What Special Circumstance Should A Rescuer Consider – Latsios G, Leopoulou M, Synetos A, Karanasos A, Papanikolaou A, Bounas P, Stamatopoulou E, Toutouzas K, Tsioufis K. Cardiac arrest and cardiopulmonary resuscitation in a “hostile” environment: reducing nurses’ risk by using automatic compression devices. J Cardiol2023;15(2): 45-55 [PMID: 36911750 DOI: 10.4330/wjc.v15.i2.45]
George Latsios, MD, PhD, Academic Fellow, Attending Physician, Lecturer, President, 1st Department of Hearts, “Hippocration” University Hospital, Medical School of Athens, Working Group on Cardiac Rehabilitation and Acute Cardiac Care, Hellenic Cardiological Society, Athens 11527, Greece . email@example.com
What Special Circumstance Should A Rescuer Consider
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The Erc Guidelines 2021: Adult Advanced Life Support (part 3/7)
George Latsios, Mariana Leopoulou, Andreas Sinetos, Antonios Karanasos, Angelos Papanikolaou, Pavlos Bounas, Evangelia Stamatopoulou, Konstantinos Toutouzas, Kostas Siofis
Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” University Hospital, Attikon University Hospital, Athens 12462, Greece
Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, “Hippocration” General Hospital, “Hippocration” University Hospital, Athens 11527, Greece
Author Contributions: Latsios G and Leopoulou M contributed equally to this work; Latsios G, Leopoulou M, Synetos A, Karanasos A, designed the research study; Latsios G, Leopoulou M, Synetos A, Karanasos A Papanikolaou A, Βounas P, Stamatopoulou E contributed bibliography; Latsios G, Leopoulou M, Synetos A, Karanasos A Papanikolaou A, Βounas P, Stamatopoulou E, Tsioufis K Toutouzas K analyzed the data / edited the manuscript; All authors read and approved the final manuscript.
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Open Access: This article is an open access article selected by an internal editor and thoroughly reviewed by external reviewers. It is distributed under the Creative Commons Attribution Non-Commercial License (CC BY-NC 4.0), which allows others to distribute, remix, adapt, construct, and license their own derivative works under various terms of this work without commercialization. First properly cited and use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
University Cardiology Department, “Hippocration” University Hospital, Athens Medical School, Working Group on Cardiac Rehabilitation and Acute Cardiac Care, Hellenic Cardiological Society, Athens 11527, Greece.
Automatic mechanical compression devices are used as an alternative to manual, “open hands”, rescuer-delivered chest compressions in cardiopulmonary resuscitation. -Theoretical- benefits include uninterrupted high-quality compressions, thereby freeing up the rescuer’s compressions and the rescuer’s ability to stand a reasonable distance from the “dangerous” victim in dangerous and/or difficult CPR situations. Such situations include cardiopulmonary resuscitation (CPR) in the cardiac catheterization laboratory, especially directly under a fluoroscopy panel, where radiation can have harmful effects on the rescuer, and CPR during/after movement of victims on land or in the air. Cardiac arrest. Finally, CPR in the 2019 coronavirus patient/ward, where infection and serious illness of the health care provider is high. The scope of this review is to review and present the current literature and guidelines regarding the use of mechanical compression in these “hostile” and dangerous settings, comparing them to manual compression.
Key tip: The use of automatic compression devices in ‘hostile’ environments, in both in-hospital and out-of-hospital cardiac arrest, appears to be beneficial in terms of compression quality but especially in terms of rescuer safety. To date, although experimental data are extensive, actual studies examining their use in non-social contexts are still limited. Because high-quality cardiopulmonary resuscitation is critical to successful resuscitation, their use in such difficult and “hostile” situations should be seriously considered. It is noteworthy that such use is actually mentioned in the guidelines.
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Cardiopulmonary resuscitation (CPR) is the mainstay of cardiac arrest treatment. A large number of people suffer cardiac arrest in and out of hospital every year and therefore, the need for high quality CPR is vital to save people’s lives.
The cornerstone of high-quality CPR is effective chest compressions (CC). Characteristics of good quality CCs are adequate size, adequate depth, complete chest retraction and minimal distraction. However, during setups that require high refresh rates, high quality CCs are not always available. Rescuer fatigue is the main reason for lower CCs, as the pressure provided by the rescuer is more demanding and tiring. In a manual compression study, the majority of rescuers reported significant back discomfort, which was strongly related to CPR duration, and nearly 20% of rescuers reported back pain or excessive disc herniation.
In addition to user fatigue, aggressive settings for cardiac arrest are often the cause of poor quality CCs. Those settings include, but are not limited to, resuscitation during patient transport in a moving ambulance, inside a computed tomography (CT) scanner, or in a cardiac catheterization laboratory (cathlab). Especially in a cathlab, it is not only difficult for the operator to maintain high CCs because of the equipment, but it is also very dangerous due to harmful ionizing radiation.
Automatic chest compression devices (ACDs) use all the necessary features to solve all the problems mentioned above and are used in clinical practice. Several studies, reviews and meta-analyses have considered the use of ACDs in the clinical setting of cardiac arrest, demonstrating both the benefits and potential drawbacks of their use. ACDs can provide high-quality, constant level and depth compression for up to one hour when disconnected from their power source[4, 5].
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There are mainly two types of ACD devices based on compression delivery style (Figure 1). The first type is piston-driven (PD) (Lucas
Michigan Instruments, United States) – thereby applying an anteroposterior thrust to the sternum. A recent study showed that the use of a piston-driven ACD (which uses a suction cup) is associated with higher coronary perfusion pressure. A second type of ACD uses a load distribution band (LDB) (autopulse
Joll Medical Corp, United States) and evenly distributes the force applied to the patient’s body . Both models have been studied in the settings of both in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) and appear to be more beneficial in the setting of IHCA. However, a new idea is that they may be most valuable in the ‘unfriendly’ setting of cardiac arrest, whether IHCA or OHCA. In this review, we present current data and literature on the implementation of ACDs in cardiac arrest in a ‘hostile’ environment.
Figure 1 Automatic compression devices instead of manual cardiopulmonary resuscitation to reduce rescuer risk in in-hospital and out-of-hospital cardiac arrest resuscitation.
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The use of ACDs in the hospital environment (Figure 1) has various advantages. The devices can be deployed quickly and this solves the problem of energy loss, as hospital beds in hospitals absorb up to 40% of the energy generated during chest compressions. They are easier to use and less invasive than extracorporeal membrane oxygenation used in cardiac arrest settings and additionally require easier training. In addition, the hospital’s local infrastructure is highly advanced, providing high-quality post-resuscitation care, a well-trained resuscitation team, efficient airway management and reduced response times; Therefore, in-hospital CPR, aided by ACDs, provides superior, more coordinated early care for patients. To date, data have shown that the use of ACDs is beneficial in the setting of IHCA compared to manual cardiac compression, but additional data will clarify the standing debate.
However, although ACDs can provide a stable solution to the critical problem of high-quality compression, they can impose limitations. Patient safety has been studied and patient injuries (such as rib fractures, liver fractures, or vertebral body fractures) have occasionally been reported. In addition, device failure has also been reported[10, 11]. The learning curve required for proper use and placement of devices with minimal interference from continuous manual compression has also been appreciated. The randomized COMPRESS-RCT study, although terminated early due to adverse effects in the use of a specific type of ACD (Lucas) in the hospital setting, highlighted important aspects and limitations of the implementation of ACD study protocols. In-hospital survival was poor, but complications such as delayed internal randomization of arrest, poor compression quality in the Lucas arm, and poor overall recruitment were noted.
Radiation exposure: Despite the limitations arising from the use of ACDs in the hospital environment, data suggest that their use in unique and non-friendly situations is beneficial and recommended. In particular, although cardiac arrest cases in the cardiac cath lab[ 13 ] are decreasing due to improved techniques, equipment and training, chronic CPR may still be necessary[ 13 ]. The presence of machinery and ionizing radiation creates a ‘hostile’ environment. Radiation exposure is a major concern during manual CCs, as accumulated doses over time are associated with several health risks[ 14 ]. As a result, protection of lifeguards from radiation should be prioritized. The use of ACDs in the cathlab can replace manual compression, thereby eliminating the need for additional personnel in the recovery process. In addition, ACDs can provide good quality compression during continuous catheterization procedure (i.e. primary PCI) because they are very bright.
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