ACLS. HN Harsha Kumar et al have also shown poor level of training among the UG medical students.[14]Low levels of training have been reported from Pakistan and the UK.[15],[16]
Statistically significant correlation was seen between the formal training of the participants and their knowledge in both BLS and ACLS(see Table 3).Shrestha Roshana et al. also showed that CPR training significantly influenced BLS knowledge of the participants as those who had received some CPR training within 5 years obtained the highest mean score of 8.62±2.49.[17]Other studies have also concluded  that the knowledge of trained personnels was better than those of untrained ones.[18]
Also a significant correlation was observed between the qualification of medical students and their knowledge (see Table 2).Interns who get training in BLS in their anaesthesia rotations had a significantly higher knowledge than the medical UGs who had no such exposure. Chaudhari A et al showed improvement in knowledge and skill of CPR followinga BLS training.[19]Elif et al also observed that past experience in real life resuscitation improved the awareness.[20]
According to the General Medical Council of the UK, preregistration house officers shouldhave training in BLS before they join their post and that theyshould receive ACLS training during the first year.[21]The royalcollege of physicians has also stated that ALS should be taught in theUG courses and the preregistration house officers should be capable ofinstituting ALS.[22]Participants (96%) felt BLS and ACLS training should be a part of routine training in the UG curriculum which is similar to other study, thus, reflecting that these are “felt needs” of the students.[14]
Training of resuscitation skills is poor due to lack of resources in developing countries like India.[23],[24]Moreover, as the guidelines are updated every 5 years, the need for repetitive training is a must so as to ensure that these changes are implemented. Medical schools are expected to produce well-trained doctors who are competent in clinical practice which include the techniques ofbasic resuscitation, thus, it is time that we standardize training in BLS and ACLS and make it a mandatory component of all medical UG curricula. The Medical Council of India has already incorporated emergency medicine as a separate speciality. Spreading awareness and teaching the basics of ALS to the medical and paramedical team as well as teaching BLS and first aid to the community will be the prime responsibility of this new emergency specialty.[13]
In conclusion, this study has revealed a critical issue that medical students in New Delhi lack adequate knowledge in BLS and ACLS which should be addressed promptly. Since prior CPR training and
clinical exposure influence the retention of knowledge, standard BLS/ACLS training should be incorporated in the UG curriculum and should be repeated periodically. It is also necessary to evaluate and update the knowledge of medical students in BLS and ACLS for better patient outcome and bringing about uniformity in healthcare delivery.
  1. Lloyd-Jones D, Adams RJ, Brown TM, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2010 update: a report from the American Heart Association. Circulation.2010;121:e46-e215.
  2. Nichol G, Thomas E, Callaway CW, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008;300:1423-1431.
  3. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. CircCardiovascQual Outcomes. 2010;3:63-81.
  4. Lee K. Cardiopulmonary resuscitation: new concept.TubercRespir Dis (Seoul).May 2012;72(5):401-408.
  5. John M. Field, Mary Fran Hazinski, Michael R. Sayre, et al.Part 1: Executive summary 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.Circulation. 2010;122:S640-S656.
  6. Skinner D, Camm A, Miles S. Cardiopulmonary skills of preregistration house officers.BMJ.1985; 290: 1549-1550.
  7. Zaheer H, Haque Z. Awareness about BLS (CPR) among medical students: status and requirements. JPMA.2009; 59(1):57-59.
  8. Chandrasekaran S, Kumar S, Bhat SA, et al. Awareness of basic life support among medical, dental, nursing students and doctors. Indian J Anaesth. 2010;54:121-126..
  9. Businger A, Rinderknecht S, Blank R, Merki L, Carrel T. Students’ knowledge of symptoms and risk factors of potential life-threatening medical conditions. Swiss Med Wkly. 2010;140:78-84.
  10. Chojnacki P, Ilieva R, Kolodziej A, Krolikowska A, Lipka J, Ruta J. Knowledge of BLS and AED resuscitation algorithm amongst medical students–preliminary results. AnestezjolIntensTer 2011;43:29-32.
  11. Sharma R, Attar NR. Adult basic life support (BLS) awareness and knowledge among medical and dental interns completing internship from deemed university. NUJHS. 2012;2:6-13.
  12. Larren MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out of hospital cardiac arrest: a graphic method. Ann Emerg Med.1993; 22:1652-1658.
  13. K.ShreedharaAvabratha, Bhagyalakshmi K, GanapathyPuranik,VaradarajShenoy,SanjeevaRai.A study of the knowledge of resuscitation among interns.Al Ame en J Med Sci (2 012 )5 (2 ) :1 5 2 -1 5 6
  14. HN Harsha Kumar, P SwasthikUpadhya, P Shruthi Ashok.A cross-sectional study on awareness and perception about basic life support/cardio-pulmonary resuscitation among undergraduate medical students from coastal South India.Int J Med Pub Health. 2013(3) ;146-150.
  15. Zaheer H, Haque Z. Awareness about BLS (CPR) among medical students: status and requirements. J Pak Med Assoc. 2009;59:57-59.
  16. Mastoridis S, Shanmugarajah K, Kneebone R. Undergraduate education in trauma medicine: the students’ verdict on current teaching. Med Teach. 2011;33:585-587.
  17. Shrestha Roshana1, Batajoo KH, Piryani RM, Sharma MW.Basic life support: knowledge and attitude of medical/paramedical professionals.World J Emerg Med, vol 3, no 2, 2012.
  18. Abbas A, Bukhari SI, Ahmed F. Knowledge of first aid and basic life support amongst medical students:a comparison between trained and un-trained students. JPMA.2011; 61: 613-616.
  19. Chaudhary A, Parikh H, Dave V. Current scenario: knowledge of basic life support in medical college. Natl J Med Res. 2011; 1: 80-82.
  20. Elif AA, Zeynep K. Knowledge of basic life support: a pilot study of the Turkish population by Baskentuniversity  in Ankara. Resuscitation.2003; 58: 187-192.
  21. Philips PS, Nolan JP. Training in basic and advanced life support in UK medical schools: questionnaire survey.BMJ.2001; 323(7303): 22-23.
  22. Royal College of Physicians of London.Resuscitation from cardiopulmonary arrest.J R Coll Physicians Lond.1987; 21:175-182.
  23. Garg RH. Who killed Rambhor?:the state of emergency medical services in India. J Emerg Trauma Shock. 2012;5:49-54.
  24. Jakob de Vries. Learning by (re)searching.J Young Med Researchers. 2013.

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.


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

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