Disclaimer: Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly being deployed for selected patients in cardiac arrest who do not attain a native circulation with conventional ...CPR (ECPR). This ELSO guideline is intended to be a practical guide to implementing ECPR and the early management following establishment of ECMO support. Where a paucity of high-quality evidence exists, a consensus has been reached amongst the authors to provide guidance to the clinician. This guideline will be updated as further evidence in this field becomes available.
BACKGROUND—The 2010 American Heart Association guidelines suggested an increase in cardiopulmonary resuscitation compression depth with a target >50 mm and no upper limit. This target is based on ...limited evidence, and we sought to determine the optimal compression depth range.
METHODS AND RESULTS—We studied emergency medical services–treated out-of-hospital cardiac arrest patients from the Resuscitation Outcomes Consortium Prehospital Resuscitation Impedance Valve and Early Versus Delayed Analysis clinical trial and the Epistry-Cardiac Arrest database. We calculated adjusted odds ratios for survival to hospital discharge, 1-day survival, and any return of circulation. We included 9136 adult patients from 9 US and Canadian cities with a mean age of 67.5 years, mean compression depth of 41.9 mm, and a return of circulation of 31.3%, 1-day survival of 22.8%, and survival to hospital discharge of 7.3%. For survival to discharge, the adjusted odds ratios were 1.04 (95% CI, 1.00–1.08) for each 5-mm increment in compression depth, 1.45 (95% CI, 1.20–1.76) for cases within 2005 depth range (>38 mm), and 1.05 (95% CI, 1.03–1.08) for percentage of minutes in depth range (10% change). Covariate-adjusted spline curves revealed that the maximum survival is at a depth of 45.6 mm (15-mm interval with highest survival between 40.3 and 55.3 mm) with no differences between men and women.
CONCLUSIONS—This large study of out-of-hospital cardiac arrest patients demonstrated that increased cardiopulmonary resuscitation compression depth is strongly associated with better survival. Our adjusted analyses, however, found that maximum survival was in the depth interval of 40.3 to 55.3 mm (peak, 45.6 mm), suggesting that the 2010 American Heart Association cardiopulmonary resuscitation guideline target may be too high.
CLINICAL TRIAL REGISTRATION—URLhttp://www.clinicaltrials.gov. Unique identifierNCT00394706.
This is the first scientific statement from the American Heart Association on maternal resuscitation. This document will provide readers with up-to-date and comprehensive information, guidelines, and ...recommendations for all aspects of maternal resuscitation. Maternal resuscitation is an acute event that involves many subspecialties and allied health providers; this document will be relevant to all healthcare providers who are involved in resuscitation and specifically maternal resuscitation.
Background
Mechanical chest compression devices have been proposed to improve the effectiveness of cardiopulmonary resuscitation (CPR).
Objectives
To assess the effectiveness of resuscitation ...strategies using mechanical chest compressions versus resuscitation strategies using standard manual chest compressions with respect to neurologically intact survival in patients who suffer cardiac arrest.
Search methods
On 19 August 2017 we searched the Cochrane Central Register of Controlled Studies (CENTRAL), MEDLINE, Embase, Science Citation Index‐Expanded (SCI‐EXPANDED) and Conference Proceedings Citation Index–Science databases. Biotechnology and Bioengineering s and Science Citation s had been searched up to November 2009 for prior versions of this review. We also searched two clinical trials registries for any ongoing trials not captured by our search of databases containing published works: Clinicaltrials.gov (August 2017) and the World Health Organization International Clinical Trials Registry Platform portal (January 2018). We applied no language restrictions. We contacted experts in the field of mechanical chest compression devices and manufacturers.
Selection criteria
We included randomised controlled trials (RCTs), cluster‐RCTs and quasi‐randomised studies comparing mechanical chest compressions versus manual chest compressions during CPR for patients with cardiac arrest.
Data collection and analysis
We used standard methodological procedures expected by Cochrane.
Main results
We included five new studies in this update. In total, we included 11 trials in the review, including data from 12,944 adult participants, who suffered either out‐of‐hospital cardiac arrest (OHCA) or in‐hospital cardiac arrest (IHCA). We excluded studies explicitly including patients with cardiac arrest caused by trauma, drowning, hypothermia and toxic substances. These conditions are routinely excluded from cardiac arrest intervention studies because they have a different underlying pathophysiology, require a variety of interventions specific to the underlying condition and are known to have a prognosis different from that of cardiac arrest with no obvious cause. The exclusions were meant to reduce heterogeneity in the population while maintaining generalisability to most patients with sudden cardiac death.
The overall quality of evidence for the outcomes of included studies was moderate to low due to considerable risk of bias. Three studies (N = 7587) reported on the designated primary outcome of survival to hospital discharge with good neurologic function (defined as a Cerebral Performance Category (CPC) score of one or two), which had moderate quality evidence. One study showed no difference with mechanical chest compressions (risk ratio (RR) 1.07, 95% confidence interval (CI) 0.82 to 1.39), one study demonstrated equivalence (RR 0.79, 95% CI 0.60 to 1.04), and one study demonstrated reduced survival (RR 0.41, CI 0.21 to 0.79). Two other secondary outcomes, survival to hospital admission (N = 7224) and survival to hospital discharge (N = 8067), also had moderate quality level of evidence. No studies reported a difference in survival to hospital admission. For survival to hospital discharge, two studies showed benefit, four studies showed no difference, and one study showed harm associated with mechanical compressions. No studies demonstrated a difference in adverse events or injury patterns between comparison groups but the quality of data was low. Marked clinical and statistical heterogeneity between studies precluded any pooled estimates of effect.
Authors' conclusions
The evidence does not suggest that CPR protocols involving mechanical chest compression devices are superior to conventional therapy involving manual chest compressions only. We conclude on the balance of evidence that mechanical chest compression devices used by trained individuals are a reasonable alternative to manual chest compressions in settings where consistent, high‐quality manual chest compressions are not possible or dangerous for the provider (eg, limited rescuers available, prolonged CPR, during hypothermic cardiac arrest, in a moving ambulance, in the angiography suite, during preparation for extracorporeal CPR ECPR, etc.). Systems choosing to incorporate mechanical chest compression devices should be closely monitored because some data identified in this review suggested harm. Special attention should be paid to minimising time without compressions and delays to defibrillation during device deployment.
Guideline compliant CPR is associated with improved survival for patients with cardiac arrest. Conventional Basic Life Support (BLS) training results in suboptimal CPR competency and skill retention. ...We aimed to compare the effectiveness of distributed CPR training with real-time feedback to conventional BLS training for CPR skills in pediatric healthcare providers.
Healthcare providers were randomized into receiving annual BLS training (control) or distributed training with real-time feedback (intervention). The intervention group was asked to practice CPR for 2 min on mannequins while receiving real-time CPR feedback, at least once per month. Control group participants were not asked to practice CPR during the study period. Excellent CPR was defined as 90% guideline-compliance for depth, rate and recoil of chest compressions. CPR performance of participants was assessed (on infant and adult-sized mannequins) every 3 months for a duration of 12 months. CPR performance was compared between the 2 groups.
A total of 87 healthcare providers were included in the analyses (control n = 41, intervention n = 46). Baseline assessment showed no significant difference in CPR performance across the 2 groups. The intervention group has a significantly greater proportion of participants with excellent CPR compared with the control group on an adult sized mannequin (14.6% vs. 54.3%, p < 0.001) and infant-sized mannequin (19.5% vs. 71.7%, p < 0.001) at the end of the study. In the intervention group, all CPR metrics except infant depth were improved and retained over the course of the study.
Distributed CPR training with real-time feedback improves the compliance of AHA guidelines of quality of CPR.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
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