Manual vs Mechanical Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest on a Ski Slope: A Pilot Study.

INTRODUCTION: The quality of cardiopulmonary resuscitation (CPR) is critical in increasing the probability of survival with a good neurologic outcome after out-of-hospital cardiac arrest. In an austere environment with a potentially salvageable patient, bystanders or first responders may need to provide chest compressions for a prolonged duration or during physically challenging transportation scenarios. Consequently, they may be at risk of fatigue or injury, and chest compression quality may deteriorate. The study sought to assess whether or not access to and utilization of a mechanical compression device (Lund University Cardiopulmonary Assist System) was feasible and not inferior to manual compressions while extricating and transporting a patient from a ski slope. METHODS: Variable 3-person ski patrol teams responded to a simulated patient with out-of-hospital cardiac arrest in a nonshockable rhythm. Using a mannequin and CPR quality monitor, performance during manual CPR was compared with that of a mechanical compression device. This is a prospective, crossover analysis of CPR quality during extrication from a ski slope. Across 8 total runs, chest compression fraction, which is the proportion of time without spontaneous circulation during which compressions occurred, and high-quality CPR, as measured by appropriate rate and depth, were compared between the 2 groups. Extrication times between the 2 groups were also measured. RESULTS: There was no difference in compression fraction between the manual (91.4%; 95% CI [86.8-96.1]) and mechanical arms (92.8%; 95% CI [88.8-96.8]) (P=0.67). There was an increase in the time performing high-quality CPR in the mechanical group (58.5%; 95% CI [45.8-71.2]) vs that in the manual group (25.6%; 95% CI [13.5-37.8]) (P<0.001). There was a statistically significant difference in the extrication times between the 2 groups, 7.6 ± 0.5 min in the manual group vs 8.6 ± 0.4 min in the mechanical group (P=0.014). CONCLUSIONS: Mechanical CPR devices are noninferior for use in ski areas during initial resuscitation and transportation. Compared with manual CPR, mechanical CPR would likely improve the fraction of time performing high-quality CPR.

Goal-directed cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest in the emergency Department: A feasibility study.

AIM: To describe the feasibility of prospective measurement of intra-arrest diastolic blood pressure (DBP) and goal-directed treatment of refractory out-of-hospital cardiac arrest (OHCA) in the emergency department (ED). METHODS: Retrospective case series performed at an urban, tertiary-care hospital from 12/1/2018 - 12/31/2019. We studied consecutive adults presenting with refractory, non-traumatic OHCA treated with haemodynamic-targeted resuscitation that entailed placement of a femoral arterial catheter, transduction of continuous BP during CPR, and administration of vasopressors (1 mg noradrenaline) and, if applicable, Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), to achieve DBP ≥ 40 mmHg. Feasibility was measured by the success rate and time to achieve arterial catheterization and BP transduction. Additional outcomes included the change in DBP with vasopressor administration and occurrence of sustained ROSC. RESULTS: Goal-directed treatment was successfully performed in 8/9 (89%) patients. Arterial access required 1.5 (interquartile range (IQR) 1-2) attempts and BP transduction occurred within 10.5 ± 2.4 minutes of patient arrival. Noradrenaline slightly increased DBP (pre 21.6 ± 8.3 mmHg, post 26.1 ± 12.1 mmHg, p < 0.025), but only 4/23 (17%) doses resulted in DBP ≥ 40 mmHg. REBOA was attempted in 2/8 (25%) patients and placed successfully in both cases. Three (37.5%) patients achieved ROSC, but none survived to hospital discharge. CONCLUSIONS: In ED patients with refractory OHCA, measurement of DBP during CPR and titration of resuscitation to a DBP goal is feasible. Future research incorporating this approach should seek to develop haemodynamic-targeted treatment strategies for OHCA patients that do not achieve ROSC with initial resuscitation.

Design and implementation of a temporary emergency department-intensive care unit patient care model during the COVID-19 pandemic surge.

The ongoing pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in rapid surges of critically ill patients infected with coronavirus disease 2019 (COVID-19) pneumonia presenting to the emergency department (ED) and requiring ICU admission nationwide. Despite adaptations in critical care personnel staffing, bed availability and supply provision, many inpatient ICUs have become acutely crowded, leading to boarding of critically ill patients with COVID-19 and other diseases in the ED. To address this scenario at our urban, safety net, tertiary care institution in the spring of 2020, we designed and implemented a temporary "emergency department-intensive care unit" (ED-ICU) patient care service. Critical care-trained emergency physicians took call and came into the hospital overnight/on weekends to provide bedside treatment to admitted ICU patients boarding for prolonged periods in our ED. In this manuscript, we describe the creation and execution of the ED-ICU service and the characteristics and management of the patients who received care under this model.