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      Real‐Time Ventricular Fibrillation Amplitude‐Spectral Area Analysis to Guide Timing of Shock Delivery Improves Defibrillation Efficacy During Cardiopulmonary Resuscitation in Swine

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          Abstract

          Background

          The ventricular fibrillation amplitude spectral area (AMSA) predicts whether an electrical shock could terminate ventricular fibrillation and prompt return of spontaneous circulation. We hypothesized that AMSA can guide more precise timing for effective shock delivery during cardiopulmonary resuscitation.

          Methods and Results

          Three shock delivery protocols were compared in 12 pigs each after electrically induced ventricular fibrillation, with the duration of untreated ventricular fibrillation evenly stratified into 6, 9, and 12 minutes: AMSA‐Driven (AD), guided by an AMSA algorithm; Guidelines‐Driven (GD), according to cardiopulmonary resuscitation guidelines; and Guidelines‐Driven/AMSA‐Enabled (GDAE), as per GD but allowing earlier shocks upon exceeding an AMSA threshold. Shocks delivered using the AD, GD, and GDAE protocols were 21, 40, and 62, with GDAE delivering only 2 AMSA‐enabled shocks. The corresponding 240‐minute survival was 8/12, 6/12, and 2/12 (log‐rank test, P=0.035) with AD exceeding GDAE ( P=0.026). The time to first shock (seconds) was (median [Q1–Q3]) 272 (161–356), 124 (124–125), and 125 (124–125) ( P<0.001) with AD exceeding GD and GDAE ( P<0.05); the average coronary perfusion pressure before first shock (mm Hg) was 16 (9–30), 10 (6–12), and 3 (−1 to 9) ( P=0.002) with AD exceeding GDAE ( P<0.05); and AMSA preceding the first shock (mV·Hz, mean±SD) was 13.3±2.2, 9.0±1.6, and 8.6±2.0 ( P<0.001) with AD exceeding GD and GDAE ( P<0.001). The AD protocol delivered fewer unsuccessful shocks (ie, less shock burden) yielding less postresuscitation myocardial dysfunction and higher 240‐minute survival.

          Conclusions

          The AD protocol improved the time precision for shock delivery, resulting in less shock burden and less postresuscitation myocardial dysfunction, potentially improving survival compared with time‐fixed, guidelines‐driven, shock delivery protocols.

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          Most cited references 43

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          Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos.

          The use of automated external defibrillators by persons other than paramedics and emergency medical technicians is advocated by the American Heart Association and other organizations. However, there are few data on the outcomes when the devices are used by nonmedical personnel for out-of-hospital cardiac arrest. We studied a prospective series of cases of sudden cardiac arrest in casinos. Casino security officers were instructed in the use of automated external defibrillators. The locations where the defibrillators were stored in the casinos were chosen to make possible a target interval of three minutes or less from collapse to the first defibrillation. Our protocol called for a defibrillation first (if feasible), followed by manual cardiopulmonary resuscitation. The primary outcome was survival to discharge from the hospital. Automated external defibrillators were used, 105 patients whose initial cardiac rhythm was ventricular fibrillation. Fifty-six of the patients 153 percent) survived to discharge from the hospital. Among the 90 patients whose collapse was witnessed (86 percent), the clinically relevant time intervals were a mean (+/-SD) of 3.5+/-2.9 minutes from collapse to attachment of the defibrillator, 4.4+/-2.9 minutes from collapse to the delivery of the first defibrillation shock, and 9.8+/-4.3 minutes from collapse to The arrival of the paramedics. The survival rate was 74 percent for those who received their first defibrillation no later than three minutes after a witnessed collapse and 49 percent for those who received their first defibrillation after more than three minutes. Rapid defibrillation by nonmedical personnel using an automated external defibrillator can improve survival after out-of-hospital cardiac arrest due to ventricular fibrillation. Intervals of no more than three minutes from collapse to defibrillation are necessary to achieve the highest survival rates.
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            Part 3: Adult Basic Life Support and Automated External Defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

            This review comprises the most extensive literature search and evidence evaluation to date on the most important international BLS interventions, diagnostics, and prognostic factors for cardiac arrest victims. It reemphasizes that the critical lifesaving steps of BLS are (1) prevention, (2) immediate recognition and activation of the emergency response system, (3) early high-quality CPR, and (4) rapid defibrillation for shockable rhythms. Highlights in prevention indicate the rational and judicious deployment of search-and-rescue operations in drowning victims and the importance of education on opioid-associated emergencies. Other 2015 highlights in recognition and activation include the critical role of dispatcher recognition and dispatch-assisted chest compressions, which has been demonstrated in multiple international jurisdictions with consistent improvements in cardiac arrest survival. Similar to the 2010 ILCOR BLS treatment recommendations, the importance of high quality was reemphasized across all measures of CPR quality: rate, depth, recoil, and minimal chest compression pauses, with a universal understanding that we all should be providing chest compressions to all victims of cardiac arrest. This review continued to focus on the interface of BLS sequencing and ensuring high-quality CPR with other important BLS interventions, such as ventilation and defibrillation. In addition, this consensus statement highlights the importance of EMS systems, which employ bundles of care focusing on providing high-quality chest compressions while extricating the patient from the scene to the next level of care. Highlights in defibrillation indicate the global importance of increasing the number of sites with public-access defibrillation programs. Whereas the 2010 ILCOR Consensus on Science provided important direction for the “what” in resuscitation (ie, what to do), the 2015 consensus has begun with the GRADE methodology to provide direction for the quality of resuscitation. We hope that resuscitation councils and other stakeholders will be able to translate this body of knowledge of international consensus statements to build their own effective resuscitation guidelines.
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              Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation.

              Use of automated external defibrillators (AEDs) by first arriving emergency medical technicians (EMTs) is advocated to improve the outcome for out-of-hospital ventricular fibrillation (VF). However, adding AEDs to the emergency medical system in Seattle, Wash, did not improve survival. Studies in animals have shown improved outcomes when cardiopulmonary resuscitation (CPR) was administered prior to an initial shock for VF of several minutes' duration. To evaluate the effects of providing 90 seconds of CPR to persons with out-of-hospital VF prior to delivery of a shock by first-arriving EMTs. Observational, prospectively defined, population-based study with 42 months of preintervention analysis (July 1, 1990-December 31, 1993) and 36 months of post-intervention analysis (January 1, 1994-December 31, 1996). Seattle fire department-based, 2-tiered emergency medical system. A total of 639 patients treated for out-of-hospital VF before the intervention and 478 after the intervention. Modification of the protocol for use of AEDs, emphasizing approximately 90 seconds of CPR prior to delivery of a shock. Survival and neurologic status at hospital discharge determined by retrospective chart review as a function of early ( or =4 minutes) response intervals. Survival improved from 24% (155/639) to 30% (142/478) (P=.04). That benefit was predominantly in patients for whom the initial response interval was 4 minutes or longer (survival, 17% [56/321] before vs 27% [60/220] after; P = .01). In a multivariate logistic model, adjusting for differences in patient and resuscitation factors between the periods, the protocol intervention was estimated to improve survival significantly (odds ratio, 1.42; 95% confidence interval, 1.07-1.90; P = .02). Overall, the proportion of victims who survived with favorable neurologic recovery increased from 17% (106/634) to 23% (109/474) (P = .01). Among survivors, the proportion having favorable neurologic function at hospital discharge increased from 71% (106/150) to 79% (109/138) (P<.11). The routine provision of approximately 90 seconds of CPR prior to use of AED was associated with increased survival when response intervals were 4 minutes or longer.
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                Author and article information

                Contributors
                raul.gazmuri@rosalindfranklin.edu
                Journal
                J Am Heart Assoc
                J Am Heart Assoc
                10.1002/(ISSN)2047-9980
                JAH3
                ahaoa
                Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease
                John Wiley and Sons Inc. (Hoboken )
                2047-9980
                04 November 2017
                November 2017
                : 6
                : 11 ( doiID: 10.1002/jah3.2017.6.issue-11 )
                Affiliations
                [ 1 ] Rosalind Franklin University of Medicine and Science North Chicago IL
                [ 2 ] Resuscitation Institute Rosalind Franklin University of Medicine and Science North Chicago IL
                [ 3 ] Scientific Affairs at ZOLL Medical Corporation Chelmsford MA
                [ 4 ] Critical Care Medicine Captain James A. Lovell Federal Health Care Center North Chicago IL
                Author notes
                [* ] Correspondence to: Raúl J. Gazmuri, MD, PhD, FCCM, Resuscitation Institute, Rosalind Franklin University of Medicine and Science, 3333 Green Bay Rd, North Chicago, IL 60064. E‐mail: raul.gazmuri@ 123456rosalindfranklin.edu
                Article
                JAH32729
                10.1161/JAHA.117.006749
                5721767
                29102980
                © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

                This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                Page count
                Figures: 8, Tables: 1, Pages: 15, Words: 9210
                Product
                Funding
                Funded by: ZOLL Medical Corporation
                Categories
                Original Research
                Original Research
                Resuscitation Science
                Custom metadata
                2.0
                jah32729
                November 2017
                Converter:WILEY_ML3GV2_TO_NLMPMC version:5.2.6 mode:remove_FC converted:21.11.2017

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