Resus today Spring 2018 by Media Publishing Company

Volume 5 No. 1

Spring 2018

Resuscitation Today A Resource for all involved in the Teaching and Practice of Resuscitation Supported by CPRO

when every breath counts 9 Application proven: pre-hospital, emergency, critical care & resuscitation 9 Provides compliance to 2015 ERC/UK ALS waveform capnography guidelines

In this issue EMT - LED Laryngeal Tube vs Face Mask Common intensive Care Scoring Systems Life Connections Resuscitation Conference Programme

EMMAÂŽ

Waveform Capnograph

medical

CONTENTS

CONTENTS 4

EDITORS COMMENT

CLINICAL PAPER EMT - LED Laryngeal Tube vs Face Mask

CLINICAL PAPER So let’s talk about reality

CLINICAL PAPER Common intensive care scoring systems

CLINICAL PAPER Controlled automated reperfusion

330

NEWS

Resuscitation Today This issue edited by: Russell D Metcalfe-Smith MSc. FRPSH NRP CHSE-A c/o Media Publishing Company Media House 48 High Street SWANLEY, Kent BR8 8BQ ADVERTISING & CIRCULATION: Media Publishing Company Media House, 48 High Street SWANLEY, Kent, BR8 8BQ Tel: 01322 660434 Fax: 01322 666539 E: info@mediapublishingcompany.com www.MediaPublishingCompany.com PUBLISHED: Spring, Summer and Autumn

COVER STORY EMMA Waveform Capnograph portable waveform capnography from MEDACX EMMA Waveform Capnograph is the second generation following the huge success of the EMMA Capnometer first introduced by MEDACX in 2006. With over 12 years of proven UK application experience EMMA Waveform Capnograph builds on its huge reputation, now with its waveform display and breath by breath EtC02 and Respiratory Rate values plus a ‘pulsing heart’, it’s the first choice in many hospitals, ambulance and emergency organisations in the United Kingdom, Europe and around the world. October 2015: European Resuscitation Council issued NEW 2015 ALS Guidelines1, with particular emphasis on the use of waveform capnography to confirm and continually monitor tracheal tube placement, quality of CPR and to provide an early indication of return of spontaneous circulation [ROSC].

‘when every breath counts’ You can find more information about the MEDACX capnography range at: www.medacx.co.uk/products/capnography [also see Outside back cover of this edition]. MEDACX Limited, Alexander House, 60-62 Station Road, Hayling Island, Hampshire, PO11 0EL, United Kingdom. Tel: +44 (0) 2392 469737 Email: info@medacx.co.uk Website: www.medacx.co.uk

PUBLISHERS STATEMENT: The views and opinions expressed in this issue are not necessarily those of the Publisher, the Editors or Media Publishing Company. Next Issue Summer 2018 Subscription Information – Spring 2018 Resuscitation Today is a tri-annual publication published in the months of March and September. The subscription rates are as follows:UK: Individuals - £12.00 inc. postage Commercial Organisations - £30.00 inc. postage Rest of the World: Individuals - £60.00 inc. postage Commercial Organisations - £72.00 inc. postage We are also able to process your subscriptions via most major credit cards. Please ask for details. Cheques should be made payable to MEDIA PUBLISHING. Designed in the UK by Hansell Design

RESUSCITATION TODAY - SPRING 2018

EMMA Waveform Capnograph provides compliance to ALS guidelines and more… It is ideal for patient transfer and can be used with bags and face masks. With clear and precise EtC02 waveform display together with EtC02 and Respiratory rate values opens up its use for both intubated and non-intubated and for Adult/Paediatric through to Infant/Neonate patients. Confirming efficacy of endotracheal tube placement; providing early recognition of ROSC, instant feedback of effectiveness of CPR, indication of Hypercapnia & Hypocapnia states. Plus, alarm functionality; High/Low EtC02, Apnoea, Blocked Airway and Battery Status.

References: 1European Resuscitation Council [ERC] - ERC Guidelines 2015

EDITORS COMMENT

RESUSCITATION TODAY - SPRING 2018

â&#x20AC;&#x153;The development of teams, working together collectively in an environment of shared knowledge can only support our dedication to improved patient careâ&#x20AC;?

As we develop our strategies to prevent and reduce the incidence of cardiac arrest we must not reduce the emphasis placed on the effective development of resuscitation teams. The importance of training, continued training and frequent exposure of clinical teams is likely to help us develop improved outcomes in clinical care. The drive towards optimal survival from cardiac arrest has the potential to be improved greatly through appropriate application of resuscitation techniques, integration of developing technologies and well-trained teams. Significant variations in outcome exist globally which provides us the opportunity to expose ourselves to those demonstrating increased survival to discharge. The implementation of approaches to detect sick patients and prevent cardiac arrest still are not prevalent in many health systems. The introduction of new science can sometimes be delayed and educational strategies, while significant can be costly and fail to reach large numbers of learners. The complexity of engaging administrators and senior clinicians to adopt new science supporting improved outcomes may also be a limiting factor to improving the outcomes we would wish to achieve. The opportunity however to continue developing and achieving better outcomes is evident. The continued dedication of clinicians to improve outcomes and a commitment to implement current science, while learning the lessons from other systems and industries maybe the key. The development of teams, working together collectively in an environment of shared knowledge can only support our dedication to improved patient care. This issue offers some great work from those striving to provide the best possible care.

Russell D Metcalfe-Smith MSc. FRPSH NRP CHSE-A

Carts f

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Â£75

exc V AT

CLINICAL PAPER

EMT-LED LARYNGEAL TUBE VS. FACE-MASK VENTILATION DURING CARDIOPULMONARY RESUSCITATION A MULTICENTER PROSPECTIVE RANDOMIZED TRIAL Anna Fiala, Wolfgang Lederer, Agnes Neumayr, Tamara Egger, Sabrina Neururer, Ernst Toferer, Michael Baubin and Peter Paal Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2017 25:104

Abstract Background Laryngeal tube (LT) application by rescue personnel as an alternate airway during the early stages of out-of-hospital cardiac arrest (OHCA) is still subject of debate. We evaluated ease of handling and efficacy of ventilation administered by emergency medical technicians (EMTs) using LT and bag-valve-mask (BVM) during cardiopulmonary resuscitation of patients with OHCA. Methods An open prospective randomized multicenter study was conducted at six emergency medical services centers over 18 months. Patients in OHCA initially resuscitated by EMTs were enrolled. Ease of handling (LT insertion, tight seal) and efficacy of ventilation (chest rises visibly, no air leak) with LT and BVM were subjectively assessed by EMTs during prestudy training and by the attending emergency physician on the scene. Outcome and frequency of complications were compared. Results Of 97 eligible patients, 78 were enrolled. During pre-study training EMTs rated efficacy of ventilation with LT higher than with BVM (66.7% vs. 36.2%, p = 0.022), but efficacy of on-site ventilation did not differ

between the two groups (71.4% vs. 58.5%, p = 0.686). Frequency of complications (11.4% vs. 19.5%, p = 0.961) did not differ between the two groups. Conclusions EMTs preferred LT ventilation to BVM ventilation during pre-study training, but on-site there was no difference with regard to efficacy, ventilation safety, or outcome. The results indicate that LT ventilation by EMTs during OHCA is not superior to BVM and cannot substitute for BVM training. We assume that the main benefit of the LT is the provision of an alternative airway when BVM ventilation fails. Training in BVM ventilation remains paramount in EMT apprenticeship and cannot be substituted by LT ventilation. Trial registration ClinicalTrials.gov (NCT01718795). Keywords Airway management, Cardiac arrest, Cardiopulmonary resuscitation, Laryngeal tube, Prehospital emergency medicine

Background Supraglottic airways including the laryngeal tube (LT) enable rapid

Application of the LT by trained EMTs during CPR has been legal in

and effective ventilation in most cases [1]. Contrarily, conventional

Austria since 2010. We aimed to investigate subjectively assessed ease

bag-valve-mask (BVM) ventilation and endotracheal intubation may be

of handling (LT insertion, tight seal) and efficacy of ventilation (chest

difficult, especially when caregivers have little experience.

rises visibly, no air leak) with LT as compared to BVM ventilation as performed by EMTs after pre-study training and during CPR in OHCA.

RESUSCITATION TODAY - SPRING 2018

The promoted simplicity in handling makes the LT an attractive device for airway management during cardiopulmonary resuscitation (CPR), even for healthcare providers with only basic training [2]. Success rates after short training on manikins were reported between 72% and

Methods

94% in emergency medical technicians (EMTs) [1, 3, 4, 5]. Kurola et al.

Study design

observed that the LT may enable rapid and effective airway control as

The Institutional Review Board of the Medical University of Innsbruck

compared to BVM when used by inexperienced personnel [6]. The quick

approved this open prospective randomized multicenter study, which was

insertion of the LT may result in shorter hands-off intervals, increased

conducted from September 2012 to February 2014. Airway management

chest compression fraction [7] and may consequently improve chest

with EMT-led LT vs. BVM ventilation during out-of-hospital cardiac arrest

compression quality [8]. Muller et al. observed that mean tidal volume

(OHCA) was investigated in six physician-staffed emergency medical

and mean minute volume were higher with LT ventilation than with BVM

services (EMS) centers in Tyrol, Austria. In the case of presumed OHCA

ventilation [8]. Ventilation by LT may be particularly advantageous when

reported to the dispatch center, the ambulance and physician-staffed

anatomic conditions, e.g. facial hair, edentulism, facial dysmorphia and

EMS closest to the emergency site were simultaneously dispatched. Due

obesity, make BVM ventilation difficult or even impossible.

to the high density of ambulances EMTs frequently arrived on the scene

CLINICAL PAPER first and provided basic life support until the emergency physician arrived. Only patients initially resuscitated by EMTs who completed their prestudy training were randomly assigned to airway management with either laryngeal tube suction – disposable (LTS-D, VBM Medizintechnik GmbH, Sulz a.N., Germany) or BVM (AMBU Spur II by Ambu A/S, Baltorpbakken 13, Ballerup, Denmark). All ambulances in the catchment area were equipped with an opaque envelope attached to each airway management set containing information on the randomization order. On scene, EMTs started basic life support (BLS, i.e. chest compression, ventilation according to randomization, and defibrillation if indicated) [2]. During BLS, chest compression and ventilation were continued at a ratio of 30:2 in both groups [2]. Efficacy of the EMT-guided ventilation was evaluated by the emergency physician as soon as he arrived at the scene by determining whether the chest rises visibly after each inflation without air leak. Data were recorded with mobile medical devices (Corpuls3, software ed.2.3, YOM 2011, G.Stemple GmbH, 86,916 Kaufering, Germany). Inclusion criteria were: OHCA in patients ≥18 years of age. Exclusion criteria were: lack of consent of the involved EMT and/or emergency physician, emergency physician arriving at scene and starting airway management prior to arrival of the EMT, presumed airway obstruction, death of the patient before EMS arrival. It was agreed that if two attempts failed, the mode of airway management would be changed to the alternate ventilation technique. The study was designed according to intention to treat. A study manager regularly observed completeness of equipment and documentation. Pre-study training LT training followed the manufacturer’s recommendations (http://www. vbm-medical.de/cms/files/a5-1.0_06.08-de%2D-web%2D-.pdf). Similarly, BMV training was conducted according to international CPR guidelines [2]. Three months before study commencement, 203 EMTs completed a 2-h training session in LT insertion and ventilation, and a refresher course in BVM ventilation on manikins (Resusci Anne Advanced Skilltrainer CE, 151–20,033, YOM 2011, Laerdal Medical, 4002 Stavanger, Norway) at the Red Cross Academy in Innsbruck, Austria. At least three successful LT insertions with consequent sufficient ventilation (i.e. chest rises visibly after each ventilation without relevant air leak, evaluation performed by an emergency physician) were required to pass the training course.

During pre-study training ventilation efficacy was subjectively assessed by EMTs using an on-line questionnaire (www.2ask.at; amundis Communications GmbH, Felix-Wankel-Str. 4, Constance, Germany). The primary study end-points were ease of handling and efficacy of ventilation assessed by EMTs. Secondary study end-points included ventilation attempts, efficacy of ventilation assessed by emergency

The assumed null hypothesis for the primary study end-points was that ease of handling and efficacy of ventilation do not differ between LT and BVM ventilation. The sample size was calculated for an alpha-error of 0.05 and a power of 80% (beta-error of 0.2) to detect significant efficacy of ventilation in the LT group. A minimum of 25 applications in each group was deemed sufficient according to evaluation of the pre-study training. Categorical data were reported as frequencies and compared using the chi-square test. Ordinal data were reported as median and were analyzed using the Mann–Whitney U test or Spearman-Rho correlations. Results were deemed significant with a p value <0.05.

Results Pre-study training assessment All participating EMTs completed the questionnaire after training. Efficacy of LT ventilation was rated successful by most (66.7%) and regarded as more efficient (p = 0.022) than BVM ventilation (Table 1). According to the EMTs’ subjective assessment, ease of handling correlated with efficiency of ventilation when using the LT (p = 0.037). Ventilation problems were reported frequently in both groups (LT 44.4% vs. BVM 48.3%, p = 0.695). 86.1% of EMTs considered their LT training to be sufficient; 13.9% would have preferred additional training.

Table 1 Subjective EMT assessment of efficacy and ease of handling for LT and BVM ventilation after pre-study training using a 10-point scale regarding efficacy (1 = very low, 10 = very high) and ease of handling (1 = impossible, 10 = very easy) LT group (n = 54)

BVM group (n = 58)

Efficacy, credits (n; %)

p-value 0.022

14 (25.9)

13 (22.4)

1 (1.9)

7 (12.1)

4 (6.9)

1 (1.9)

3 (5.2)

2 (3.4)

1 (1.9)

3 (5.2)

5 (8.6)

1 (1.9)

10 (17.2)

6 (11.1)

5 (8.6)

29 (53.7)

6 (10.3)

4 (7.4)

7 (12.1)

2 (3.7)

1 (1.7)

4 (7.4)

3 (5.2)

4 (6.9)

2 (3.7)

8 (13.8)

7 (12.1)

5 (8.6)

8 (14.8)

10 (17.2)

8 (14.8)

7 (12.1)

24 (44.4)

5 (8.6)

Ease of handling, credits (n; %)

0.171

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Data collection The data spread sheet was composed according to the Utstein Style Guidelines for OHCA [9], and the CONSORT 2010 guidelines [10]. Data collection was jointly performed by the attending EMT, the pre-hospital emergency physician, and the admitting hospital physician. The EMT arriving first at the scene assessed quality of bystander CPR (location, depth and frequency of chest compressions, and whether ventilation was performed or not). The EMT recorded initial cardiac rhythm, interval between arrival on site and adequate ventilation, interval between CA (if witnessed) and arrival of EMT, interval between onset of CPR and arrival of emergency physicians.

Statistical analysis

physicians, and complications.

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RESUSCITATION TODAY - SPRING 2018

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Fig. 1 Flow Diagram (Consort 2010) of patient enrolment, randomization, allocation, and analysis

On-site assessment

efficacy, frequency of complications and outcome showed no

During the study period 469 calls of presumed OHCA (i.e. unresponsive

differences between the two methods. We prospectively studied ease

person, no detectable breathing) were reported to the dispatch centre.

of handling and efficacy of LT and BVM ventilation performed by EMTs

372 patients were not eligible to randomization (in 216 cases advanced

during pre-study training. The standardized training program allowed

life support was started either with EMTs lacking LT pre-training and/

comparison of LT and BVM airway management and ventilation in real

or with lacking EMT written consent). Ninety-seven cases were

life OHCA patients. However, data acquisition was prone to incomplete

randomized (randomization rate 20.7%), and ultimately 78 patients

recording as compared to findings of previous experimental studies.

included (inclusion rate 80.4%). Two patients were excluded because

As simulated conditions may substantially differ from real CPR

of incomplete data. Thus, 35 (46.1%) patients were ultimately allocated

situations, our prospective study design allowed subjective assessment

to the LT group and 41 (53.9%) to the BVM group (Fig. 1). There were no significant differences in patient characteristics or OHCA findings between the two groups (Table 2). In 26 (74.3%) patients the LT was successfully inserted and positioned on the first attempt. Efficient 71.4% vs. BVM 58.5%, p = 0.686). We noted a tendency to lower oxygen saturation (first measurement after ROSC) with BVM ventilation. ROSC occurred in 16 patients (21.1%). On-site complications comprised aspiration in one patient (BVM group) and injuries to the mucosal membrane indicated by blood stain on the device, one in the LT group and one in the BVM group.

ventilation by emergency physicians during real OHCA. After training, 66.7% of EMTs in our study appraised LT ventilation as being highly efficient. This corresponds with findings made in other studies of LT ventilation administered by EMTs and nurses showing success rates between 72 and 94% [1, 3, 4, 5, 11]. Although most EMTs in our study had only basic experience (fewer than ten LT insertions), they more often cited good ease of handling and fewer problems as compared to BVM. Roth et al. reported that LT ventilation in real CPR was more successful than BVM ventilation (93% vs. 30%) [1]. In our study the attending emergency physicians confirmed efficient ventilation by EMTs in cases for LT (71.4%) as well as for BVM (58.5%; p = 0.686). Presumably, the pre-study refresher in BVM ventilation may have had an

Discussion

impact on the frequency of efficient BVM ventilation. After training, EMTs regarded LT ventilation as superior to BVM

EMTs preferred LT ventilation over BVM ventilation in the pre-study

ventilation; only 13.9% of EMTs considered additional training with LT

training, but on-site assessment regarding ease of handling and

insertion and ventilation necessary. However, EMTs frequently reported

RESUSCITATION TODAY - SPRING 2018

ventilation was confirmed by the attending emergency physician (LT

of ventilation by EMTs after pre-study training and objective evaluation of

CLINICAL PAPER Table 2 Patient characteristics and cardiac arrest findings on-site in thirty-five patients with laryngeal tube ventilation and in fortyone patients with bag valve mask ventilation LT group (n = 35)

BVM group (n = 41)

p-value

23; 65.7

26; 63.4

0.811

Patient characteristics Male gender (n; %) Age (year; SD)

69.1 ± 17.4

71.4 ± 13.7

0.554

Witnessed arrest (n; %)

11; 31.4

15; 36.6

0.993

Hospital discharge (n; %)

1; 2.9

1; 2.4

0.848

Intervals Call - CPR onset (median; IQR)

3 (1; 9.5)

4 (1; 7)

0.885

Call - effective ventilation (min; ±SD)

10.1 ± 8.0

8.9 ± 5.8

0.705

Call - hospital arrival (min; ±SD)

68.4 + 50.5

53.1 + 13.3

0.953

Bystander CPR (n; %)

18; 51.4

13; 31.7

0.169

Effective CPR (n; %

11; 31.4

6; 14.6

0.095

Effective ventilation (n; %)

25; 71.4

24; 58.5

0.686

Tracheal intubation (n; %)

11; 31.4

9; 22.0

0.374

First CO2 (mm Hg; SD)

33.0 ± 16.9

23.5 ± 19.6

0.12

Asystole (n; %)

20; 57.1

17; 41.5

Pulse-less electrical activity (n; %)

6; 17.1

7; 17.0

pVT/VF (n; %)

8; 22.9

11; 26.8

Basic Life Support

Advanced Life Support

First documented ECG rhythm

ROSC (n; %)

0.606

9; 25.7

7; 17.1

0.478

Heart rate (mean, ±SD)

87.2 ± 23.1

73.0 ± 38.6

0.375

Systolic blood pressure (mean, ±SD)

122.4 ± 39.2

94.6 ± 28.8

0.185

O2 saturation (mean, ±SD)

91.1 ± 7.9

86.8 ± 8.7

0.272

Aspiration (n)

Airway bleeding (n)

Regurgitation (n)

Complications

0.961

BVM bag valve mask, CO2 carbon dioxide, CPRcardiopulmonary resuscitation, ECG Electrocardiography, IQR interquartile range, LT laryngeal tube, n number, O2 oxygen, pVT pulseless ventricular tachycardia, ROSCreturn of spontaneous circulation, SD standard deviation, VF ventricular fibrillation

RESUSCITATION TODAY - SPRING 2018

difficulties with ventilation in both groups during pre-study training.

of CPR [14]. Maignan et al. compared 41 cases with intermittent

Sunde et al. observed a high number of insertion-related problems

chest compressions in the BVM group to 41 cases with continuous

with LT ventilation [12]. The authors concluded that promising

chest compressions in the LT group. Airway management with the

results in manikin studies may not be applicable to real-life CPR

LT was associated with a 27% increase in the chest compression

[12]. We assume that high expectations for the LT may create a

fraction and significantly reduced hands-off intervals but survival

subjective reality. Perceptions of advantage and disadvantage

to discharge did not differ significantly between the two groups

may influence performance and efficacy beliefs in a competitive

[7]. We doubt that increased chest compression fraction can

situation [13]. Applied to our pre-study results this would mean that

be achieved with the comparatively low LT leak pressure. An

expectations of EMTs for the LT may eventually lead them to behave

estimated leak pressure of approximately 36 cm H2O was reported

and achieve in ways that confirm their expectations.

for LT ventilation [15]. Therefore, in our study intermittent chest compression and ventilation were continued at a ratio of 30:2 after

In most patients on site, effective ventilation was provided within

LT insertion as we expected low LT leak pressure to interfere with

the first 10 min of OHCA. Within this interval airway management

continuous chest compression and simultaneous ventilation.

is not expected to substantially influence outcome. Iwami et al. reported that in patients with CA of presumed cardiac origin chest

We encountered only one airway bleeding (blood stain on the

compression only (and defibrillation, if indicated) is superior to

device) and no case of aspiration in the LT group. However, factors

combined respiratory and cardiac resuscitation within the first 5 min

associated with unsuccessful LT ventilation in the prehospital

CLINICAL PAPER setting are numerous including incorrect placement of the tube in the trachea or in the pharynx, mucosa swelling of the tongue and throat and unrecognized airway obstruction [7, 16, 17]. Incorrect LT placement may cause gastric inflation, regurgitation and massive pulmonary aspiration. Dengler et al. recommended that LTS should be used in all cases of emergency airway management [16]. Tanabe et al. reported in a nation-wide study that prehospital use of supraglottic airway devices was associated with poorer neurological outcome as compared to tracheal intubation [18]. Results from animal research indicate that carotid blood flow in the

Declarations Acknowledgements We thank everyone involved in the study, in particular the EMTs from EMS Tyrol (Rotes Kreuz Tirol gem. Rettungsdienst GmbH), the emergency physicians and the medical personnel from the emergency departments of Innsbruck Medical University Hospital, Hall State Hospital and Kufstein County Hospital. Funding The LTs used in this study were provided free of charge by VBM

low-perfusion state during CPR is further diminished by pressure on

Medizintechnik GmbH. No grants were received. The authors have no

the carotid arteries from inflated LT cuffs [19].

conflict of interest to declare.

The time may be nearing when BVM ventilation will lose its

Availability of data and materials

prominence as the standard ventilation technique during basic life

All data generated or analyzed during the study are included in this

support in favor of supraglottic airway devices [20]. However, LT

published article.

ventilation during cardiac arrest is not a strikingly simple solution. Currently, training in BVM ventilation remains paramount in EMT

Authors’ contributions

apprenticeship.

Conceptualization, design and conduction of the study were undertaken by WL, PP, AN, ET and MB. Airway management training of emergency

Limitations of our study arise from the fact that the study was

medical technicians was performed by ET and AF. TE allocated data.

conducted in a selected sample of OHCA patients collected from

AN, SN, TE and WL analyzed data. AF, WL and PP wrote the manuscript

six different centers. The study design determined the enrollment

and the other authors performed revisions. All authors read and

of cases with OHCA, where one of 203 trained EMTs had started

approved the final manuscript.

CPR and airway management before arrival of the emergency physician. This offers considerable risk of a selection bias as EMTs

Ethics approval and consent to participate

without training were not allowed to participate in the study, and

The study was approved by the Ethics Committee of the Medical

whenever the emergency physician arrived first he initiated ALS

University of Innsbruck, Austria (AN4355–300/4.15).

airway management. As EMTs do not intubate OHCA patients in our county, we did not evaluate tracheal intubation by EMTs for efficacy

Consent for publication

and ease of handling. Of the EMTs 13.9% would have preferred

Consent of relatives was planned to be sought “post hoc” after enrolment

additional training after the pre-study training. Procedural bias from

and treatment on site but was not necessary during the study. Patients’

anticipated pressure to perform might have induced some of the EMTs to not participate. Correlations between mode of ventilation and survival to discharge were not calculated as we do not know the various clinical aspects that might have influenced the outcome.

informed written consent in those who survived with good cerebral performance was planned to be obtained during recovery. Written informed consent from EMTs was obtained after successful training and from EMS physicians after general information was provided at the centers. Written consent of the EMS was given by the designated Medical Director. Comprehensive insurance coverage for patients and EMTs was

Conclusions EMTs preferred LT ventilation to BVM ventilation during pre-study training, but on site no difference was seen in efficacy, ventilation during OHCA is not superior to BVM ventilation and that LT cannot substitute for BVM training. We assume that the main benefit of the

Competing interests The authors declare that they have no competing interests. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

LT is the provision of an alternative airway when BVM ventilation fails. Training in BVM ventilation remains paramount in EMT

Open Access

apprenticeship and cannot be substituted by LT ventilation.

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/

Abbreviations

licenses/by/4.0/), which permits unrestricted use, distribution, and

BVM: Bag valve mask, CPR: Cardiopulmonary resuscitation, ECG:

reproduction in any medium, provided you give appropriate credit to

Electrocardiography, EMS: Emergency medical services, EMT:

the original author(s) and the source, provide a link to the Creative

Emergency medical technicians, ERC: European Resuscitation

Commons license, and indicate if changes were made. The Creative

Council LT: Laryngeal tube, OHCA: Out-of-hospital cardiac

Commons Public Domain Dedication waiver (http://creativecommons.

arrest, pVT: Pulseless ventricular tachycardia, ROSC: Return of

org/publicdomain/zero/1.0/) applies to the data made available in this

spontaneous circulation, VF: Ventricular fibrillation.

article, unless otherwise stated.

RESUSCITATION TODAY - SPRING 2018

safety or outcome. The results indicate that LT ventilation by EMTs

provided by Innsbruck Medical University Hospital.

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emergency medical training. Resuscitation. 2004;61(2):149–53.

Chest compression-only cardiopulmonary resuscitation for out-of-

7. Maignan M, Koch FX, Kraemer M, Lehodey B, Viglino D, Monnet MF, Pham D, Roux C, Genty C, Rolland C, Bosson JL, Danel V, Debaty G. Impact of laryngeal tube use on chest compression fraction during out-of-hospital cardiac arrest. A prospective alternate month study. Resuscitation. 2015;93:113–7. 8. Müller JU, Semmel T, Stepan R, Seyfried TF, Popov AF, Graf BM, Wiese CH. The use of the laryngeal tube disposable by paramedics

hospital cardiac arrest with public-access defibrillation: a nationwide cohort study. Circulation. 2012;126(24):2844–51. 15. Ocker H, Wenzel V, Schmucker P, Steinfath M, Dörges V. A comparison of the laryngeal tube with the laryngeal mask airway during routine surgical procedures. Anesth Analg. 2002;95(4):1094–7. 16. Dengler V, Wilde P, Byhahn C, Mack MG, Schalk R. Prehospital airway management of laryngeal tubes. Should the laryngeal tube S with gastric drain tube be preferred in emergency medicine? Anaesthesist. 2011;60(2):135–8. 17. Martin-Gill C, Prunty HA, Ritter SC, Carlson JN, Guyette FX. Risk factors for unsuccessful prehospital laryngeal tube placement. Resuscitation. 2015;86:25–30.

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18. Tanabe S, Ogawa T, Akahane M, Koike S, Horiguchi H, Yasunaga H, Mizoguchi T, Hatanaka T, Yokota H, Imamura T. Comparison of neurological outcome between tracheal intubation and supraglottic airway device insertion of out-of-hospital cardiac arrest patients: a nationwide, population-based, observational study. J Emerg Med. 2013;44(2):389–97. 19. Segal N, Yannopoulos D, Mahoney BD, Frascone RJ, Matsuura T, Cowles CG, McKnite SH, Chase DG. Impairment of carotid artery blood flow by supraglottic airway use in a swine model of cardiac arrest. Resuscitation. 2012;83(8):1025–30. 20. Paal P, Gruber E, Beikircher W, Herff H, Brugger H. Sunset of bagvalve mask and rise of supra-glottic airway ventilation devices during basic life support. Resuscitation. 2010;81(11):1594–5.

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CLINICAL PAPER

SO LET’S TALK ABOUT REALITY: CHALLENGES IN SIMULATION DESIGN AND PRESENTATION Mike Davis PhD FAcadMEd Freelance consultant in continuing medical education, Blackpool, UK Role-play and simulation have been a feature of medical education for a number of years and they are making an increasingly important contribution to teaching and assessment of doctors and other health professionals in a variety of settings, without putting patients at risk. It may well be that many of you have experienced a simulated environment and learned from the experience. The purpose of this paper is to explore how this works for us as learners, if it does indeed do so, and by implication, to identify some things that get in the way of it working when it fails to provide a useful experience. My view is that it all depends on the nature of the relationship of the simulated environment to “reality” and there are three dimensions I would like to explore: Physical reality Sociological reality Psychological reality

Role play – an aside Role play is a prerequisite of simulation and has the following features: Playing self in familiar situation, Playing self in unfamiliar situation, Playing other in familiar situation, Playing other in unfamiliar situation It is likely that people will find Playing self in familiar situation the easiest of these roles to fulfil and in some respects, this type of simulation allows participants to explore complexity, particularly if there is an opportunity to switch focus from, say, technical competence (managing a trauma) to the more social phenomena such as non-technical skills (managing a team managing a trauma). This latter approach is a feature of, for example, the European Trauma Course (ETC), subtitled “The Team Approach”. Playing other in a familiar situation can be illuminating for participants and can offer a challenge to everything from knowledge and experience

Physical reality This relates to the extent to which the “real world” is adequately reproduced in the simulated setting, and includes the environment and the type of equipment available. In some respects, this is both the easiest to manage and the least likely to be achieved. It is easy to manage because it is always possible to replicate features of the clinical or other setting, to get access to (even limited) equipment and other resources and even to gain access to real “patients”. It is a challenge because the patient is not “real”, even if an actor with specific physical characteristics (e.g. amputated limb). This is because the context (a simulation) and the interaction with the patient (some kind of script), both act as potential barriers to learners’ “buy in”.

based clinical competence to empathy. Participants should never be put in a situation where they are expected to behave beyond their capacity: a medical student would struggle to role play a professor of anatomy but could manage role playing a willing assistant who could be instructed to undertake certain basic skills. Playing other in unfamiliar situation is rarely a useful experience as participants are likely to lack both personal competence and familiarity with content or context. Playing self in unfamiliar situation can be the most valuable, putting people beyond their comfort zone and providing appropriate support mechanisms – everything from pre-reading (the flipped classroom) to “help”.

What this means is that while there is merit in maximising physical reality, other realities that are explored below, can have a more significant impact on nature of the learner experience. RESUSCITATION TODAY - SPRING 2018

Sociological reality

Psychological reality For simulation to be fully effective, this “reality” has to be paramount and is achieved to a greater or lesser extent by the other two (physical and sociological), supplemented by some key ingredients, summarised

In many settings, managing illness and trauma is a responsibility

neatly as participants having “a busy brain”: in other words, being in a

shared among a number of people representing different professional

situation where they are responding to a variety of stimuli that maximises

groups. The simulated environment may be problematic in this respect

their cognitive capacity to process the simulation as it unfolds. Much of

as there are organisational and other challenges associated with multi-

the challenge is informed by psychological theory related to issues like

professional training. The consequence of this is that introductions

schema, cognition (including cognitive overload), perception, memory

to simulation training is often in student groups (undergraduates

capacity etc.

in medicine, nursing, paramedicine) and this is a challenge the sociological reality because of certain requirements of effective and

Psychological realism, then, is the product of complex interactions

powerful role play. The increasing use of in situ and/or multi-professional

between a number of components. To explore this, consider a real

simulation in CPD is an effort to overcome this.

clinical case:

CLINICAL PAPER A patient arrives in your care and you are, to all intents and purposes,

• the session may have a title (e.g. “the septic child”)

faced with an ill-defined problem. You manage the patient following

• there may be some essential pre-reading

agreed protocols and your interactions and investigations determine your actions. Especially when an analysis of the situation does not reveal a clear-cut diagnosis, you use clinical judgement. In all cases, you are constantly monitoring the impact of your actions to determine “what happens next”. You interact with others who share the experience but may have different interpretations/perceptions so you have to weigh up alternatives included in your own schema for the situation. Final outcomes depend on a wide range of issues, some of which are in your control, and others which are not. You will be aware of some of these but others will remain a mystery.

• you are surrounded by a group of fellow learners • patient responses are, to a greater or lesser extent, subject to intervention by the facilitator There is little you can do about the first six of these but the final one is a vital component in creating a situation where the brain is busy. Psychological realism can be achieved through careful planning and subsequent management of information flow: those characteristics of the simulation that reflect the real world of patient management in a timely manner.

A simulated event works against a background of features that can mitigate against the realism that is evident in this clinical case. These features might include some or all of the following: • it takes place in a simulated setting (either a sim lab or in situ) • the patient is a mannikin or human patient actor • everyone knows there is a fictitious scenario to unfold

A future paper will explore some of the psychological theory in more depth. This paper has its origins in “How to teach using simulation in healthcare” written and co-edited by the author Mike Davis and Jacky Hanson, Mike Dickinson, Lorna Lees and Mark Pimblett and published in 2017 by Wiley-Blackwell.

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CLINICAL PAPER COMMON INTENSIVE CARE SCORING SYSTEMS DO NOT OUTPERFORM AGE AND GLASGOW COMA SCALE SCORE IN PREDICTING MID-TERM MORTALITY IN PATIENTS WITH SPONTANEOUS INTRACEREBRAL HEMORRHAGE TREATED IN THE INTENSIVE CARE UNIT Marika Fallenius1, Markus B. Skrifvars1,2, Matti Reinikainen3, Stepani Bendel4 and Rahul Raj5* Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2017 25:102

Abstract Background Intensive care scoring systems are widely used in intensive care

discrimination (AUC 0.84, p > 0.05 for all models). SAPS II showed

units (ICU) around the world for case-mix adjustment in research and

satisfactory calibration (p = 0.058 in the Hosmer-Lemeshow test),

benchmarking. The aim of our study was to investigate the usefulness of

whereas all other models showed poor calibration (p < 0.05).

common intensive care scoring systems in predicting mid-term mortality in patients with spontaneous intracerebral hemorrhage (ICH) treated in

Discussion

intensive care units (ICU).

In this retrospective multi-center study, we found that SAPS II and APACHE II were of no additional prognostic value to a simple model

Methods

based on only age and GCS score for patients with ICH treated in

We performed a retrospective observational study including adult

the ICU. In fact, the major predictive ability of APACHE II and SAPS II

patients with spontaneous ICH treated in Finnish ICUs during

comes from their age and GCS score components. SOFA performed

2003–2012. We used six-month mortality as the primary outcome of

significantly poorer than the other models and is not applicable as

interest. We used logistic regression to customize Acute Physiology

a prognostic model for ICH patients. All models displayed poor

and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology

calibration, highlighting the need for improved prognostic models for

Score (SAPS) II and Sequential Organ Failure Assessment (SOFA) for

ICH patients.

six-month mortality prediction. To assess the usefulness of the scoring systems, we compared their discrimination and calibration with two

Conclusion

simpler models consisting of age, Glasgow Coma Scale (GCS) score,

The common intensive care scoring systems did not outperform a simpler

and premorbid functional status.

model based on only age and GCS score. Thus, the use of previous intensive care scoring systems is not warranted in ICH patients.

Results Totally 3218 patients were included. Overall six-month mortality was

Keywords

48%. APACHE II and SAPS II outperformed SOFA (area under the

Intracerebral hemorrhage, Hemorrhagic stroke, Intensive care,

receiver operator curve [AUC] 0.83 and 0.84, respectively, vs. 0.73)

Outcome, Prognosis, Apache ii, Saps ii, Sofa, Glasgow coma scale

but did not show any benefit over the simpler models in terms of

score, Age

Background

RESUSCITATION TODAY - SPRING 2018

The mortality of patients with spontaneous intracerebral hemorrhage

prediction model, the Sequential Organ Failure Assessment (SOFA)

(ICH) is markedly high. Studies from the U.S. and Europe have shown

has also been used to predict outcomes of mixed-ICU populations, but

mortality rates as high as 30–60% one-year after the ICH [1–3].

has not specifically been tested in ICH patients [10, 11]. Earlier studies

Notably, is that mortality after ICH has not decreased recently [4, 5].

have suggested that both age and level of consciousness are some

The existing guidelines for the management of spontaneous ICH [6]

of the most important prognostic factors in patients with spontaneous

recommend blood pressure control, reversal of anticoagulation, glucose

ICH [12, 13]. Only a few small studies have, however, compared these

management, seizure treatment and selective surgery. The guidelines

single prognostic factors with more complex prognostic models in ICH

recommend initial treatment and monitoring in an intensive care unit

outcome prediction.

(ICU) or a dedicated stroke unit [6]. Intensive care is, however, resourcedemanding, and many patients face poor outcome. Prognostic models

We conducted this study to investigate the usefulness of common

that provide prognostic information may aid in recourse allocation,

intensive care severity scores (APACHE II, SAPS II and SOFA) in

improve ICH research by providing baseline risk stratification and

predicting six-month mortality in patients with ICH treated in ICUs. We

improve comparison of cohorts in comparative effectiveness research

also investigated whether these scores are of any additional prognostic

[7]. Although common intensive care severity scores such as the

value compared to the value of simpler models. Based on our earlier

Acute Physiology and Chronic Health Evaluation (APACHE) II [8] and

study on traumatic brain injury (TBI) [14] we hypothesized that a

Simplified Acute Physiology Score (SAPS) II [9] are commonly used

simple model comprising age, premorbid functional ability, and level

for ICU-treated patients, they are both complex and non-specific for

of consciousness performs as well as do more complex ICU scoring

ICH patients. Furthermore, although not originally developed as a

systems in predicting six-month mortality.

* 5

Correspondence: rahul.raj@hus.fi Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland Full list of author information is available at the end of the article

CLINICAL PAPER Methods Study population and data collection

Vienna, Austria). We explored differences in baseline characteristics

We conducted a retrospective observational study using a nationwide

using a χ2 test (two-tailed) for categorical data and the Mann-Whitney

multi-center high quality ICU database, the Finnish Intensive Care

U-test for continuous skewed data. The categorical data are presented

Consortium (FICC). Ethical approval to conduct the study was obtained

as proportions (%) and continuous data as medians with inter-quartile

from the ethics committee of North Savonia hospital district (Dnro

ranges (IQR). We defined p values <0.05 as statistically significant.

30.03.2012 §19). The FICC database has been described in detail elsewhere [15, 16]. In short, the FICC database was established in

To be able to provide a more accurate estimate of model performance,

1994 to improve the quality of intensive care in Finland. It includes

we internally validated all prognostic models [18]. In order to implement

prospectively collected data on mortality and factors that affect

this, we applied a split-sample technique were the cohort was divided

prognosis such as co-morbidities and severity of illness from 21

randomly into two independent parts named development and

different hospitals all over Finland. Data on physiologic variables is

validation group [19].

collected and validated from electronic patient monitoring systems and stored automatically. Data on co-morbidities, admission type, discharge

All APACHE II, SAPS II, and SOFA severity scores use in-hospital

status, and diagnoses are entered manually by ICU staff into the

mortality as endpoint. Yet many intensive care patients with poor

electronic database. The database is maintained by Tieto Healthcare &

prognosis are discharged to other institutions, where some will die

Welfare Ltd. (Helsinki, Finland).

during the following months. Therefore, using in-hospital mortality as the primary endpoint may bias the results [20]. Therefore, we wanted

From the database, we collected the APACHE II, SAPS II and SOFA

to investigate the adequacy of severity scores in predicting mid-term

scores. APACHE II and SAPS II are per definition collected during the

mortality and, thus, used six-month mortality as the primary outcome

first 24 h of ICU admission. For comparability, we used SOFA from the

of interest. Hence, we used logistic regression analysis, using the logit-

first ICU day [17]. We included adult patients (>18 years) treated for

transformed original prediction as the independent variable and six-

spontaneous ICH in Finnish ICUs between 2003 and 2012. We excluded

month mortality as the dependent variable, to first-level customize the

patients being re-admitted or transferred from another ICU. Furthermore,

ICU scores. First-level customization usually only improves calibration

patients with incomplete data, deficient APACHE II, SAPS II or SOFA

in the given data set without affecting discrimination [21]. We then

data or those who were lost to follow-up were excluded (Fig. 1).

created two different simpler reference models for comparison. The first one was composed of age and the worst GCS score measured during the first 24 h after ICU admission (reference-1). The second one included premorbid functional status in addition to age and GCS score (reference-2). Premorbid functional status describes the patient’s need for assistance in the daily life before hospitalization, and we categorized the patients into being either independent or dependent. We evaluated the performance of the prognostic models by assessing discrimination and calibration. Discrimination is a measure of the model’s ability to distinguish between those patients who do experience the event of interest and those who do not. To measure discriminative ability, we constructed a receiver operator characteristic (ROC) curve and calculated the Area Under the Receiver Operator Curve (AUC). The AUC curve plots the combination of sensitivity and the complement of specificity covering the whole range of probabilities [22]. An AUC of >0.9 indicates excellent discrimination, discrimination, 0.6–0.7 indicates poor discrimination, and an AUC of 0.5 indicates that the model does not predict better than mere chance. Calibration is a measure of the model’s ability to generate estimates of risks that are in accordance with the observed outcomes at different classes of risk. To assess the models’ calibration, we used the

Fig. 1 Study population. Abbreviations: FICC, Finnish Intensive Care Consortium; ICH, intracerebral hemorrhage; ICU, intensive care unit

Hosmer-Lemeshow (H-L) goodness-of-fit test. It examines how well the expected number of deaths are in accordance with the observed number of deaths over deciles of predicted risk. A p-value >0.05

Statistical analysis

indicates that the observed mortality does not differ significantly from the predicted and implies good calibration [23]. Although the

For the statistical analyses, we used SPSS software for Macintosh,

H-L test is the most widely used test to measure calibration, it has

Version 23.0 (Armonk, NY: IBM Corp) and R: A Language Environment

been criticized for several reasons. First, H-L test plots average risk

for Statistical Computing (R-Foundation for Statistical Computing,

over deciles, not individual patients. Second, the calibration curve

RESUSCITATION TODAY - SPRING 2018

0.8–0.9 indicates good discrimination, 0.7–0.8 indicates satisfactory

CLINICAL PAPER

RESUSCITATION TODAY - SPRING 2018

CLINICAL PAPER Table 1 Patient baseline characteristics according to six-month outcome All patients (n = 3218)

Development (n = 1589)

Validation (n = 1629)

P-value*

Survivors (n = 1691)

Non-survivors (n = 1527)

P-value†

0.392

<0.001

Age, in years < 45

416 (13)

216 (14)

200 (12)

263 (16)

153 (10)

45–75

2467 (77)

1202 (75)

1265 (78)

1283 (76)

1184 (78)

> 75

335 (10)

171 (11)

164 (10)

145 (8)

190 (12)

Secondary (Central)

866 (27)

435 (27)

431 (27)

295 (17)

571 (37)

Tertiary (University)

2352 (73)

1154 (73)

1198 (73)

1396 (83)

956 (63)

Independent

2917 (91)

1435 (90)

1482 (91)

1578 (93)

1339 (88)

Dependent

301 (9)

154 (10)

147 (9)

113 (7)

188 (12)

Level of care hospital 0.557

<0.001

Prior functional ability 0.515

<0.001

GCS 3 to 8

1999 (62)

992 (62)

1007 (62)

9 to 12

485 (15)

243 (15)

242 (15)

0.764

654 (39)

1345 (88)

374 (22)

111 (7)

663 (39)

71 (5)

17 (12, 23)

27 (23, 31)

<0.001

13 to 15

734 (23)

354 (22)

380 (23)

APACHE II

23 (16, 28)

22 (16, 28)

SAPS II

47 (30, 57)

47 (30, 58)

46 (30, 57)

0.466

33 (23, 46)

56 (48, 63)

<0.001

SOFA

7 (4, 9)

0.073

5 (3, 8)

8 (6, 10)

<0.001

Total score

73 (44, 143)

74 (44, 145)

72 (44, 141)

0.605

80 (44, 163)

68 (44, 122)

<0.001

Average score

28 (23, 33)

28 (22, 32)

0.055

26 (21, 31)

29 (24, 34)

<0.001

Mechanical ventilation

2437 (76)

1213 (76)

1224 (75)

0.428

1052 (62)

1385 (91)

<0.001

Operative admission

1105 (34)

564 (36)

541 (33)

0.173

677 (40)

428 (28)

<0.001

Comorbidity

303 (9)

157 (10)

146 (9)

0.373

125 (7)

178 (12)

<0.001

ICU

2 (1, 4)

2 (1,4)

0.875

2 (1, 5)

1 (1, 3)

<0.001

Hospital

5 (2, 12)

5 (2,12)

0.502

8 (4, 15)

3 (1, 7)

<0.001

ICU

695 (22)

345 (22)

350 (22)

0.876

695 (46)

Hospital

1139 (35)

559 (35)

580 (36)

0.801

1139 (75)

Six-month

1527 (48)

741 (47)

786 (48)

0.358

1527 (100)

0.311

<0.001

TISS-76‡

ICU admission characteristics

Length of stay, in days

Mortality

Categorical variables are presented as n (%), all continuous variables were highly skewed and are therefore presented as median (IQR); APACHE II Acute Physiology And Chronic Health Evaluation II; GCS Glasgow Coma Scale; ICU intensive care unit; NA not available; SAPS II Simplified Acute Physiology Score II; SOFA Sequental Organ Failure Assessment; TISS-76 Therapeutic Intervention Scoring System 76. *Between development and validation cohorts. †Between the survivors and non-survivors. ‡ TISS-76 score calculations were done once each calendar day. The total score refers to the sum of all TISS score calculations during the ICU stay. The average score refers to the mean daily score

Post-hoc analyses

drawn between points [24]. Third, it has been criticized for being

In response to a reviewer comment, we assessed the discrimination of

very sensitive to sample size [25]. For these reasons, we combined

the calibrated SAPS II and APACHE II scores without the age and GCS

H-L goodness-of-fit test with a newer test for calibration, the GiViTI

score components in a cohort including all patients (development and

calibration belt [26, 27]. Unlike the calibration curve usually seen

validation cohort).

with the H-L test, the calibration belt offers both 80% confidence interval (CI; light gray area) and 95% CI (dark grey area) for the curve. The advantage of this new approach is that it allows to

Results

assess the degree of deviation from the ideal calibration line, and also to evaluate the direction of this phenomenon. When the 95%

Baseline characteristics

CI does not include the bisector line, the model is defined as poorly

A total of 3218 patients from 21 different hospitals met the inclusion

calibrated in that specific risk interval [24, 26].

criteria and were included in the study. After the random splitting was

RESUSCITATION TODAY - SPRING 2018

constructed to complement H-L test is not a curve, but a jagged line

CLINICAL PAPER Table 2 The relationship between age and Glasgow Coma Scale with six-month mortality Mortality, % (absolute numbers)

Six-month mortality prediction Both APACHE II and SAPS II-based customized models showed good discrimination with AUCs of 0.83 (95% CI, 0.81–0.85) and 0.84 (95% CI, 0.82–0.86), respectively. Both reference models showed good

Age, years patients GCS 3 to 8age and GCS Glasgow 9 to 12 Coma GCS 13 to15 Table 2 TheAllrelationship between (n = 3218) (n = 1999) (n = 485) (n = 734) Scale with six-month mortality

discrimination with an AUC of 0.84 (95% CI, 0.82–0.86) for each. The reference models’ AUCs did not differ significantly from the AUCs of

<40 34 (88/258) 57 (83/146) Mortality, % (absolute numbers) 40 to 49 41 (171/415) 66 (155/235) Age, years All patients GCS 3 to 8 (n =(400/860) 3218) (n =(360/557) 1999) 50 to 59 47 65

8 (3/40)

3 (2/72)

11 (6/56) GCS 9 to 12 (n =(26/126) 485) 21

8 (10/124) GCS 13 to15 = 734) 8(n(14/177)

<40 60 to 69

34 (448/946) (88/258) 47

57 67 (83/146) (397/589)

821(3/40) (32/151)

39 (2/72) (19/206)

SOFA-based model showed significantly poorer performance compared

40 70 to to 49 79

41 58 (171/415) (350/607)

66 75 (155/235) (297/398)

11 39 (6/56) (35/91)

815(10/124) (18/118)

to all other models, as its discrimination was only satisfactory with an

50 to 59 ≥ 80

47 53 (400/860) (70/132)

65 71 (360/557) (53/74)

21 43 (26/126) (9/21)

822(14/177) (8/37)

AUC of 0.73 (95% CI, 0.71–0.76, compared to both reference models

60 to 69

47 (448/946)

67 (397/589)

21 (32/151)

9 (19/206)

70 to 79 58 (350/607) 75 (297/398) 39 (35/91) 15 (18/118) performed, 1589 (49%) patients were stratified to the development ≥ 80 53 (70/132) 71 (53/74) 43 (9/21) 22 (8/37) cohort and 1629 (51%) to the validation cohort (Fig. 1).

The patients’ baseline characteristics are shown in Table 1. Patient median age was 60 years (IQR, 52–69) and 91% (n = 2917/3218) of the patients were independent in activities of daily living prior to admission. The overall six-month mortality was 48% (n = 1527/3218). Of the non-survivors, 45% (n = 695/1527) died in the ICU, and 75% (n = 1139/1527) died before hospital discharge. There were no significant differences in age, prior functional ability, level of consciousness, and

APACHE II and SAPS II (compared to APACHE II ΔAUC +0.01, p for refenrece-1 = 0.277, p for reference-2 = 0.336; compared to SAPS II, ΔAUC +0.00, p for reference-1 = 0.509, p for reference-2 = 0.466). The

ΔAUC −0.11, p < 0.001) (Table 3). The SAPS II-based model showed satisfactory calibration according to the H-L test with a p-value of 0.058. All other models showed poor calibration according to the H-L test with P-values <0.001. The GiViTI calibration belt showed poor calibration for all models as there were significant deviations from the bisector line for every model tested. The deviation from ideal calibration was towards observed mortality, and therefore all models underestimated six-month mortality (Fig. 2). In the post-hoc analyses the calibrated SAPS II and APACHE II scores without their age and GCS score components had an AUC of 0.76 (95% CI 0.74–0.77) and 0.74 (0.72–0.75), respectively.

comorbidities between the development and validation cohorts. The relationship between age and GCS score with six-month mortality is shown in Table 2. Mortality was significantly higher for patients with GCS scores between 3 to 8 compared to those with higher GCS scores. Furthermore, the mortality rate rose dramatically with age (Table 2). The

Key findings This is, by our knowledge, the largest study investigating the usefulness

effect of age on mortality was most notable in patients with GCS scores

of common severity scores in predicting mid-term mortality in patients

between 9 and 12, as the mortality was only 8% for patients aged <40,

with spontaneous intracerebral hemorrhage treated in ICUs. Of the

but as high as 43% for patients aged ≥80. Performance Discrimination variable AUC 95% CI

commonly used intensive care severity scores, both the APACHE II- and

Table 3 Scoring system performance for six-month mortality Calibration H-L P-value

GiViTI P-value

Table 3 Scoring system performance for six-month mortality

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Discussion

SAPS II-based models showed good discrimination, whereas SOFA displayed only satisfactory discrimination. In regard to calibration, only the SAPS II-based model showed satisfactory calibration whereas the

Development cohort Performance Discrimination APACHE II 0.86 0.84, 0.88 variable AUC 95% CI SAPS II 0.86 0.84, 0.88

Calibration 0.766 H-L P-value 0.624

NA GiViTI P-value NA

Development cohort0.74 SOFA

0.71, 0.76

0.001

power. Thus, the main predictive ability of SAPS II and APACHE II in ICH

other models showed poor calibration. In the post-hoc analyses, the discrimination of the SAPS II and APACHE II scores without their age and GCS score components markedly lowered their discriminative

APACHE II * Reference

0.86 0.85

0.84, 0.86 0.88 0.83,

0.766 0.001

NA NA

patients comes from the strong predictive effect of age and the GCS

SAPS II Reference †

0.86 0.85

0.84, 0.83, 0.88 0.87

0.624 0.001

NA NA

score. This is strengthened by the study’s main finding, which is that

SOFA cohort Validation

0.74

0.71, 0.76

0.001

compared to a simple prognostic model, including only age and GCS

ReferenceII * APACHE

0.85 0.83

0.83, 0.81, 0.86 0.85

0.001 <0.001

NA <0.001

score, the more complex ICU scores were of no additional prognostic

Reference † SAPS II

0.85 0.84

0.83, 0.86 0.87 0.82,

0.001 0.058

NA 0.014

Validation SOFA cohort

0.73

0.71, 0.76

<0.001

APACHE II * Reference

0.83 0.84

0.81, 0.86 0.85 0.82,

<0.001 <0.001

SAPS II Reference †

0.84 0.84

0.82, 0.82, 0.86 0.86

0.058 <0.001

0.014 0.003

SOFAII Acute Physiology 0.73 and Chronic 0.71, 0.76 <0.001II; GCS Glasgow <0.001 APACHE Health Evaluation Coma Scale; ICU intensive care unit; NA not available; SAPS II Simplified Acute Reference * 0.84 0.82, 0.86 <0.001 <0.001 Physiology Score II; SOFA Sequential Organ Failure Assessment. *Reference model including age and GCS. † Reference model including age, GCS and Reference † 0.84 0.82, 0.86 <0.001 0.003 premorbid functional status APACHE II Acute Physiology and Chronic Health Evaluation II; GCS Glasgow Coma Scale; ICU intensive care unit; NA not available; SAPS II Simplified Acute Physiology Score II; SOFA Sequential Organ Failure Assessment. *Reference model including age and GCS. † Reference model including age, GCS and premorbid functional status

value. It is not surprising that SOFA did not match the predictive performances of APACHE II and SAPS II (or the simple age and GCS score model) as SOFA was originally intended as a descriptive measure of organ failure and not as a predictive measure. Thus, for ICH patients treated in the ICU, there is nothing to favor the use of previous complex ICU scoring systems, as age and GCS alone adequately predict mortality. Furthermore, abstracting age and GCS score is much more time-efficient than abstracting the complex intensive care scoring systems. Interestingly, adding pre-admission functional status to the reference model (including age and GCS) did not improve the prognostic performance. This is somewhat surprising, as a recent study showed

CLINICAL PAPER pre-admission functional status to be a strong independent predictor of

Fig. 2 GiVi including including show a sig poor calib observed six-month

outcome in general ICU patients [28]. Our results might indicate that in ICH patients, the injury severity itself is more important in determining patient prognosis than pre-admission functional status. Yet, only 9% of included patients were dependent in daily functions prior to admission. Thus, the effect of this variable is probably underpowered, which probably explains why it did not add any predictive power. Furthermore, included patients that were dependent prior to admission probably represent a selected cohort that have been considered to have a reasonable prognosis and therefore admitted to the ICU, increasing the likelihood of a type II error. Thus, any foregone conclusions regarding the association between pre-admission functional status and outcome cannot be drawn from our study. Comparison with previous studies Clinical studies concerning the common intensive care severity scores in outcome prediction after ICH are limited, especially with regards to mid- or long-term mortality prediction. The results of our study are in concordance with previous studies. In a prospective study including 90 patients with acute stroke, Handshu et al. showed that the prognostic performance of GCS was almost equal to SAPS II in both 90-day (AUC 0.68, AUC 0.75 respectively) and 365-day mortality prediction (AUC 0.73, AUC 0.77 respectively) [13]. However, the study included both hemorrhagic (54%, n = 49) and ischemic stroke (46%, n = 41) patients and, thus, the results may be biased, as these are two very different patient populations. Huang KB et al. showed in a retrospective single-center study, including 75 patients, that APACHE II, SAPS II and ICH score predicted 30-day mortality well in patients with primary pontine hemorrhage (AUC for APACHE II 0.92, AUC for SAPS II 0.89, AUC for ICH score 0.84) [29]. Yet similarly to our study, the discriminative power of the GCS score (AUC 0.88) did not differ substantially from these more complex scoring systems. Furthermore, as in our study, SAPS II displayed the best calibration (p = 0.682). Patients with primary brain stem hemorrhage are, however, a specific group of stroke patients as their prognosis is significantly worse to other ICH patients. Additionally, in a large prospective study investigating the role of APACHE II in prediction of outcome after acute intracerebral hemorrhage, Huang Y et al. found the mortality prediction of APACHE II to correlate well with the observed outcome (r = 0.84, p < 0.001) [30]. The primary endpoint used was 3-month mortality, while we used six-month mortality as the primary outcome.

compared to the other models. This can be explained by the nature of the score itself. First, SOFA is an organ dysfunction score, originally designed to detect the degree of organ dysfunction instead of predicting outcome in critically ill patients. Second, the score is constructed of the level of dysfunction of six organ systems (cardiovascular, respiratory, hepatic, renal, coagulation, central nervous system) aiming to describe the degree of multi-organ failure which is common in sepsis, whereas ICH is more of a single organ problem, although multi-organ failure may occur [31]. In a large retrospective study investigating causes of death after ICH, Zurasky et al. found that only 9% of the deaths were due to non-neurologic reasons whereas neurological condition was the cause of death in overwhelming majority [32]. Also, SOFA does not consider patient

Fig. 2 GiViTI calibration belt. Reference 1 refers to reference model including age and GCS. Reference 2 refers to reference model including age, GCS and premorbid functional status. All figures show a significant deviation from the bisector line indicating poor calibration. The deviation from ideal calibration is towards observed mortality, and therefore all models underestimated six-month mortality

RESUSCITATION TODAY - SPRING 2018

In this study, SOFA showed significantly poorer performance

age, which is a major prognostic factor in ICH patients.

CLINICAL PAPER Mortality in our sample is in line with previous studies, the six-month

GiViTI: Italian Group for the Evaluation of Intervention in Intensive Care

mortality being 48%. Huang KB et al. reported a 30-day mortality of

Medicine; H-L test: Hosmer-Lemeshow goodness-of-fit test; ICH:

41% [29], whereas the three-month mortality was 40% in the study

intracerebral hemorrhage; ICU: intensive care unit; IQR: inter-quartile

conducted by Huang Y et al. [30]. However, the mortality in the study

range; ROC: receiver operator characteristic curve; SAPS II: Simplified

conducted by Handshu et al. was substantially higher compared to

Acute Physiology Score II; SOFA: Sequential Organ Failure Assessment;

all others, as the 90-day mortality was as high as 59% and one-year

TBI: traumatic brain injury

mortality being 68% [13]. Acknowledgments In summary, the discriminative performance of a simple prognostic

Not applicable.

model composed of only age and GCS was equivalent to that of the more complex intensive care severity scores in patients with

Funding

spontaneous ICH treated in the ICU. Thus, in regard to discriminative

This study was funded with grants from Helsinki University (three-year

power, the age and GCS score based model can replace the previous

project grant: H3702 73,702,705) and Helsinki University Hospital (state

severity scores. Yet, all models showed relatively poor calibration in

funding: VTR-TYH2014221). MK has received personal research grants

predicting six-month mortality. Thus, as the clinical utility of a predictive

from Finska Läkaresällskapet. RR has received personal research grants

model is influenced by both its discrimination and calibration [33]

from Svenska Kulturfonden, Medicinska Understödsföreningen Liv and

additional studies are necessary to improve the quality of predictive

Hälsa, Finska Läkaresällskapet, Maud Kuistilan Säätiö, Eemil Aaltosen

models used for quality assurance and research in intensive care for

Säätiö, Ella and Georg Ehrnroothin Säätiö, Suomalais-Norjalainen

patients with spontaneous ICH. Furthermore, future studies should also

Lääketieteen Säätiö, Suomen Lääketieteen Säätiö, and Maire Taposen

take into account radiological parameters of the ICHs to improve the

Säätiö. The funders had no role in the study design, data collection and

prognostic accuracy.

analysis, decision to publish, or preparation of the manuscript.

Strengths and limitations

Availability of data and materials

The major strength of our study is its adequate power to detect an

Due to the sensitive nature of the datasets used during the study, data

effect, as our sample size is large, consisting of 3218 patients and up to

will not be freely shared. It is possible to apply for data from the Finnish

our knowledge the largest study of this type published so far. Also, the

Intensive Care Consortium.

majority of all ICUs within one country were involved, which improves generalizability. An additional strength of the study is the high quality

Authors’ contributions

of the database used [16]. There are, however, some limitations to

RR, MS, SB, MR designed the study. MF and RR collected the data.

this study that deserve attention. First, as the study is retrospective in

MF conducted the statistical analyses with the help of RR and MS. All

nature we are restricted to the data available in the database. The FICC

authors participated in the interpretation and analysis of the results. All

database is not a specific neurological ICU-database and it does not

authors contributed to the writing and editing of the paper.

include variables that may be of specific interest in ICH patients, such as radiological data or information regarding use of anticoagulation

Ethics approval and consent to participate

medication. Thus, we were unable to get data on measures of ICH

The ethics committee of Finnish National Institute for Health and Welfare

radiological parameters such as hematoma volume, intraventricular

(Dnro THL/1543/5.05.01/2014) approved the study and waived the need

hemorrhage, and ICH location. Therefore, we are unable to study the

for written consent in May 2014.

performance of radiological scores, such as the ICH score, which has proved useful [34]. Second, as the management practices differ and ICU admission criteria are not equal, our findings may not be generally applicable to different healthcare systems in all cases.

Consent for publication Not applicable. Competing interests

RESUSCITATION TODAY - SPRING 2018

Conclusion

The authors declare no conflict of interest. Publisher’s Note

APACHE II and SAPS II showed good discrimination, while SOFA only

Springer Nature remains neutral with regard to jurisdictional claims in

satisfactory discrimination for predicting six-month mortality in in ICH

published maps and institutional affiliations.

patients. Only the SAPS II-based prediction model showed satisfactory calibration, whereas the other models displayed poor calibration. The

Author details

APACHE II and SAPS II scoring systems did not outperform a simpler

model based on only age and GCS score. Thus, the use of previous

Care and Pain Medicine, University of Helsinki and Helsinki University

common intensive care scoring systems is not warranted in ICH

Hospital, Helsinki, Finland. 2Australian and New Zealand Intensive Care

patients.

Research Centre, School of Public Health and Preventive Medicine,

Division of Intensive Care, Department of Anesthesiology, Intensive

Monash University, Melbourne, Australia. 3Department of Intensive Abbreviations

Care, North Karelia Central Hospital, Joensuu, Finland. 4Department of

APACHE II: Acute Physiology and Chronic Health Evaluation II; AUC:

Anesthesiology and Intensive Care, Kuopio University Hospital, Kuopio,

area under the receiver operator curve; CI: confidence interval; FICC:

Finland. 5Department of Neurosurgery, University of Helsinki and

Finnish Intensive Care Consortium; GCS: Glasgow Coma Scale;

Helsinki University Hospital, Helsinki, Finland.

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CLINICAL PAPER

CONTROLLED AUTOMATED REPERFUSION OF THE WHOLE BODY AFTER 120 MINUTES OF CARDIOPULMONARY RESUSCITATION: FIRST CLINICAL REPORT Georg Trummer1,4*, Alexander Supady2, Friedhelm Beyersdorf1, Christian Scherer1, Tobias Wengenmayer2, Markus Umhau3 and Christoph Benk1 Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2017 25:66

Abstract Background Cardiopulmonary resuscitation (CPR) is associated with a high mortality rate. Furthermore, the few survivors often have severe, persistent cerebral dysfunction. A potential cause for this unsatisfactory outcome after CPR is the combination of cardiac arrest (ischemia) and the inability to restore adequate hemodynamics during conventional CPR (reperfusion), resulting in ischemia/ reperfusion injury of the whole body. Therefore we developed a concept counteracting this ischemia/reperfusion injury during the process of CPR. Case presentation We present data from a patient, in whom the concept of a novel controlled automated reperfusion of the whole body (CARL) was applied after 120 min of CPR under normothermic conditions. The patient survived without cerebral deficits and showed full recovery of all organs after prolonged cardiac arrest (CA) except for the spinal cord, where a defect at the level of the 11th thoracic vertebra caused partial loss of motoric function of the legs.

Trial Registration Trial was retrospectively registered in the “German Clinical Trials Register” (www.germanctr.de) under No.: DRKS00005773 on July 28th, 2015. Keywords Cardiopulmonary resuscitationECPRControlled reperfusionReperfusion injuryExtracorporeal circulationACLSECLSVA-ECMOSpinal ischemia

Background

Case presentation

Despite continuous efforts, cardiopulmonary resuscitation (CPR) is

We report the case of a 44-year-old woman who underwent CPR for

still associated with high mortality and many survivors suffer from

120 min after CA followed by CARL for 60 min. The patient experienced

neurological complication [1, 2, 3]. Currently, re-establishment of

an acute onset of severe chest pain at her home that was followed by

circulation is the main goal in patients undergoing CPR, either manually

CA. Family members called emergency services and started basic life-

or with the help of extracorporeal circulatory support devices [4, 5, 6,

support procedures. When the medical team arrived, the patient was not

7, 8]. However, from a pathophysiological point of view, an individual

responsive to several cycles of advanced circulatory life support. In this

who experiences acute circulatory arrest (CA) requires individualized,

devastating situation, the onsite team decided to transport the patient

continuous reperfusion in order to limit generalized ischemia/reperfusion

to our medical center to obtain access to a mechanical circulatory

injury to the whole body [9, 10]. All currently available CPR methods

support device. During transport, the medical team continued CPR with

only provide some sort of hemodynamic support, leaving a substantial

chest compressions using the LUCAS™-system (Physio-Control; Lund/

gap in the therapeutic approach of the life-threatening situation of acute

Sweden).

RESUSCITATION TODAY - SPRING 2018

CA. On the basis of this important clinical demand, we developed in preclinical studies a novel whole-body reperfusion protocol (Controlled

The patient arrived at the hospital 90 min after the initial CA. Under

Automated Reperfusion of the whoLe body—CARL) over the last 10

the conditions of ongoing CPR, her arterial blood pH at this time was

years [11, 12, 13]. After approval of the ethics-committee, CARL has

6.8. Decision for CARL was made by an interdisciplinary team of a

been used in a total of 13 patients with extremely prolonged CPR

cardiologist, cardiovascular surgeon and an intensive-care physician

(unpublished data). The patient discussed in the current case report

and cannulation of the femoral artery and vein in preparation for the

was the 4th in the row of these 13 patients, distinguished from the other

CARL treatment was started immediately. However, access to the very

cases by the fact that it was a) the first surviving patient with cerebral

small and spastic femoral artery was difficult and time-consuming.

recovery treated with CARL, b) the patient with the longest CPR-duration

Finally, after successful femoral cannulation (17 Ch arterial, 23 Ch

(120 min) and c) the patient with the lowest arterial blood-pH (6.8) with

venous; HLS cannula Maquet, Rastatt/Germany) and a total time of

survival and cerebral recovery thereafter. The following report describes

exactly 120 min of CPR, blood circulation was provided via a new type

the course of this a patient undergoing extremely prolonged CPR with

of extracorporeal circulation device (controlled, integrated resuscitation

subsequent CARL-therapy.

device [CIRD]). This device was developed by our group in order to

Correspondence: georg.trummer@universitaets-herzzentrum.de Cardiovascular Surgery, Heart Center Freiburg University, Hugstetter Str. 55, 79106 Freiburg, Germany 4 Cardiovascular Surgery, Department of Cardiovascular Surgery, Heart Center Freiburg University, Hugstetter Str. 55, D-79104 Freiburg, Germany Full list of author information is available at the end of the article *

Conclusion This is the first reported clinical application of CARL after CA. The implementation of CARL resulted in unexpected survival and recovery after prolonged normothermic CA and CPR. In synopsis with the preclinical experience in pigs this case shows, that the new concept of CARL treating ischemia/reperfusion during the CPR may be an important element within the future treatment of CA.

CLINICAL PAPER facilitate CARL, i.e. treatment of the previously ischemic whole body.

In the ensuing days, organ function recovered stepwise. The

Chest compressions were terminated with the start of the CIRD. In order

reestablishment of satisfactory pulmonary and myocardial

to prevent ischemia of the leg, an additional sheath (8.5 Ch., Arrow,

function allowed removal of the CIRD 3 days after CPR. The need

Everett/USA) was been inserted into the femoral artery distal of the

for mechanical ventilation was prolonged due to concomitant

arterial cannula and connected to the arterial cannula.

pneumonia most likely related to aspiration during CPR. However, after 12 days, the patient was separated from the ventilator. She

The CIRD (CIRD 1.0, ResuSciTec GmbH, Freiburg/Germany) was used

regained full consciousness and showed no signs of cerebral

to apply the novel post-cardiac arrest reperfusion protocol CARL, which

deficits. These findings were consistent with the findings in the MRI

has been designed to limit the extent of ischemia/reperfusion injury of

scans of the brain (Fig. 2). Beyond that, the patient showed signs

the whole body (Fig. 1). The principle of CARL is to modify the initial conditions of reperfusion (e.g. high arterial blood pressure, pulsatile blood flow, immediate mild hypothermia) and adapt the composition of the initial blood (reperfusate) (e.g. pH-stat, limited arterial oxygen contents, hyperosmolarity, hypocalcemia) to allow the damaged organs to recover. The CIRD circuit was primed with a hyperosmolar priming solution (including albumin, mannitol, sodium-citrate and lidocaine) to provide maximum organ protection after CA. After initiation of the CIRD, the ongoing and previously uncorrectable

of spinal injury with a consecutive loss of motor function of the legs with preserved sensory function. MRI-scans of the spinal cord revealed a defect at the level of the 11th thoracic vertebra, most likely related to insufficient perfusion of the spinal vessels during the prolonged period of CA and the subsequent CPR for 120 min. The patient was discharged 21 days after CPR to a neurological rehabilitation facility. One year later the patient experiences a good quality of life without manifest deficits of cerebral function and with recurring motor function of the legs and the ability to walk again.

ventricular fibrillation was converted into asystole with the application of a bolus of intravenous potassium analogue secondary cardioplegia used in cardiac surgery. Shortly thereafter, the heart regained a stable

Discussion

sinus rhythm. Immediately after initiation of CARL-therapy, coronary angiography was done via the contralateral femoral artery. Parallel to the

Full recovery of cerebral function after 120 min of continuous CPR

CARL therapy, an acute occlusion of the proximal left anterior descending

following CA in a normothermic setting is an extremely rare event

coronary artery was diagnosed. PCI was performed and a drug-eluting

[14]. The course of this case indicates the potential of CARL.

coronary stent was implanted. CARL was applied for 60 min, followed by

However, the process of CPR, somewhat typical in these cases,

continuous extracorporeal circulatory support by the CIRD for 3 days.

deserves closer attention. First of all, the question arises of how

RESUSCITATION TODAY - SPRING 2018

Fig. 1 Schematic outline of the Controlled Integrated Resuscitation Device (CIRD) for the application of CARL. The Controlled Integrated Resuscitation Device (CIRD 1.0; ResuSciTec GmbH, Freiburg/Germany) provides continuous venous and arterial blood - gas monitoring (vBA and aBA). Gas-mixture and flow are adapted accordingly in a near closed-loop- fashion. Two blood pumps are used to provide high and pulsatile blood-flow during the reperfusion process while hypothermia is applied via the oxygenator offering immediate temperature-control of the body. The infusion-port on the venous-side of the CIRD is designed for fluid-replacement and supportive medication during the reperfusion-process

CLINICAL PAPER long resuscitative attempts should be extended before they are declared unsuccessful. The relevant CPR guidelines are limited regarding CPR duration and time-frames, despite the common practice in an out-of-hospital setting to perform CPR for 30 to 45 min before considering termination in non-responsive patients [15,

Conclusion In conclusion, this is the first reported clinical application of CARL after CA. The patient suffered a severe ischemic insult after 120 min of conventional CPR following CA: She had a pH of 6.8 and a temporary

16]. Current CPR guidelines focus on optimized perfusion-flow and

spinal cord injury. The implementation of CARL using the CIRD −1.0

pressure generated by accurately performed chest compressions

- system resulted in unexpected survival along with recovery from a

[6, 17]. Medical devices (e.g. LUCAS™, Physio-Control; Lund,

spinal cord injury after prolonged CA and CPR. The clinical application

Sweden) have been developed to substitute high-tech performance

of CARL is based on our preclinical research over many years [11, 12,

for human efforts and support transportation. Although these

13]. In the near future, we will further improve our CARL technique and

devices provide a continuously improving quality of manual chest

develop a mobile CIRD system (CIRD 2.0) that will allow us to start

compressions, possible risks of injuring lung, heart, liver, spleen

CARL treatment even outside the hospital.

and chest wall have to be considered [18, 19]. Even though the patient was transported using a compression device, the severe metabolic acidosis with high lactate levels and low pH at the time of

Declarations

arrival were indicative of severe ischemia followed by a continued, generalized low-flow/low-pressure situation.

Acknowledgements Not applicable.

The profound ischemia associated with CA is generally followed by severe cellular injury at the beginning of reperfusion. This triad

Funding

of symptoms is known as “post-resuscitation syndrome” and has

Hospital - resources only. No funding provided by a third party.

been a major challenge in the treatment of these patients [20, 21]. The therapeutic approach of CARL was developed to limit these detrimental effects. CARL is based mainly on continuous adjustments of reperfusion conditions with the recirculating blood according to the individual readings of the patient. An exemplary and immediate effect of this strategy is the generation of a comparably high and pulsatile blood pressure during extracorporeal circulation. Despite the initial, profound ischemia, which is frequently followed by severe vasoplegia, only low-dose norepinephrine was necessary in this case during the first 60 min of CARL therapy. Supported by the current guidelines recommending extracorporeal circulatory support in CPR, a detailed description of the CARL-protocol became available as part of a standard operating procedure (SOP) within the Heart Center of the Freiburg University before its first use in patients [17, 20] The spinal cord

Availability of data and materials Please contact author for data requests. Authors’ contributions MU performed CPR at the patient’s home and transferred the patient into the hospital. AS, GT, MU and TW performed treatment of the patient in the cath-lab and the intensive-care unit. FB provided clinical resources and helped to draft the manuscript. CS and CB organized and performed extracorporeal circulation. All authors read and approved the final manuscript. Ethics approval and consent to participate Ethics approval granted by the Ethics Committee of Albert-Ludwig University Freiburg/Germany, No.: 86/14 (§23b MPG) on May 15th, 2014.

injury underlines the severity of the ischemia caused by the CA and the 120 min of CPR, which obviously resulted in this neurological

Consent for publication

complication. Spinal cord ischemia after CA has been described

Patient consented the anonymized publication of the case.

previously [22, 23] and is a sign of severe ischemia that is

RESUSCITATION TODAY - SPRING 2018

obviously neglected after CPR. The superb clinical outcome of

Competing interests

this patient with no neurological deficits after a follow-up of 1 year

GT, CB and FB are shareholder of Resuscitec Ltd. GT and CB receive

shows the potential for this novel treatment after CA.

salaries for part-time employment. All other authors declare no competing interests.

Limitations We are aware of the fact, that the result of this case only demonstrates one narrow example and may be not extrapolated generally to other patients. However, the above mentioned reasons are supporting the

Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Cardiovascular Surgery, Heart Center Freiburg University, Hugstetter

exceptional character of the medical course. Beyond that, the case

Str. 55, 79106 Freiburg, Germany. 2Cardiology and Angiology I, Heart

report has been performed and evaluated with attention to accepted

Center Freiburg University, Hugstetter Str. 55, 79106 Freiburg, Germany.

methodical elements for case studies like significance of the case,

unusual general public interest, well-balanced discussion based on the

Hugstetter Str. 55, 79104 Freiburg, Germany. 4Cardiovascular Surgery,

relevant literature and different perspectives regarding the treatment of

Department of Cardiovascular Surgery, Heart Center Freiburg University,

the medical entity [24].

Hugstetter Str. 55, D-79104 Freiburg, Germany.

Institute for Cell and Gene Therapy, University Hospital Freiburg,

CLINICAL PAPER References 1. Chen LM, Nallamothu BK, Spertus JA, et al. Association between a hospital’s rate of cardiac arrest incidence and cardiac arrest survival. JAMA Intern Med. 2013;173:1186–95. 2. Nolan J, Soar J, Smith GB, et al. Incidence and outcome of inhospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit. Resuscitation. 2014;85:987–92. 3. Ehlenbach WJ, Barnato AE, Curtis JR, Kreuter W, Koepsell TD, Deyo RA, Stapleton RD. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;361:22–31. 4. Mazzeffi MA, Sanchez P, Herr D, Krause E, Evans C, Rector R, McCormick B, Pham S, Taylor B, Griffith B, Kon Z. Outcomes of extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest in adult cardiac surgery patients. J Thorac Cardiovasc Surg. 2016. doi: 10.1016/j.jtcvs.2016.06.014. [Epub ahead of print]. 5. Chen Y-S, Lin J-W, Yu H-Y, et al. Cardiopulmonary resuscitation with assisted extracorporeal life support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet. 2008;372:554–61. 6. Brooks SC, Anderson ML, Bruder E, Daya MR, Gaffney A, Otto CW, Singer AJ, Thiagarajan RR, Travers AH. Part 6: Alternative Techniques and Ancillary Devices for Cardiopulmonary Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;18(Suppl 2):S436–43. 7. Guenther SP, Brunner S, Born F, Fischer M, Schramm R, Pichlmaier M, Massberg S, Hagl C, Khaladj N. When all else fails: extracorporeal life support in therapy-refractory cardiogenic shock. Eur J Cardiothorac Surg. 2016;49(3):802–9. doi:10.1093/ejcts/ ezv212. Epub 2015 Jun 23 8. Truby L, Naka Y, Kalesan B, Ota T, Kirtane AJ, Kodali S, Nikic N, Mundy L, Colombo P, Jorde UP, Takayama H. Important role of mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock. Eur J Cardiothorac Surg. 2015;48(2):322–8. doi:10.1093/ejcts/ezu478. Epub 2014 Dec 4

13. Taunyane IC, Benk C, Beyersdorf F, Foerster K, Cristina Schmitz H, Wittmann K, Mader I, Doostkam S, Heilmann C, Trummer G. Preserved brain morphology after controlled automated reperfusion of the whole body following normothermic circulatory arrest time of up to 20 minutes. Eur J Cardiothorac Surg. 2016. doi: 10.1093/ejcts/ezw186. 14. He F, Xu P, Wei ZH, Zhang J, Wang J. Complete Recovery With the Chain of Survival After a Prolonged (120 Minutes) Out-of-Hospital Cardiac Arrest Due to Brugada Syndrome: A Case Report. Medicine (Baltimore). 94 (2015) e1107. doi: 10.1097/MD.0000000000001107. 15. Verhaert DV, Bonnes JL, Nas J, Keuper W, van Grunsven PM, Smeets JL, de Boer MJ, Brouwer MA. Termination of resuscitation in the prehospital setting: A comparison of decisions in clinical practice vs. recommendations of a termination rule. Resuscitation. 2016;100:60–5. 16. Klein HH, Arntz HR. When to terminate resuscitation in adults? Dtsch Med Wochenschr. 2016;141:292–4. 17. Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ, Gazmuri RJ, Travers AH, Rea T. Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 5. Circulation. 2015;132(18 Suppl 2):S414–35. 18. Deras P, Manzanera J, Millet I, Charbit J, Capdevila X. Fatal pancreatic injury due to trauma after successful cardiopulmonary resuscitation with automatic mechanical chest compression. Anesthesiology. 2014;120:1038–41. 19. Kralj E, Podbregar M, Kejžar N, Balažic J. Frequency and number of resuscitation related rib and sternum fractures are higher than generally considered. Resuscitation. 2015;93:136–41. 20. Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VR, Deakin CD, Bottiger BW, Friberg H, Sunde K. Sandroni C European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation. 2015;95:202–22. 21. Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Böttiger BW, Callaway C, Clark RS, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Hoek TV. Post-cardiac arrest syndrome:

Sudden cardiac death: directing the scope of resuscitation towards

epidemiology, pathophysiology, treatment, and prognostication.

the heart and brain. Resuscitation. 2006;70:44–51.

A Scientific Statement from the International Liaison Committee

10. Buckberg GD. Controlled reperfusion after ischemia may be the unifying recovery denominator. J Thorac Cardiovasc Surg. 2010;140:12–8. 11. Trummer G, Foerster K, Buckberg GD, Benk C, Heilmann C, Mader I, Feuerhake F, Liakopoulos O, Brehm K, Beyersdorf F. Successful resuscitation after prolonged periods of cardiac arrest: a new field in cardiac surgery. J Thorac Cardiovasc Surg. 2010;139:1325–32. 12. Trummer G, Foerster K, Buckberg GD, Benk C, Mader I, Heilmann C, Liakopoulos O, Beyersdorf F. Superior neurologic recovery after 15 minutes of normothermic cardiac arrest using an extracorporeal life support system for optimized blood pressure and flow. Perfusion. 2014;29:130–8.

on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation. 2008;79:350–79. 22. Turkoz A, Gulcan O, Kizilkilic O, Kocum A, Turkoz R. Spinal cord ischemia caused by cardiac arrest secondary to pericardial effusion. J Cardiothorac Vasc Anesth. 2007;21:91–2. 23. Cheshire WP, Santos CC, Massey EW, Howard JF. Spinal cord infarction: etiology and outcome. Neurology. 1996;47:321–30.

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9. Athanasuleas CL, Buckberg GD, Allen BS, Beyersdorf F, Kirsh MM.

24. Yin RK. In: 5t. Edition, editor. Case study Research. Design and Methods. Thousand Oaks: Sage Publications; 2014.

NEWS Restart a Heart 2017 sees 195,000 young people trained in life-saving CPR By Dr Andrew Lockey, Resuscitation Council (UK) Honorary Secretary and Jason Carlyon, Restart a Heart day Project Manager

A record number of people have been trained in life-saving CPR for the fourth annual European Restart a Heart day. In October each year, charities, ambulance trusts, volunteers and private training providers join together with one common goal - to train as many young people as possible in CPR on European Restart a Heart day. Previous years have seen over 150,000 young people trained in life-saving skills. In this fourth year, we set out to beat this number in the best way possible - and we did. Restart a Heart Day 2017 was bigger and better than ever - and saw record numbers of people trained in lifesaving CPR all across the United Kingdom. This year we saw a total of 195,000 people trained - all thanks to the brilliant charities, emergency services, and volunteers who donated their time and effort. Restart a Heart day was organised in partnership by the Resuscitation Council (UK), The British Heart Foundation, British Red Cross, St John Ambulance, Greater Manchester Fire and Rescue Service, and Yorkshire Ambulance Service. Every UK Ambulance service took part in the event, and, for the first time, private training providers also participated. This year saw opportunities for CPR education all over the UK. Schools, community centres, hospitals and emergency service stations hosted events to provide more trained

bystanders to improve nationwide chances for survival. Many events included cardiac arrest survivors and celebrities - including cardiac arrest survivor and ex-France international footballer David Ginola who attended a Restart a Heart day event at Norbury Manor Business and Enterprise College for Girls. In addition, the Royal College of Emergency Medicine celebrated the 50th anniversary of its specialty by organising a mass CPR-training event also under the banner of Restart a Heart. East of England Ambulance Service reunited cardiac arrest survivor Roger Baines with the paramedics who saved his life at an event which saw 60 people learn life-saving CPR. North West Ambulance Service set up CPR training stands at the Premier League match between Burnley and West Ham - and even did a special training session at halftime to ensure all the fans at the match would know what to do in an emergency. In Wales, sports stars and Welsh first minister Carwyn

Howell Jones joined together to highlight the importance of the day. Bystander CPR continues to be a crucial link in the chain of survival. Around 60,000 people in the UK have an out-of-hospital cardiac arrest each year. [1] Less than 10% of these people will survive. [2] If CPR is started early, it can double the person’s chances of survival. [3] The more people educated in crucial lifesaving techniques, the more people will survive out-of-hospital cardiac arrests in the future. As part of our determination to increase these survival odds, Restart a Heart day culminated with a visit to UK Parliament to talk to MPs about the importance of CPR education, particularly in schools. The Resuscitation Council (UK), the British Heart Foundation, St John Ambulance and The British Red Cross attended an event in UK Parliament to offer CPR training through hands-on demonstrations and virtual reality to MPs and UK Parliament staff.

RESUSCITATION TODAY - SPRING 2018

For Restart a Heart day 2018, we’ll be aiming to train over 200,000 students - and it will be the first World Restart a Heart day with countries across the world taking part! However, we won’t be able to train the lifesavers of tomorrow without the experts of today. If you would like to register your details to get involved with next year’s Restart a Heart day, please email rsah@resus.org.uk to be added to the Restart a Heart day mailing list. References [1] Ambulance Service Association, National Out-ofHospital Cardiac Arrest Project, 2006 [2] BHF analysis of OHCA figures where available [3] Resuscitation to Recovery, 2017

Life Connections 2018 NEWS

Harrogate/Bristol Resuscitation Conferences Harrogate - March 15 Resuscitation Conference Programme

Bristol - June 21 Resuscitation Conference Programme

Thursday 15th March 2018

Thursday 21st June 2018

The Pavilions of Harrogate,

Bristol UWE, Frenchay Campus,

HG2 8NZ

Bristol, BS34 8QZ

Time

Presentation

Speaker

Position

Time

Presentation

12.00-12.30

Registration

12.00-12.30

Registration

12.30-14.00

Lunch/Exhibition

12.30-14.00

Lunch/Exhibition

14.00-14.30

Pre-Hospital Antibiotics and Red Flag Sepsis

14.30-15.00

Systemic Local Anaesthetic Toxicity-A Case Study

15.00-15.30

Development of the Red Arrest Team

15.30-16.00

Tea/Coffee/Exhibition

16.00-16.30

Post ROSC Care Bundle

16.30-17.00

Ultrasound Augmented Clinical Examination in Major Trauma

Speaker

Position

Sian Annakin

Sepsis Nurse Practitioner

Jonathon Green

Research Paramedic

Amy Chan-Dominy

Paediatric Consultant

John Chippendale

Clinical Development Lead

14.00-14.30

Sepsis - Time Critical Treatment in the Acute Setting

Giles Farrington

Senior Operating Department Practitioner

14.30-15.00

Airways 2

Mark Millins

Associate Director

15.00-15.30

What Does Adult Congenital Heart Disease Mean?

15.30-16.00

Tea/Coffee/Exhibition

16.00-16.30

Leadership and Management During Crisis

Adam Layland

Senior Lecturer in Leadership & Management

16.30-17.00

Decision Making in Cardiac Arrest

Kim Kirby/Joanne Stonehouse

Research Paramedic/ Macmillan Cancer |Project Manager

Kirsty Lowery Richardson

Lead Paramedic

TBA

Topics & Speakers correct at the time of press but may be subject to change.

To view all conference programmes or to register please visit www.lifeconnections.uk.com or call 01322 660434

Only 50 Places are available on each Conference at a cost of ÂŁ30pp to include VAT, lunch/tea/coffee and free parking. Delegates can also attend our morning Paramedic Conference for a combined rate of just ÂŁ42 to include VAT, lunch, etc. To view all programmes and to secure your delegate place please visit: www.lifeconnections.uk.com or call the organisers on: 01322 660434

Further Conferences are planned later in the year for Aylesbury and Stoke-on-Trent

www.lifeconnections.uk.com

RESUSCITATION TODAY - SPRING 2018

Topics & Speakers correct at the time of press but may be subject to change.

when every breath counts Waveform Capnography  2015 ERC/UK ALS waveform capnography guidelines

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EMMA Capnograph Mainstream Waveform EtC0 2 + Respiratory Rate + Alarms

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Waveform EtC02 + Respiratory Rate + FiC02 + Sp02 + Alarms + Trends + Data store & Transfer

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