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PubMed1997

The relationship of carbon dioxide excretion during cardiopulmonary resuscitation to regional blood flow and survival.

Currently, there are no practical means of prospectively determining cardiopulmonary resuscitation (CPR) adequacy in the field. Airway CO2 excretion can be noninvasively and stably measured under changing environmental conditions. We investigated the relationships between the volume of airway CO2 excreted (CO2EX) during CPR to regional blood flow (RBF) and survival. A total of 21 dogs were randomly divided into four CO2EX groups (< 5, 5-6, > 6-7 and > 7 ml CO2/min per kg), anesthetized, instrumented and ventilated with an in-line infrared airway CO2 sensor. Anesthesia was reduced and baseline measurements made. Ventricular fibrillation (VF) was initiated and resuscitation withheld for 3 min, followed by 17 min of CPR. Compression force alone was adjusted to maintain predetermined CO2EX. Animals were resuscitated, monitored for 2 h and observed for an additional 22 h. RBF was determined at baseline, 16 min post-VF and 60 min post-resuscitation. Mean CO2EX during CPR was significantly higher in survivors than nonsurvivors. The probability of survival increased as CO2EX increased. The highest CO2EX group had the highest rate of survival (86%), but did not always have significantly higher cardiac output (CO), myocardial or cerebral blood flows (MBF, CBF) than the lowest CO2EX group with a 0% survival rate. These data suggest survival is tracked better by CO2EX than by CO, MBF or CBF. Therefore, CO2EX appears to provide a practical reliable noninvasive method of determining CPR efficacy in the field.

Analysis of Variance↗
PubMed1997

Open chest cardiopulmonary resuscitation in out-of-hospital cardiac arrest.

Because closed chest cardiopulmonary resuscitation (CCCPR) achieve restoration of spontaneous circulation (ROSC) in less than 50% of cases, and because of the apparent physiological superiority of open-chest cardiopulmonary resuscitation (OCCPR), we evaluated OCCPR in out-of hospital cardiac arrest in cases who did not respond to standard external cardiopulmonary resuscitation with advanced life support. Over a period of 12 years, OCCPR was performed in 33 patients with out-of-hospital cardiac arrest arising from different causes, after unsuccessful attempts to achieve ROSC with CCCPR efforts over 7-121 min (median 25 min). With OCCPR, ROSC was achieved in 13/33 patients. Of these, two recovered to discharge (one with no neurological deficit and one with mild brain damage). The other 11 rearrested either in the emergency department after a median period of 70 min of resuscitation, or in the intensive care unit after a median period of 104 h. One case of iatrogenic cardiac injury was observed. The OCCPR attempts were well accepted by the public. Our data suggest that OCCPR is more effective than CCCPR in achieving ROSC outside hospital in patients with major cardiac disease and prolonged arrest. OCCPR is feasible in the out-of-hospital setting. Survival without neurological deficit cannot be expected when CCCPR with no-flow is continued beyond 25 min.

Adolescent↗
PubMed1998

Neurological and circulatory outcomes of cardiopulmonary resuscitation in progress: influence of pre-arrest and arrest factors.

Possible correlations between the circulatory and neurological responses to cardiopulmonary resuscitation (CPR) and the influence of pre-arrest factors (demographic data, medical history and aetiology of circulatory arrest) and arrest factors (location of arrest, ECG configurations, and duration of resuscitation) on the course of circulatory and neurological recovery were investigated in 111 victims of circulatory arrest. At the start of resuscitation 57 patients (Group I) had some brain function and 54 (Group II) had no brain function. Sixty nine patients (62%) had circulation restored but 54 (78%) were left with heart failure. Forty one patients (39%) survived the first day, 26 (63%) with heart failure; only 34 (31%) were alive after 48 h, 17 (50%) with heart failure. Half of the patients surviving 24 or 48 h had awakened. Consciousness returned in 32 patients (29%) during the first 48 h, more frequently in Group I than in Group II. Patients in Group I had a higher incidence of in-hospital arrest and had their circulation restored more often than those in Group II. Survival and post-resuscitation heart failure was alike in the groups. The pre-arrest factors explored did not modify the circulatory or neurological outcome whereas initial ventricular fibrillation was significantly related to recovery of consciousness. The revivability of spontaneous circulation and of neurological functions was found thus mainly to be determined by global ischaemia sustained prior to and during CPR.

Aged↗
PubMed1998

The incidence of regurgitation during cardiopulmonary resuscitation: a comparison between the bag valve mask and laryngeal mask airway.

The risk of gastric regurgitation and subsequent pulmonary aspiration is a recognised complication of cardiac arrest--a risk which may be further increased by the resuscitative procedure itself. The purpose of this study was to compare the incidence of gastric regurgitation between the bag valve mask (BVM) and laryngeal mask airway (LMA). The resuscitation data collection forms of 996 patients who underwent in-hospital cardiopulmonary resuscitation over a 3.5 year period were reviewed. Of these, 199 patients were excluded from the study because there was no airway management involving a BVM or LMA. The incidence and timing of regurgitation was studied in the remaining 797 patients. Regurgitation was recorded to have occurred at some stage in 180 of these patients (22.6%). However, 84 regurgitated prior to CPR (46.7% of those patients who regurgitated). These patients were excluded from further analysis as regurgitation could not have been affected by any form of ventilation. Of the remaining 713 patients, BVM ventilation was used in 636 cases. In 170 of these the LMA was also used following the BVM. Where the patient was ventilated with the BVM alone or BVM followed by ETT the incidence of regurgitation during CPR was 12.4%. The LMA was used during resuscitation in 256 cases of which 170 had BVM ventilation prior to the LMA. Where the patient was ventilated with the LMA alone or LMA followed by ETT the incidence of regurgitation during CPR was 3.5%. The study confirms experience reported in earlier studies that when an LMA is used as a first line airway device, regurgitation is relatively uncommon.

Cardiopulmonary Resuscitation↗
PubMedDate not supplied

Resuscitation training for medical students.

This paper describes the systematic training of undergraduate medical students in resuscitation skills, aimed at overcoming the well known deficiencies in the resuscitation skills of junior doctors. This training can be integrated with the medical curriculum, but takes a considerable commitment in teaching time. To give each of our 240 medical students 36 h of resuscitation training, including an advanced life support (ALS) course for all students, 2442 h of teacher's time is required each year. It is important that teaching is continued on the wards as part of the training of pre-registration house officers. The amount of teaching time required justifies the appointment of Medical School Resuscitation Officers, dedicated to teaching medical students, dental students and pre-registration house officers.

Curriculum↗
PubMed1999

Appointment of a Resuscitation Training Officer is associated with improved survival from in-hospital ventricular fibrillation/ventricular tachycardia cardiac arrest.

OBJECTIVE: To determine if the appointment of a Resuscitation Training Officer improves survival to discharge from in-hospital ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. DESIGN: A 22-month prospective study. SETTING: A 1100-bed teaching hospital. SUBJECTS: All inpatients suffering ventricular fibrillation or ventricular tachycardia cardiorespiratory arrests. INTERVENTIONS: Appointment of a Resuscitation Training Officer at start of study, who introduced coordinated resuscitation training for all staff. MAIN OUTCOME: Survival to discharge. RESULT: Improvement in survival to discharge of 20-75% (P<0.03, Spearman Rank Correlation test). CONCLUSION: Appointment of a Resuscitation Training Officer is associated with improved survival to discharge in ventricular fibrillation and ventricular tachycardia in-hospital cardiac arrest.

Cardiopulmonary Resuscitation↗
PubMed1999

Normoxic ventilation during resuscitation and outcome from asphyxial cardiac arrest in rats.

The formation of reactive oxygen species during reperfusion is one trigger for neuronal injury after global cerebral ischemia. Because formation of reactive oxygen species requires delivery of molecular oxygen to ischemic tissue, restricting inspired oxygen during reperfusion may decrease neurological damage. This study examined whether ventilation with room air rather than pure oxygen during resuscitation would improve neurological recovery after cardiac arrest in rats. Adult, male rats were subjected to 8 min of asphyxia resulting in cardiac arrest. During resuscitation, rats were ventilated either with hyperoxia (FiO2 = 1.0) or normoxia (FiO2 = 0.21, room air). Neurobehavioral deficits were scored daily for 72 h after resuscitation, after which brains were collected for histology. Normoxia decreased arterial oxygen content. Other physiological parameters and mortality did not differ between groups. All surviving rats exhibited behavioral and histological signs of brain damage. Neurological deficit scores did not differ between normoxia and hyperoxia conditions at any time point. The number of ischemic neurons in the hippocampus also did not differ between groups. These data indicate neither benefit nor detriment of reducing inspired oxygen concentration during resuscitation from asphyxial cardiac arrest in rats.

Air↗
PubMed1977

Effects of sodium bicarbonate administration during cardiopulmonary resuscitation.

To study whether sodium bicarbonate given in cardiopulmonary resuscitation may produce life-threatening hyperosmolality or hypernatremia, arterial blood was analysed for blood gas, alcohol, blood urea nitrogen, electrolyte and osmolality. The blood was drawn after resuscitation in successful cases, and while effective massage and ventilation were being applied in unsuccessful resuscitations. Seven of the 17 resuscitations were successful. Serum sodium concentrations ranged from 135 to 154 with one exception and did not correlate with the amount of sodium bicarbonate administered. Arterial pH ranged from 6.38 to 7.71; only one patient had metabolic alkalosis. Serum osmolality ranged from 301 to 407. The data suggests a net increase in osmolality of 6 mOsm/50 mEq of sodium bicarbonate.

Alkalosis↗
PubMed1978

Shock and resuscitation. II: Volume repletion with minimal edema using the "HALFD"(Hypertonic Albuminated Fluid Demand) regimen.

A hypertonic albuminated fluid demand regimen (HALFD) for resuscitation has been used in burn patients since January 1, 1976. The effects of the HALFD method were compared with hypertonic fluid and Ringer's lactate resuscitation. Specific attention was directed to fluid, colloid, and volume changes. Resuscitation was guided by maintaining the mean arterial pressure between 60 to 110 torr, and urine volume at 30 to 50 ml/hr. Patients treated with the HALFD method fared significantly better clinically, needed less fluid, had less weight gain and plasma leak, and experienced slower plasma volume repletion than those treated more traditionally. We conclude that the HALFD method is a physically and physiologically appropriate paradigm for resuscitating the volume-depleted patient.

Adult↗
PubMed1999

Ethical issues of resuscitation.

There is a wide variety of ethical issues and dilemmas involving resuscitation, the act of restoring life to a patient in cardiorespiratory arrest. Decisions must be made rapidly and often must be based on suboptimal levels of information available at the time. Certain issues should be considered when one is making decisions in the resuscitation arena, including positive-aspects of resuscitation, not only the possibility of restoring life to the patient but also providing a sense of closure and resolution of guilt for the survivors. During and following resuscitative efforts, the psychologic and emotional well-being of the survivors should also be given close attention.

Activities of Daily Living↗
PubMed2001

alpha-Methylnorepinephrine, a selective alpha2-adrenergic agonist for cardiac resuscitation.

OBJECTIVES: The purpose of this study was to investigate the effects of a selective alpha2-adrenergic agonist, alpha-methylnorepinephrine (alphaMNE) as an alternative vasopressor agent during cardiopulmonary resuscitation (CPR). BACKGROUND: For more than 40 years, epinephrine has been the vasopressor agent of choice for CPR. Its beta- and alpha1-adrenergic effects increase myocardial oxygen consumption, magnify global myocardial ischemia and increase the severity of postresuscitation myocardial dysfunction. METHODS: Ventricular fibrillation (VF) was induced in 20 Sprague-Dawley rats. After 8 min of untreated VF, mechanical ventilation and precordial compression began. AlphaMNE, epinephrine or saline placebo was injected into the right atrium 2 min after the start of precordial compression. As an additional control, one group of animals was pretreated with alpha2-receptor blocker, yohimbine, before injection of alphaMNE. Defibrillation was attempted 4 min later. Left ventricular pressure, dP/dt40, negative dP/dt and cardiac index were measured for an interval of 240 min after resuscitation. RESULTS: Except for saline placebo and yohimbine-treated animals, comparable increases in coronary perfusion pressure were observed after each drug intervention. All animals were successfully resuscitated. Left ventricular diastolic pressure, cardiac index, dP/dt40 and negative dP/dt were more optimal after alphaMNE; this was associated with significantly better postresuscitation survival. Pretreatment with vohimbine abolished the beneficial effects of alphaMNE. CONCLUSIONS: The selective alpha2-adrenergic agonist, alphaMNE, was as effective as epinephrine for initial cardiac resuscitation but provided strikingly better postresuscitation myocardial function and survival.

Adrenergic alpha-Antagonists↗
PubMed1985

Pharmacokinetic differences between peripheral and central drug administration during cardiopulmonary resuscitation.

Advanced resuscitation techniques are dependent on drug therapy to increase survival. Because drugs must reach their site of action instantaneously, the choice of appropriate route of administration may be critical. To study the pharmacokinetics of drug administration by peripheral and central venous routes during resuscitation, nine mongrel dogs were studied. Arterial blood pressure and electrocardiograms were monitored continuously. Cardiac output was evaluated before resuscitation to determine control levels. After thoracotomy and fibrillation of the heart, cardiac massage was started with a frequency of compression maintained at 60/min. Bolus injections of two different radioisotopes were given simultaneously through a peripheral and a central vein. Isotope activity was sampled through a catheter in the right femoral artery at 5 second intervals for 90 seconds and at 30 second intervals for 210 seconds. The major differences between the two routes of administration were that central injection produced a 270% higher peak concentration (p less than 0.001) and significantly shorter lag times to the first appearance of tracer (16 +/- 7 versus 38 +/- 13 seconds, p less than 0.05) and times to peak concentration (13 +/- 5 versus 27 +/- 12 seconds, p less than 0.01). In contrast, there were no significant differences in area under the time-counts curve, mean residence time, total body clearance and steady state volume of distribution. The central compartment volume of distribution was significantly smaller after central than after peripheral injection (26.1 +/- 56 versus 76.3 +/- 16.5 ml, p less than 0.01). The therapeutic implications of these findings must be investigated for individual drugs used during cardiorespiratory resuscitation to determine the most appropriate route and dosage for each agent.

Animals↗
PubMed1997

Diagnostic accuracy of transesophageal echocardiography during cardiopulmonary resuscitation.

OBJECTIVES: We sought to establish the diagnostic accuracy of transesophageal echocardiography (TEE) during cardiopulmonary resuscitation. BACKGROUND: Because of its bedside diagnostic capabilities, excellent cardiac images and lack of interference with resuscitation efforts, TEE is ideally suited to determine the cause of a circulatory arrest that is not due to severe arrhythmia. However, the diagnostic accuracy of TEE during resuscitation is unknown. METHODS: TEE was performed in patients with prolonged circulatory arrest. The TEE diagnoses were compared with diagnoses from autopsy, surgery and clinical follow-up. RESULTS: Of the 48 study patients (29 male, 19 female, mean age +/- SD 61 +/- 20 years), 28 had an in-hospital cardiac arrest and 20 an out-of-hospital onset of arrest. Forty-four patients eventually died; four survived to discharge. The diagnoses made with TEE were cardiac tamponade (n = 6), myocardial infarction (n = 21), pulmonary embolism (n = 6), ruptured aorta (n = 1), aortic dissection (n = 4), papillary muscle rupture (n = 1), other diagnosis (n = 2) and absence of structural cardiac abnormalities (n = 7). A definite diagnosis from a reference standard was available in 31 patients. The TEE diagnosis was confirmed in 27 of the 31-by postmortem examination (n = 19), operation (n = 2), angiography (n = 2) or clinical course (n = 4). In the other four patients the TEE diagnosis proved incorrect by postmortem examination. The sensitivity, specificity and positive predictive value of TEE were 93%, 50% and 87%, respectively. In 15 patients (31%), major therapeutic decisions were based on TEE findings. CONCLUSIONS: TEE can reliably establish the cause of a circulatory arrest during cardiopulmonary resuscitation.

Adult↗
PubMed1996

In-hospital resuscitation among the elderly: substantial survival to hospital discharge.

The appropriateness of aggressive resuscitation in many clinical settings has been questioned. Survival rates from cardiac arrest in the elderly are generally reported as poor, and satisfactory results from resuscitation attempts prolonged beyond 15 minutes are said to be rare. It was the purpose of this study to examine success rates for resuscitation in a cohort of elderly inpatients suffering cardiac arrest. We retrospectively reviewed 213 consecutive cardiac arrests occurring during a 12-month period in a large tertiary private hospital. Patient age, presenting rhythm, and survival to hospital discharge were recorded. Elderly was defined as 70 years or older. Cardiac arrests in the elderly totaled 89. Average age in this cohort was 76.2 +/- 4.5 years. Eighteen patients (20.2%) had return of spontaneous circulation and 8 patients survived to hospital discharge (44.4% of those with return of spontaneous circulation). No significant difference in age or presenting rhythm of survivors versus nonsurvivors could be demonstrated, although a trend to more frequent ventricular fibrillation or ventricular tachycardia was seen (P = .059, Fisher's exact). Time for resuscitation averaged 25.75 +/- 9.2 minutes for survivors and 32.6 +/- 22.1 minutes for nonsurvivors. Survival to hospital discharge occurs in 9% of in-hospital cardiac arrests in the elderly following average CPR times substantially in excess of 15 minutes.

Age Factors↗
PubMed1996

Resuscitation of the critically ill in the ED: responses of blood pressure, heart rate, shock index, central venous oxygen saturation, and lactate.

To describe the simultaneous responses of systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MAP), heart rate (HR), shock index (SI = HR/SBP), central venous oxyhemoglobin saturation (ScvO2), and arterial blood lactate concentration (Lact) to resuscitation of critically ill patients in the emergency department (ED), an observational descriptive study was conducted in the ED of an urban teaching hospital. Thirty- six patients admitted from the ED to the medical intensive care unit were studied. Vital signs were measured immediately on arrival to the ED (phase 1). After initial resuscitation and stabilization, ie, HR between 50 and 120 beats/min and MAP between 70 and 110 mm Hg (phase 2), ScvO2 and Lact were measured and additional therapy was given in the ED to increase ScvO2 to > 65% and decrease Lact to < 2 mmol/L, if needed (phase 3). SBP, DBP, MAP, HR. SI, ScvO2, and Lact were measured. Initial resuscitation increased SBP from 103 +/- 39 to 118 +/- 29 mm Hg (P < .05) and MAP from 67 +/- 35 to 82 +/- 22 mm Hg (P < .05) but did not affect DBP (53 +/- 35 to 63 +/- 22 mm Hg, P = NS), HR (110 +/- 26 to 110 +/- 22 beats/min, P = NS) or SI (from 1.3 +/- 0.7 to 1.0 +/- 0.3, P =NS) from phase 1 to phase 2. ScvO2 remained < 65% and/or Lact > 2.0 mmol/L in 31 of 36 patients at phase 2, and additional therapy was required. Lact was decreased (from 4.6 +/- 3.8 to 2.6 +/- 2.5 mmol/L, P < .05) and ScvO2 was increased (from 52 +/- 18 to 65 +/- 13%, P < .05) without significant additional changes in SBP, DBP, MAP, HR, or SI at phase 3. The in-hospital mortality was 14% for this group of patients. It was concluded that additional therapy is required in the majority of critically ill patients to restore adequate systemic oxygenation after initial resuscitation and hemodynamic stabilization in the ED. Additional therapy to increase ScvO2 and decrease Lact may not produce substantial responses in SBP, DBP, MAP, HR, and SI. The measurement of ScvO2 and Lact can be utilized to guide this phase of additional therapy in the ED.

Adolescent↗
PubMed1998

Effectiveness of mechanical versus manual chest compressions in out-of-hospital cardiac arrest resuscitation: a pilot study.

A prospective, randomized effectiveness trial was undertaken to compare mechanical versus manual chest compressions as measured by end-tidal CO2 (ETCO2) in out-of-hospital cardiac arrest patients receiving advanced cardiac life support (ACLS) resuscitation from a municipal third-service, emergency medical services (EMS) agency. The EMS agency responds to approximately 6,700 emergencies annually, 79 of which were cardiac arrests in 1994, the study year. Following endotracheal intubation, all cardiac arrest patients were placed on 100% oxygen via the ventilator circuit of the mechanical cardiopulmonary resuscitation (CPR) device. Patients were randomized to receive mechanical CPR (TCPR) or human/manual CPR (HCPR) based on an odd/even day basis, with TCPR being performed on odd days. ETCO2 readings were obtained 5 minutes after the initiation of either TCPR or HCPR and again at the initiation of patient transport to the hospital. All patients received standard ACLS pharmacotherapy during the monitoring interval with the exception of sodium bicarbonate. CPR was continued until the patient was delivered to the hospital emergency department. Age, call response interval, initial electrocardiogram (ECG) rhythm, scene time, ETCO2 measurements, and arrest outcome were identified for all patients. Twenty patients were entered into the study, with 10 in each treatment group. Three patients in the TCPR group were excluded. Measurements in the HCPR group revealed a decreasing ETCO2 during the resuscitation in 8 of 10 patients (80%) and an increasing ETCO2 in the remaining 2 patients. No decrease in ETCO2 was noted in the TCPR group, with 4 of 7 patients (57%) actually showing an increased reading and 3 of 7 patients (43%) showing a constant ETCO2 reading. The differences in the ETCO2 measurements between TCPR and HCPR groups were statistically significant. Both groups were similar with regards to call response intervals, patient ages, scene times, and initial ECG rhythms. One patient in the TCPR group was admitted to the hospital but later died, leaving no survivors in the study. TCPR appears to be superior to standard HCPR as measured by ETCO2 in maintaining cardiac output during ACLS resuscitation of out-of-hospital cardiac arrest patients.

Carbon Dioxide↗
PubMed2000

Vasopressin, renin, and adrenocorticotropic hormone levels during the resuscitation of hemorrhagic shock in dogs.

Hemorrhage is a potent stimulus for the release of vasopressin (VP), renin, and adrenocorticotropic hormone (ACTH). The goal of this study was to analyze changes in plasma VP, renin, and ACTH levels during hemorrhagic shock and resuscitation with two different solutions: hypertonic acetate dextran (HAD) and lactated Ringer's (LR) solution. Eight randomized dogs were shocked by removing 37 +/- 9 mL/kg of blood while maintaining the mean arterial pressure (MAP) at 45 +/- 5 mmHg for 1 h. Test solutions were randomized and infused as needed with the hemorrhaged blood to restore the MAP and cardiac index to baseline. Blood samples for hormone analyses were taken in baseline, shock, and resuscitation periods. For each experiment, all hormone levels increased in the postshock period and then returned to baseline values after resuscitation with both solutions. VP and renin levels rapidly returned to baseline values after resuscitation in the LR dogs compared with the HAD dogs (p < 0.05). By contrast, there was no significant difference in ACTH levels between the two solutions. High-volume infusion with LR achieves more rapid restoration than small-volume infusion with HAD for VP and renin levels.

Adrenocorticotropic Hormone↗
PubMedDate not supplied

Quantification of procedures and resuscitations in an emergency medicine residency.

Currently, there are no data that govern the number of procedures that are necessary to promote competence during emergency medicine (EM) training. Nonetheless, the Residency Review Committee requires each program to report the average number of procedures and resuscitations performed by its residents. For 7 years, we have used a computer database to track resuscitation and procedure experience for 42 residents. We have documented resident experience both in our 36,000-visit Level I Trauma Center emergency department and during off-service rotations in our 400-bed university teaching hospital. We report data from four graduating classes (n = 24). We estimate that residents have recorded 60% of the actual procedures performed. The 24 residents documented 11,947 procedures, averaging 498 per resident (range 264-1055), and participated in 3432 resuscitations, or 143 per resident (range 64-379). Mean and standard deviations are reported for 20 specific EM procedures and 4 types of resuscitations. EM residents perform a large number of procedures, but there is wide inter-resident variability. There is no documentation that some residents perform even one of some rare but critical procedures. This tracking system suggests, then, that procedure simulations, or cadaver and animal models, must be developed and used to enhance experience. This program can be modified to track resident experience in any specialty, as well as to document supervision by faculty and support credentialling inquiries.

California↗