Finite Element Analysis of a Rib Cage Model: Influence of Four Variables on Fatigue Life during Simulated Manual CPR.

Cardiopulmonary resuscitation (CPR) is a life-saving technique used in emergencies when the heart stops beating, typically involving chest compressions and ventilation. Current adult CPR guidelines do not differentiate based on age beyond infancy and childhood. This oversight increases the risk of fatigue fractures in the elderly due to decreased bone density and changes in thoracic structure. Therefore, this study aimed to investigate the correlation and impact of factors influencing rib fatigue fractures for safer out-of-hospital manual cardiopulmonary resuscitation (OHMCPR) application. Using the finite element analysis (FEA) method, we performed fatigue analysis on rib cage models incorporating chest compression conditions and age-specific trabecular bone properties. Fatigue life analyses were conducted on three age-specific rib cage models, each differentiated by trabecular bone properties, to determine the influence of four explanatory variables (the properties of the trabecular bone (a surrogate for the age of the subject), the site of application of the compression force on the breastbone, the magnitude of applied compression force, and the rate of application of the compression force) on the fatigue life of the model. Additionally, considering the complex interaction of chest compression conditions during actual CPR, we aimed to predict rib fatigue fractures under conditions simulating real-life scenarios by analyzing the sensitivity and interrelation of chest compression conditions on the model's fatigue life. Time constraints led to the selection of optimal analysis conditions through the use of design of experiments (DOE), specifically orthogonal array testing, followed by the construction of a deep learning-based metamodel. The predicted fatigue life values of the rib cage model, obtained from the metamodel, showed the influence of the four explanatory variables on fatigue life. These results may be used to devise safer CPR guidelines, particularly for the elderly at a high risk of acute cardiac arrest, safeguarding against potential complications like fatigue fractures.

Effectiveness of Palliative Care before Death in Reducing Emergency Care Utilization for Patients with Terminal Cancer and Trends in the Utilization of Palliative Care from 2005-2018.

This retrospective cohort study aimed to examine the effect of palliative care for patients with terminal cancer on healthcare utilization. The National Health Insurance (NHI) Research Database and death certificates were utilized to identify patients who died of cancer between 2005 and 2018. The number of terminal cancer patients between 2005 and 2018 was 605,126. Propensity score matching and conditional logistic regression were performed. The odds ratios (ORs) for "emergency care utilization", "CPR", "endotracheal intubation", and "ICU admission" were significantly lower for enrolled patients regardless of enrollment time compared to unenrolled patients. Compared to unenrolled patients, the OR for "emergency care utilization" increased from 0.34 to 0.68, the OR for "CPR use" increased from 0.13 to 0.26, the OR for "intubation" increased from 0.15 to 0.26, and the OR for "ICU admission" increased from 0.27 to 0.40 in enrolled patients. Between 2005 and 2010, CPR utilization, intubation, and ICU admission in patients enrolled in palliative care declined each year. Since the inclusion of palliative care in NHI (from 2010 onward), its utilization has increased slightly each year. Patients with terminal cancer enrolled in palliative care consume fewer medical resources before death than unenrolled patients; however, the difference decreases with longer times before death.

Impact of the COVID-19 pandemic on prehospital characteristics and outcomes of out-of-hospital cardiac arrest among the elderly in Japan: A nationwide study.

Aim: To assess the impact of the 2020 coronavirus disease (COVID-19) pandemic on the prehospital characteristics and outcomes of out-of-hospital cardiac arrest (OHCA) in the elderly. Methods: In this population-based nationwide observational study in Japan, 563,100 emergency medical service-unwitnessed OHCAs in elderly (≥65 years) patients involving any prehospital resuscitation efforts were analysed (144,756, 140,741, 140,610, and 136,993 cases in 2020, 2019, 2018, and 2017, respectively). The epidemiology, characteristics, and outcomes associated with OHCAs in elderly patients were compared between 3 years pre-pandemic (2017-2019) and the pandemic year (2020). The primary outcome was neurologically favourable one-month survival. The secondary outcomes were the rate of bystander cardiopulmonary resuscitation (CPR), defibrillation by a bystander, dispatcher-assisted (DA)-CPR attempts, and one-month survival. Results: During the pandemic year, the rates of neurologically favourable 1-month survival (crude odds ratio, 95% confidence interval: 1.19, 1.14-1.25), bystander CPR (1.04, 1.03-1.06), and DA-CPR attempts (1.10, 1.08-1.11) increased, whereas the incidence of public access defibrillation (0.88, 0.83-0.93) decreased. Subgroup analyses based on interaction tests showed that the increased rate of neurologically favourable survival during the pandemic year was enhanced in OHCA at care facilities (1.51, 1.36-1.68) and diminished or abolished on state-of-emergency days (0.90, 0.74-1.09), in the mainly affected prefectures (1.08, 1.01-1.15), and in cases with shockable initial rhythms (1.03, 0.96-1.12). Conclusions: The COVID-19 pandemic increased the bystander CPR rate in association with enhanced DA-CPR attempts and improved the outcomes of elderly patients with OHCAs.

Association between regional cerebral oxygen saturation and outcome of patients with out-of-hospital cardiac arrest: An observational study.

Aim: This study aimed to evaluate the association between cerebral oxygen saturation (StO2) and return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest (OHCA). Methods: We retrospectively evaluated the data of patients with OHCA to determine the association between ROSC and various StO2 parameters (initial_StO2, final_StO2, mean_StO2, and Δ_StO2 [=final_StO2-initial_StO2]). Time-domain near-infrared spectroscopy was used to determine absolute StO2 values. Results: Of the 108 patients with OHCA, 23 achieved ROSC. Although initial_StO2 values did not differ between the groups, final_StO2, mean_StO2, and Δ_StO2 were higher in the ROSC group than in the non-ROSC group. The cut-off values for initial_StO2, mean_StO2, and Δ_StO2 as predictors of ROSC were 35%, 30%, and 5%, respectively. The odds ratio for ROSC had markedly increased in the Δ_StO2 ≥ 5% subgroup (19.70 [6.06-64.11], p < 0.001). When the change in StO2 (=d_StO2) at 8 min from the initiation of StO2 measurement was assessed, the d_StO2 ≥ 5% subgroup had a higher odds ratio for ROSC than the d_StO2 < 5% subgroup (5.8 [1.78-18.85], p = 0.002), and this tendency was maintained until 20 min. In the evaluation using a two-by-two contingency table with initial_StO2 and Δ_StO2 as two parameters, 61.9% of the patients fell under the categories of initial_StO2 < 35% and Δ_StO2 < 5% and had the lowest rate of ROSC achievement (4.6%). In the Δ_StO2 ≥ 5% subgroup, approximately-two-thirds of the patients achieved ROSC irrespective of the initial_StO2 (initial_StO2 ≥ 35%, 66.7%; initial_StO2 < 35%, 60.0%). Conclusions: Initial_StO2 and Δ_StO2 were associated with the achievement of ROSC.

A descriptive study of the multidisciplinary healthcare experiences of inpatient resuscitation events.

Background: In-hospital resuscitation events have complex and enduring effects on clinicians, with implications for job satisfaction, performance, and burnout. Ethically ambiguous cases are associated with increased moral distress. We aim to quantitatively describe the multidisciplinary resuscitation experience. Methods: Multidisciplinary in-hospital healthcare professionals at an adult academic health center in the Midwestern United States completed surveys one and six weeks after a resuscitation event. Surveys included demographic data, task load (NASA-TLX), overall and moral distress, anxiety, depression, and spiritual peace. Spearman's rank correlation was computed to assess task load and distress. Results: During the 5-month study period, the study included 12 resuscitation events across six inpatient units. Of 82 in-hospital healthcare professionals eligible for recruitment, 44 (53.7%) completed the one-week post-resuscitation event survey. Of those, 37 (84.1%) completed the six-week survey. Highest median task load burden at one week was seen for temporal demand, effort, and mental demand. Median moral distress scores were low, while "at peace" median scores tended to be high. There were no significant non-zero changes in task load or distress scores from weeks 1-6. Mental demand (r = 0.545, p < 0.001), physical demand (r = 0.464, p = 0.005), performance (r = -0.539, p < 0.001), and frustration (r = 0.545, p < 0.001) significantly correlated with overall distress. Performance (r = -0.371, p = 0.028) and frustration (r = 0.480, p = 0.004) also significantly correlated with moral distress. Conclusions: In-hospital healthcare professionals' experiences of resuscitation events are varied and complex. Aspects of task load burden including mental and physical demand, performance, and frustration contribute to overall and moral distress, deserving greater attention in clinical contexts.

A Multimodal Approach to Training Coronavirus Disease (COVID-19) Processes Across Four Intensive Care Units.

Background: Coronavirus disease (COVID-19) required innovative training strategies for emergent aerosol generating procedures in intensive care units. This manuscript summarizes institutional operationalization of COVID-specific training, standardized across four intensive care units. Methods & Results: An interdisciplinary team collaborated with the Simulator Program and OpenPediatrics refining logistics using process maps, walkthroughs and simulation. A multimodal approach to information dissemination, high-volume team training in modified resuscitation practices and technical skill acquisition included instructional videos, training superusers, small-group simulation using a flipped classroom approach with rapid cycle deliberate practice, interactive webinars, and cognitive aids. Institutional data on application of this model are presented. Conclusion: Success was founded in interdisciplinary collaboration, resource availability and institutional buy in.

What can be learned from the literature about intervals and strategies for paediatric CPR retraining of healthcare professionals? A scoping review of literature.

Background: Effective training and retraining may be key to good quality paediatric cardiopulmonary resuscitation (pCPR). PCPR skills decay within months after training, making the current retraining intervals ineffective. Establishing an effective retraining strategy is fundamental to improve quality of performance and potentially enhance patient outcomes. Objective: To investigate the intervals and strategies of formal paediatric resuscitation retraining provided to healthcare professionals, and the associated outcomes including patient outcomes, quality of performance, retention of knowledge and skills and rescuer's confidence. Methods: This review was drafted and reported using the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews (PRISMA-ScR). PubMed, Medline, Cochrane, Embase, CINAHL Complete, ERIC and Web of Science were searched and studies addressing the PICOST question were selected. Results: The results indicate complex data due to significant heterogeneity among study findings in relation to study design, retraining strategies, outcome measures and length of intervention. Out of 4706 studies identified, 21 were included with most of them opting for monthly or more frequent retraining sessions. The length of intervention ranged from 2-minutes up to 3.5 hours, with most studies selecting shorter durations (<1h). All studies pointed to the importance of regular retraining sessions for acquisition and retention of pCPR skills. Conclusions: Brief and frequent pCPR retraining may result in more successful skill retention and consequent higher-quality performance. There is no strong evidence regarding the ideal retraining schedule however, with as little as two minutes of refresher training every month, there is the potential to increase pCPR performance and retain the skills for longer.

Survival From Pediatric Out-of-Hospital Cardiac Arrest During Nights and Weekends: An Updated Japanese Registry-Based Study.

Background: Disparities in survival after pediatric out-of-hospital cardiac arrest (OHCA) between on-duty hours and off-duty hours have previously been reported. However, little is known about whether these disparities have remained in recent years. Objectives: This study aimed to examine the association of outcomes after pediatric OHCA with time of day and day of week. Methods: This observational study analyzed the Japanese government-led nationwide population-based registry data of OHCA patients. Pediatric (<18 years) patients who experienced OHCA between 2012 and 2017 were included. A multivariable logistic regression model was used to examine the association of both time of day (day/evening vs night) and day of week (weekday vs weekend) with outcomes after OHCA. The primary outcome was 1-month survival. Results: A total of 7,106 patients (mean age, 5.7 ± 6.5 years; 60.9% male) were included. 1,897 events (26.7%) occurred during night hours, and 2,096 events (29.5%) occurred on weekends. Overall, 1,192 (16.8%) survived 1 month after OHCA. After adjusting for potential confounders, 1-month survival during day/evening (1,047/5,209 [20.1%]) was significantly higher than that at night (145/1,897 [7.6%]) (adjusted odds ratio: 2.31 [95% CI: 1.87-2.86]), whereas there was no significant difference in 1-month survival between weekdays (845/5,010 [16.9%]) and weekends (347/2,096 [16.6%]) (adjusted odds ratio: 1.04 [95% CI: 0.88-1.23]). Conclusions: One-month survival after pediatric OHCA remained significantly lower during night than during day/evening, although disparities in 1-month survival between weekdays and weekends have been eliminated over time. Further studies are warranted to investigate the mechanisms underlying decreased survival at night.

The learning impact of a virtual CPR webinar for seniors.

Aim: To assess the learning impact of a virtual interactive CPR webinar for seniors through mix-methods quantitative and qualitative survey analysis. Methods: We surveyed 350 webinar attendees. The webinar trained participants in hands-only CPR technique and AED use. Survey questions included multiple-choice selection and open-ended responses. Qualitative inductive thematic analysis was conducted on open-ended question responses. Knowledge of CPR was measured on a 3-point scale (very little knowledge, some knowledge, a lot of knowledge). Proportions were compared pre and post seminar using a z-test. Results: 231 respondents ≥ 65 years participated in the survey (response rate 66.0 %). There was a significant increase in self-reported knowledge of CPR pre and post webinar (very little knowledge 33.9 % to 1.8 % P < 0.00001, some knowledge 54.2 % to 12.1 % P < 0.0001, a lot of knowledge 11.9 % to 86.1 % P < 0.0001). We found 5 main themes on participant feedback: Positive affective comments, learning, constructive criticism, the desire to share information and comments on CPR ability. We identified 4 main themes related to further questions: Performing CPR in different circumstances, risks of CPR, information sharing, and prevention of death from myocardial infarction. Following the webinar, 89.9 % of respondents chose that they would be very likely to perform CPR on a friend, family member or colleague. Conclusion: This study highlights the success of virtual CPR webinars for senior citizens in improving self-reported CPR knowledge. This has potential to address barriers to online education for seniors and increase bystander CPR rates.

Corticosteroid use with extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A nationwide observational study.

Aim: Several studies have reported that corticosteroid administration for cardiac arrest patients may improve outcomes. However, these previous studies have not examined the effect of corticosteroid use in out-of-hospital cardiac arrest (OHCA) patients administered extracorporeal cardiopulmonary resuscitation (ECPR). Therefore, we aimed to examine the effectiveness of corticosteroids in OHCA patients administered ECPR. Methods: Using the Japanese Diagnosis Procedure Combination inpatient database, we included OHCA patients who were administered ECPR on the day of admission between July 2010 and March 2019. The patients were categorized into the corticosteroid and control groups according to whether they received corticosteroids on the day of admission or not. The primary outcome was in-hospital mortality and the secondary outcomes included percentages of neurologically favorable survival, major bleeding complications, and infection-related complications. We compared the outcomes using a propensity score matching analysis. Results: We identified 6,142 eligible patients (459 vs 5,683, the corticosteroid and control group, respectively). One-to-four propensity score matching analysis (457 vs 1,827) showed in-hospital mortality was significantly higher in the corticosteroid group compared with the control group (82.1% vs 76.6%; risk difference, 5.5%; 95% CI, 1.5 to 9.5%). Neurologically favorable outcomes did not differ between the two groups (13.6% vs 16.9%; risk difference, -3.3%; 95% CI, -6.9 to 0.3%). The percentage of major bleeding complications and infection-related complications did not significantly differ between the two groups. Conclusions: The results of this study demonstrated that administration of corticosteroids on the day of admission to OHCA patients administered ECPR was associated with increased in-hospital mortality.

Protocol for a cluster randomised controlled feasibility study of Prehospital Optimal Shock Energy for Defibrillation (POSED).

Aims: The Prehospital Optimal Shock Energy for Defibrillation (POSED) study will assess the feasibility of conducting a cluster randomised controlled study of clinical effectiveness in UK ambulance services to identify the optimal shock energy for defibrillation. Methods: POSED is a pragmatic, allocation concealed, open label, cluster randomised, controlled feasibility study. Defibrillators within a single UK ambulance service will be randomised in an equal ratio to deliver one of three shock strategies 120-150-200 J, 150-200-200 J, 200-200-200 J. Consecutive adults (≥18 years) presenting with out of hospital cardiac arrest requiring defibrillation will be eligible. The study plans to enrol 90 patients (30 in each group). Patients (or their relatives for non-survivors) will be informed about trial participation after the initial emergency has resolved. Survivors will be invited to consent to participate in follow-up (i.e., at 30 days or discharge).The primary feasibility outcome is the proportion of eligible patients who receive the randomised study intervention. Secondary feasibility outcomes will include recruitment rate, adherence to allocated treatment and data completeness. Clinical outcomes will include Return of an Organised Rhythm (ROOR) at 2 minutes post-shock, refibrillation rate, Return of Spontaneous Circulation (ROSC) at hospital handover, survival and neurological outcome at 30 days. Conclusion: The POSED study will assess the feasibility of a large-scale trial and explore opportunities to optimise the trial protocol.Trial registration: ISRCTN16327029.

Suction cup on a piston-based chest compression device improves coronary perfusion pressure and cerebral oxygenation during experimental cardiopulmonary resuscitation.

Introduction: The presented study aimed to investigate whether a mechanical chest compression piston device with a suction cup assisting chest recoil could impact the hemodynamic status when compared to a bare piston during cardiopulmonary resuscitation. Methods: 16 piglets were anesthetized and randomized into 2 groups. After 3 minutes of induced ventricular fibrillation, a LUCAS 3 device was used to perform chest compressions, in one group a suction cup was mounted on the device's piston, while in the other group, compressions were performed by the bare piston. The device was used in 30:2 mode and the animals were manually ventilated. Endpoints of the study were: end tidal carbon dioxide, coronary and cerebral perfusion pressures, and brain oxygenation (measured using near infrared spectroscopy). At the end of the protocol, the animals that got a return to spontaneous circulation were observed for 60 minutes, then euthanized. Results: No difference was found in end tidal carbon dioxide or tidal volumes. Coronary perfusion pressure and cerebral oxygenation were higher in the Suction cup group over the entire experiment time, while cerebral perfusion pressure was higher only in the last 5 minutes of CPR. A passive tidal volume (air going in and out the airways during compressions) was detected and found correlated to end tidal carbon dioxide. Conclusions: The use of a suction cup on a piston-based chest compression device did not increase end tidal carbon dioxide, but it was associated to a higher coronary perfusion pressure.

CLInical Profile and Side Effects of chronic use of oral Amiodarone in cardiology outpatients department (CLIPSE-A Study)- A prospective observational study.

Background: Amiodarone belongs to Class-III anti-arrhythmic drugs. It is one of the most effective anti-arrhythmic drugs used to treat or prevent several types of arrhythmias including atrial fibrillation, atrial flutter, ventricular tachycardia, and wide complex tachycardia, but unfortunately carries a high toxicity profile. Also, side effects of amiodarone involving various organs can be life-threatening. Materials & methods: This was an observational study carried out for six months i.e from April to September. The study included patients who are on amiodarone for greater than or equal to six months. The required data was collected in-person from the case sheets, treatment charts, and by interviewing the patients. The data for 67 patients was documented in suitable data collection form for analysis. Results: From our study data, it was noted that amiodarone was used for 3 different indications-atrial fibrillation, atrial flutter, and ventricular tachycardia. Among 67 patients enrolled, 38 had no side-effects. Side-effects data in the rest grouped basing on the organ system affected: 9 patients had renal effects, 6 patients had ophthalmic effects, 4 patients had endocrine effects, and 5 patients had hepatic effects. Conclusion: From our study, it is concluded that amiodarone is a safe and effective anti-arrhythmic drug at lower doses i.e. 200-1100 mg/week. When treated in lower doses of 1400-2800 mg/week, many side effects have been incident. Although these effects are mild and develop only after prolonged usage of the drug, it should be used judiciously.

Transient return of spontaneous circulation related to favourable outcomes in out-of-hospital cardiac arrest patients resuscitated with extracorporeal cardiopulmonary resuscitation: A secondary analysis of the SAVE-J II study.

Aim: This study aimed to investigate the relationship between transient return of spontaneous circulation (ROSC) before extracorporeal membrane oxygenation (ECMO) initiation and outcomes in out-of-hospital cardiac arrest (OHCA) patients, who were resuscitated with extracorporeal cardiopulmonary resuscitation (ECPR). Methods: This study was a secondary analysis of the SAVE-J II study, which was a retrospective multicentre registry study involving 36 participating institutions in Japan. We classified patients into two groups according to the presence or absence of transient ROSC before ECMO initiation. Transient ROSC was defined as any palpable pulse of ≥1 min before ECMO initiation. The primary outcome was favourable neurological outcomes (cerebral performance categories 1-2). Results: Of 2,157 patients registered in the SAVE-J II study, 1,501 met the study inclusion criteria; 328 (22%) experienced transient ROSC before ECMO initiation. Patients with transient ROSC had better outcomes than those without ROSC (favourable neurological outcome, 26% vs 12%, P < 0.001; survival to hospital discharge, 46% vs 24%, respectively; P < 0.001). A Kaplan-Meier plot showed better survival in the transient ROSC group (log-rank test, P < 0.001). In multiple logistic analyses, transient ROSC was significantly associated with favourable neurological outcomes and survival (favourable neurological outcomes, adjusted odds ratio, 3.34 [95% confidence interval, 2.35-4.73]; survival, adjusted odds ratio, 3.99 [95% confidence interval, 2.95-5.40]). Conclusions: In OHCA patients resuscitated with ECPR, transient ROSC before ECMO initiation was associated with favourable outcomes. Hence, transient ROSC is a predictor of improved outcomes after ECPR.

Coronary Artery Disease, Cardiac Arrest, and Shared Decision Making in a Recreational Athlete.

A highly active 59-year-old-man with a history of cardiac arrest and myocardial infarction presented for exercise recommendations. Multimodality risk stratification led to ventricular fibrillation cardiac arrest at the completion of a maximal effort cardiopulmonary exercise test. Using shared decision making, the safety and feasibility of returning to exercise were discussed. (Level of Difficulty: Intermediate.).

The association between CPR quality of In-hospital resuscitation and sex: A hypothesis generating, prospective observational study.

Introduction: The relationship between sex and cardiopulmonary resuscitation (CPR) outcomes remains unclear. Particularly, questions remain regarding the potential contribution of unmeasured confounders. We aimed to examine the differences in the quality of chest compression delivered to men and women. Methods: Prospective study of observational data recorded during consecutive resuscitations occurring in a single tertiary center (Feb-1-2015 to Dec-31-2018) with real-time follow-up to hospital discharge. The studied variables included time in CPR, no-flow-time and fraction, compression rate and depth and release velocity. The primary study endpoint was the unadjusted association between patient sex and the chest compression quality (depth and rate). The secondary endpoint was the association between the various components of chest compression quality, sex, and survival to hospital discharge/neurologically intact survival. Results: Overall 260 in-hospital resuscitations (57.7% male patients) were included. Among these 100 (38.5%) achieved return of spontaneous circulation (ROSC) and 35 (13.5%) survived to hospital discharge. Female patients were significantly older. Ischemic heart disease and ventricular arrhythmias were more prevalent among males. Compression depth was greater in female vs male patients (54.9 ± 11.3 vs 51.7 ± 10.9 mm; p = 0.024). Other CPR quality-metrics were similar. The rates of ROSC, survival to hospital discharge and neurologically intact survival did not differ between males and females. Univariate analysis revealed no association between sex, quality metrics and outcomes. Discussion: Women received deeper chest compressions during in-hospital CPR. Our findings require corroboration in larger cohorts but nonetheless underscore the need to maintain high-quality CPR in all patients using real-time feedback devices. Future studies should also include data on ventilation rates and volumes which may contribute to survival outcomes.

Comparison of different methods of more effective chest compressions during cardiopulmonary resuscitation (CPR) in the dental chair.

Introduction: When performing cardiopulmonary resuscitation (CPR) on a patient who has suffered a cardiopulmonary arrest during dental treatment, few dental chairs have sufficient stability to perform effective chest compressions. We previously proposed a method of stabilizing the backrest of a dental chair using a support stool. As a result, we confirmed that the vertical displacement of the backrest could be significantly reduced. In the present study, we verified the effectiveness of the stool stabilization method using several dental chairs (flat and curved) with significantly different backrest shapes. Methods: Vertical displacement of the backrests of dental chairs was recorded. Data were obtained at three different stool positions (without a stool, under the chest at the level that participants were performing manual chest compressions, and under the shoulders). Reduction displacement ratios were calculated to evaluate the effectiveness of the stool positions. Results: The method significantly reduced the vertical displacement of the backrest for all types. When the curvature of the backrest was large, the reduction in vertical displacement was 40% when the stool was placed under the chest at the level of manual chest compressions and 65% when placed underneath the shoulder. In the case of a flat dental chair, this reduction was 90% when using a stool in either position, compared to no stool. Conclusion: When we need to perform CPR on a patient in the dental chair, placing a stool under the shoulders allows effective manual chest compression by firmly supporting the backrest of a dental chair of any shape.

Association of multiple rib fractures with the frequency of pneumonia in the post-resuscitation period.

Purpose: Successful cardiopulmonary resuscitation is associated with a high incidence of chest wall injuries. However, few studies have examined chest wall injury as a risk factor for respiratory complications after cardiopulmonary resuscitation. Therefore, herein, we investigated the association of multiple rib fractures on the incidence of post-resuscitation pneumonia. Methods: This single-centre retrospective cohort study enrolled adult, nontraumatic, out-of-hospital cardiac arrest patients who maintained circulation for more than 48 h between June 2015 and May 2019. Rib fractures were evaluated by computed tomography on the day of hospital admission. The association with newly developed pneumonia within 7 days of hospitalisation was analysed using a Fine-Gray proportional hazards regression model adjusted for the propensity score of multiple rib fractures estimated from age, sex, presence of witnessed status, bystander CPR, initial rhythm, and total CPR time and for previously reported risk factors for pneumonia (therapeutic hypothermia and prophylactic antibiotics). Results: Overall, 683 patients with out-of-hospital cardiac arrest were treated; 87 eligible cases were enrolled for analysis. Thirty-two (36.8%) patients had multiple rib fractures identified on computed tomography, and 35 (40.2%) patients developed pneumonia. The presence of multiple rib fractures was significantly associated with a higher incidence of pneumonia, consistently both with and without adjustment for background factors (unadjusted hazard ratio 4.63, 95% confidence interval: 2.35-9.13, p < 0.001; adjusted hazard ratio 4.03, 95% confidence interval: 2.08-7.82, p < 0.001). Conclusions: Multiple rib fractures are independently associated with the development of pneumonia after successful resuscitation.