Cardiac arrest patients admitted to intensive care unit after cardiopulmonary resuscitation: a retrospective cohort study to find predictors for mortality

Abstract Background In-hospital cardiac arrest is a common situation in hospital settings. Therefore, healthcare providers should understand the reasons that could affect the results of cardiopulmonary resuscitation. We aimed to determine the independent predictors for poor outcomes after the return of spontaneous circulation in in-hospital cardiac arrest patients, and also look for a relationship between patient's background parameters and the status at intensive care unit. Methods We did a retrospective cohort study using cardiac arrest patients admitted to the intensive care unit after successful cardiopulmonary resuscitation between 2011-2015. Patients' data were gathered from hospital database. Estimated probabilities of survival were computed using the Kaplan-Meier method. Cox proportional hazard models were used to determine associated risk factors for mortality. Results In total, 197 cardiac arrest patients were admitted to anesthesia intensive care unit after successful cardiopulmonary resuscitation in a 4-years period. Of 197 patients, 170 (86.3%) died in intensive care unit. Median of survival days was 4 days. Comorbidity (p= 0.01), higher duration of cardiopulmonary resuscitation (p= 0.02), lower Glasgow Coma Score (p= 0.00), abnormal lactate level (p= 0.00), and abnormal mean blood pressure (p= 0.01) were the main predictors for increased mortality in cardiac arrest patients after intensive care unit admission. Conclusion The consequent clinical status of the patients is affected by the physiological state after return of spontaneous circulation. Comorbidity, higher duration of cardiopulmonary resuscitation, lower arrival Glasgow Coma Score, abnormal lactate level, and abnormal mean blood pressure were the main predictors for increased mortality in patients admitted to the intensive care unit after successful cardiopulmonary resuscitation.

Embolia de líquido amniótico asociada a paro cardiorrespiratorio recuperado y síndrome de Sheehan / Amniotic fluid embolism associated with recovered cardiac arrest and postpartum Sheehan's syndrome

Resumen La embolia de líquido amniótico es una condición catastrófica propia del embarazo que ocurre típicamente durante el parto o justo posterior a este, cuyo sustrato fisiopatológico no ha sido aclarado por completo. Se ha estimado, según cifras de los Estados Unidos, que su incidencia rondaría 1 por cada 12.953 partos, y en el Reino Unido 1 por cada 50.000 partos; sin embargo, estas cifras pueden ser imprecisas debido a que no existen una referencia ni un consenso respecto a los criterios diagnósticos, además de que el cuadro clínico se puede confundir con otras emergencias obstétricas. Se presenta el caso de una paciente sin antecedentes mórbidos que presenta un cuadro de embolia de líquido amniótico no fatal, caracterizado por un estado fetal no tranquilizador durante la inducción del trabajo de parto, seguido de un paro cardiorrespiratorio durante la cesárea de urgencia y la rápida y catastrófica aparición de signos clínicos de una coagulopatía de consumo grave. Se describen además las complicaciones posoperatorias y su manejo, entre ellas un síndrome de Sheehan y la aparición de convulsiones tónico-clónicas generalizadas con alteración de neuroimágenes.

Abstract Amniotic fluid embolism is a catastrophic pregnancy condition that typically occurs during or inmediately after delivery, and whose pathophysiological background has not been fully clarified. According to US records the incidence of amniotic fluid embolism could been around 1 for every 12,953 births and in the United Kingdom 1 for every 50,000 births, however these numbers may be imprecise because there is no gold standard as well as no consensus regarding the diagnostic criteria, in addition that the clinical presentation can be misdiagnosis with other obstetric emergencies. We present the clinical case of a patient without a morbid history who presents with a non-fatal amniotic fluid embolism, characterized by an non-reassuring fetal status during labor induction, followed by cardiorespiratory arrest during emergency cesarean section and the rapid and catastrophic appearance of clinical signs of a severe consumptive coagulopathy. Postoperative complications and their management are also described, including Sheehans syndrome and the appearance of generalized tonic-clonic seizures with impaired neuroimaging.

Effect and influence factors of cardiopulmonary resuscitation in children with congenital heart disease in pediatric intensive care unit / 中华儿科杂志

Objective: To investigate the prognostic factors of children with congenital heart disease (CHD) who had undergone cardiopulmonary resuscitation (CPR) in pediatric intensive care unit (PICU) in China. Methods: From November 2017 to October 2018, this retrospective multi-center study was conducted in 11 hospitals in China. It contained data from 281 cases who had undergone CPR and all of the subjects were divided into CHD group and non-CHD group. The general condition, duration of CPR, epinephrine doses during resuscitation, recovery of spontaneous circulation (ROSC), discharge survival rate and pediatric cerebral performance category in viable children at discharge were compared. According to whether malignant arrhythmia is the direct cause of cardiopulmonary arrest or not, children in CHD and non-CHD groups were divided into 2 subgroups: arrhythmia and non-arrhythmia, and the ROSC and survival rate to discharge were compared. Data in both groups were analyzed by t-test, chi-square analysis or ANOVA, and logistic regression were used to analyze the prognostic factors for ROSC and survival to discharge after cardiac arrest (CA). Results: The incidence of CA in PICU was 3.2% (372/11 588), and the implementation rate of CPR was 75.5% (281/372). There were 144 males and 137 females with median age of 32.8 (5.6, 42.7) months in all 281 CPA cases who received CPR. CHD group had 56 cases while non-CHD had 225 cases, with the percentage of 19.9% (56/281) and 80.1% (225/281) respectively. The proportion of female in CHD group was 60.7% (34/56) which was higher than that in non-CHD group (45.8%, 103/225) (χ2=4.00, P=0.045). There were no differences in ROSC and rate of survival to discharge between the two groups (P>0.05). The ROSC rate of children with arthythmid in CHD group was 70.0% (28/40), higher than 6/16 for non-arrhythmic children (χ2=5.06, P=0.024). At discharge, the pediatric cerebral performance category scores (1-3 scores) of CHD and non-CHD child were 50.9% (26/51) and 44.9% (92/205) respectively. Logistic regression analysis indicated that the independent prognostic factors of ROSC and survival to discharge in children with CHD were CPR duration (odds ratio (OR)=0.95, 0.97; 95%CI: 0.92~0.97, 0.95~0.99; both P<0.05) and epinephrine dosage (OR=0.87 and 0.79, 95%CI: 0.76-1.00 and 0.69-0.89, respectively; both P<0.05). Conclusions: There is no difference between CHD and non-CHD children in ROSC and survival rate of survival to discharge was low. The epinephrine dosage and the duration of CPR are related to the ROSC and survival to discharge of children with CHD.

Retenção das Habilidades de Ressuscitação Cardiopulmonar nos Estudantes de Medicina / Retention of Cardiopulmonary Resuscitation Skills in Medical Students

Resumo Fundamento A redução da mortalidade e das sequelas de uma vítima de parada cardíaca depende de um atendimento eficaz, rápido e iniciado o mais precocemente possível. O suporte básico de vida (SBV) compreende uma série de etapas que podem ser iniciadas fora do ambiente hospitalar, e ensinadas para qualquer pessoa em cursos específicos. Porém, é importante que o socorrista retenha o conhecimento e as habilidades, pois nunca se sabe quando será necessário realizar uma ressuscitação cardiopulmonar (RCP). Entretanto, estudos mostram que existe uma perda das habilidades em executar uma RCP já com 30 dias após o treinamento, com variações segundo algumas características das pessoas e da atividade profissional. Objetivo Avaliar se os estudantes de medicina são capazes de reter as habilidades por mais de seis meses. Métodos Estudo prospectivo, caso controle, observacional. Estudantes de medicina realizaram um curso sobre morte súbita e parada cardíaca de 40 horas. A avaliação das habilidades foi realizada imediatamente após o curso e seis meses depois. Foram comparadas as notas individuais entre dois momentos, foi avaliada a porcentagem de acerto em cada etapa e uma análise global do atendimento foi classificado como ótimo, bom e ruim. Os avaliadores e critérios foram os mesmos nos dois momentos. Os dados foram analisados pelos teste-t pareado e teste de McNemar, onde para um nível de confiança de 95% o critério para significância foi p < 0,05. Resultados Cinquenta estudantes (27 do sexo feminino) do primeiro ano, com idade entre 18 e 24 anos (média 21), realizaram o curso. O número de etapas cumpridas de forma correta após seis meses foi significativamente menor que logo após o curso (10,8 vs 12,5 p < 0,001). O sexo e idade não interferiram nos resultados. A qualidade global foi considerada ótima em 78% dos atendimentos realizados logo após o curso, significativamente, maior que os 40% após seis meses (p < 0,01). Após seis meses, maior número de erros foi observado nas etapas relacionadas às habilidades mais práticas (como posicionamento das mãos). Conclusão Seis meses após o curso observamos uma perda significativa das habilidades, entre estudantes de medicina, prejudicando a eficácia global do atendimento.

Abstract Background Reduction of mortality and sequelae of cardiac arrest depends on an effective and fast intervention, started as soon as possible. Basic life support involves a series of steps that may be initiated out of the hospital setting and taught to any person in specific courses. However, it is important that the rescuers retain the knowledge and skills to perform cardiopulmonary resuscitation (CPR), as one never knows when they will be required. Studies have shown that a loss of skills occurs as early as 30 days after the training course, with variations according to personal and professional characteristics. Objectives to assess whether medical students are able to retain skills acquired in a BLS course for more than six months. Methods Prospective, case-control, observational study. Medical students attended a 40-hour course on sudden death and cardiac arrest. Skills acquired during the course were evaluated immediately after and six months after the course. Students' individual scores were compared between these time points, the percentage of correct answers was evaluated, and overall performance was rated as excellent, good, and poor. Observers and evaluation criteria were the same immediately after the course and six months later. Data were analyzed using the paired t-test and the McNemar test. The 95% confidence interval was established, and a p < 0.05 was set as statistically significant. Results Fifty students (27 female) in the first year of medical school aged from 18 to 24 years (mean of 21 years) attended the course. The number of steps successfully completed by the students at six months was significantly lower than immediately after the course (10.8 vs 12.5 p < 0.001). Neither sex nor age affected the results. Overall performance of 78% of the students was considered excellent immediately after the course, and this percentage was significantly higher than six months later (p < 0.01). After six months, the steps that the students failed to complete at six months were those related to practical skills (such as a correct hand positioning). Conclusion A significant loss of skills was detected six months after the BLS course among medical students, compromising their overall performance.

Principales recomendaciones de reanimación cardiopulmonar y atención cardiovascular de emergencia para el año 2020 / Best practice recommendations for cardiopulmonary resuscitation and emergency cardiovascular care for 2020

Las altas tasas de letalidad y mortalidad a causa del paro cardiorespiratorio por fibrilación ventricular son considerados un problema de salud pública, cobrando gran relevancia la posibilidad de que sean revertidos rápidamente con la presencia de profesionales capacitados o por personal "lego" actualizados en reanimación cardiopulmonar. El objetivo del presente artículo de revisión fue analizar las nuevas recomendaciones de la American Heart Association para reanimación cardiopulmonar y atención cardiovascular de emergencia para el año 2020.

High rates of lethality and mortality due to ventricular fibrillation cardiorespiratory arrest are considered a public health problem, Thus, the possibility of reversed quickly by trained professionals or updated "lego" staff in cardiopulmonary resuscitation is taking great relevance. The objective of this review article was to discuss the New Recommendations of the American Heart Association for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care for 2020.

Paro cardiorrespiratorio en la embarazada y cesárea perimortem / Maternal cardiac arrest and perimortem cesarean delivery

Resumen El paro cardiorrespiratorio (PCR) en la mujer embarazada es una situación infrecuente, grave y de manejo multidisciplinario. La reanimación cardiopulmonar requiere consideraciones y particularidades propias de la embarazada, centradas en la fisiología y la anatomía, teniendo especial consideración la compresión aortocava, la intubación-ventilación difícil, la presencia de estómago lleno y el hecho que hay dos vidas involucradas. Las principales causas de PCR son las hemorrágicas, seguidas de las embólicas, cardiovasculares, anestésicas e infecciosas. Las principales acciones incluyen activación del código azul obstétrico con respuesta rápida para una eventual realización de histerotomía de emergencia oportuna en el mismo sitio evitando el traslado al quirófano, compresiones torácicas de buena calidad, desviación manual uterina a la izquierda, intubación endotraqueal y manejo avanzado de la vía aérea, todo esto con el fin de mejorar la sobrevida materno-fetal. La cesárea perimortem es un pilar en el manejo, favoreciendo el desenlace materno y eventualmente el fetal. Se debe realizar a los 4 minutos de una reanimación cardiopulmonar no exitosa. Sin embargo, aún hay retardo a la hora de indicarla, por lo que se debe incentivar el entrenamiento, la simulación en resucitación cardiopulmonar materna y las guías clínicas para todo el personal involucrado en la atención de pacientes obstétricas.

Abstract Cardiopulmonary arrest is a rare event during pregnancy and labor. It involves many subspecialties and allied health providers. Besides it requires knowledge of maternal physiology as it relates to resuscitation, particularly aortocaval compression, difficult airway, full stomach and the fact that there are two lives involved. The most frequent causes of cardiac arrest during pregnancy include bleeding, followed by embolism, infection, anesthesia complications and heart failure. The main steps required are: obstetric code activation with appropriate response for performing timely emergent hysterotomy in the same place avoiding the transfer to operating room; good-quality chest compressions; manual uterine displacement to the left, advanced pharmacological and airway management; and optimal care after resuscitation to improve maternal and fetal outcomes. Although current recommendations for maternal resuscitation include the performance of perimortem cesarean section after four minutes of unsuccessful cardiopulmonary resuscitation, deficits in knowledge about this procedure are common. Therefore, training and available evidence-based guidelines should be put in place for all obstetric caregivers.

First case of extracorporeal membrane oxygenation in cardiorespiratory arrest in an emergency room in Brasil: a possible reality?

SUMMARY The extracorporeal membrane oxygenation (ECMO) is a procedure that has been used for a long time in reference centers worldwide. Its fundamental precept is to serve as a bridge to a definitive treatment in patients with severe, but potentially reversible, clinical conditions. Despite this, its use in cardiopulmonary arrest (ECPR) is still a matter of debate, especially when indicated in the emergency department. There is not yet a sufficient level of evidence to support its routine use. In Brasil, the procedure stopped being considered an experimental technique by the Federal Council of Medicine only in 2017. The objective of the present case is to share the pioneering spirit of a Brazilian reference center with ECPR in the emergency room and to discuss the future challenges of the ECMO technique.

Modificações no perfil de paradas cardíacas após implantação de um Time de Resposta Rápida / Changes in cardiac arrest profiles after the implementation of a Rapid Response Team

RESUMO Objetivo: Avaliar as modificações nas características das paradas cardíacas no hospital após a implantação de um Time de Resposta Rápida. Métodos: Este foi um estudo observacional prospectivo de paradas cardíacas ocorridas no hospital entre janeiro de 2013 e dezembro de 2017. O critério de exclusão foi parada cardíaca na unidade de terapia intensiva, na emergência ou na sala cirúrgica. O Time de Resposta Rápida foi introduzido no hospital do estudo em julho de 2014. Os pacientes foram classificados em dois grupos: Pré-Time de Resposta Rápida (parada cardíaca no hospital antes da implantação do Time de Resposta Rápida) e Pós- Time de Resposta Rápida (parada cardíaca no hospital após a implantação do Time de Resposta Rápida). Os pacientes foram seguidos até a alta hospitalar ou óbito. Resultados: Ocorreram 308 paradas cardíacas (64,6 ± 15,2 anos; 60,3% homens; 13,9% com ritmo inicial chocável). Houve diminuição de 4,2 para 2,5 no índice de parada cardíaca no hospital por 1.000 admissões após o início da atuação do Time de Resposta Rápida, além de cerca de 124 chamados por 1.000 admissões. A parada antes da implantação do Time de Resposta Rápida se associou com hipóxia (29,4 versus 14,3%; p = 0,006) e alteração da frequência respiratória (14,7 versus 4,2%; p = 0,004) em comparação aos dados referentes à parada cardíaca após a implantação do Time de Resposta Rápida. Parada cardíaca por hipóxia foi mais comum antes da implantação do Time de Resposta Rápida (61,2 versus 38,1%; p < 0,001). Na análise multivariada, o retorno à circulação espontânea se associou com ritmo chocável (RC 2,97; IC95% 1,04 - 8,43) e parada cardíaca testemunhada (RC 2,52; IC95% 1,39 - 4,59) mas não com a implantação do Time de Resposta Rápida (RC 1,40; IC95% 0,70 - 2,81) ou sinais premonitórios (RC 0,71; IC95% 0,39 - 1,28). Na análise multivariada, a mortalidade hospitalar se associou com ritmo não chocável (RC 5,34; IC95% 2,28 - 12,53) e idade (RC 1,03; IC95% 1,01 - 1,05), porém não com a implantação do Time de Resposta Rápida (RC 0,89; IC95% 0,40 - 2,02). Conclusão: Apesar de a implantação de um Time de Resposta Rápida se associar com redução na incidência de parada cardíaca no hospital, ela não se associou com a redução da mortalidade das vítimas de parada cardíaca no hospital. Observou-se significante diminuição nas paradas cardíacas devidas a causas respiratórias após a implantação do Time de Resposta Rápida.

ABSTRACT Objective: To evaluate changes in the characteristics of in-hospital cardiac arrest after the implementation of a Rapid Response Team. Methods: This was a prospective observational study of in-hospital cardiac arrest that occurred from January 2013 to December 2017. The exclusion criterion was in-hospital cardiac arrest in the intensive care unit, emergency room or operating room. The Rapid Response Team was implemented in July 2014 in the study hospital. Patients were classified into two groups: a Pre-Rapid Response Team (in-hospital cardiac arrest before Rapid Response Team implementation) and a Post-Rapid Response Team (in-hospital cardiac arrest after Rapid Response Team implementation). Patients were followed until hospital discharge or death. Results: We had a total of 308 cardiac arrests (64.6 ± 15.2 years, 60.3% men, 13.9% with initial shockable rhythm). There was a decrease from 4.2 to 2.5 in-hospital cardiac arrest/1000 admissions after implementation of the Rapid Response Team, and we had approximately 124 calls/1000 admissions. Pre-Rapid Response Team cardiac arrest was associated with more hypoxia (29.4 versus 14.3%; p = 0.006) and an altered respiratory rate (14.7 versus 4.2%; p = 0.004) compared with post-Rapid Response Team cardiac arrest. Cardiac arrest due to hypoxia was more common before Rapid Response Team implementation (61.2 versus 38.1%, p < 0.001). In multivariate analysis, return of spontaneous circulation was associated with shockable rhythm (OR 2.97; IC95% 1.04 - 8.43) and witnessed cardiac arrest (OR 2.52; IC95% 1.39 - 4.59) but not with Rapid Response Team implementation (OR 1.40; IC95% 0.70 - 2.81) or premonitory signs (OR 0.71; IC95% 0.39 - 1.28). In multivariate analysis, in-hospital mortality was associated with non-shockable rhythm (OR 5.34; IC95% 2.28 - 12.53) and age (OR 1.03; IC95% 1.01 - 1.05) but not with Rapid Response Team implementation (OR 0.89; IC95% 0.40 - 2.02). Conclusion: Even though Rapid Response Team implementation is associated with a reduction in in-hospital cardiac arrest, it was not associated with the mortality of in-hospital cardiac arrest victims. A significant decrease in cardiac arrests due to respiratory causes was noted after Rapid Response Team implementation.

Management of cardiopulmonary arrest in an educational video: contributions to education in pediatric nursing / Manejo da parada cardiorrespiratória em vídeo educativo: contribuições para o ensino na enfermagem pediátrica / Manejo del paro cardiorrespiratorio en un video educativo: contribuciones a la enseñanza en enfermería pediátrica

Objective: to make and validate an educational video about the management of pediatric cardiopulmonary arrest caused by respiratory failure. Method: methodological study developed in three stages: preparation and validation of a clinical case; production; and validation of educational video. To build the educational video, the Fleming, Reynolds and Wallace methodological framework was used. Results: the clinical case was validated by ten expert referees, who worked as nurses in different regions in Brazil, by completing an online form, with one round of evaluation and calculation of the content validity index. The educational video was validated by three expert judges and 25 nursing students in an evaluation round and contains six scenes, with duration of nine minutes and 56 seconds. An agreement over 80% was reached for most of the items in both the clinical case and the educational video. Conclusion: the educational video proved valid regarding face and content. This educational technology has the potential to meet the demands of students, who are digital natives, related to teaching of management of pediatric cardiopulmonary arrest caused by respiratory failure.

Objetivo: construir e validar um vídeo educativo sobre o manejo da parada cardiorrespiratória pediátrica por insuficiência respiratória. Método: estudo metodológico desenvolvido em três etapas: elaboração e validação de um caso clínico; produção; e validação de vídeo educativo. Para construção do vídeo educativo foi utilizado o referencial metodológico de Fleming, Reynolds e Wallace. Resultados: o caso clínico foi validado por 10 juízes expertises e enfermeiros de diferentes regiões do Brasil, por meio de formulário on-line, com uma rodada de avaliação e cálculo do Índice de Validação de Conteúdo. O vídeo educativo foi validado por três juízes expertises e 25 acadêmicos de Enfermagem em uma rodada de avaliação e contém seis cenas e duração de nove minutos e cinquenta e seis segundos. Tanto o caso clínico quanto o vídeo educativo obteve-se para a maior parte dos itens, 80% ou mais de concordância. Conclusão: vídeo educativo mostrou-se válido quanto à aparência e ao conteúdo. Essa tecnologia educacional tem potencial para atender às demandas de alunos, nativos digitais, tanto quanto ao ensino do manejo da parada cardiorrespiratória pediátrica ocasionada por insuficiência respiratória.

Objetivo: construir y validar un video educativo sobre manejo del paro cardiorrespiratorio pediátrico por insuficiencia respiratoria. Método: estudio metodológico desarrollado en tres etapas: elaboración y validación de un caso clínico; producción; y validación de video educativo. Para la construcción del video educativo se utilizó el marco metodológico de Fleming, Reynolds y Wallace. Resultados: el caso clínico fue validado por 10 jurados expertos, enfermeros de diferentes regiones de Brasil, mediante formulario online, en una ronda de evaluación y calculándose Índice de Validación de Contenido. El video educativo fue validado por tres jueces expertos y 25 estudiantes de enfermería en una ronda de evaluación y contiene seis escenas, de nueve minutos cincuenta y seis segundos. Se obtuvo concordancia de 80% o superior para la mayoría de los ítems del caso clínico y del video educativo. Conclusión: el video educativo demostró validez en cuanto a apariencia y contenido. Esta tecnología educacional tiene potencial para satisfacer la demanda de alumnos nativos digitales en la enseñanza del manejo del paro cardiorrespiratorio pediátrico ocasionado por insuficiencia respiratoria.

Epidemiology of pediatric cardiopulmonary resuscitation / Epidemiologia da ressuscitação cardiopulmonar pediátrica

Abstract Objective: To analyze the main epidemiological aspects of prehospital and hospital pediatric cardiopulmonary resuscitation and the impact of scientific evidence on survival. Source of data: This was a narrative review of the literature published at PubMed/MEDLINE until January 2019 including original and review articles, systematic reviews, meta-analyses, annals of congresses, and manual search of selected articles. Synthesis of data: The prehospital and hospital settings have different characteristics and prognoses. Pediatric prehospital cardiopulmonary arrest has a three-fold lower survival rate than cardiopulmonary arrest in the hospital setting, occurring mostly at home and in children under 1 year. Higher survival appears to be associated with age progression, shockable rhythm, emergency medical care, use of automatic external defibrillator, high-quality early life support, telephone dispatcher-assisted cardiopulmonary resuscitation, and is strongly associated with witnessed cardiopulmonary arrest. In the hospital setting, a higher incidence was observed in children under 1 year of age, and mortality increased with age. Higher survival was observed with shorter cardiopulmonary resuscitation duration, occurrence on weekdays and during daytime, initial shockable rhythm, and previous monitoring. Despite the poor prognosis of pediatric cardiopulmonary resuscitation, an increase in survival has been observed in recent years, with good neurological prognosis in the hospital setting. Conclusions: A great progress in the science of pediatric cardiopulmonary resuscitation has been observed, especially in developed countries. The recognition of the epidemiological aspects that influence cardiopulmonary resuscitation survival may direct efforts towards more effective actions; thus, studies in emerging and less favored countries remains a priority regarding the knowledge of local factors.

Resumo Objetivo: Analisar os principais aspectos epidemiológicos da ressuscitação cardiopulmonar pediátrica pré-hospitalar e hospitalar e o impacto das evidências científicas na sobrevida. Fonte de dados: Revisão narrativa da literatura publicada em Pubmed/Medline até janeiro de 2019, inclusive artigos originais e de revisão, revisões sistemáticas, metanálises, anais de Congresso, além de busca manual dos artigos selecionados. Síntese dos dados: Os cenários pré-hospitalar e hospitalar apresentam características e prognósticos distintos. A parada cardiorrespiratória pré-hospitalar pediátrica apresenta sobrevida três vezes menor do que a hospitalar, ocorre em sua maioria nas residências e nos menores de um ano. A maior sobrevida parece estar associada a progressão da idade, ritmo chocável, atendimento por serviço médico de emergência, uso de desfibrilador externo automático, suporte básico de vida precoce de alta qualidade e orientação de ressuscitação cardiopulmonar via telefônica por atendente e está fortemente associada com parada cardiorrespiratória presenciada. No cenário hospitalar, observou-se maior incidência em menores de um ano e mortalidade crescente com a idade. Maior sobrevida foi observada quanto a menor duração da ressuscitação cardiopulmonar, ocorrência em dias da semana e período diurno, ritmo chocável inicial e monitoração prévia. Apesar do prognóstico reservado da ressuscitação cardiopulmonar pediátrica, observou-se nos últimos anos incremento da sobrevida com bom prognóstico neurológico no cenário hospitalar. Conclusões: Houve grande avanço na ciência da ressuscitação cardiopulmonar pediátrica, especialmente em países desenvolvidos. O reconhecimento dos aspectos epidemiológicos que influenciam a sobrevida da ressuscitação cardiopulmonar pode direcionar esforços para ações mais efetivas. Assim, a pesquisa em países emergentes e menos favorecidos persiste como prioridade no conhecimento de fatores locais.

Supervivencia a 30 días y 1 año de pacientes con muerte súbita con posterior colocación de dispositivo cardíaco implantable en un hospital de alta complejidad / Patients with sudden cardiac death receiving an implantable cardiac device: survival at 30 days and one year

Background: The use of implantable cardiac devices in patients with sudden cardiac arrest has contributed to their survival. Aim: To determine the survival rate at 30 days and one year after hospital discharge of patients who had a cardiac arrest with subsequent placement of an implantable cardiac device. Material and Methods: Twenty-three patients older than 18 years who presented sudden extra-institutional or intra-institutional death with subsequent implantation of an implantable cardiac device and whose survival was recorded at 30 days and one year, were included. A univariate analysis was performed. Results: Eighteen patients had an extra institutional cardiac arrest. All patients were discharged alive. We could not ascertain the health status of one patient at follow-up. Twenty-one patients had a Cerebral Performance Category (CPC) of 1 at discharge. One patient died of a stroke within 30 days and one patient died due to an arrhythmic electrical storm one year later. Twenty patients survived at least one year after hospital discharge. Conclusions: Survival at 30 days and one year, was high in patients with sudden death or cardiac arrest who required intracardiac devices.

Factors Associated to the Knowledge of Cardiac Arrest by Health Professionals

Abstract Background: Knowledge of cardiac arrest by health professionals is associated with sociodemographic, occupational and training characteristics. Objectives: To evaluate the factors associated with the knowledge of health professionals on Cardiac Arrest. Methods: A cross-sectional study conducted in a large public hospital in the countryside of Bahia - Brazil. The sample consisted of 18 doctors, 32 nurses and 50 nursing technicians. To evaluate the knowledge of the professionals, a questionnaire was constructed according to the current guidelines for resuscitation of the American Heart Association of 2015, and after that, it was submitted to three judges with expertise in PCR to verify content validity. Data were analyzed through descriptive statistics with univariate, bivariate and multivariate analyses using the logistic regression model. A value of p < 0.05 was adopted as level of significance. Results: The prevalence of insufficient knowledge of cardiac arrest among health professionals was 78%. After logistic regression, belonging to the professional category of nursing technician (p = 0.003) and nurse (p = 0.001) and working in the form of on-call duty for 24h (p = 0.005) was associated to insufficient knowledge. Conclusions: Insufficient knowledge of cardiac arrest among health professionals is high, which is a problem that requires urgent interventions in order to guarantee the quality of care. These actions should be based on realistic scenarios involving theoretical and practical activities. The periodicity of training should be short, given the deterioration of knowledge. The creation and validation of the data collection instrument allows for its applicability in other studies.

Medical Behavior in Cardiorespiratory Arrest before and After Simulation Based on Advanced Cardiac Life Support (ACLS) Course

Abstract Background: The Advanced Cardiac Life Support (ACLS) course is designed to teach cardiovascular emergency, aiming to promote a harmonious and synchronized work of the entire hospital team, making the multidisciplinary job more effective in the execution of cardiopulmonary resuscitation (CPR). Objective: To compare the effectiveness of CPR performed between physicians trained on ACLS and non-trained physicians. Methods: A questionnaire was applied to physicians working at the emergency room of hospitals in Curitiba, state of Paraná, whose resolution required theoretical and practical knowledge about CPR. For analysis, descriptive statistics and Fisher's association analysis were used, and the medians of the groups were evaluated by Mann-Whitney/Kruskal-Wallis with significance of 5%. Results: Thirty-four physicians were volunteers, of whom 20 had taken the ACLS course (Group A) and 14 had not (Group B). The trained physicians obtained the highest median (4.00 vs. 3.00, p = 0.06) of correct answers. Group A scored at least 3 of the 5 questions in the questionnaire, showing better performance than Group B (OR = 6.75, 95% CI, 1.1 < OR < 41.0, p = 0.04). The year of the course did not significantly change the performance in the questionnaire. Conclusion: It is suggested that the ACLS course was effective in qualifying physicians to handle situations of cardiorespiratory arrest properly, which was reproduced by the better performance in the resolution of the questionnaire. It is believed that when the sample of volunteers is increased, the trends found materialize the other hypotheses proposed.

Assessment of the quality of pediatric cardiopulmonary resuscitation using the in situ mock code tool / Avaliação da qualidade da ressuscitação cardiopulmonar pediátrica por meio da ferramenta in situ mock code

ABSTRACT Objective: To evaluate the quality of individual and team care for cardiac arrest in a pediatric hospital using clinical surprise simulation (in situ mock code). Methods: We conducted an observational study with a sample of the hospital staff. Clinical simulations of cardiorespiratory arrest were performed in several sectors and work shifts. The mock code occurred in vacant beds of the sector without previous notification to the teams on call. One researcher conducted all mock codes and another evaluated individual and team attendance through a questionnaire contemplating recommendation for adequate cardiopulmonary resuscitation, based on the Pediatric Advanced Life Support (PALS) guidelines. At the end of the simulations, the research team provided a debriefing to the team tested. Results: Fifteen in situ mock code were performed with 56 nursing professionals (including nurses, nursing residents and technicians) and 11 physicians (including two pediatric residents and four residents of pediatric subspecialties). The evaluation showed that 46.7% of the professionals identified cardiac arrest checking for responsiveness (26.7%) and pulse (46.7%); 91.6% requested cardiac monitoring and venous access. In one case (8.3%) the cardiac compression technique was correct in depth and frequency, while 50% performed cardiopulmonary resuscitation correctly regarding the proportion of compressions and ventilation. According to PALS guidelines, the teams had a good performance in the work dynamics. Conclusions: There was low adherence to the PALS guidelines during cardiac arrest simulations. The quality of cardiopulmonary resuscitation should be improved in many points. We suggest periodical clinical simulations in pediatric services to improve cardiopulmonary resuscitation performance.

RESUMO Objetivo: Avaliar a qualidade do atendimento individual e de equipe à parada cardiorrespiratória (PCR) em hospital pediátrico, utilizando a ferramenta de simulação clínica surpresa (in situ mock code). Métodos: Estudo observacional transversal com profissionais de saúde. Foram realizadas simulações clínicas de PCR em diversos setores, em turnos variados, em leito vago do setor sem notificação prévia às equipes de plantão. Um pesquisador conduziu todos os mock code e outro avaliou o atendimento individual e de equipe por meio de questionário contendo recomendações para adequada ressuscitação cardiopulmonar baseadas no protocolo do Suporte Avançado de Vida em Pediatria (PALS). Ao término das simulações, realizou-se debriefing com a equipe testada. Resultados: Foram realizados 15 in situ mock code e incluídos 56 profissionais de enfermagem (entre enfermeiros, residentes em enfermagem e técnicos) e 11 médicos (sendo dois residentes em pediatria e quatro pediatras residentes em subespecialidade pediátrica). A avaliação mostrou que profissionais identificaram a PCR checando responsividade (26,7%) e pulso (46,7%); 91,6% solicitaram monitorização cardíaca e acesso venoso. Em um caso (8,3%), a técnica de compressão cardíaca foi correta em profundidade e frequência, enquanto 50% executaram a ressuscitação cardiopulmonar corretamente na proporção de compressão e ventilação. As equipes apresentaram bom desempenho na dinâmica de trabalho, segundo variáveis recomendadas pelo PALS. Conclusões: Houve baixa adesão ao protocolo do PALS durante simulações de PCR, observando-se que a qualidade da ressuscitação cardiopulmonar oferecida pode melhorar em muitos pontos. Sugere-se que, em locais de assistência a pacientes pediátricos, sejam realizados treinamentos com simulações clínicas periódicas para melhor atendimento à PCR pediátrica.

Atualização do atendimento do paciente em parada cardiorrespiratória: O que todo clínico deve saber? / Update of medical care in cardiorespiratory arrest: What should every clinician know?

O objetivo deste estudo foi apresentar uma revisão narrativa do atendimento à parada cardiorrespiratória, baseada nas diretrizes mais atuais e, também, uma análise crítica de informações de literatura recente, que vão além das recomendações gerais das diretrizes vigentes. A parada cardiorrespiratória, quando ocorre de forma inesperada, abrupta, em indivíduo que se encontrava estável horas antes do evento, é chamada de morte súbita. Essa condição é a principal causa de óbito extra-hospitalar não traumático e, dentre suas diversas causas, a síndrome coronariana aguda é a mais comum em adultos. Uma vez que a frequência de síndrome coronariana aguda tende a aumentar com o aumento da expectativa de vida e de prevalência de outros fatores de risco na população, a ocorrência de morte súbita também tende a aumentar nesse cenário. No intuito de orientar o atendimento de pacientes em parada cardiorrespiratória, há mais de quatro décadas foram criadas diretrizes internacionais, que evoluíram com o surgimento de novas evidências, especialmente nos últimos 20 anos. Todo médico deve estar preparado para atender uma situação de parada cardiorrespiratória, pois ele pode ser chamado para atender tais casos em diferentes cenários (emergência, unidade de internação ou em ambiente extra-hospitalar). Entretanto, apesar da importância da incorporação de novas evidências nessas diretrizes, mudanças frequentes nas recomendações representam grande desafio para os clínicos se manterem atualizados. Além da dificuldade na atualização permanente, há recomendações feitas pelas diretrizes de sociedades médicas que divergem entre si e são questionadas por especialistas, o que gera dúvida na tomada de decisão do clínico. Conforme pormenorizado neste artigo de atualização, as etapas do algoritmo de Suportes Básico e Avançado de Vida são apresentadas como uma sequência, para facilitar para o socorrista que atua sozinho a oferecer intervenções com impacto na sobrevivência do paciente, devendo priorizar a reanimação cardiopulmonar de qualidade e a desfibrilação precoce, se indicada.

The objective of this study was to present a narrative review of cardiac arrest care based on the most current guidelines, and also a critical analysis of recent literature information that goes beyond the general recommendations of the current guidelines. Cardiac arrest, when occurring unexpectedly, abruptly, in an individual who was stable hours before the event, is called sudden death. This condition is the leading cause of non-traumatic out-of-hospital death and, among its many causes, acute coronary syndrome is the most common in adults. Since the frequency of acute coronary syndrome tends to increase with increasing life expectancy and the prevalence of other risk factors in the population, sudden death also tends to increase in this scenario. In order to guide the care of patients with cardiopulmonary arrest, for over 4 decades, international guidelines have been created and have evolved with the emergence of new evidence, especially in the last 20 years. Every physician should be prepared to deal with a cardiac arrest situation as he or she may be called upon to treat such cases in different scenarios (emergency, inpatient unit or out-of-hospital setting). However, despite the importance of incorporating new evidence into these guidelines, frequent changes to the recommendations pose a major challenge for clinicians to update their knowledge. In addition to the difficulty of constantly updating, there are recommendations made by the guidelines of medical societies that differ from each other and are questioned by specialists, which creates doubt in the process of decision making among clinicians. As detailed in this update article, the stages of the algorithm of Basic and Advanced Life Support are presented in a sequence to help the rescuer who works alone to provide interventions that impact the patient's survival, and prioritize quality cardiopulmonary resuscitation and early defibrillation, if required.

Como discutir sobre não ressuscitação cardiopulmonar na unidade de terapia intensiva? / How to discuss about do-not-resuscitate in the intensive care unit?

RESUMO A melhoria da qualidade da ressuscitação cardiopulmonar vem reduzindo a mortalidade dos indivíduos atendidos em parada cardiorrespiratória. Porém, os sobreviventes apresentam risco elevado de dano cerebral grave em caso de retorno à circulação espontânea. Dados sugerem que paradas cardiorrespiratórias, que ocorram em pacientes criticamente doentes com ritmos cardíacos não chocáveis, apresentem somente 6% de chance de retorno à circulação espontânea e, destes, somente um terço consiga recuperar sua autonomia. Optaríamos, assim, pela realização de um procedimento em que a chance de sobrevida é mínima, e os sobreviventes apresentam risco de aproximadamente 70% de morte hospitalar ou dano cerebral grave e definitivo? Valeria a pena discutir se este paciente é ou não ressuscitável, em caso de parada cardiorrespiratória? Esta discussão traria algum benefício ao paciente e a seus familiares? As discussões avançadas de não ressuscitação se baseiam no princípio ético do respeito pela autonomia do paciente, pois o desejo dos familiares e dos médicos, muitas vezes, não se correlaciona adequadamente aos dos pacientes. Não somente pela ótica da autonomia, as discussões avançadas podem ajudar a equipe médica e assistencial a anteciparem problemas futuros, fazendo-os planejar melhor o cuidado dos enfermos. Ou seja, nossa opinião é a de que discussões sobre ressuscitação ou não dos pacientes criticamente doentes devam ser realizadas em todos os casos internados na unidade de terapia intensiva logo nas primeiras 24 a 48 horas de internação.

Abstract The improvement in cardiopulmonary resuscitation quality has reduced the mortality of individuals treated for cardiac arrest. However, survivors have a high risk of severe brain damage in cases of return of spontaneous circulation. Data suggest that cases of cardiac arrest in critically ill patients with non-shockable rhythms have only a 6% chance of returning of spontaneous circulation, and of these, only one-third recover their autonomy. Should we, therefore, opt for a procedure in which the chance of survival is minimal and the risk of hospital death or severe and definitive brain damage is approximately 70%? Is it worth discussing patient resuscitation in cases of cardiac arrest? Would this discussion bring any benefit to the patients and their family members? Advanced discussions on do-not-resuscitate are based on the ethical principle of respect for patient autonomy, as the wishes of family members and physicians often do not match those of patients. In addition to the issue of autonomy, advanced discussions can help the medical and care team anticipate future problems and, thus, better plan patient care. Our opinion is that discussions regarding the resuscitation of critically ill patients should be performed for all patients within the first 24 to 48 hours after admission to the intensive care unit.

Ativação de oxigenação por membrana extracorpórea: uma atitude terapêutica a ponderar / Activation of extracorporeal membrane oxygenation: a therapeutic approach to be considered

RESUMO Objetivo: Descrever o perfil epidemiológico das vítimas assistidas pela Viatura Médica de Emergência e Reanimação em paragem cardiorrespiratória e refletir se tinham critérios para utilizar a oxigenação por membrana extracorpórea. Métodos: Estudo retrospectivo, de coorte, descritivo e exploratório. A colheita de dados foi efetuada durante o mês de janeiro de 2018, na região Norte de Portugal, por meio da consulta à base de registos da Viatura Médica de Emergência e Reanimação sobre assistências prestadas no período de 2012 a 2016. Foi elaborada uma grelha de observação suportada pelo instrumento utilizado para a colheita de dados do registo nacional de paragem cardiorrespiratória pré-hospitalar. Resultados: Após aplicar critérios de inclusão, a amostra foi composta por 36 vítimas. Verificou-se que a oxigenação por membrana extracorpórea poderia ter sido aplicada a 24 vítimas no período balizado da colheita de dados, o que resultaria em várias possibilidades de transplantação e/ou sobrevivência, quer da própria vítima quer de outras vidas. Conclusão: A Viatura Médica de Emergência e Reanimação tem potencial para ser incluída na rede oxigenação por membrana extracorpórea da área em estudo.

ABSTRACT Objective: To describe the epidemiological profile of victims of cardiac arrest assisted using a nontransporting emergency medical service vehicle and to determine whether these patients met the criteria for the use of extracorporeal membrane oxygenation. Methods: This study employed a retrospective, cohort, descriptive, and exploratory design. Data were collected in January 2018 in northern Portugal by consulting the records of nontransporting emergency medical service vehicles that provided assistance between 2012 and 2016. An observation grid was prepared that was supported by the instrument used for collecting data from the national registry of out-ofhospital cardiac arrests. Results: After applying the inclusion criteria, the sample consisted of 36 victims. Extracorporeal membrane oxygenation could have been applied to 24 victims during the period analyzed, which might have increased the odds for transplantation, survival, or both, for either the victim or other individuals. Conclusion: Nontransporting emergency medical service vehicles have the potential for inclusion in the extracorporeal membrane oxygenation network of the study area.

Conhecimento e atuação da equipe de enfermagem de um setor de urgência no evento parada cardiorrespiratória / The knowledge and acting of a nursing team from a sector of cardiorespiratory arrest urgent care / Conocimiento y actuación del equipo de enfermería de un sector de urgencia en el evento parada cardiorrespiratoria

Objective: The study's purpose has been to describe the knowledge and performance of an urgency nursing team of the University Hospital from the Universidade Federal do Vale do São Francisco in Petrolina city, Pernambuco State, with regards to the cardio respiratory arrest event. Methods: It is a descriptive and cross-sectional study with a quantitative approach, which was carried out through a non-probabilistic sample of 101 nursing professionals who answered a questionnaire. Data were analyzed by observing the frequencies of each isolated response and the crossing of variables. Results: Twenty-three nurses and 78 nurse technicians were interviewed. Regarding the detection of a cardio respiratory arrest, immediate conduct, and the actions of both the basic life support and advanced life support, most professionals answered in a partially correct way. Conclusion: The low percentage of totally correct answers evidences the need to update the entire nursing team, maintaining the uniformity of the professional performance, thus improving the care provided to the patient showing serious health condition

Objetivo: Descrever o conhecimento e atuação da equipe de enfermagem da urgência do Hospital Universitário da Universidade Federal do Vale do São Francisco de Petrolina/PE, perante o evento PCR. Métodos: Estudo quantitativo, descritivo e transversal por uma amostragem não probabilística de 101 profissionais de enfermagem que responderam a um questionário. Os dados foram analisados por meio da observação das frequências de cada resposta isolada e do cruzamento de variáveis. Resultados: Foram entrevistados 23 enfermeiros e 78 técnicos de enfermagem. Com relação à detecção de PCR, conduta imediata, ações de SBV e SAV, a maioria dos profissionais respondeu de maneira parcialmente correta. Conclusão: O baixo percentual de respostas totalmente corretas, evidencia a necessidade de atualização de toda a equipe de enfermagem, mantendo a uniformidade das condutas, melhorando assim o atendimento prestado ao paciente grave

Objetivo: Describir el conocimiento y actuación del equipo de enfermería de la urgencia del Hospital Universitario de la Universidad Federal del Valle del São Francisco de Petrolina / PE, ante el evento PCR. Métodos: Estudio cuantitativo, descriptivo y transversal por un muestreo no probabilístico de 101 profesionales de enfermería que respondieron a un cuestionario. Los datos fueron analizados por medio de la observación de las frecuencias de cada respuesta aislada y del cruce de variables. Resultados: Fueron entrevistados 23 enfermeros y 78 técnicos de enfermería. Con respecto a la detección de PCR, conducta inmediata, acciones de SBV y SAV, la mayoría de los profesionales respondió de manera parcialmente correcta. Conclusión: El bajo porcentaje de respuestas totalmente correctas, evidencia la necesidad de actualización de todo el equipo de enfermería, manteniendo la uniformidad de las conductas, mejorando así la atención prestada al paciente grave