Cardiopulmonary Resuscitation in Emergency Medicine: What Have We Learned and How Do We Move On?

Background: Every year, approximately 200,000 patients will experience in-hospital cardiac arrest (IHCA) in the United States. Survival has been shown to be greatest with the prompt initiation of CPR and early interventions, leading to the development of time-based quality measures. It is uncertain how documentation practices affect reports of compliance with time-based quality measures in IHCA. Methods: A retrospective review of all cases of IHCA that occurred in the Cardiac Intensive Care Unit (CICU) at an academic quaternary hospital was conducted. For each case, a member of the code team (observer) documented performance measures as part of a prospective cardiac arrest quality improvement database. We compared those data to those abstracted in the retrospective review of “real-time” documentation in a Resuscitation Narrator module within electronic health records (EHRs) to investigate for discrepancies. Results: We identified 52 cases of IHCA, all of which were witnessed events. In total, 47 (90%) cases were reviewed by observers as receiving epinephrine within 5 min, but only 42 (81%) were documented as such in the EHR review (p = 0.04), meaning that the interrater agreement for this metric was low (Kappa = 0.27, 95% CI 0.16–0.36). Four (27%) eligible patients were reported as having defibrillation within 2 min by observers, compared to five (33%) reported by the EHR review (p = 0.90), and with substantial agreement (Kappa = 0.73, 95% CI 0.66–0.79). There was almost perfect agreement (Kappa = 0.82, 95% CI 0.76–0.88) for the initial rhythm of cardiac arrest (25% shockable rhythm by observers vs. 29% for EHR review, p = 0.31). Conclusion: There was a discrepancy between prospective observers’ documentation of meeting quality standards and that of the retrospective review of “real-time” EHR documentation. A further study is required to understand the cause of discrepancy and its consequences. Full article

Background: The potential use of manikins made of environmentally friendly materials (biodegradable or easily recycled) could be a milestone in promoting cardiac arrest awareness and mass resuscitation training without the threat of generating large amounts of unprocessable waste. The main aim of the study was to compare the attitude of young adults from Asia and Poland towards cardiopulmonary resuscitation training forms and to evaluate the innovative concept of an ecological resuscitation manikin; Methods: This was a survey-based study conducted during two events in Thailand and Poland in 2023; Results: A total of 226 questionnaires were included in the final analysis. Asian respondents were significantly more likely to choose traditional training than Polish participants (78% vs. 58%, respectively). A manikin that is mainly biodegradable was the most common choice across the entire study group. Young Asians were significantly more likely to choose a traditional stationary course, while Polish respondents were highly significantly more likely to opt for hybrid training (online with practical training provided at the student’s home). Conclusions: In the total study group, young people from Poland and parts of Asia are most likely to participate in traditional on-site instructor-led training, but a comparison across groups showed a significant tendency for young Poles to choose a hybrid training option, i.e., a combination of online and hands-on training. Despite some differences, both study groups showed a strong interest in pro-environmental behavior and the use of more ecofriendly solutions than previously used in resuscitation training. Full article

Background: There is growing interest in the quality of manual ventilation during cardiopulmonary resuscitation (CPR), but accurate assessment of ventilation parameters remains a challenge. Waveform capnography is currently the reference for monitoring ventilation rate in intubated patients, but fails to provide information on tidal volumes and inspiration–expiration timing. Moreover, the capnogram is often distorted when chest compressions (CCs) are performed during ventilation compromising its reliability during CPR. Our main purpose was to characterize manual ventilation during CPR and to assess how CCs may impact on ventilation quality. Methods: Retrospective analysis were performed of CPR recordings fromtwo databases of adult patients in cardiac arrest including capnogram, compression depth, and airway flow, pressure and volume signals. Using automated signal processing techniques followed by manual revision, individual ventilations were identified and ventilation parameters were measured. Oscillations on the capnogram plateau during CCs were characterized, and its correlation with compression depth and airway volume was assessed. Finally, we identified events of reversed airflow caused by CCs and their effect on volume and capnogram waveform. Results: Ventilation rates were higher than the recommended 10 breaths/min in 66.7% of the cases. Variability in ventilation rates correlated with the variability in tidal volumes and other ventilatory parameters. Oscillations caused by CCs on capnograms were of high amplitude (median above 74%) and were associated with low pseudo-volumes (median 26 mL). Correlation between the amplitude of those oscillations with either the CCs depth or the generated passive volumes was low, with correlation coefficients of −0.24 and 0.40, respectively. During inspiration and expiration, reversed airflow events caused opposed movement of gases in 80% of ventilations. Conclusions: Our study confirmed lack of adherence between measured ventilation rates and the guideline recommendations, and a substantial dispersion in manual ventilation parameters during CPR. Oscillations on the capnogram plateau caused by CCs did not correlate with compression depth or associated small tidal volumes. CCs caused reversed flow during inspiration, expiration and in the interval between ventilations, sufficient to generate volume changes and causing oscillations on capnogram. Further research is warranted to assess the impact of these findings on ventilation quality during CPR. Full article

Introduction: Out-of-hospital cardiac arrests (OHCAs) represent critical medical emergencies in which timely interventions can make a significant difference in patient outcomes. Despite their importance, the role of on-scene witnesses during such events remains relatively unexplored. Aim of the Study: This research seeks to shed light on the influence of witnesses, especially family members, during OHCAs and the effect of their interventions, or the absence thereof, on outcomes. Drawing from existing literature, our working hypothesis suggests that the presence of a witness, particularly one who is knowledgeable about CPR, can increase the likelihood of obtaining the return of spontaneous circulation (ROSC), potentially enhancing overall survival rates. Methods: Using a retrospective analytical method, we thoroughly reviewed medical records from the Lublin Voivodeship between 2014–2017. Out of 5111 events identified using ICD-10 diagnosis codes and ICD-9 medical procedure codes, 4361 cases specifically related to sudden cardiac arrest were chosen. Concurrently, 750 events were excluded based on predefined criteria. Results: Both basic and advanced EMS teams showed higher rates of CPR initiation and an increased likelihood of obtaining ROSC. Notably, the presence of a trained EMS professional as a witness significantly increased the chances of CPR initiation. The presenting rhythms most often detected were ventricular tachycardia (VT) and ventricular fibrillation (VF). Different urgency codes were directly linked to varying ROSC outcomes. When witnesses, especially family members, began chest compressions, the use of amiodarone was notably higher. A significant finding was that 46.85% of OHCA patients died without witnesses, while family members were present in 23.87% of cases. Actions taken by witnesses, especially chest compressions, generally extended the overall duration of patient care. Conclusion: The crucial influence of witnesses, particularly family members, on OHCA outcomes is evident. Therefore, it is essential to increase public awareness of CPR techniques and rapid intervention strategies to improve outcomes in emergency situations. Full article

Background: Out-of-hospital cardiac arrest is considered a global problem. In the last few years, there has been a growing interest in telephone-cardiopulmonary resuscitation guided by a telecommunicator. Indeed, several studies have demonstrated that it increases the chances of survival rate. This study focuses on the key points the operator should follow when performing telephone-cardiopulmonary resuscitation. The main objective of this paper is to design an algorithm to improve the telephone-cardiopulmonary resuscitation response protocol. Methods: The available evidence and the areas of uncertainty that have not been previously mentioned in the literature are discussed. All the information has been analyzed by two discussion groups. Later, a consensus was reached among all members. Finally, a response algorithm was designed and implemented in clinical simulation. Results: All the witnesses were able to recognize the OHCA, call for emergency assistance, follow all the operator’s instructions, move the victim, and place their hands in the correct position to perform CPR. Discussion: The results of the pilot study provide us a basis for further experimental studies using randomization and experimental and control groups. Conclusions: No standardized recommendations exist for the operator to perform telephone-guided CPR. For this reason, a response algorithm was designed. Full article

Background: Chest compression and defibrillation are essential components of cardiac arrest treatment. Mechanical chest compression devices (MCCD) and automated external defibrillators (AED) are used separately in clinical practice. We developed an automated compression–defibrillation apparatus (ACDA) that performs mechanical chest compression and automated defibrillation. We investigated the performance of cardiopulmonary resuscitation (CPR) with automatic CPR (A-CPR) compared to that with MCCD and AED (conventional CPR: C-CPR). Methods: Pigs were randomized into A-CPR or C-CPR groups: The A-CPR group received CPR+ACDA, and the C-CPR group received CPR+MCCD+AED. Hemodynamic parameters, outcomes, and time variables were measured. During a simulation study, healthcare providers performed a basic life support scenario for manikins with an ACDA, MCCD, and AED, and time variables and chest compression parameters were measured. Results: The animals showed no significant in hemodynamic effects, including aortic pressures, coronary perfusion pressure, carotid blood flow, and end-tidal CO₂, and resuscitation outcomes between the two groups. In both animal and simulation studies, the time to defibrillation, time to chest compression, and hands-off time were significantly shorter in the A-CPR group than those in the C-CPR group. Conclusions: CPR using ACDA showed similar hemodynamic effects and resuscitation outcomes as CPR using AED and MCCD separately, with the advantages of a reduction in the time to compression, time to defibrillation, and hands-off time. Full article

Low blood sugar is commonly found during cardiopulmonary resuscitation (CPR). However, current guidelines do not mention the importance of glucose testing and acute management for hypoglycemia during CPR. We intended to investigate the association between dextrose administration and resuscitation outcomes in patients with blood sugar less than 150 mg/dL during cardiac arrest in the emergency department (ED). We conducted a retrospective cohort study at a tertiary hospital between 2017 and 2020, including patients with intra-arrest blood glucose <150 mg/dL. Logistic regression with inverse probability treatment weighting (IPTW) was used. The primary outcome was the return of spontaneous circulation (ROSC). Secondary outcomes included survival to hospital admission and hospital discharge and favorable neurological outcomes at discharge. A total of 865 patients received CPR at the ED during the study period. Of these, 229 with low blood sugar were included (60 in the treatment group and 169 in the non-treatment group). The mean age was 59.5 ± 21.4 years. After IPTW, dextrose administration during CPR was not associated with ROSC (adjusted OR [aOR] 1.44, 95% CI 0.30–0.69), survival to hospital admission (aOR 1.27, 95% CI 0.54–3.00), survival to hospital discharge (aOR 0.68, 95% CI 0.20–2.29), and favorable neurological status (aOR 2.21, 95% CI 0.23–21.42). Our findings suggested that dextrose administration during CPR at the ED might not lead to better or worse resuscitation outcomes. Owing to the design limitations and residual confounding factors, strong recommendations for dextrose administration could not be formulated. Further evidence is needed from prospective trials to confirm the efficacy of dextrose during CPR. Full article

Background: In recent years, several actions have been made to shorten the chain of survival in out-of-hospital cardiac arrest (OHCA). These include placing defibrillators in public places, training first responders, and providing dispatcher-assisted CPR (DA-CPR). In this work, we aimed to evaluate the impact of these changes on patients’ outcomes, including achieving return of spontaneous circulation (ROSC), survival to discharge, and survival with favorable neurological function. Methods: We retrospectively retrieved data of all calls to the national emergency medical service in Ashdod city, Israel, of individuals who underwent OHCA at the age of 18 and older between the years 2018 and 2021. Data was collected on prehospital and hospital interventions. The association between pre-hospital and hospital interventions to ROSC, survival to discharge, and neurological outcomes was evaluated. Logistic regression was used for multivariable analysis. Results: During the years 2018–2021, there were 1253 OHCA cases in the city of Ashdod. ROSC was achieved in 207 cases (32%), survival to discharge was attained in 48 cases (7.4%), and survival with favorable neurological function was obtained in 26 cases (4%). Factors significantly associated with good prognosis were shockable rhythm, witnessed arrest, DA-CPR, use of AED, and treatment for STEMI. All patients that failed to achieve ROSC outside of the hospital setting had a poor prognosis. Conclusions: This study demonstrates the prognostic role of the initial rhythm and the use of AED in OHCA. Hospital management, including STEMI documentation and catheterization, was also an important prognostication factors. Additionally, when ROSC is not achieved in the field, hospital transfer should be considered. Full article

Background: Unnecessary resuscitation is defined as putting in a disproportionate amount of effort compared to the patients’ prognosis and chance of survival. The primary objective of this study was to determine the number of resuscitations perceived as unnecessary by emergency medical personnel and to correlate it with the characteristics of resuscitation team members, patient particularities and organizational factors related to the professional environment. Methods: This was a prospective cross-sectional study carried out in the emergency department of a university hospital, exploring the perception of the uselessness of cardiopulmonary resuscitation (CPR) through the completion of a questionnaire. Results: In total, 70.37% of respondents are often involved in CPR attempts in which the efforts made are disproportionate compared to the patients’ expected prognosis, in terms of survival or quality of life. The presence of a non-shockable rhythm increased, by two times, the chances of medical staff finding it unnecessary to initiate CPR. Conclusions: The current study was the first in Romania to investigate the perception of unnecessary CPR, based on the recollection of the last resuscitation performed by the emergency medical staff. The objective criteria related to the patient were the most important predictors for assessing the adequacy of the decision to initiate CPR. Full article

Background. The survival benefit of complete versus infarct-related artery (IRA)-only revascularization during the index hospitalization in patients resuscitated from an out-of-hospital cardiac arrest (OHCA) with multivessel disease is unknown. Methods. We considered all the OHCA patients prospectively enrolled in the Lombardia Cardiac Arrest Registry (Lombardia CARe) from 1 January 2015 to 1 May 2021 who underwent coronary angiography (CAG) at the Fondazione IRCCS Policlinico San Matteo (Pavia). Patients’ prehospital, angiographical and survival data were reviewed. Results. Out of 239 patients, 119 had a multivessel coronary disease: 69% received IRA-only revascularization, and 31% received a complete revascularization: 8 during the first procedure and 29 in a staged-procedure after a median time of 5 days [IQR 2.5–10.3]. The complete revascularization group showed significantly higher one-year survival with good neurological outcome than the IRA-only group (83.3% vs. 30.4%, p < 0.001). After correcting for cardiac arrest duration, shockable presenting rhythm, peak of Troponin-I, creatinine on admission and the need for circulatory support, complete revascularization was independently associated with the probability of death and poor neurological outcome [HR 0.3 (95%CI 0.1–0.8), p = 0.02]. Conclusions. This observation study shows that complete myocardial revascularization during the index hospitalization improves one-year survival with good neurological outcome in patients resuscitated from an OHCA with multivessel coronary disease. Full article

Since current cardiac arrest guidelines do not address the benefit of blood glucose measurement, the ideal ranges and target of blood glucose (BG) levels during cardiac arrest to achieve a better result are warranted. We intended to investigate the associations between intra-arrest BG levels and outcomes of cardiac arrest resuscitation at the emergency department (ED). We conducted a retrospective observational study at a single university hospital. Cardiac arrest patients at the ED between 2017 and 2020 were included. Multivariable logistic regression analysis was performed to examine the associations between intra-arrest BG levels and clinical outcomes. We categorized intra-arrest BG into five groups: <70 mg/dL, 70–99 mg/dL, 100–180 mg/dL, 181–250 mg/dL, and >250 mg/dL. Eight hundred and nineteen patients experienced ED cardiac arrest during the study period. Of all, 385 intra-arrest BG measurements were included in the data analysis. The mean age was 60.4 years. The mean intra-arrest BG level was 171.1 mg/dL, with 64 (16.6%) patients who had intra-arrest BG level below 70 mg/dL and 73 (19.0%) patients who had intra-arrest BG level more than 250 mg/dL. Markedly low (<70 mg/dL) and low (70–99 mg/dL) intra-arrest BG levels were significantly associated with a lower chance of return of spontaneous circulation (ROSC, OR 0.36, 95% CI 0.14–0.99, p = 0.05 and OR 0.33, 95% CI 0.12–0.93, p = 0.04, respectively). For patients who experienced cardiac arrest at the ED, an intra-arrest BG level of less than 100 was inversely correlated with sustained ROSC. Although we could not draw a causal relationship between variables concerning this study design, normalizing intra-arrest BG was shown to result in good clinical outcomes. Full article

Novel medical technologies are designed to aid in cardiopulmonary resuscitation both in and out of the hospital. Out-of-hospital innovations utilize the skills of paramedics, bystanders, and other prehospital personnel, while in-hospital innovations traditionally aid in physician intervention. Our review of current literature aims to describe the benefits and limitations of six main technologic advancements with wide adoption for their practicality and functionality. The six key technologies include: extracorporeal membrane oxygenation (ECMO), real-time feedback devices, smart devices, video review, point-of-care ultrasound, and unmanned aerial vehicle (drone) automated external defibrillator (AED) delivery. The benefits and limitations of each technology were independently reviewed and expounded upon. Newer technologies like drone AED delivery, paramedic ultrasound use, and smart devices have been demonstrated to be safe and feasible, however, further studies are needed to compellingly demonstrate improved patient outcomes. In-hospital use of ECMO and ultrasound is well established by current literature to aid in cardiopulmonary resuscitation and improve patient outcomes. Full article

Nearly 565,000 patients will suffer from prehospital and inpatient cardiac arrest in the United States per annum. Cardiopulmonary resuscitation and all associated interventions used to achieve it remain an essential focus of emergency medicine. Current ACLS guidelines give clear instructions regarding mainstay medications such as epinephrine and antiarrhythmics; however, the literature remains somewhat controversial regarding the application of adjunctive therapeutics such as calcium, magnesium, sodium bicarbonate, and corticosteroids. The available data acquired in this field over the past three decades offer mixed pictures for each of these medications on the effects of core metrics of cardiopulmonary resuscitation (e.g., rate of return of spontaneous circulation, survival-to-hospitalization and discharge, 24 h and 30 d mortality, neurological outcome), as well as case-specific applications for each of these interventions (e.g., polymorphic ventricular tachycardia, electrolyte derangements, acidosis, post-arrest shock). This narrative literature review provides a comprehensive summary of current guidelines and published data available for these four agents and their use in clinical practice. Full article

Cardiopulmonary resuscitation (CPR) research traditionally focuses on survival. In 2018, the International Liaison Committee on Resuscitation (ILCOR) proposed more patient-centered outcomes. Our narrative review assessed clinical trials after 2018 to identify the trends of outcome metrics in the field OHCA research. We performed a search of the PubMed database from 1 January 2019 to 22 September 2023. Prospective clinical trials involving adult humans were eligible. Studies that did not report any patient-related outcomes or were not available in full-text or English language were excluded. The articles were assessed for demographic information and primary and secondary outcomes. We included 89 studies for analysis. For the primary outcome, 31 (35%) studies assessed neurocognitive functions, and 27 (30%) used survival. For secondary outcomes, neurocognitive function was present in 20 (22%) studies, and survival was present in 10 (11%) studies. Twenty-six (29%) studies used both survival and neurocognitive function. Since the publication of the COSCA guidelines in 2018, there has been an increased focus on neurologic outcomes. Although survival outcomes are used frequently, we observed a trend toward fewer studies with ROSC as a primary outcome. There were no quality-of-life assessments, suggesting a need for more studies with patient-centered outcomes that can inform the guidelines for cardiac-arrest management. Full article

The prediction of outcomes following cardiac arrest continues to provide significant difficulties. A preferred strategy involves adopting a multimodal approach, which encompasses the careful evaluation of the biomarker neuron-specific enolase (NSE). This systematic review and meta-analysis aimed to gather and summarize new and existing evidence on the prediction effect of neuron-specific enolase for survival to hospital discharge among adult patients with cardiac arrest. We searched PubMed Central, Scopus, EMBASE databases, and the Cochrane Library without language restrictions from their inceptions until 30 October 2023 and checked the reference lists of the included studies. Pooled results were reported as standardized mean differences (SMDs) and were presented with corresponding 95% confidence intervals (CIs). The primary outcome was survival to hospital discharge (SHD). Eighty-six articles with 10,845 participants were included. NSE showed a notable degree of specificity in its ability to predict mortality as well as neurological status among individuals who experienced cardiac arrest (p < 0.05). This study demonstrates the ability to predict fatality rates and neurological outcomes, both during the time of admission and at various time intervals after cardiac arrest. The use of NSE in a multimodal neuroprognostication algorithm has promise in improving the accuracy of prognoses for persons who have undergone cardiac arrest. Full article

Current guidelines for treating cardiac arrest recommend administering 1 mg of epinephrine every 3–5 min. However, this interval is based solely on expert opinion. We aimed to investigate the impact of the epinephrine administration interval (EAI) on resuscitation outcomes in adults with cardiac arrest. We systematically reviewed the PubMed, EMBASE, and Scopus databases. We included studies comparing different EAIs in adult cardiac arrest patients with reported neurological outcomes. Pooled estimates were calculated using the IVhet meta-analysis, and the heterogeneities were assessed using Q and I² statistics. We evaluated the study risk of bias and overall quality using validated bias assessment tools. Three studies were included. All were classified as “good quality” studies. Only two reported the primary outcome. Compared with a recommended EAI of 3–5 min, a favorable neurological outcome was not significantly different in patients with the other frequencies: for <3 min, odds ratio (OR) 1.93 (95% CI: 0.82–4.54); for >5 min, OR 1.01 (95% CI: 0.55–1.87). For survival to hospital discharge, administering epinephrine for less than 3 min was not associated with a good outcome (OR 1.66, 95% CI: 0.89–3.10). Moreover, EAI of >5 min did not pose a benefit (OR 0.87, 95% CI: 0.68–1.11). Our review showed that EAI during CPR was not associated with better hospital outcomes. Further clinical trials are necessary to determine the optimal dosing interval for epinephrine in adults with cardiac arrest. Full article