Novel gas mixture combined with an auto-transfusion tourniquet enhances cerebral O2 transport and hemodynamic indices in CPR swine. Part B - A pilot experimental study.

Objectives: The cognitive outcome of CPR is poor. This study aims to evaluate if enhancing blood flow to the brain and oxygen dissociation from the hemoglobin improve cerebral O2 transport during CPR in cardiac arrest swine. Methods: Standard swine-CPR model of induced VF and recovery was treated with an auto-transfusion tourniquet (A-TT®; HemaShock® (HS) Oneg HaKarmel Ltd. Israel) and ventilation with a novel mixture of 30% Oxygen, 5% CO2, and 65% Argon (COXAR™). Five swine received the study treatment and 5 controls standard therapy. Animals were anesthetized, ventilated, and instrumented for blood draws and pressure measurements. Five minutes of no-CPR arrest were followed by 10 min of mechanical CPR with and without COXAR-HS™ enhancement followed by defibrillation and 45 min post ROSC follow-up. Results: All 5 COXAR-HS™ animals were resuscitated successfully as opposed to 3 of the control animals. Systolic (p < 0.05), and diastolic (p < 0.01) blood pressures, and coronary (p < 0.001) and cerebral (p < 0.05) perfusion pressures were higher in the COXAR-HS™ group after ROSC, as well as cerebral flow and O2 provided to the brain (p < 0.05). Blood pressure maintenance after ROSC required much higher doses of norepinephrine in the 3 resuscitated control animals vs. the 5 COXAR-HS™ animals (p < 0.05). jugular vein PO2 and SO2 exceeded 50 mmHg and 50%, respectively with COXAR-HS™. Conclusions: In this pilot experimental study, COXAR-HS™ was associated with higher diastolic blood pressure and coronary perfusion pressure with lower need of vasopressors after ROSC without significant differences prior to ROSC. The higher PjvO2 and SjvO2 suggest enhanced O2 provision to the brain mitochondria, while limb compression by the HS counteracts the vasodilatory effect of the CO2. Further studies are needed to explore and validate the COXAR-HS™ effects on actual post-ROSC brain functionality.

Out of hospital cardiac arrest, first steps to know and follow in Mexico to have cardioprotected territories. A point of view of a group of experts / Paro cardiaco extrahospitalario, primeros pasos que se deben conocer y hacer en México para tener espacios cardioprotegidos. Punto de vista de un grupo de expertos

Abstract Sudden cardiac death is a common occurrence. Out-of-hospital cardiac arrest is a global public health problem suffered by ≈3.8 million people annually. Progress has been made in the knowledge of this disease, its prevention, and treatment; however, most events occur in people without a previous diagnosis of heart disease. Due to its multifactorial and complex nature, it represents a challenge in public health, so it led us to work in a consensus to achieve the implementation of cardioprotected areas in Mexico as a priority mechanism to treat these events. Public access cardiopulmonary resuscitation (CPR) and early defibrillation require training of non-medical personnel, who are usually the first responders in the chain of survival. They should be able to establish a basic and efficient CPR and use of the automatic external defibrillator (AED) until the emergency services arrive at the scene of the incident. Some of the current problems in Mexico and alternative solutions for them are addressed in the present work.

Resumen La muerte súbita cardíaca (SCD) es un acontecimiento común. El paro cardiaco extrahospitalario (OHCA) es un problema de salud pública mundial que sufren ≈3.8 millones de personas al año. Se ha avanzado en el conocimiento de esta enfermedad, su prevención y tratamiento, sin embargo, la mayoría de los eventos se producen en personas sin diagnóstico previo de cardiopatía. Debido a su carácter multifactorial y complejo, representa un reto en salud pública, lo que obliga a trabajar en un consenso para lograr la implementación de "Espacios Cardio protegidos" en México, como mecanismo prioritario de atención a estos eventos. La reanimación cardiopulmonar básica (RCPB) y la desfibrilación temprana de acceso público requieren de entrenamiento al personal no médico, que suelen ser los primeros respondientes para iniciar la cadena de la supervivencia. Ellos deberían instaurar una RCPB eficiente y el uso del desfibrilador automático externo (AED) hasta que lleguen al lugar del incidente los servicios de emergencias. El presente trabajo menciona algunos de los problemas actuales en México y algunas opciones de solución para los mismos.

Anesthetic Considerations and Outcomes in Amniotic Fluid Embolism: A Retrospective Study over a 15-Year Period.

(1) Background: A rare and unexpected consequence of childbirth, labor, or the immediate postpartum period is amniotic fluid embolism (AFE). This study aims to identify AFE cases during or immediately after birth from anesthetic management perspectives. Secondary goals include assessing patient clinical features, obstetric care techniques, birth outcomes, and case survival. (2) Methods: A retrospective observational study assessed AFE patients hospitalized in three Romanian clinical institutions from October 2007 to April 2023. Based on the Society of Maternal-Fetal Medicine (SMFM) criteria, we diagnosed 11 AFE patients. (3) Results: AFE occurred in eight cases (73%) during peripartum, two (18%) within 30 min after placental delivery, and 1 (9%) during a scheduled cesarean surgery. Only one of six cardiorespiratory arrest patients responded to external cardiac massage, while the other five (83%) needed defibrillation. The patients received, on average, five units of red blood cells, six of fresh frozen plasma, and two of activated platelets. Six patients (55%) received factor VIIa infusions. Maternal mortality was 36.3%. Six neonates (75%) needed neonatal resuscitation, and two (25%) died on the second and third days. (4) Conclusions: AFE management necessitates a multidisciplinary approach and the incorporation of advanced life support techniques to optimize outcomes for both the mother and newborn.

Cardiopulmonary Resuscitation Training and Reinforcement: A Bulwark against Death.

How to cite this article: Sinha S. Cardiopulmonary Resuscitation Training and Reinforcement: A Bulwark against Death. Indian J Crit Care Med 2024;28(4):317-319.

Public Attitude towards Implementing DNAR and a Stance on Pediatric DNAR in Poland-A Prospective Survey Study.

Background: Do not attempt resuscitation (DNAR) is a document signed by a patient, which states that they do not want to be resuscitated. In Poland, DNAR is not regulated by law. We aimed to assess people's perceptions on DNAR and pediatric DNAR in Poland. Methods: An anonymous survey was distributed via the snowball sampling method in different voivodeships in Poland in the years 2014-2018. The survey consisted of questions regarding knowledge and attitudes towards DNAR and pediatric DNAR. Results: A total of 1049 responses were collected. Moreover, 82% support introducing DNAR in Poland, but 78% believe that this is not a pressing issue. In a general question, 46% of respondents believe that DNAR should be obtainable only for adults. However, in a specific question, this number drops to 17%, with people agreeing for pediatric DNAR if it contains a boundary-23% agree if both parents agree to the solution and 45% if both parents and the child's doctor agree to it. Conclusions: Even though someone supports DNAR, it does not mean that they support pediatric DNAR. People outside the medical community are more likely to be against DNAR. Giving a boundary in using pediatric DNAR may lead to the ease of its implementation in a legislative manner.

Out of hospital cardiac arrest, first steps to know and follow in Mexico to have cardioprotected territories. A point of view of a group of experts.

Sudden cardiac death is a common occurrence. Out-of-hospital cardiac arrest is a global public health problem suffered by ≈3.8 million people annually. Progress has been made in the knowledge of this disease, its prevention, and treatment; however, most events occur in people without a previous diagnosis of heart disease. Due to its multifactorial and complex nature, it represents a challenge in public health, so it led us to work in a consensus to achieve the implementation of cardioprotected areas in Mexico as a priority mechanism to treat these events. Public access cardiopulmonary resuscitation (CPR) and early defibrillation require training of non-medical personnel, who are usually the first responders in the chain of survival. They should be able to establish a basic and efficient CPR and use of the automatic external defibrillator (AED) until the emergency services arrive at the scene of the incident. Some of the current problems in Mexico and alternative solutions for them are addressed in the present work.

La muerte súbita cardíaca (SCD) es un acontecimiento común. El paro cardiaco extrahospitalario (OHCA) es un problema de salud pública mundial que sufren ≈3.8 millones de personas al año. Se ha avanzado en el conocimiento de esta enfermedad, su prevención y tratamiento, sin embargo, la mayoría de los eventos se producen en personas sin diagnóstico previo de cardiopatía. Debido a su carácter multifactorial y complejo, representa un reto en salud pública, lo que obliga a trabajar en un consenso para lograr la implementación de "Espacios Cardio protegidos" en México, como mecanismo prioritario de atención a estos eventos. La reanimación cardiopulmonar básica (RCPB) y la desfibrilación temprana de acceso público requieren de entrenamiento al personal no médico, que suelen ser los primeros respondientes para iniciar la cadena de la supervivencia. Ellos deberían instaurar una RCPB eficiente y el uso del desfibrilador automático externo (AED) hasta que lleguen al lugar del incidente los servicios de emergencias. El presente trabajo menciona algunos de los problemas actuales en México y algunas opciones de solución para los mismos.

Does a Transition to Single-Occupancy Patient Rooms Affect the Incidence and Outcome of In-Hospital Cardiac Arrests?

BACKGROUND: It is proposed that patients in single-occupancy patient rooms (SPRs) carry a risk of less surveillance by nursing and medical staff and that resuscitation teams need longer to arrive in case of in-hospital cardiac arrest (IHCA). Higher incidences of IHCA and worse outcomes after cardiopulmonary resuscitation (CPR) may be the result. OBJECTIVES: Our study examines whether there is a difference in incidence and outcomes of IHCA before and after the transition from a hospital with multibedded rooms to solely SPRs. METHODS: In this prospective observational study in a Dutch university hospital, as a part of the Resuscitation Outcomes in the Netherlands study, we reviewed all cases of IHCA on general adult wards in a period of 16.5 months before to 16.5 months after the transition to SPRs. RESULTS: During the study period, 102 CPR attempts were performed: 51 in the former hospital and 51 in the new hospital. Median time between last-seen-well and start basic life support did not differ significantly, nor did median time to arrival of the CPR team. Survival rates to hospital discharge were 30.0% versus 29.4% of resuscitated patients (p = 1.00), with comparable neurological outcomes: 86.7% of discharged patients in the new hospital had Cerebral Performance Category 1 (good cerebral performance) versus 46.7% in the former hospital (p = .067). When corrected for telemetry monitoring, these differences were still nonsignificant. CONCLUSIONS: The transition to a 100% SPR hospital had no negative impact on incidence, survival rates, and neurological outcomes of IHCAs on general adult wards.

Factors that influence paramedic decision-making about resuscitation for treatment of out of hospital cardiac arrest: Results of a discrete choice experiment in National Health Service ambulance trusts in England and Wales.

Background: During out of hospital cardiac arrest (OHCA) paramedics must make decisions to commence, continue, terminate or withhold resuscitation. These decisions are known to be complex, subject to variability and often dependent on provider preference. This study aimed to understand paramedic decision-making regarding the commencement of resuscitation using a discrete choice experiment. Methods: A discrete choice experiment between October-December 2022 surveying paramedics from ten National Health Service ambulance trusts in England and Wales. Respondents were presented with fourteen vignettes, each comprising thirteen attributes, and asked to decide if they would provide resuscitation or not. Results: Eight hundred and sixty-four paramedics completed the survey (61.8% male, median age 36 years (IQR 17.1)) and half had < 5 years clinical experience (n = 443 (51.2%). Respondents expressed a general preference to offer resuscitation (p = <0.01). All attributes except patient gender were statistically significant and important regarding an offer of resuscitation. Cut-offs where an offer of resuscitation was less likely were patient age of 73 years (p=>0.05), mild dementia (p = >0.05) and moderate frailty (p = <0.01). Paramedic characteristics of female gender, longest (>10 years) and shortest (<5 years) period qualified, lower academic qualification, lower skill level and attending fewer OHCA's were more likely to result in an offer of resuscitation. Conclusion: During OHCA paramedics use objective and non-objective factors to make pragmatic decisions regarding an offer of resuscitation. Future research should focus on how best to support paramedics to make decisions during OHCA, how variability in decision-making impacts patient outcomes and how this relates to patient and public expectations.

Accredited cardiac arrest centers facilitate eCPR and improve neurological outcome.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains a frequent medical emergency with low survival rates even after a return of spontaneous circulation (ROSC). Growing evidence supports formation of dedicated teams in scenarios like cardiogenic shock to improve prognosis. Thus, the European Resuscitation Council (ERC) recommended introduction of Cardiac Arrest Centers (CAC) in their 2015 guidelines. Here, we aimed to elucidate the effects of newly introduced CACs in Germany regarding survival rate and neurological outcome. METHODS: A multicenter retrospective observational cohort study was performed at three university hospitals and outcomes after OHCA were compared before and after CAC accreditation. Primary outcomes were survival until discharge and favorable neurological status (CPC 1 or 2) at discharge. RESULTS: In total 784 patients (368 before and 416 after CAC accreditation) were analyzed. Rates of immediate percutaneous coronary intervention (40 vs. 52%, p = 0.01) and implementation of extracorporeal CPR (8 vs. 13%, p < 0.05) increased after CAC accreditation. Likelihood of favorable neurological status at discharge was higher after CAC accreditation (71 vs. 87%, p < 0.01), whereas overall survival remained similar (35 vs. 35%, p > 0.99). CONCLUSION: CAC accreditation is linked to higher rates of favorable neurological outcome and unchanged overall survival.

Epidemiology of out-of-hospital cardiac arrest: comparison of Turkish nationals and refugees.

The aim of this study is to conduct an epidemiological examination of Turkish citizens and refugees who requested an ambulance due to Out-of-hospital cardiac arrest (OHCA) at the Kayseri 112 emergency services between 2019 and 2020. This study was carried out in the province of Kayseri, which is one of the largest cities in Turkey. The study population includes OHCA patients for whom EMS were activated for any reason in 2019-2020. Data were taken from the Emergency Healthcare Automation System used by Kayseri Emergency Medical Services. A total of 5977 OHCA cases (Turkish 5736, Refugees 241) in which Emergency Medical Servises (EMS) was activated during the research period were included. A rate of 55.6% of patients Turkish nationality and 66.0% refugees were male (p<0.001). Observing at the cause of arrest, we find that 95.7% of cases among Turkish citizens and 82.6% of cases among refugees had a medical cause; while the suicide rate among Turkish citizens was 0.9%, this rate was 5.0% in refugee patients (p<0.001). It was found that the rate of OHCA increased with age and that the average OHCA age was lower in men and refugees. In addition, there is no difference between Turkish nationals and refugees in the use of emergency services for OHCA cases.

Long-term heart function in cardiac-arrest survivors.

Purpose: To assess outcomes and predictors of long-term myocardial dysfunction after cardiac arrest (CA) of cardiac origin. Methods: We retrospectively included consecutive, single-center, prospective-registry patients who survived to hospital discharge for adult out-of-hospital and in-hospital CA of cardiac origin in 2005-2019. The primary objective was to collect the 1-year New York Heart Association Functional Class (NYHA-FC) and major adverse cardiovascular events (MACE). Results: Of 135 patients, 94 (72%) had their NYHA-FC determined after 1 year, including 75 (75/94, 80%) who were I, 17 (17/94, 18%) II, 2 (2/94, 2%) III, and none IV. The echocardiographic left ventricular ejection fraction was abnormal in 87/130 (67%) patients on day 1, 52/123 (42%) at hospital discharge, and 17/52 (33%) at 6 months. During the median follow-up of 796 [283-1975] days, 38/119 (32%) patients experienced a MACE. These events were predominantly related to acute heart failure (13/38) or ischemic cardiovascular events (16/38), with acute coronary syndrome being the most prevalent among them (8/16). Pre-CA cardiovascular disease was a risk factor for 1-year NYHA-FC > I (P = 0.01), absence of bystander cardiopulmonary resuscitation was significantly associated with NYHA-FC > I at 1 year. Conclusion: Most patients had no heart-failure symptoms a year after adult out-of hospital or in-hospital CA of cardiac origin, and absence of bystander cardiopulmonary resuscitation was the only treatment component significantly associated with NYHA-FC > I at 1 year. Nearly a third experienced MACE and the most common types of MACE were ischemic cardiovascular events and acute heart failure. Early left ventricular dysfunction recovered within 6 months in half the patients with available values.

Is epinephrine still the drug of choice during cardiac arrest in the emergency department of the hospital? A meta-analysis.

Epinephrine is the first-line emergency drug for cardiac arrest and anaphylactic reactions but is reported to be associated with many challenges resulting in its under- or improper utilization. Therefore, in this meta-analysis, the efficacy and safety of epinephrine as a first-line cardiac emergency drug for both out-of-hospital and in-hospital patients was assessed. Pertinent articles were searched in central databases like PubMed, Scopus, and Web of Science, using appropriate keywords as per the PRISMA guidelines. Retrospective and prospective studies were included according to the predefined PICOS criteria. RevMan and MedCalc software were used and statistical parameters such as odds ratio and risk ratio were calculated. Twelve clinical trials with a total of 208,690 cardiac arrest patients from 2000 to 2022 were included, in accordance with the chosen inclusion criteria. In the present meta-analysis, a high odds ratio (OR) value of 3.67 (95 % CI 2.32-5.81) with a tau2 value of 0.64, a chi2 value of 12,446.86, df value of 11, I2 value of 100 %, Z-value 5.53, and a p-value < 0.00001 were reported. Similarly, the risk ratio of 1.89 (95 % CI 1.47-2.43) with a tau2 value of 0.19, chi2 value of 11,530.67, df value of 11, I2 value of 100 %, Z-value of 4.95, and p-value < 0.000001. The present meta-analysis strongly prefers epinephrine injection as the first cardiac emergency drug for both out-of-hospital and in-hospital patients during cardiac arrest.

[In-hospital cardiac arrest and basic life support]. / Kórházon belüli keringésmegállás és alapszintu újraélesztés.

Survival of in-hospital cardiac arrests is still as low as 15-35%. Healthcare workers should closely monitor patients' vital signs, notice any deterioration, and initiate the necessary actions to prevent cardiac arrest. The introduction of early warning sign protocols (including the monitoring of respiratory rate, oxygen saturation, pulse, blood pressure, consciousness, etc.) can improve the recognition of periarrest patients during hospital stay. However, when a cardiac arrest occurs, healthcare workers should also be able to work in team and follow the relevant protocols delivering good quality chest compressions and early defibrillation. To achieve this goal, regular trainings, appropriate infrastructure and system-wide teamwork are needed. In this paper, we discuss the challenges of the first phase of in-hospital resuscitation and its integration into the hospital-wide medical emergency response system. Orv Hetil. 2023; 164(12): 449-453.

Left-ventricular unloading in extracorporeal cardiopulmonary resuscitation due to acute myocardial infarction - A multicenter study.

BACKGROUND: Guidelines advocate the use of extracorporeal cardio-pulmonary resuscitation with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in selected patients with cardiac arrest. Effects of concomitant left-ventricular (LV) unloading with Impella® (ECMELLA) remain unclear. This is the first study to investigate whether treatment with ECMELLA was associated with improved outcomes in patients with refractory cardiac arrest caused by acute myocardial infarction (AMI). METHODS: This study was approved by the local ethical committee. Patients treated with ECMELLA at three centers between 2016 and 2021 were propensity score (PS)-matched to patients receiving VA-ECMO based on age, electrocardiogram rhythm, cardiac arrest location and Survival After Veno-Arterial ECMO (SAVE) score. Cox proportional-hazard and Poisson regression models were used to analyse 30-day mortality rate (primary outcome), hospital and intensive care unit (ICU) length of stay (LOS) (secondary outcomes). Sensitivity analyses on patient demographics and cardiac arrest parameters were performed. RESULTS: 95 adult patients were included in this study, out of whom 34 pairs of patients were PS-matched. ECMELLA treatment was associated with decreased 30-day mortality risk (Hazard Ratio [HR] 0.53 [95% Confidence Interval (CI) 0.31-0.91], P = 0.021), prolonged hospital (Incidence Rate Ratio (IRR) 1.71 [95% CI 1.50-1.95], P < 0.001) and ICU LOS (IRR 1.81 [95% CI 1.57-2.08], P < 0.001). LV ejection fraction significantly improved until ICU discharge in the ECMELLA group. Especially patients with prolonged low-flow time and high initial lactate benefited from additional LV unloading. CONCLUSIONS: LV unloading with Impella® concomitant to VA-ECMO therapy in patients with therapy-refractory cardiac arrest due to AMI was associated with improved patient outcomes.

Feasibility and performance of a combined extracorporeal assisted cardiac resuscitation and an organ donation program after uncontrolled cardiocirculatory death (Maastricht II).

INTRODUCTION: Approximately 500.000 people in Europe sustain cardiac arrest (CA) every year, being myocardial infarction the main etiology. Interest has been raised in a new approach to refractory cardiac arrest (rCA) using extra-corporeal oxygenation (ECMO). In settings where it can be rapidly implemented, ECMO assisted resuscitation (ECPR) may be considered. Additionally, donation after circulatory death, which seeks to obtain solid organs donation from patients suffering rCA, has increased its role effectively increasing the pool of donors. Combined programs with integration of ECPR and uncontrolled donation after circulatory determination of death (uDCDD) are worldwide limited and experience integrating these two techniques is lacking. METHODS: We report a 24 months experience of ECPR and uDCDD kidney transplantation based on a management protocol in a university teaching hospital in the urban area of Lisbon. RESULTS: Over a period of 24 months, 58 patients were admitted to our ICU with rCA, 6 (10%) in the ECPR program and 52 (90%) in the uDCDD. Seventy-eight percent of patients were male, with an average age of 49 year-old. CA was witnessed in 83% of cases and initial rhythm was ventricular fibrillation in 20 cases (35%). 13 (25%) patients were effective organ donors. Refusal for effective donation was mainly due to prior comorbidities. DISCUSSION: The development of an integrated program for ECPR and uDCDD is feasible and requires a well-established and efficient activation program. In an era of significant organ shortage, it provides a viable option for increasing the organ donation pool, with promising results.

Public attitudes towards bystander CPR and their association with social deprivation: Findings from a cross sectional study in North England.

Background: Bystander cardiopulmonary resuscitation (BCPR) is undertaken in only 40% of out of hospital cardiac arrests (OHCAs) in the UK. Lower rates of BCPR and public access defibrillator (PAD) use have been correlated with lower socio-economic status (SES). The aim of this study was to examine knowledge and attitudes towards BCPR and PAD's using a study specific questionnaire, and to understand how these potentially interact with individual characteristics and SES. Methods: Cross-sectional study between July-December 2021 across areas of varying SES in North England. Results: Six hundred and one individuals completed the survey instrument (mean age = 51.9 years, 52.2 % female). Increased age was associated with being less willing to call 999 (p < 0.001) and follow call handler advice (p < 0.001). Female respondents were less comfortable performing BCPR than male respondents (p = 0.006). Individuals from least deprived areas were less likely to report comfort performing CPR, (p = 0.016) and less likely to know what a PAD is for, (p = 0.025). Higher education level was associated with increased ability to recognise OHCA (p = 0.005) and understanding of what a PAD is for (p < 0.001). Individuals with higher income were more likely to state they would follow advice regarding BCPR (p = 0.017) and report comfort using a PAD (p = 0.029). Conclusion: Individual characteristics such as age and ethnicity, rather than SES, are indicators of knowledge, willingness, and perceived competency to perform BCPR. Policy makers should avoid using SES alone to target interventions. Future research should examine how cultural identity and social cohesion intersect with these characteristics to influence willingness to perform BCPR.

Knowledge, attitude, and practice towards basic life support among graduating class health science and medical students at Dilla University; a cross sectional study.

Introduction: Basic Life Support is a level of medical care Applied to victims of life-threatening illnesses and injuries before professional help is provided. This study aimed to assess the knowledge, attitude, and practice toward Basic Life support in Graduating class of health science and medical students at Dilla university referral hospital. Method: ology: A cross-sectional study was conducted on graduating class students of Dilla University, college of medicine and health science from September 10/2021 to December 13/2021. A total of 167 participants were selected by a systematic random sampling technique. A bi-variable and multi-variable logistic regression analysis were carried out. Result: Among the study participants, 95 (56.9%) and 86(51.5%) have good knowledge and good practice towards basic life support respectively. Being trained for basic life support and advanced life support, exposure with the person in need of basic life support were found more knowledgeable with odd ratio of [AOR = 13.8, 95% CI (6.3-30.1)], [AOR = 27.7, 95% CI (6.4-119)] and [AOR = 15.7, 95% CI (6.6-37.5)]. Learning anesthesia increases knowledge about basic life support nearly two times [AOR = 1.8, 95% CI (o.4-9.5)] when compared to medicine. Conclusion: The findings of this study suggest that nearly half of health science students in our hospital lack adequate knowledge and skills in BLS. Training on basic life support and advanced life support, learning in anesthesia and medicine departments, and exposure to the person in need of basic life support were significantly associated with high knowledge. To increase knowledge of BLS standardized Training and assessments are recommended.

Decision-making ethics in regards to life-sustaining interventions: when physicians refer to what other patients decide.

BACKGROUND: Health decisions occur in a context with omnipresent social influences. Information concerning what other patients decide may present certain interventions as more desirable than others. OBJECTIVES: To explore how physicians refer to what other people decide in conversations about the relevancy of cardio-pulmonary resuscitation (CPR) or do-not-attempt-resuscitation orders (DNAR). METHODS: We recorded forty-three physician-patient admission interviews taking place in a hospital in French-speaking Switzerland, during which CPR is discussed. Data was analysed with conversation analysis. RESULTS: Reference to what other people decide in regards to CPR is used five times, through reported speech. The reference is generic, and employed as a resource to deal with trouble encountered with the patient's preference, either because it is absent or potentially incompatible with the medical recommendation. In our data, it is a way for physicians to present decisional paths and to steer towards the relevancy of DNAR orders ("Patients tell us 'no futile care'"). By calling out to a sense of membership, it builds towards the patient embracing norms that are associated with a desirable or relevant social group. CONCLUSIONS: Introducing DNAR decisions in terms of what other people opt for is a way for physicians to bring up the eventuality of allowing natural death in a less overt way. Formulating treatment choices in terms of what other people do has implications in terms of supporting autonomous and informed decision making, since it nudges patients towards conformity with what is presented as the most preferable choice on the basis of social norms.

Mechanical life support algorithm developed by simulation for inpatient emergency management of recipients of implantable left ventricular assist devices.

Background: Published guidance concerning emergency management of left ventricular assist device (LVAD) recipients is both limited and lacking in consensus which increases the risk of delayed and/or inappropriate actions. Methods: In our specialist tertiary referral centre we developed, by iteration, a novel in-hospital resuscitation algorithm for LVAD emergencies which we validated through simulation and assessment of our multi-disciplinary team. A Mechanical Life Support course was established to provide theoretical and practical education combined with simulation to consolidate knowledge and confidence in algorithm use. We assessed these measures using confidence scoring, a key performance indicator (the time taken to restart LVAD function) and a multiple-choice question (MCQ) examination. Results: The mean baseline staff confidence score in management of LVAD emergencies was 2.4 ± 1.2 out of a maximum of 5 (n = 29). After training with simulation, mean confidence score increased to 3.5 ± 0.8 (n = 13).Clinical personnel who were provided with the novel resuscitation algorithm were able to reduce time taken to restart LVAD function from a mean value of 49 ± 8.2 seconds (pre-training) to 20.4 ± 5 seconds (post-training) (n = 42, p < 0.0001).The Mechanical Life Support course increased mean confidence from 2.5 ± 1.2 to 4 ± 0.6 (n = 44, p < 0.0001) and mean MCQ score from 18.7 ± 3.4 to 22.8 ± 2.6, out of a maximum of 28 (n = 44, p < 0.0001). Conclusion: We present a simplified LVAD Advanced Life Support algorithm to aid the crucial first minutes of resuscitation where basic interventions are likely to be critical in assuring good patient outcomes.

Public attitudes towards cardiopulmonary resuscitation training and performance in Singapore.

BACKGROUND: Bystander cardiopulmonary resuscitation (CPR) rates remain fairly low through most communities despite multiple interventions through the years. Understanding the attitudes and fears behind CPR training and performance would help target education and training to raise the rates of bystander CPR and consequently survival rates of victims. 7909 participants at a single-day mass CPR training session in Singapore were given survey questionnaires to fill out. 6473 people submitted completed forms upon the conclusion of the training session. Some issues looked at were the overall level of difficulty of CPR, difficulty levels of specific skills, attitudes towards refresher training, attitudes towards performing CPR, and fears when doing so. RESULTS: The mean level of difficulty of CPR was rated 3.98 (scale of 1-10), with those with previous CPR training rating it easier. The skills rated most difficult were performing mouth-to-mouth breathing and chest compressions, while the easiest rated was recognizing non-responsiveness. A majority (69.7%) would agree to go for refresher training every 2 years and 88.7% felt everyone should be trained in CPR. 71.6% would perform full CPR for a member of the public in cardiac arrest and only 20.7% would prefer to only do chest compressions. The most cited fear was a low level of confidence, and fears of acquiring infections or aversion to mouth-to-mouth breathing were low. CONCLUSIONS: The survey results show that most participants in Singapore are keen to perform conventional CPR for a member of the public and can help to target future CPR training accordingly.