Effect of chest compressions only during experimental basic life support on alveolar collapse and recruitment.

AIM: The importance of ventilatory support during cardiac arrest and basic life support is controversial. This experimental study used dynamic computed tomography (CT) to assess the effects of chest compressions only during cardiopulmonary resuscitation (CCO-CPR) on alveolar recruitment and haemodynamic parameters in porcine model of ventricular fibrillation. MATERIALS AND METHODS: Twelve anaesthetized pigs (26+/-1 kg) were randomly assigned to one of the following groups: (1) intermittent positive pressure ventilation (IPPV) both during basic life support and advanced cardiac life support, or (2) CCO during basic life support and IPPV during advanced cardiac life support. Measurements were acquired at baseline prior to cardiac arrest, during basic life support, during advanced life support, and after return of spontaneous circulation (ROSC), as follows: dynamic CT series, arterial and central venous pressures, blood gases, and regional organ blood flow. The ventilated and atelectatic lung area was quantified from dynamic CT images. Differences between groups were analyzed using the Kruskal-Wallis test, and a p<0.05 was considered statistically significant. RESULTS: IPPV was associated with cyclic alveolar recruitment and de-recruitment. Compared with controls, the CCO-CPR group had a significantly larger mean fractional area of atelectasis (p=0.009), and significantly lower PaO2 (p=0.002) and mean arterial pressure (p=0.023). The increase in mean atelectatic lung area observed during basic life support in the CCO-CPR group remained clinically relevant throughout the subsequent advanced cardiac life support period and following ROSC, and was associated with prolonged impaired haemodynamics. No inter-group differences in myocardial and cerebral blood flow were observed. CONCLUSION: A lack of ventilation during basic life support is associated with excessive atelectasis, arterial hypoxaemia and compromised CPR haemodynamics. Moreover, these detrimental effects remain evident even after restoration of IPPV.

Anglo-American vs. Franco-German emergency medical services system.

It has been stated that the Franco-German Emergency Medical Services System (FGS) has considerable drawbacks compared to the Anglo-American Emergency Medical Services System (AAS): 1. The key differences between the AAS and the FGS are that in the AAS, the patients is brought to the doctor, while in the FGS, the doctor is brought to the patient. 2. In the FGS, patients with urgent conditions usually are evaluated and treated by general practitioners in their offices or at the patient's home; initially, very few approach an emergency department. 3. Emergency patients with life-threatening trauma or disease are treated by emergency physicians at the scene and during transport. Paramedics often are first to arrive at the scene, and until the emergency physician arrives at the scene, are allowed to defibrillate, to intubate endotracheally, and to administer life-saving drugs (epinephrine endotracheally, glucose intravenously, etc.). 4. Prehospital emergency physicians treat patients at the scene and during transport. 5. Emergency patients are guaranteed to be reached by an appropriate emergency vehicle and a respective crew within 10 minutes in 80% of the responses and within 15 minutes in 95% of cases. 6. The FGS deploys qualified emergency physicians assisted by qualified paramedics as prehospital intensive care providers; extended immediate care is standard. Total Prehospital Times (TPT) and scene times only are minimally longer than in the AAS. 7. Emergency Medicine is recognized as a supra-specialty to the base specialties. Specific training programs exist for emergency physicians, medical directors of emergency medical services systems (EMSS), and chief emergency physicians (CEP). 8. Resuscitation attempts are carried out not only by anesthesiologists, but also by internists, surgeons, pediatricians, etc. Emergency medicine encompasses cardiopulmonary resuscitation (CPR) and shock cases, and patients with an acute myocardial infarction, stroke, poly-trauma, status asthmaticus, etc. Emergency patients are admitted directly to emergency departments of the hospitals, which, depending upon the size of the hospital. 9. The incidence of life-threatening trauma victims has decreased to <10% in the FGS. Of a total of 830,000 deaths/year, fatal trauma cases ranked the lowest at 4%. 10. Survival figures on cardiac arrest (asystole, ventricular fibrillation/ventricular tachycardia (VF/VT), pulseless electrical activity (PEA, etc.) reported in the German EMSS correspond to those in Europe and the United States. 11. Paramedic training is characterized by a two-year program followed by a theoretical and a practical examination. 12. Paramedics and emergency physicians-in-training are supervised at the scene and during transport. Quality assurance (Q/A) constitutes an integral and legally compulsory part of the EMSS. 13. In the majority of cases, the emergency patients are evaluated and treated by the respective specialties without delays caused by patient transfer to other hospitals. 14. The FGS does not require a greater number of ambulances and/or personnel than does the AAS. 15. The German healthcare system creates less expenses/capita than the does the U.S. system at a similar level of quality of care. 16. Emergency procedures are carried out by anesthesiologists, emergency physicians, surgeons, internists, and other specialists.

Comparison of standard cardiopulmonary resuscitation versus the combination of active compression-decompression cardiopulmonary resuscitation and an inspiratory impedance threshold device for out-of-hospital cardiac arrest.

BACKGROUND: Active compression-decompression (ACD) CPR combined with an inspiratory impedance threshold device (ITD) improves vital organ blood flow during cardiac arrest. This study compared survival rates with ACD+ITD CPR versus standard manual CPR (S-CPR). METHODS AND RESULTS: A prospective, controlled trial was performed in Mainz, Germany, in which a 2-tiered emergency response included early defibrillation. Patients with out-of-hospital arrest of presumed cardiac pathogenesis were sequentially randomized to ACD+ITD CPR or S-CPR by the advanced life support team after intubation. Rescuers learned which method of CPR to use at the start of each work shift. The primary end point was 1-hour survival after a witnessed arrest. With ACD+ITD CPR (n=103), return of spontaneous circulation and 1- and 24-hour survival rates were 55%, 51%, and 37% versus 37%, 32%, and 22% with S-CPR (n=107) (P=0.016, 0.006, and 0.033, respectively). One- and 24-hour survival rates in witnessed arrests were 55% and 41% with ACD+ITD CPR versus 33% and 23% in control subjects (P=0.011 and 0.019), respectively. One- and 24-hour survival rates in patients with a witnessed arrest in ventricular fibrillation were 68% and 58% after ACD+ITD CPR versus 27% and 23% after S-CPR (P=0.002 and 0.009), respectively. Patients randomized > or =10 minutes after the call for help to the ACD+ITD CPR had a 3 times higher 1-hour survival rate than control subjects (P=0.002). Hospital discharge rates were 18% after ACD+ITD CPR versus 13% in control subjects (P=0.41). In witnessed arrests, overall neurological function trended higher with ACD+ITD CPR versus control subjects (P=0.07). CONCLUSIONS: Compared with S-CPR, ACD+ITD CPR significantly improved short-term survival rates for patients with out-of-hospital cardiac arrest. Additional studies are needed to evaluate potential long-term benefits of ACD+ITD CPR.