Science topic

Cardiopulmonary Resuscitation - Science topic

The artificial substitution of heart and lung action as indicated for HEART ARREST resulting from electric shock, DROWNING, respiratory arrest, or other causes. The two major components of cardiopulmonary resuscitation are artificial ventilation (RESPIRATION, ARTIFICIAL) and closed-chest CARDIAC MASSAGE.
Questions related to Cardiopulmonary Resuscitation
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Ventilation during adult cardiopulmonary resuscitation (CPR) is poorly understood. Therefore, guideline recommendations are limited. The use of waveform capnography is in part recommended to monitor frequency. Other ventilation measurements such as tidal volume or inspiratory pressure are not regularly obtained, especially when a bag-valve system is used. The use of new monitoring devices can improve guideline adherence and could lead to better understanding of ventilation during CPR. Different EMS systems have varying levels of training, equipment and resources during CPR of out-of-hospital cardiac arrest (OHCA) patients. To better understand the current state of ventilation monitoring during OHCA CPR researcher/practitioner feedback and international perspectives on this question are needed and very much appreciated.
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Current guidelines recommend giving the maximum feasible inspired oxygen during CPR based on the premise that restoring depleted oxygen levels and correcting tissue hypoxia improves survival.
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The study of ventilation during adult cardiac arrest remains challenging due to the unexpected nature of sudden cardiac arrest and the limited resources/personnel on site. This is especially true for interventions that influence outcomes when applied early in the cardiac arrest phase. Therefore, animal models (i.e. pigs, dogs), manikins, human cadavers and computer models have been used to study intra-arrest ventilation. Also, some data has been made available from registries and clinical studies in humans.
While the possible answers to my question heavily depend on the respective research question, personal perspectives on the well known experimental models, as well as lesser known models for this niche of cardiac arrest research, would be very much appreciated.
Please note, that I do not to intend to discuss airway management during cardiac arrest. Although, I'm aware that both intra-arrest ventilation and airway management are closely connected.
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Yet to be developed
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As far as we know, TEAM and OSCAR tools are introduced for teamwork assessment in cardiopulmonary resuscitation, what other tools do you know for teamwork assessment in resuscitation?
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An exact measurement-protocol is not known, I think. In practice, I check whether these points were performed in the scenario. But if they did or not I decide for myself actually - therefore in this point a little bit "semi-valid" :-/
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Teamwork is one of the most important components of non-technical skills in cardiopulmonary resuscitation. Efforts have been made more than two decades ago to clarify the dimensions of teamwork in a resuscitation situation. The purposes of this group are to share the experiences and knowledge of experts on the factors that influence teamwork, training programs or guides to promote teamwork, teamwork assessment tools, and teamwork barriers to resuscitation. I hope that by sharing teamwork knowledge and skills, we will play an important role in promoting the care of critically ill patients. so you can share your experiences, knowledge, and suggestions for improvement in CPR.
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Frequent mock exercise improves familiarity with equipment, medicines, maneuvers, consequences; develop synchronicity and synergy.
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The use of ultrasound applied to critical patients is based on the international guidelines for the use of ultrasound in Intensive Care issued by the Round Table of Experts on Ultrasound in the UCI and the American College of Chest Physicians (CHEST) / La Société de Reanimation of Langue Française (SRFL).
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To improve US utilization in the ICU settings, two major factors are:
- sufficient staff training on the availabile ultrasound devices in the ICU
- adapting the international bedside ultrasound guidelines into hospital policy
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What is the effect of cardiac arrest on GI perfusion?
What are the short term (acute) consequences of cardiac arrest on GI function?
If someone were to restore spontaneous circulation, would the gut have taken a significant enough beating to not be able to well absorb an oral medication for example?
Thank you
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Please comment on the potential difference,current outflow,energy and related parameters and please do give any references if possible.
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This may help for the LifePak15. Quite a useful document
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Our recent focus has been working on survivors of CPR cognitive outcome. Do you know any groups or are you involved in similar projects? what are the most important issues to approach? Are there any findings with regard to pharmacological cerebral protection in such patients that have improved outcome?
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Two things also help:
Cooling the body: many references in Google e.g. https://www.ncbi.nih.gov/pubmedhealth/PMH0012557.
Steroids were used a lot in my day. See Buddineni "Epinephrine, vasopressin and steroids..."Crit Care 2014, 18, 308
Hope this helps. Most useful thing is a team of strong nurses to really
compress sternum; with frequent changes to avoid tiredness. One day we
will realize the floor is the best place to be doing this, and legs and feet are better and stronger than arms and legs on a bed.
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is there any standard check mark for testing CPCR in practice ? 
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You can use PHTLS Checklist for your student s test.(It is hand on )
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I am trying to convince hospital administration to allow the use of nebulized lidocaine prior to placement of NG aspiration.
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Thanks everyone for the help. Ian
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In the past 2 years there was an indication to use Atropine in asystole but then so many papers came to this point that, there is no indication for Atropine as vagolytic in asystole . Is there any strong guideline ?
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Part 7: Adult Advanced Cardiovascular Life Support
2015 American Heart Association Guidelines Update for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. (Circulation. 2015;132[suppl 2]:S444–S464. DOI: 10.1161/CIR.0000000000000261.)
European Resuscitation Council Guidelines for Resuscitation 2015Section 3. Adult advanced life support. Resuscitation 95 (2015) 100–147
This may be what you are looking for?
Best regards.
Gian Paolo Castelli
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Termination of resuscitation rules for EMS bls+aed providers (when there is no ALS on scene) are in use in several countries. Does your EMS system use them? Do you have results? How do they work in work EMS Systems? I'm collecting data and trying to validate their use in Portugal. Thank you for your collaboration.
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The on scene senior clinician, usually paramedic, follows local and national (NICE) guidelines to terminate on scene. This is where ALS has proven to be without positive effect and no ROSC achieved but there are also other factors. Children, hypothermic patients etc are conveyed to an appropriate facility for further intervention and are very rarely, if at all, pronounced 'life extinct' on scene.
As to BLS terminating on scene without an ALS provider attending; I feel that is an awkward and maybe a little dangerous situation, to be caught up in.
Personally, I would not cease CPR if only BLS was being attempted.
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Feedback devices seem to improve compliance to Guidelines in CPR. Are there any outcome studies proving improved outcomes (i.e. ROSC, admission to hospital) in humans?
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Dear Paul, I Think that Answer is YES! Look This Attachment:
"Depth, Rate of Chest Compressions During CPR Impact Survival in Cardiac Arrest" -  Febbraio 6, 2015
DALLAS, Tex -- February 6, 2015 -- The depth of chest compressions and the rate at which they were applied make a significant impact on survival and recovery of patients, according to 2 studies published in Circulation and Critical Care Medicine.
Contrary to popular belief, the studies showed that cardiopulmonary resuscitation (CPR) compressions deeper than 5.5 cm resulted in decreased survival, possibly because of collateral damage to other internal organs.
Previously, investigations and guidelines indicated that deeper compressions were better. The American Heart Association's (AHA) 2010 CPR guidelines recommend compressing the chest at least 5 cm without providing any upper limit.
“Most people do not recognise that it takes quite a bit of thrust to compress the chest 2 inches,” said Ahamed Idris, MD, by UT Southwestern Medical Center, Dallas, Texas. “About 60 pounds [27 kg] of pressure are required to reach this depth, but in some cases a burly fireman or well-intended volunteer can go way past that amount, which can harm the patient.”
The researchers also found that the rate at which chest compression was applied was most important. Compression rates of 100 to 120 per minute were optimal for survival when other factors were considered.
“Survival depends on the quality of the CPR,” said Dr. Idris. “Both the depth of chest compressions and the rate at which they are applied can have important results for patients in the first moments of cardiac arrest.”
About half of responders are giving chest compressions too fast, with about a third above 120 compressions per minute, and 20% above 140 per minute, said Dr. Idris.
The researchers will continue to oversee innovative clinical trials to test the early delivery of interventions for serious trauma and cardiac arrest as part of a federally funded consortium aimed at advancing prehospital emergency care.
The Resuscitation Outcomes Consortium (ROC) has enrolled tens of thousands of patients to test prehospital interventions to improve outcomes in severely ill or injured patients before they are transported to a hospital.
SOURCE: University of Texas Southwestern Medical Center
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Published or unpublished data about cardiac arrests (affecting children or adults) occurring on school grounds.
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Thank you. One last question: how many were there it total for adults? 
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Seattle: 1/70.000 citizens, with excellent results in urban areas (40% survival in witnessed VF cardiac arrest).
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In our experience (Genoa, Italy), where the ratio means ALS and inhabitants is 1: 130,000 the survival rate of patients in cardiac arrest (with any heart rhythm) on field is 13% at 30 days. For all the details you can refer to my thesis: DOI: 10.13140 / 2.1.4653.600 or a technical report DOI: 10.13140/2.1.4737.6163
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Currently there seems to be a standard rule of waiting for 20 mins of asystole prior to actually terminating resuscitative efforts in the pre-hospital environment (including a load-and-go to hospital approach). This seems reasonable for the non-trauma patient especially if an automatic chest compression device (LUCAS) is available.
For the critically injured trauma patient, these automatic devices are generally contra-indicated and furthermore, doing CPR in the back of a fast-moving ambulance is both ineffective and dangerous. A lot of these patients present with a PEA rhythym for long periods as well as with injuries that appear to be incompatible with life.
So, what does the paramedic do in these situations? Continue a futile resuscitation or terminate? Any thoughts or experience with this situation will be appreciated.
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Dear Yugan,
Your question is one of those questions that is both simple and difficult in that it appears simple, but is in fact quite difficult.  As a Mobile Intensive Care Ambulance Paramedic in Victoria, Australia, I worked in a system which permitted ambulance officers of all levels to declare a patient deceased at the scene.  The written certification of death and the completion of the final 'death certificate' were restricted to medical practitioners.  However, the field declaration of death by an ambulance paramedic entailed the cessation of all treatment and, very often, the leaving of the body at the scene.
Although I cannot speak with any authority, I have suspicions that a percentage of these declarations lacked rigour and were conducted on the spur of the moment.  This does not mean that the decision taken was wrong, just that no one knows.  In the absence of a closely monitored process for making such decisions, there will be a degree of institutional blindness as to the appropriateness of the practice. This is the crux of the problem as flexibility and control collide.
In researching this question it would pay for you to look at the experience in the USA.  Until recently, many US jurisdictions restricted the declaration of death to qualified medical practitioners.  This led to many, many corpses being transported under emergency conditions to already overcrowded emergency departments.  This practice killed and injured ambulance personnel who were performing CPR when their vehicles suffered accidents.
It also ensured that hospital mortuaries were constantly overflowing with remains and it tied up valuable time in the emergency department, particularly physician time, as the legal paperwork was completed.
For all of these reasons and more, jurisdictions began to move towards legally empowering ambulance paramedics to declare death in the field.  The fears of some were that there would be a spate of declarations as paramedics wielded their new powers.  However, and I have no evidence for this assertion, I suspect the real problem will be breaking the culture of performing CPR en-route to the hospital.  I would be interested to hear what our US colleagues have to say on this matter.
Some of my thoughts on the pros of allowing paramedics to declare death are:
1. It quickly releases valuable ambulance resources for the next emergency or case
2. It lowers the administrative overhead on physicians by keeping the deceased out of the hospital and it removes the risk of the physician being called before the courts to give routine evidence on the process used.
3. It reduces the cost of handling the deceased as the funeral arrangements can be done from the home resulting in a single ambulance trip to the scene and a return funeral vehicle trip from mortuary to home and back.  This also reduces the number of times the deceased needs to be lifted and moved from nine to four.  With hospital based declarations there can be up to three other transportation legs and nine lifts involved.
4.  It leaves the deceased within the control of the family.  This lowers stress, allows grieving and leaves the family in charge of what actually happens to the remains.  This is, as far as I am concerned, the major benefit of the system.
5.  Paramedics in many jurisdictions have proven themselves highly competent in declaring death.  With good training, proper peer review of cases and transparency of medical oversight, I believe the system works well.
The Cons.
1.  There will be a level of risk that mistakes will be made.
2.  There needs to be an acceptance for field declarations by paramedics within the culture of the medical practitioners over-sighting the system.  The US experience of keeping medical control of declarations of death before then relaxing and removing the restrictions on paramedics may be due to the growth in confidence of the medical profession in the reliability of their paramedics.  In your own situation, this is the starting point.  You need to win the confidence of your peers.
3.  Public expectations.  This cannot be discounted.  There are some ethnic and religious groups who require that everything possible be done for the sick or injured patient.  This expectation needs to be met.  This again requires the creation of confidence within the community concerned and this may take some time.  This confidence will only arise from knowledge imparted by those whom the public respects.  Education and information from the medical profession concerned is essential, particularly where the highly skilled paramedic is a new addition to the health care team.
4.  There will be a reduction in the transportation of patients suffering the more extensive and untreatable injuries that are presently being seen.  When surgeons or physicians are attempting to push the boundaries of what can be done, the declaration of death by paramedics on scene will impact the availability of the very marginal case.  This requires that a system of varying the procedures be available for research purposes so that recently deceased patients fitting particular clinical criteria are transported.  Again, this will require close co-ordination with ethics committees and other stake holders.
5.  Too tight a procedure or protocol for declaring death in the field will not work.  There has to be a balance between flexibility and central control.  Usually, the best way forward is a graduated approach where field declarations can be used on the most obvious cases and, as confidence in the capacity of the paramedics increases, the range of cases can be widened.
I believe that paramedics are more than capable of declaring death in the field and that by doing so, they lower the pressure on physicians and hospitals.  However, the oversight of the medical system is vested in the physician and the first thing that must be done is to interest the physicians in how this practice will benefit them.  If this can be demonstrated, then it is essential to show them how their standards will be maintained by the paramedics, so that they can become confident that their patients are getting the best available care.
Field declarations of death by paramedics can only really occur where physicians feel confident.
Hope this helps you.
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I think it's not feasible, but someone else doesn't agree.
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If they need analgesia, they don't need CPR; if they need CPR, they don't need analgesia.
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Method of CPR:
1. D.R.A.B.C
2. D.R.C.A.B
Checking the pulse of the patient/victim: method 1 is done but, method 2 not...why?
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Hi Roger, I very much agree with Alexander. Before I even got involved in CPR research, in my own CPR teaching I would actually train my students (back in the day of 9-hour courses) to really take the carotid pulse. I would do this by verifying their pulse count on another student against my own (simultaneously). This was very time consuming, and I was convinced of two things, it was very difficult, and despite the concerns about loss of peripheral pulse (e.g., radial) due to shock, the carotid was still a bad choice due to high rate of false negative, and I figured in case of pulselessness, most likely false positive due to feeling one's own pulse. As an EMT, I did find radial pulse much easier in conscious patients. So, I was not at all surprised as a researcher when studies by Dick and colleagues in Germany showed that carotid pulse was unreliable to point of uselessness. They never tested an alternative pulse, as far as I recall. So, at least in lay CPR, the pulse check is omitted once apnea has been confirmed. In traditional CPR, rescue breaths are attempted, which serves as another check, that you have a relatively lifeless victim. Of course, in continuous compression CPR, increasingly advocated for laypersons, sometimes for the wrong reasons, you do go right for compressions after determining apnea, which is a bit more extreme, but a largely useless check of the carotid pulse isn't going to help so much. I have watched videotaped performances of hundreds of laypersons doing skill tests immediately after CPR training, and the opening sequence, even if done well (as done relatively more often after our video) takes a lot of time from unresponsiveness check to first compression and really long when done badly. What I might do personally is probably a little different from AHA or ILCOR standards, but I would not take a carotid pulse on anyone including myself--it's stupid, but I did not say I wouldn't check a pulse. You can find a bunch of CPR papers and letters to the editor back a few pages on my profile. Also, if you look at the editorial "Pump and Blow Isn't Hit or Miss" on the first page of my profile, I reference an important editorial by Douglas Chamberlain and Mary Fran Hazinski about CPR training, not about the pulse check, but about CPR education, that you might find interesting. Bob
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F test formula
F = {variance between treatments} /
{variance within treatments}
F = {MS Treatments}/
{MS Error}
F = {SS Treatments} / (I-1) /
{SS Error} / (n_T-I)
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Thank you Francsois, Hope you can send me more papers on your works regarding CPRs and literature reviews. You are a great help. God bless you.
Duke
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How to ensure the respect to autonomy in such situation?
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To perform CPR or not, and when to stop, who decide to stop the procedure and when to discuss futility??
The main questions for ICU’s and ED physicians.
Whereas, it is relatively easy in the ICUs to discuss these questions, since patients are classified, de facto, with “full code ICU management, three to five days unlimited ICU management before reappraisal and potential end of life decision, do not increase invasive procedures or vasopressor administration, NTBR, and withdrawal”. Despite, these recommendations, in May 2010, “1 in 4 ICU nurses and 1 in 3 ICU physicians believed that they delivered inappropriate care to at least 1 of their patients on the day of the survey “, (Piers RD, Azoulay E, Ricou B, et al. Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians. JAMA. 2011; 306(24):2694-2703.)
In the ED, we may have three possibilities.
First, the patient is not yet in cardiac arrest (CA) and ED team have the possibility to discuss with the family and thus decide, in view the previous health status and the “ the desiderata of the patient”, to perform or not CPR, if requested.
Second, CPR is performed in absence of a family member and without informations concerning the previous health status, resuscitation should be performed as usual, until…. If the patient survives, as for all patients who suffered from CA, the outcome will be frequently clear crystal within the first three ICU days.
Third, whereas CPR is being performed, a discussion with a family member or a relative is possible. ED and ICU’s physicians will explain the CA possible consequences and propose to withdraw or not life support, according to CA story (unwitnessed, delay before CPR initiation, responsiveness ..) and of course pre- arrest conditions.
For the patients admitted in wards, medical teams frequently anticipate whereas ICU admission is warranted or not, particularly for cancer patients, and thus, de facto, the futility of CPR for patients which should not be transferred to the ICU. Patient preferences for resuscitation and end-of-life issues, are of interest but very rare…
At evidence, information given by ICU’s or ED physicians to patients’ relatives for a “shared decision-making”, looks like “together decision”, but in clinical practice, medical decision seems to be the major factor. In case of conflict with the family, CPR followed by ICU admission until conflict resolution, and/or situation appraisal within the first ICU days, should be proposed.
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The advanced cardiac life support guidelines emphasize the ventilation rate of 8 to 10 breaths per minute with a tidal volume of 500 to 600 ml per breath.. Not infrequently, we attend patients with ARDS under lung protective ventilation developing sudden cardiac arrest. How reliable is the guideline in achieving ROSC in such patients?
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Hello to all -
Fantastic question that does not receive any attention in the 2010 CoSTR documents or the AHA guidelines after a quick check. I have the privilege of being a member of the 2015 ILCOR ACLS Subcommittee that is in the process of reviewing evidence for 2015 CoSTR document. As you know this will then inform the guidelines councils around the world. I will bring this question to the committee and try to make a case for them to commission a worksheet on the topic so that there is at least a comment on this important scenario in the 2015 documents. Thanks for highlighting this!
Regards,
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One of the most critical points of CPR is to check for efficacy of chest compression on blood circulation. In some cases, we tested CPR value by using echocardiography after the 3rd cycle of cardiac massage. This could be helpful into decision of stopping CPR, as the LV (or RV) are more or less thrombized. Any ideas?
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Whilst I would agree with some of the above points I would caution the feeling that the probe can be stuck on the chest to answer some key questions. To answer those key questions, the sonographer must be skilled so that they are quick (images in less that 10secs, or during compresions, knwledgeable so that they do not misinterpet a dilated RV asa PE and miss the inferior akinesis, suggesting that the dilated RV with poor function is an RV infarct.
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Recently a paper published by Seamon raised the question of performing ED Thoracotomies in Traumatic Cardiac arrest cases. Do you think it is worth it in non-penetrating trauma cases?
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I believe there is merit in performing EDRT for blunt trauma if vital signs were lost within 5 minutes of arrival, and particularly if ED ultrasound is available and there is any sign of cardiac activity. Clearly the presence of pericardial effusion, cardiac activity and no pulse (tamponade physiology) would merit immediate needle pericardiocentesis if not full-out EDRT. Hope this helps...