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Demonstration of the 2-handed technique in initial use of the impedance threshold device (ITD) with a face mask, maintain- ing a continuously tight seal during compressions and ventilations. (Courtesy of Advanced Circulatory Systems, Minneapolis, Minnesota.)
Source publication
To determine the impact of the 2005 American Heart Association cardiopulmonary resuscitation (CPR) guidelines, including use of an impedance threshold device (ITD), on survival after in-hospital cardiac arrest.
Two community hospitals that tracked outcomes after in-hospital cardiac arrest pooled and compared their hospital discharge rate before and...
Contexts in source publication
Context 1
... ITD (ResQPOD, Advanced Circulatory Systems, Minneapolis, Minnesota) shown in Figure 1 was initially used on a face mask and then transferred to an advanced airway device as needed. When the ITD was used on a face mask, a 2-handed technique was implemented to main- tain a continuous tight seal between the face and the mask during compressions and ventilations. ...
Context 2
... performed by various hospital personnel, whereas airway management is typically performed pre- dominantly by respiratory therapy staff. While the ITD enhances circulation to the heart and brain, it is attached to the airway. Accordingly, respiratory care personnel were taught ITD use and the importance of proper 2-handed face mask technique (see Fig. 1). Furthermore, all person- nel were encouraged to correct colleagues when CPR was not performed according to the AHA guidelines. The im- plementation process was an intense and coordinated pro- cess by personnel from respiratory care, the intensive care unit, and the emergency department. To maintain high- quality CPR, retraining ...
Citations
... Although simulated training programs or other methods improve skills in CPR (as proved by many other studies), no previous study has determined the assessment of CPR guideline compliance. [15,[18][19][20] Hence, this may be the first study to assess indirectly the guideline compliance by seeing the documentation content and quality. However, outcomes of CPR did not improve significantly, perhaps due to lack of control over other factors involved in the system of care. ...
Background
Cardiopulmonary resuscitation (CPR) should be performed as per the international guidelines; however, compliance to these guidelines is difficult to assess. This study was conducted to determine the compliance to American Heart Association (2010) guideline on CPR documentation by among resident physicians before and after resident training (two arms).
Methods
This pre–postinterventional quality improvement study was conducted in a referral center, North India. Data of hospitalized in-hospital CPR patients were collected in the form of quality indicators (checklists) as defined by the guideline and compared between two arms of before–after resident training. Residents were given appropriate training in CPR technique as per the guideline. The compliance of CPR documentation was assessed pre- and post-intervention.
Results
The baseline arm compliance of various components of CPR documentation was low. The postintervention arm compliances of all components significantly increased (baseline, 2.5% to postintervention, 15.11%, P = 0.03). Individual components assessed were documentation of assessment of responsiveness (65% to 77.9%, P = 0.19), assessment of breathing (37.5% to 58.1%, P = 0.03), assessment of carotid pulse (62.5% to 79%, P = 0.05), rate of chest compressions (20% to 39.5%, P = 0.04), airway management (62.5% to 82.5%, P = 0.02), and compressions to breaths ratio (12.5% to 31.4%, P = 0.02). Documentation of chest compression rate compared to nondocumentation (12 of 42 vs. 11 of 84, P = 0.04) was independently associated with a higher rate of return of spontaneous circulation. The study however did not show any survival benefits.
Conclusions
This study establishes that the compliance to CPR documentation is poor as assessed by CPR documentation content and quality, which improves after physician training, but not up to the mark level (100%) that may be due to busy Indian hospital settings and human behavioral factors. Due to ethical constraints of live CPR assessment, this document checklist approach may be considered as an internal quality assessment method for CPR compliance. Furthermore, correct instruction in CPR technique along with proper documentation of the procedure is required, followed up with periodic re-education during the residency period and beyond.
... The Human Subjects Committees at the University of Minnesota and Toho patients in cardiac arrest. [12][13][14][15][16][17][18][19][20][21][22]26 It has shown great promise in terms of improving circulation, 27 blood pressure, 28 and survival 12,16,20,27,29 when used in emergency medical service (EMS) and hospital systems focusing on high-quality CPR. However, one prospective, randomized, blinded, multicenter factorialdesign clinical trial in North America (the Resuscitation Outcomes Consortium Prehospital Resuscitation Impedance Valve and Early Versus Delayed Analysis (ROC PRIMED) trial) found no benefit or harm from use of an active ITD compared with a sham ITD in patients with OHCA. ...
Background:
The quality of cardiopulmonary resuscitation (CPR) has been recently shown to affect clinical outcome. The Resuscitation Outcomes Consortium (ROC) Prehospital Resuscitation Impedance Valve and Early Versus Delayed Analysis (PRIMED) trial showed no differences in outcomes with an active vs. sham impedance threshold device (ITD), a CPR adjunct that enhances circulation. It was hypothesized the active ITD would improve survival with favorable neurological outcomes in witnessed out-of-hospital cardiac arrest patients when used with high-quality CPR.Methods and Results:Using the publicly accessible ROC PRIMED database, a post-hoc analysis was performed on all witnessed subjects with both compression rate and depth data (n=1,808) who received CPR within the study protocol definition of adequate CPR quality (compression rate 80-120/min and depth 4-6 cm; n=929). Demographics were similar between sham and active ITD groups. In witnessed subjects who received quality CPR, survival with favorable neurological function was 11.9% for the active ITD subjects (56/470) vs. 7.4% for the sham (34/459) (odds ratio 1.69 [95% confidence interval 1.08, 2.64]). There were no statistically significant differences for this primary outcome when CPR was performed outside the boundaries of the definition of adequate CPR quality. Multivariable models did not change these associations.
Conclusions:
An active ITD combined with adequate-quality conventional CPR has the potential to significantly improve survival after witnessed cardiac arrest.
... 21-24 The newly appreciated concept of intrathoracic pressure regulation (IPR) has resulted in innovative technologies and approaches to enhance perfusion, decrease ICP, and improve cardiac arrest outcomes. 3,4,12,25,26,30,67,69,88,115,[122][123][124][125][126][127][128][129][130][131][132][133][134][135][136][137][138][139][140][141] Additional discoveries associated with cardiac arrest include ways to reduce the potential for reperfusion injury, new insight into the potential importance of the position of the head during CPR, and methods to improve postresuscitation care. Essential for all of these potential advances is the need for the delivery of high-quality CPR in accordance to AHA guidelines. 1 There has also been significant progress in incorporating multiple advances in the care of cardiac patients into a bundled approach to care. ...
... 19,106,115 Such system-based approaches to resuscitation are based on a multipronged biophysical approach to significantly improve the likelihood for survival with restoration of neurological function after cardiac arrest. 19,106,115,122,169 Currently, the bundled approach to prehospital care has significantly improved survival with good neurological function for all patients to as high as 20% in some cities and counties. 19,115,118 Care is provided by highly trained prehospital personnel and specialized resuscitation hospitals. ...
... 19,115 In-hospital survival rates with favorable neurological function have been reported upward of 35%, and this includes patients with ventricular fibrillation, pulseless electrical activity, and asystole. 122 ...
Outcomes after cardiac arrest remain poor more than a half a century after closed chest cardiopulmonary resuscitation (CPR) was first described. This review article is focused on recent insights into the physiology of blood flow to the heart and brain during CPR. Over the past 20 years, a greater understanding of heart-brain-lung interactions has resulted in novel resuscitation methods and technologies that significantly improve outcomes from cardiac arrest. This article highlights the importance of attention to CPR quality, recent approaches to regulate intrathoracic pressure to improve cerebral and systemic perfusion, and ongoing research related to the ways to mitigate reperfusion injury during CPR. Taken together, these new approaches in adult and pediatric patients provide an innovative, physiologically based road map to increase survival and quality of life after cardiac arrest.
... In our study, female sex had statistically significant survival only in immediate survival (P = 0.003) but survival at 24 h, 6 weeks and at 1-year was not significant. In another retrospective In one of the studies, [14] [15] Valuable time is lost in the process of waiting for a defibrillator. One more option would be to place AED in unmonitored areas since nurses are not trained in use of manual defibrillators and ACLS. ...
Cardiac arrest has multifactorial aetiology and the outcome depends on timely and correct interventions. We decided to investigate the circumstances, incidence and outcome of cardiopulmonary resuscitation (CPR) at a tertiary hospital in India, in relation to various factors, including extensive basic life support and advanced cardiac life support training programme for all nurses and doctors.
It has been over a decade and a half with periodical updates and implementation of newer guidelines prepared by various societies across the world about CPR for both in-hospital and out-of hospital cardiac arrests (IHCA and OHCA). We conducted a prospective study wherein all cardiac arrests reported in the hospital consecutively for 12 months were registered for the study and followed their survival up to 1-year. Statistical analysis was performed by using Chi-square test for significant differences in proportions applied to various parameters of the study.
The main outcome measures were; (following CPR) return of spontaneous circulation, survival for 24 h, survival from 24 h to 6 weeks or discharge, alive at 1-year. For survivors, an assessment was made about their cerebral performance and overall performance and accordingly graded. All these data were tabulated. Totally 419 arrests were reported in the hospital, out of which 413 were in-hospital arrests. Out of this 260 patients were considered for resuscitation, we had about 27 survivors at the end of 1-year follow-up (10.38%).
We conclude by saying there are many factors involved in good clinical outcomes following IHCAs and these variable factors need to be researched further.
... Several human studies have demonstrated that the use of an ITD was associated with a higher ROSC and short-term survival, and some studies have found improvements in long-term survival. [55][56][57] Veterinary medicine clinical studies are lacking. ...
RECOVER was created to optimize survival of small animal patients from cardiopulmonary arrest. Several findings from this study are applicable to cardiopulmonary resuscitation in the neonatal foal. In particular, chest compressions should be a priority with no pauses and a "push hard, push fast" approach. The importance of ventilation is minimized with short, infrequent breaths at a rate of 10 to 20 per minute recommended.
... C ardiac arrests remain a significant health problem and leading cause of death both in and out of hospitals. Regardless of the setting, prompt initiation of quality cardiopulmonary resuscitation (CPR) improves patient survival and outcomes (Abella, Alvarado, Mykelbust, Edelson, & Barry, 2005;Bobrow et al., 2013;Idris et al., 2012;Meaney et al., 2013;Thigpen et al., 2010;Wallace, Abella, & Becker, 2013). Nurses, other health care providers, and laypersons need to be trained effectively to develop and retain their CPR skills. ...
... Most recently, two large studies have focused on the use of ITD in the management of patients with OOHCA undergoing CPR, with disappointingly conflicting results (11,12). This is at odds with realworld observational data, which suggest that ITD has a significant beneficial impact on patient prognosis (13,14). As systematic reviews of randomized trials represent a unique opportunity to summarize and appraise the clinical evidence on any given issue (15)(16)(17)(18), we aimed to conduct an updated and comprehensive systematic review and meta-analysis on ITD during CPR for OOHCA aiming to reconcile such differences and explore suitable moderators. ...
Introduction
Uncertainty persists on the clinical impact of impedance threshold devices in out-of-hospital cardiac arrest. We conducted an updated systematic review on impedance threshold devices.
Methods
Several databases were searched for studies testing the effectiveness of impedance threshold devices in patients with cardiac arrest. The primary endpoint was long-term survival.
Results
Seven trials (11,254 patients) were included. In 4 studies (2,284 patients) impedance threshold devices were used with active compression-decompression-cardiopulmonary resuscitation, and in the others alone. Overall, impedance threshold devices did not impact on the rate of return of spontaneous circulation (odds ratio=1.17 [0.96-1.43], p=0.114), favorable neurologic outcome (odds ratio=1.56 [0.97-2.50], p=0.065), or long-term survival (odds ratio=1.22 [0.94-1.58], p=0.127). These analyses were fraught with heterogeneity (respectively, p=0.055, p=0.236, and p=0.011) and inconsistency (respectively, I-squared=51% , I-squared=27% , and I-squared=67%). Exploratory analysis showed that combined use of impedance threshold devices with active compression-decompression significantly increased the likelihood of return of spontaneous circulation (odds ratio=1.19 [1.00-1.40], p=0.045), favorable neurologic outcome (odds ratio=1.60 [1.14-2.25], p=0.006), and long-term survival (odds ratio=1.52 [1.11-2.08], p=0.009). The favorable impact of the interaction between impedance threshold devices and active compression-decompression was also confirmed at meta-regression analysis (respectively, b=0.195 [0.004-0.387], p=0.045, b=0.500 [0.079-0.841], p=0.018, b=0.413 [0.063-0.764], p=0.021).
Conclusions
The evidence base on impedance threshold devices is apparently inconclusive, with a neutral impact on clinically relevant outcomes. However, exploratory analysis focusing on the combined use of impedance threshold devices with active compression-decompression suggests that this combo treatment may be useful to improve patient prognosis.
... Nonetheless, they demonstrated improved survival to discharge and to 1 year with a favorable neurological condition for the group receiving active compression-decompression CPR and ventilation with ITD. Thigpen et al 95 prospectively collected data on cardiac arrest patients receiving CPR after implementation of the 2005 AHA guidelines in conjunction with ITD use and compared outcomes with retrospective control subjects resuscitated without ITD and before implementation of the 2005 guidelines. They demonstrated a significant increase in hospital discharge rate in the intervention group. ...
... In addition, to further complicate interpretation of studies with the ITD, the Resuscitation Outcomes Consortium terminated a randomized double-blind study of the ITD because of results that demonstrated no benefit for the device (National Heart, Lung, and Blood Institute press release dated November 6, 2009), the full report of which has not been published. 96 It should be emphasized that the favorable studies by Thigpen et al 95 ...
Studies of sudden cardiac death (SCD) demonstrate overwhelmingly poor outcomes regardless of the population or intervention studied. Although SCD is a complex critical illness that is understood poorly, it is clear that outcomes are influenced by timely provision of high-quality, specific interventions.1,2 However, there is considerable heterogeneity within this group of patients with regard to the cause of SCD, comorbidities, and duration of the cardiac arrest event that can be difficult to identify during the course of resuscitation.3 These variables can have a significant bearing on outcomes and efficacy of treatment. For example, compression-only bystander cardiopulmonary resuscitation (CPR) may not be ideal for all subgroups of patients experiencing SCD. In addition, a proportion of SCD patients have a significant coronary artery lesion and benefit from percutaneous coronary intervention (PCI). Finally, post–ventricular fibrillation cardiac arrest patients may respond better to therapeutic hypothermia (TH) than those with other rhythms before the return of spontaneous circulation (ROSC).4–6
SCD is a dynamic, time-dependent process, as supported by research on CPR technique, early use of automated external defibrillators (AEDs), and implementation of TH.7–9 Weisfeldt and Becker10 elaborate on this concept in their 3-phase model of resuscitation from ventricular fibrillation cardiac arrest, describing progressive disruption of cardiac electrophysiology, circulation, and metabolism. The electric phase lasts from cardiac arrest through ≈4 minutes of resuscitation efforts and is considered the time when defibrillation is most likely to be successful. Herlitz et al11 demonstrated this in a prospective observational study of inpatients with ventricular fibrillation cardiac arrest. Those defibrillated within 3 minutes of collapse had significantly improved survival compared with those defibrillated >12 minutes from collapse. Work by Chan et al12 demonstrated similar findings, with a significant outcome benefit for inpatients sustaining ventricular fibrillation cardiac arrest …
... The steps of the 'in-hospital chain of survival' are composed of prevention, calling for help, cardiopulmonary resuscitation (CPR), defibrillation, advanced life support, and post-resuscitation care. Recent studies have reported that several interventions aimed at enhancing the quality of care at each of these steps may improve the outcome of in-hospital arrest (7)(8)(9)(10)(11)(12). ...
The aim of this study was to describe the cause of the recent improvement in the outcomes of patients who experienced in-hospital cardiac arrest. We retrospectively analyzed the in-hospital arrest registry of a tertiary care university hospital in Korea between 2005 and 2009. Major changes to the in-hospital resuscitation policies occurred during the study period, which included the requirement of extensive education of basic life support and advanced cardiac life support, the reformation of cardiopulmonary resuscitation (CPR) team with trained physicians, and the activation of a medical emergency team. A total of 958 patients with in-hospital cardiac arrest were enrolled. A significant annual trend in in-hospital survival improvement (odds ratio = 0.77, 95% confidence interval 0.65-0.90) was observed in a multivariate model. The adjusted trend analysis of the return of spontaneous circulation, six-month survival, and survival with minimal neurologic impairment upon discharge and six-months afterward revealed similar results to the original analysis. These trends in outcome improvement throughout the study were apparent in non-ICU (Intensive Care Unit) areas. We report that the in-hospital survival of cardiac arrest patients gradually improved. Multidisciplinary hospital-based efforts that reinforce the Chain of Survival concept may have contributed to this improvement.
... Quality of cardiopulmonary resuscitation (CPR) is critical for survival and good neurological outcome following cardiac arrest. 1,2 However, translation of evidence-based, consensus-derived international consensus on science and treatment recommendations 3 for CPR to the bedside has been difficult to achieve. 4,5 This is particularly important because greater compliance with CPR guidelines is associated with better outcomes. ...
Cardiopulmonary resuscitation (CPR) guidelines recommend specific chest compression (CC) target depths for children. We quantitatively describe relative anterior-posterior diameter (APD) depth, actual depth, and force of CCs during real CPR events in children.
CC depth and force were recorded during real CPR events in children ≥8 years using FDA-approved CC sensor. Patient chest APD was measured at conclusion of each CPR event. CC data was stratified and analyzed according to age (pre-puberty, 8-14 years; post-puberty, 15+ years). Relative (% APD) and actual CC depth, corrected for mattress deflection, were assessed and compared with American Heart Association (AHA) 2005 and 2010 pediatric CPR guidelines.
35 events in 32 subjects included 16,158 CCs for data analysis: 16 pre-puberty (CCs=7484, age 11.9±2 years, APD 164.6±25.1 mm); 19 post-puberty (CCs=8674, age 18.0±2.7 years, APD 196.5±30.4 mm). After correction for mattress deflection, 92% of CC delivered to pre-puberty were <1/3 relative APD and 60% of CC were <38 mm actual depth. Mean actual CC depth (36.2±9.6 mm vs. 36.8±9.9 mm, p=0.64), mean relative APD (22.5%±7.0% vs. 19.5±6.7%, p=0.13), and mean CC force (30.7±7.6 kg vs. 33.6±9.4 kg, p=0.07) were not significantly less in pre-puberty vs. post-puberty.
During in-hospital cardiac arrest of children ≥8 years, CCs delivered by resuscitation teams were frequently <1/3 relative APD and <38 mm actual depth after mattress deflection correction, below pediatric and adult target guidelines. Mean CC actual depth and force were not significantly different in pre-puberty and post-puberty. Additional investigation to determine depth of CCs to optimize hemodynamics and outcomes is needed to inform future CPR guidelines.
