Circ Cardiovasc Qual Outcomes ; 3 — Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med ; — N Engl J Med ; —9. Improved survival after out-of-hospital cardiac arrest and use of automated external defibrillators.
Resuscitate!: How Your Community Can Improve Survival from Sudden Cardiac Arrest (Samuel and
Circulation ; — Mobile-phone dispatch of laypersons for CPR in out-of-hospital cardiac arrest. Department of Health. Cardiovascular Disease Outcomes Strategy: improving outcomes for people with or at risk of cardiovascular disease , Department of Health, London. Benefits and shortcomings of mandatory first aid and basic life support courses for learner drivers. Resuscitation ; 82 — Education in cardiopulmonary resuscitation in Sweden and its clinical consequences.
Cell phone cardiopulmonary resuscitation: audio instructions when needed by lay rescuers: a randomized, controlled trial. Ann Emerg Med ; 55 — Smartphone apps for cardiopulmonary resuscitation training and real incident support: a mixed-methods evaluation study.
J Med Internet Res ; 16 :e89 Lockey AS, Pitcher D. Equipping all citizens with the skills and equipment to be lifesavers. BMJ ; :f The effectiveness of ultrabrief and brief educational videos for training lay responders in hands-only cardiopulmonary resuscitation: implications for the future of citizen cardiopulmonary resuscitation training. Circ Cardiovasc Qual Outcomes ; 4 —6. British Heart Foundation. Resuscitation Council UK. Life-saver app. Secondary Life-saver app , Plant N, Taylor K. How best to teach CPR to schoolchildren: a systematic review.
Resuscitation ; 84 — Department for Education. Automated external defibrillators AEDs in schools. Secondary Automated external defibrillators AEDs in schools , Predicting survival from out-of-hospital cardiac arrest: a graphic model. Ann Emerg Med ; 22 —8. Incidence, duration and survival of ventricular fibrillation in out-of-hospital cardiac arrest patients in Sweden. Resuscitation ; 44 :7— A national scheme for public access defibrillation in England and Wales: early results.
Resuscitation ; 78 — The Department of Health National Defibrillator Programme: analysis of downloads from deployments of public access defibrillators. Resuscitation ; 64 — Public-access defibrillation and survival after out-of-hospital cardiac arrest. Colquhoun M.
National Database of AED use.
Resuscitate!: How Your Community Can Improve Survival from Sudden Cardiac Arrest
Public access defibrillation remains out of reach for most victims of out-of-hospital sudden cardiac arrest. Heart ; — Lancet ; : — In patients with out-of-hospital cardiac arrest, does the provision of dispatch cardiopulmonary resuscitation instructions as opposed to no instructions improve outcome: a systematic review of the literature. Resuscitation ; 82 —5. Using a mobile app and mobile workforce to validate data about emergency public health resources.
Drug Update: Pharmacotherapy for a Pulseless Cardiac Arrest
Emerg Med J ; 31 —8. In recent years, a new paradigm for cardiac arrest response proposed a three-phase model i. Research has demonstrated that early access to existing therapies during the electrical phase from time of cardiac arrest to approximately 4 minutes following arrest and the circulatory phase between 4 and 10 minutes after arrest can be highly effective Weisfeldt and Becker, ; see also Ewy et al. After approximately 10 minutes without treatment, patients enter the metabolic phase of cardiac arrest, which involves a number of cascading biochemical pathways that may extend beyond localized organ damage and can result in full-body systemic injury Bainey and Armstrong, ; Frohlich et al.
The metabolic phase of cardiac arrest is associated with poor survival rates and neurologic and functional outcomes. In this late phase, the standard guideline-recommended therapies, such as CPR and defibrillation, are usually unsuccessful Weisfeldt and Becker, Additional research is needed to define the role of alternate techniques for improving blood flow during a cardiac arrest to.
Box provides other examples of possible research areas by treatment phase. Metabolic therapies that target specific injury pathways have demonstrated increasing potential to improve survival following prolonged, untreated cardiac arrest Bartos et al. Furthermore, some studies suggest that the commonly accepted 4-minute time limit beyond which ischemic injuries begin to irreversibly damage critical organs may be extended Allen and Buckberg, ; Allen et al.
Recent investigations have reported that a combination of protective drugs and other treatments may be more effective in delaying the severe biological consequences of prolonged cardiac arrest Bartos et al. Using a combination of therapies targeting the circulatory and metabolic phases of cardiac arrest, animal model research suggests the potential to restore life after sustained periods of clinical death. For example, in a recent laboratory experiment using porcine models, Bartos and colleagues demonstrated improved rates of survival with minimal or no neurological deficits after 17 minutes of cardiac arrest after administering medications and treatments to mitigate the tissue damage associated with reperfusion injury.
Another swine experiment achieved survival following 30 minutes of isolated brain ischemia by infusing a warm blood reperfusate that consisted of free radical scavengers, a calcium chelating compound, inflammatory controls, osmotic controls, and energy substrates for 20 minutes instead of oxygenated blood during reperfusion Allen et al. In a recent human trial, Australian investigators treated cardiac arrest patients who had an initial cardiac rhythm of ventricular fibrillation VF , had received traditional advanced cardiac life support ACLS , but had not achieved return of spontaneous circulation after 30 minutes among other inclusion criteria Stub et al.
Researchers employed a combination of treatments that included mechanical cardiopulmonary resuscitation CPR due to long periods of resuscitation , intra-arrest cooling via intravenous ice cold saline, rapid initiation of extracorporeal membrane oxygenation, and rapid percutaneous coronary intervention for patients with coronary artery occlusion Stub et al. Of the 26 patients who participated in this study, 14 54 percent were discharged from the hospital with favorable neurologic status Stub et al. Although this was a small feasibility study, it demonstrates new possibilities in cardiac arrest recovery and the importance.
Research to reduce time to defibrillation, including the use of automated external defibrillators AEDs , implantable medical devices e.
Research to improve efficiency of CPR, which currently only provides 10 to 30 percent of regular blood flow to the heart and approximately 30 to 40 percent to the brain, as demonstrated in animal studies Meaney et al. Research into the effects of alternate manual CPR techniques, such as those that employ active compression and decompression and impedance threshold devices Pirrallo et al.
Research involving advanced circulatory systems, such as emergency cardiopulmonary bypass resuscitation, which involves the rapid placement of the arrested patient on a heart-lung machine to provide full blood circulation to the heart and brain Johnson et al. Investigation of interventions designed to control and minimize reperfusion injury, the inflammatory response responsible for cellular death and diminished organ function Anderson et al.
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- Cardiac survival rates around 6 percent for those occurring outside of a hospital;
- Chasing Conrad: A Tale of the Sea and a Glimpse Into the Abyss.
Research on the effects of hypothermia on the cellular, molecular, and physiological effects of ischemia and reperfusion Bro-Jeppesen et al. Research on the effects of other interventions targeting post-anoxic and ischemic brain injury. Over the past 30 years, many large randomized clinical trials for specific cardiac arrest treatments have found no demonstrated benefit Aufderheide et al. For instance, a recent study found that targeted temperature management at 33 o C did not improve survival or neurological outcomes over targeted temperature management at 36 o C Nielsen et al.
Similarly, research findings related to the impact of mechanical CPR devices are mixed, with trials demonstrating increases in CPR quality, but only nonsignificant impacts on survival to discharge Hallstrom et al. The lack of measured impact in these trials may be attributable to a variety of systemic factors and methodological limitations.
One possible explanation is that specific treatments are simply ineffective. As a result, researchers may focus on therapies with a limited likelihood of measurable benefit, including therapies that are based on insufficient preclinical work, that have unknown or unclear mechanisms of action, or have documented ineffectiveness. Decisions made during the design of clinical trials may also reduce the likelihood that the study will result in a demonstrated benefit or identify optimal use. This is especially true if the trials are based on sparse prior information related to the optimal treatment population, treatment efficacy, and the most appropriate biomarker or patient-centered outcome measure.
The urgency of identifying new therapies for cardiac arrest can create incentives for researchers to perform confirmatory or even pragmatic trials before clearly establishing efficacy in more controlled and limited settings. Resuscitation research investigating the efficacy of new treatments should utilize clinical designs and research strategies that have the highest probability of demonstrating benefit after accounting for the heterogeneous nature of cardiac arrest and cardiac arrest patients.
Traditional drug and device development processes, which largely uniformly apply and evaluate one therapy at a time regardless of important variations in patient populations, may fail to detect clinically important benefits when therapies are combined or used in select subsets of patients. The complex nature of cardiac arrest will likely require simultaneous testing of multiple treatment and treatment modalities in order to identify new effective treatments. The biggest successes may materialize when multiple treatment approaches are combined and carefully tailored to individual patient characteristics and responses to treatment i.
There is now broader recognition in the scientific community that the traditional sequential series of individual clinical trials—each testing a single treatment in a relatively homogeneous population—is time consuming, resource intensive, and increasingly leads to failed trials late in the testing phase Berry et al.
An analysis of research into neuroprotectants for ischemic strokes—an area that involves local effects of ischemia and reperfusion—identified more than 40 failed Phase III trials Minnerup et al. Examples of research strategies and clinical trial designs that could increase the efficiency and success rate of resuscitation research include the increased use of small, hypothesis-generating studies; a more robust exploration of dose effects and modifiers of efficacy i. For example, a randomized, withdrawal trial could be used to study the use of therapeutic hypothermia.
This type of trial would treat all patients with therapeutic hypothermia and then randomize the time of rewarming the withdrawal of the treatment only in the subset of patients who demonstrated some benefit as determined by a defined biomarker. Other novel approaches include adaptive and platform trials, which often use response-adaptive randomization so that patients who are enrolled later in the trial are preferentially randomized to treatment arms that are most likely to be beneficial Berry et al. This approach may improve the risk-to-benefit balance for research subjects, increase the chance of a definitive trial outcome, and increase the number of subjects ultimately treated with the best-performing treatment arm Meurer et al.
Criteria for defining a positive adaptive or platform trial result should be selected to ensure protection from false positive results FDA, a.go site
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A strategic approach to implementation of resuscitation science discoveries and new therapies is required to foster evidence adoption, use, and sustainability. Once a new treatment has demonstrated benefit in controlled clinical trials, it must be tested in increasingly realistic settings to confirm effectiveness and to identify the optimal clinical practice. Translational research focuses on the translation of new findings in basic science into new treatments and the adoption of those treatments in practice Rubio et al.
Table offers a summary of key areas of focus for possible future resuscitation research across the spectrum of translational research. In the resuscitation field, guidelines are a predominant mechanism for translating research into practice. The strengths and weaknesses of national guidelines related to cardiac arrest treatment are discussed later in this chapter. The rapid translation of basic research findings into new treatments and the adoption of new treatments into practice is more likely if clinical trials and related studies are designed to produce results that can facilitate evidence-based practice.
In , the NIH-sponsored PULSE Conference identified five domains for high-priority research that included 1 mechanisms, 2 pharmacology, 3 translational studies, 4 bioengineering, and 5 clinical evaluative research Becker et al.
In , the American Heart Association sponsored the Guidelines Conference and identified categories that included medical emergency teams; recognition of cardiac arrest and its causes; body position; electrical defibrillation; blood flow generation; airway management; ventilation; oxygenation; pharmacological interventions; metabolic, temperature, and post-resuscitation management; physiological monitoring and feedback; ethical issues; education and training; and outcomes Gazmuri et al. Recent progress in science, engineering, health informatics, and mobile technologies has created the potential to revolutionize treatments and care delivery in the field of cardiac arrest and resuscitation.
Previous chapters have described innovative new therapies e. This section examines emerging technologies and devices that are currently in prototype or early preclinical phase testing and, therefore, have not been widely incorporated into clinical practice. Although many of these devices and mobile applications have not yet met the U. Food and Drug Administration FDA criteria for broad distribution because of the lack of evidence from large-scale clinical trials, the committee recognizes that these state-of-the-art technologies have the potential to significantly improve worldwide survival of cardiac arrest.
Innovations in smartphone and mobile applications, social media, home monitoring devices, and wearable technologies could significantly reduce the time interval between collapse and treatment and substantially improve patient survival rates Scholten et al.