In This Issue

Volume 2 No. 1 Spring 2015 Resuscitation Today A Resource for all involved in the Teaching and Practice of Resuscitation Supported by CPRO

Four things in one pack, one less thing to think about

In this issue

Education - Effects of pre-training

Evidence - Out of hospital cardiac arrest O2

Equipment - The next generation in simulation technology www.i-gel.com

ATACC and ALSG programmes

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C02 values & waveform, Respiratory rate & Alarm functionsP Contents Resuscitation Today Provides more than just confirmation of efficacy of endotracheal This issue edited by: tube placement & proof of intubationP 5 Editors Comment David Halliwell MSc Paramedic Flfl c/o Media Publishing Company Patient transfer monitoringP 7 EDUCATION Media House 48 High Street Battery powered ~ 8 hours of continuous useP SWANLEY, Kent BR8 8BQ 15 EDUCATION NEWS Ideal for COPD assessment and outreach teams P ADVERTISING & CIRCULATION: Provides early indication of Hypercapnia & HypocapniaP 19 EVIDENCE Media Publishing Company Media House, 48 High Street

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® i-gel single use supraglottic airway from Intersurgical PUBLISHERS STATEMENT: i-gel® is the second generation supraglottic airway of choice in many hospitals in Europe and The views and opinions expressed in around the world. this issue are not necessarily those of the Publisher, the Editors or Media Publishing Company. Available in Indicated for use in resuscitation in adults, i-gel® is easy and rapid to insert and is consistently reliable – in many cases, insertion can be achieved in less than five seconds1. kPa or mmHG Next Issue Autumn 2015 The device incorporates a gastric channel for improved safety, an integral bite block to reduce the possibility of airway occlusion and a buccal cavity stabiliser to aid rapid insertion Subscription Information – Spring 2015 and eliminate the potential for rotation. Low post-operative complications and high seal Resuscitation Today is a bi-annual publication pressures provide benefits to both clinician and patient2. published in the months of March and Disposable Single Patient September. The subscription rates are as EMMA Airway Adapters P A number of case reports and clinical studies have highlighted the potential advantages follows:- i-gel® offers in the resuscitation scenario3,4,5,6, where seconds can make all the difference. UK: Adult/Paediatric The most recent addition to the i-gel® range is the i-gel® O2 Resus Pack. The i-gel® O2 has Individuals - £12.00 inc. postage been specially designed to facilitate ventilation as part of standard resuscitation protocols, Commercial Organisations - £30.00 inc. postage such as those designated by the European Resuscitation Council (ERC). However, the i-gel® O2 also incorporates a supplementary oxygen port for the delivery of passive oxygenation, Rest of the World: or Passive Airway Management (PAMTM), as part of an appropriate Cardio Cerebral Individuals - £60.00 inc. postage Need Resuscitation (CCR) protocol. Commercial Organisations - £72.00 inc. postage RESUSCITATION T Capnography We are also able to process your You can find more information about the Intersurgical i-gel® range at: www.igel.com or Call Us & Quote http://www.intersurgical.com/products/airway-management/igel-supraglottic-airway subscriptions via most major credit Pricing Promotion cards. Please ask for details. Choose Intersurgical for Quality, Innovation and Choice. Code: RTS15 Cheques should be made Contact information: Intersurgical, Crane House, Molly Millars Lane, Wokingham, payable to MEDIA PUBLISHING. Berkshire, RG41 2RZ, England. Tel: +44 (0)118 9656 300 Fax: +44 (0)118 9656 356 oday Infant [Reduced deadspace] Email: [email protected] Website: www.intersurgical.com Designed in the UK by Hansell Design - SPRING 2015 References: 1 Bamgbade OA, Macnab WR, Khalaf WM: Evaluation of the i-gel airway in 300 patients. Eur J Anaesthesiol. 2008 Oct;25(10):865-6. 2 Richez B, Saltel L, Banchereau F, Torrielli, Cros AM: A new single use supraglottic airway with a noninflatable cuff and an MEDACX LIMITED • FREDERICK HOUSE • 58 STATION ROAD • HAYLING ISLAND • HAMPSHIRE • PO11 esophageal vent: An observational study of the i-gel: Anesth Analg. 2008 Apr;106(4):1137-9. 3 Gatward JJ, Thomas MJC, Nolan JP, Cook TM: Effect of chest compressions on the time taken to insert airway devices in a manikin: Br J Anaesth. 2008 Mar;100(3):351-6 4 Gabbott DA, Beringer R: The i-gel supraglottic airway: A potential role for resuscitation?: Resuscitation. 2007 Apr;73(1):161-2. 02392 469737 5 Soar J: The i-gel supraglottic airway and resuscitation - some initial thoughts: Resuscitation. 2007 Jul;74(1):197. 6 UK Resuscitation Council Advanced Life Support Guide (5th Edition). Revised June 2008. [email protected] www.medacx.co.uk 3

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RA with QCPR and SimPad Ad 297 x 210 2014.indd 1 07/04/2014 12:24:05 Editors comment Editors Comment The last few months have seen all of us in the Resuscitation world beginning to prepare for the forthcoming 2015 guidelines, I have been keeping a close eye on the pre publication releases and following the global leaders on Twitter!

For many of us Twitter increases our exposure to new clinical advances, and often papers are published on Twitter many months before they see official journal review. Free Online Access Medical Education also continues to grow in popularity, with many now choosing to make their papers Open Access which is a fabulous way of reaching wider audiences.

As usual this journal focusses on 3 main areas, Education, Equipment and Evidence and again we have some papers that are written specifically for this resuscitation journal, we also review some “We are of the more interesting releases in the wider resuscitation press. seeing a Twitter continues to produce some great debates and those of you reading twitter will no doubt substantial be very aware of forthcoming developments and successes in resuscitation worldwide. Many growth in successes of individual cardiac arrests and clinicians are posted and new developments / observations are publicised here before ever seeing their presentation at conferences. telemedicine In the last few months I have been fortunate to have attended a few global Resuscitation and and some Simulation events, Including the ASPIH conference - in Nottingham which was amazing for of the those involved in simulation and education. I also travelled over to NEW Orleans to the SSIH conference - again leading simulation experts from around the world presenting their new ideas telemedicine and concepts. It was a privilege to learn from experts and to see some of the more cutting edge based developments in use. resuscitation We are seeing a substantial growth in telemedicine and some of the telemedicine based resuscitation crash carts in the USA were drawing great crowds, with remote monitoring and crash carts leading of cardiac arrest teams - from afar - with all data and video fed into the crash cart. We in the USA hope to have a review of telemedicine in Resuscitation in our next edition. Quality CPR starts with Resusci Anne were drawing Usually before the release of new guidelines there is a lull, but this year we have seen new manikin manufacturers entering the market, and the challenges to our traditional simulation great crowds, strategies continue with the development of new platforms and ways of using technology to the benefit of students. More than 300 million people worldwide have learnt CPR using Resusci Anne. with remote Now with improved multiple feedback options, Resusci Anne with QCPR monitoring February saw the Society in Europe for Simulation Applied to Medicine SESAM conference taking will optimise CPR performance enabling users to: place in conjunction with Clinical Simulation Conference 2015 in Dubai - with further new products and RESUSCITATION T SkillGuide and leading of concepts being released for the Global Simulation world. A review will follow in Our Summer Edition. • Practice with real-time feedback cardiac arrest • Measure the quality of CPR We also have the Social Media and Critical Care - SMACC conference in June in Chicago with teams - from 2500 delegates from around the globe. This is an incredible conference which continues to • Assess staff to ensure quality CPR double in size each year. oday competence in your organisation SimPad SkillReporter™ afar - with all - SPRING 2015 New Conferences are being proposed within the UK for this year, with the team at ATACC and data and video Lifeconnections joining up in the UK, and their Resuscitation Conference is already starting to fill. The Resusci Anne® with QCPR® works with the SimPad SkillReporter™, fed into the the Wireless SkillReporter™ software and the SkillGuide. To view our Links to other workshops and conferences can be found within this edition. Resusci Anne® with QCPR® promotions, visit www.laerdal.co.uk crash cart.” David Halliwell MSc Paramedic FIfL

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SP SERVICES (UK) LTD Bastion House, Hortonwood 30, Telford, Shropshire, TF1 7XT Tel: (+44) 01952 288 999 [email protected] www.spservices.co.uk/resus YOU EVERYTHINGNEED EDUCATION IN AN EMERGENCY Effects of pre-training using serious game technology on CPR performance – an exploratory quasi-experimental transfer study Johan Creutzfeldt1,2*, Leif Hedman1,3 and Li Background Felländer-Tsai1,2 A major bottleneck for better outcome after cardiac arrest is the availability 1 Department of Clinical Science, Intervention and Technology, of trained layman rescuers. In Sweden 68% of witnessed out-of-hospital Karolinska Institutet, K32, Stockholm, 141 86, Sweden; victims suffering sudden cardiac arrest are exposed to cardiopulmonary 2 Center for Advanced Medical Simulation and Training, Karolinska resuscitation (CPR) attempts by laymen rescuers [1,2]. In the US, Institutet and Karolinska University Hospital, Stockholm, Sweden; the corresponding number is 44%, but with large variations between 3 Department of Psychology, Umeå University, Umeå, Sweden different areas [3]. Currently CPR training normally rests on a traditional model consisting of a theoretical introduction and individual manikin Abstract based procedural training. Although this type of training has evolved to the current state over the years, essentially the model itself has been unchanged. Also, in the current CPR guidelines, teamwork issues have Background impacted the recommendations [4-7], although clarifications of what Multiplayer virtual world (MVW) technology creates opportunities to characterizes effective teamwork during CPR are lacking [8]. practice medical procedures and team interactions using serious game software. This study aims to explore medical students’ retention of With increasing computer literacy the use of computer gaming technology knowledge and skills as well as their proficiency gain after pre-training for learning and training, i.e. serious games, has been reported in using a MVW with avatars for cardio-pulmonary resuscitation (CPR) several areas including medicine [9-17]. Theoretical benefits with this team training. technology include the availability in remote settings and at free hours, but also inherent positive properties of the computer game technology Methods in itself, e.g. the opportunity to tailor it to certain contextual demands and Three groups of pre-clinical medical students, n=30, were assessed a property to match peoples’ level of knowledge and skills. Further, this and further trained using a high fidelity full-scale medical simulator: technology enables experiential learning often with ample feed-back, Two groups were pre-trained 6 and 18 months before assessment. creates a high level of engagement among participants, and carries the A reference control group consisting of matched peers had no ability to switch context in order to support transfer [18-20]. MVW pre-training. The groups consisted of 8, 12 and 10 subjects, respectively. The session started and ended with assessment scenarios, By using multiplayer virtual world (MVW) technology with avatars it is possible with 3 training scenarios in between. All scenarios were video-recorded to interactively practice situations involving several subjects. Although some for analysis of CPR performance. positive results exist [21-23], to date there is a lack of knowledge on how effective serious games are in different training situations. Also, in general, it is Results believed that the effectiveness of training is dependent on many other factors The 6 months group displayed greater CPR-related knowledge than than which modality is being used [24,25]. the control group, 93 (±11)% compared to 65 (±28)% (p<0.05), the 18 months group scored in between (73 (±23)%). We have previously developed a MVW-CPR team training model (a serious game using avatars) and reported of its use among medical At start the pre-trained groups adhered better to guidelines than the students. In a test-retest study we found that this training was feasible, control group; mean violations 0.2 (±0.5), 1.5 (±1.0) and 4.5 (±1.0) popular and increased the subjects’ concentration as well as self-efficacy for the 6 months, 18 months and control group respectively. Likewise, RESUSCITATION T beliefs indicating that the participants experienced a higher level of in the 6 months group no chest compression cycles were delivered at preparedness [26]. Similar results were also seen in an international study incorrect frequencies whereas 54 (±44)% in the control group on high-school students [27]. (p<0.05) and 44 (±49)% in 18 months group where incorrectly paced; NEW 2015 differences that disappeared during training. The aim of the current study was to explore if medical students pre-trained

CATALOGUE with MVW-CPR in teams had retained knowledge and skills and were able to oday Conclusions NOW AVAILABLE transfer their proficiency gain to a full-scale simulator environment. Signs of

This study supports the beneficial effects of MVW-CPR team training - SPRING 2015 transfer would support the value of using MVW technology for training CPR. order your FREE copy today with avatars as a method for pre-training, or repetitive training, on CPR- skills among medical students. Our main hypothesis was that subjects who had pre-trained using MVW would perform CPR faster and better in line with the guidelines. We also Keywords: hypothesized that signs of retention would be greater proximal to training, Assessment; Avatars; Cardiopulmonary resuscitation; Educational and that retention would be greater for knowledge and skills that were technology; e-learning; MVW; Virtual learning environments; Patient SP SERVICES (UK) LTD actively trained as opposed to just lectured [28]. Bastion House, Hortonwood 30, Telford, Shropshire, TF1 7XT simulation; Students; Young adults Tel: (+44) 01952 288 999 [email protected] Reprinted from the Open Access Publication: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:79 doi:10.1186/1757-7241-20-79 7 www.spservices.co.uk/resus © 2012 Creutzfeldt et al. EDUCATION

Methods Assessments and further training At start a pre-test on knowledge of basic life support was given. A post- test was performed after training. The knowledge tests consisted of 10 Recruitment and sample true/false statements. Two versions of the test existed in order to let each This study was designed as an exploratory quasi-experimental subject have different versions before and after training (Additional file controlled study with 3 groups: Two groups had attended MVWCPR 1- Knowledge quiz (A and B) at end of paper). Half of the subjects in training, 18 and 6 months respectively, before the study (18 m each group started with one version, the rest with the other, after training and 6 m), and one group served as reference group (control). The this was reversed. Three or 6 items (depending on version) were directly latter group was matched to the other groups, consisting of peers related to bystander-CPR. Scores on the test were between 0-10, scores attending the same semester of medical school. Thirty-six medical on CPR specific part were graded between 0-100 percent correct. students at Karolinska Institutet volunteered to participate during their preclinical period (second and third year). All of them had Before assessment of CPR skills the subjects were presented with a short attended a compulsory conventional manikin based CPR training (approx. 10 min) standardized lecture on BLS, including bystander-CPR in course during their first semester of medical school. Subjects order to give a common theoretical base. Also a 5 minute familiarization to were enrolled by announcements. The study was approved by the the SimMan® full-scale simulator (Laerdal Medical) and the environment regional ethics committee at Karolinska Institutet, and informed (in particular how to call for help), was included. consent was obtained from the participants.

The subjects were assessed and trained in teams of 2 or 3 rescuers. The MVW-CPR team training first scenario was an assessment scenario. It was followed by a 20 minute The first phase of the study consisted of MVW-CPR team training. standardized lecture on effective teamwork introducing the participants The training comprised two sessions. The first session started with to so called Crew Resource Management (CRM) principles [29]. a 10 minute rehearsal lecture on basic life support (BLS), followed Thereafter training scenarios ensued during which two teams took turns by an approximately 20 minute long familiarization to the virtual in performing and observing. All over each team trained in 3 scenarios. In environment. During this the participants learned how to control two of the training scenarios start of CPR was expected as required by the the avatar using the keyboard, communicate with each other using guidelines. In the third training scenario start of CPR was contra-indicated. a headset with microphone, and performing various tasks. The The fifth and last scenario was again an assessment scenario. Figure 1 actual team MVW-CPR training consisted of 4 short (4-5 minutes) summarizes the design of the study. scenarios. In these the subjects in groups of 3 had to take care of a cardiac arrest victim that collapsed in front of them. This involved approaching the victim, examining the victim and starting resuscitation as stated by the guidelines. The latter included an emergency phone call to the 911 dispatcher. The actions had to be performed in collaboration within the group. Following each scenario a brief (3-5 minute) feed-back session followed. Standard personal computers were used which were connected to the virtual world by broad band internet connections. After 6 months the subjects attended a similar session without the lecture.

Loss of subjects All subjects from previous MVW-CPR training agreed to participate, but due to personal competing interests some subjects could not attend during the short time frame the study had to be carried out in. In the 18 months group 4 out of 12 subjects were lost and in the control-group 2 subjects were lost due to scheduling difficulties before the start of this study. No subjects dropped out during the RESUSCITATION T study in any group. Background data is shown in Table 1.

Table 1

Demographic data oday

Subjects’ - SPRING 2015 Characteristics 18 months 6 months Control group group group

(n=8) (n=12) (n=10)

Female / Male 3 F / 5 M 6 F / 6 M 5 F / 5 M

Age 25.5 (± 3.9) 22.8 (± 2.6) 22.9 (± 2.0)

Figure 1. Design of the study 8 EDUCATION

During the scenarios the teams had to assess and resuscitate a victim Results by following the bystander-CPR guidelines (2005 version) [30]. At approximately 7 minutes after the yell for help the scenario was ended by Knowledge help of a paramedic arriving at the scene, taking over responsibilities. After Table 2 describes the test scores for all groups before and after training. each scenario feed-back was given by an instructor and, when present, Total test values are presented as absolute numbers, whereas the scores by observers. The feed-back focused on the CPR guidelines as well as on on CPR-specific questions are presented as % since the two versions aspects of teamwork. contained different numbers of these.

Analysis and statistical methods All scenarios were video-taped for later analysis of CPR performance. This analysis was performed by a trained blinded assessor. Several measurements of performance were used: On group level time between the rescuers entering the room until start of chest compressions was calculated and no-flow time was determined. This was calculated as the total time that elapsed between the cycles of chest compression divided by the number of cycles performed minus 1. Furthermore adherence to the CPR guidelines was scored (provided as Additional file 2). On individual level the frequency of chest compressions was calculated. Friedman repeated measures analysis of variance on ranks was used for time dependent non- parametric data. Statistical comparisons, before-after, were made by use of the Wilcoxon signed rank test. Comparisons between groups were made by ANOVA on ranks with pairwise comparisons using Dunn’s method. The test on CPR-specific knowledge was performed as a post-hoc analysis. For nominal data Chi square test was used. The significance level was The change of overall knowledge and CPR-specific knowledge in the entire set at P<0.05. As P values are not adjusted for multiple testing, they have study group changed from 7.1 (±1.5) to 8.3 (±0.9) (p<0.001) and 78% to be considered as descriptive. The calculations were performed using (±24%) to 95% (±10%) (p<0.001), respectively. SigmaStat version 3.5 (Systat Software Inc, Point Richmond, CA, USA). Data are presented as mean [±SD]. Performance

Adult basic life support – Cardiopulmonary resuscitation Time from subjects entering the room until start of chest compressions did not differ between groups (during first scenario: 18 months group 23 (±11) seconds, 6 months group 21 (±7) seconds and control group 24 (±13) seconds respectively) or change significantly over time. The no-flow time (time after start of CPR, where no chest compressions were administered) did not differ significantly between groups (during first scenario: 18 months group 7.9 (±2.0) seconds, 6 months group 9.4 (±2.5) seconds and control group 7.8 (±1.4) respectively, during the last scenario: 18 months group 7.5 (±0.8) seconds, 6 months group 6.8 (±1.0) and control group 6.9 (±1.8) seconds respectively). During video analysis it was evident that this variable was rather complex; if for example only one rescue breath was given, or if they were given to rapidly the no-flow time would be shorter, but at the same time the guidelines were violated.

There was a clear difference in the first scenario regarding adherence to the CPR guidelines (Figure 2). This included performing the actions in a non-

prescribed order, excluding diagnostic steps, stopping to check for pulses RESUSCITATION T and not performing 30:2 cycles stated by the CPR guidelines.

Figure 2. Mean number oday * European guidelines of violations to † Rescue breaths and chest compressions thereafter alternately continue until help arrives. the bystander According to 2005 ILCOR CPR guidelines published in 2005 International Consensus - SPRING 2015 on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with CPR Treatment Recommendations. Part 2: Adult basiclife support. Resuscitation 2005; guidelines in 67(2-3):187-201. each scenario Assessment of compliance to guidelines: A violation occurs every time the where steps do not occur in correct order. This may involve additions, omissions CPR was or incorrect order. Furthermore a violation also occurs if the wrong number performed. of chest compressions or rescue breaths occurs.

9 EDUCATION

This difference was not detectable during any of the following scenarios. Evidently, the rationale for CPR training is preparing potential rescuers We also noticed a tendency for less compliance with the guidelines during to actually perform CPR in real life. In this respect theoretical knowledge the last scenario for all groups. is useful only if applied correctly. It can be argued that theoretical and correctly applied knowledge are connected [24]. Better knowledge in There was also a significant difference in the number of chest theory supports correct action and might provide a scaffold for future compression cycles that did not agree with frequencies stipulated by learning. Factual knowledge may also provide basis for efficacy beliefs the CPR guidelines during the first scenario. In the 18 months group 44 and create a more complete mental model of the phenomenon to (±49)% of the compression cycles occurred at frequencies of less than promote retention of procedural knowledge. 80 /min or more than 125 /min. For the 6 months and control group these values were 0% and 54 (±44)% respectively. The difference between Time before start of CPR the control group and the 6 months group was statistically significant (p<0.001), as was the difference between the 18 months group and the During real-world CPR, time is a factor of crucial importance and 6 months group (p<0.001). Overall, as training progressed, there was was consequently recorded. As shown by the large variation, in a tendency towards increased compression rates. Also, in general, the this standardized setting, this parameter was difficult to draw any large variation of frequencies seen in the 18 months group and the control conclusions from. When assessing the recordings of the scenarios for group decreased. In particular in the 6 months group the increase over performance, we also noted a large variation in competitiveness and time of the compression frequency led to a large proportion of cycles with acting amongst the participants which in turn might have concealed frequencies over 125 /min. In the last scenario there was significantly less actual differences in how effective the initiation of CPR was. incorrectly paced cycles in the control group compared to the 6 months group (Figure 3). Adherence to CPR guidelines

Although, due to the small sample size in this exploratory study, statistical methods have not been used on this data, support for pre-training was found in how well the CPR algorithm, stated by the bystander CPR guidelines, was followed. Virtual world pre-training reduced uncertainty and initiatives outside the defined algorithm. Interestingly, this clear pattern was found, despite the fact that all subjects just minutes earlier had attended a standardized, brief rehearsal lecture. As was hypothesized, this indicated that actual training – although carried out several months earlier in a virtual world – would still outweigh the benefits of the lecture. Hence, probably memory of subject knowledge alone is not the key to correct CPR performance.

Psychomotor issues

Among individual psychomotor performance measures, compression Figure 3. Mean frequency during cycles of chest compressions are displayed for each group in the separate scenarios. frequency and quality seem to be among the most important ones for real life positive outcome. During the first scenario there was a huge variation in frequency in the 18 months and control groups. Discussion Many of these subjects were outside the stipulated frequency range. After feed-back and recurrent training this variation was considerably In this exploratory study we found that medical students who in smaller. Notably the subjects in the 6 months group were “right on addition to conventional CPR training had participated in two spot”, but as training progressed, showed a drift towards too high

RESUSCITATION T sessions of virtual world CPR team training with avatars, performed rates. This may indicate that as training goes on the participants better when assessed in full scale CPR simulation. In particular this may get overly vigorous and that more focus might be needed was reflected by both better adherence to guidelines and more on this phenomenon, alternatively support the use of technical or correct frequency of chest compressions. cognitive tools for correct psychomotor output keeping frequency of compressions correct [31-33].

oday CPR knowledge Gaps in CPR related knowledge between the groups before Another important parameter is the “no-flow time” [34,35]. In this

- SPRING 2015 training and in performance during the first scenario indicated that study it was defined as the time, after start of CPR, where no chest knowledge and behaviors trained in the virtual setting were retained compressions were administered. Although calculated during all to some degree in contrast to lectured knowledge where no scenarios, this time did not change much during the training. The retention could be detected. After having trained in 5 scenarios, the lowest no-flow time was recorded during scenarios where there were knowledge gap in CPR related knowledge was not detectable, and several quality issues, such as reduced quality in the rescue breaths. the performance gap in the last scenario had disappeared. Therefore we did not further consider this data.

10 EDUCATION

New CPR training methods have been developed and refined as team training in a serious game using avatars, showed better knowledge reactions to several problems in conventional CPR training. In a previous and performance when assessed in full scale CPR simulation. Better study we argued that the administered MVW-CPR cannot stand alone skills in terms of correctness were observed proximal to training. During as means of CPR training [26]. However, as indicated in this exploratory repetitive training, already after a single scenario, these differences were study, the use of MVW-CPR pre-training might be one way of preparing greatly reduced demonstrating the steep proficiency gain of experiential students for conventional CPR courses. This added training may serve as learning compared to traditional lectures. The possibility to practice in a cognitive support for future training and real-world tasks, and is in line with group setting during the virtual world training, as well as during scenario other trends in medicine [36]. Possibly MVW-CPR team training can also based full scale simulation addresses the need for group-focused training be used for rehearsal after other modes of CPR training, although it has of CPR. not been the focus for the current study. Abbreviations In this study the trainees are digital natives. Although CPR skills are ANOVA: Analysis of variance; BLS: Basic life support; important in many age groups, we believe that it would be easier to CPR: Cardiopulmonary resuscitation; CRM: Crew resource management; implement MVW-CPR team training in this group. The aged population, MVW: Multiplayer virtual world. in which cardiac arrests most commonly occur, might also possibly benefit from such training, however from this study we can draw no such Authors’ contribution conclusions and results from such training may be much different than JC assisted in technology development, helped conceive the study, current results. For other digital native groups we expect that the positive participated in study design and served as subject matter expert effect of MVWCPR team training would be comparable. (emergency medicine), acquired and analyzed data, took part in data interpretation as well as drafted the manuscript. LH contributed The strength of this study is its standardization regarding participants and substantially to study design, served as subject matter expert protocol. CPR is often performed in groups [5]. Virtual world CPR team (psychological assessment), interpreted data and critically revised the training with avatars has the advantage to address this issue. Although manuscript. LFT conceived the study and participated in study design as also assessments in this study to some extent were on group level, this well as interpreted data and critically revised the manuscript. All authors introduced a weakness because group assessment carries the problem read and approved the final manuscript. of decreasing statistical power. Further, the performance of groups is to some extent dependent on teamwork skills which can differ between Acknowledgements different group constellations. One way of trying to reduce such influences We would like to express our gratitude towards Carl-Johan Wallin at was by adding a lecture on teamwork to the training program. Another the Center for Advanced Medical Simulation and Training for valuable limitation of this study is its small sample size. The study was conceived contributions in design and planning of the study and Christopher Medin, as a follow-up on subjects that had already received virtual CPR training. Department of Biomedical Technology at Karolinska University Hospital The limited sample was further reduced by loss of subjects. We therefore for technical assistance and operation of equipment. We would also stress the exploratory nature of the study and must hence remember that like to express our gratitude towards Emmy Nyqvist at the time of the the results have to be interpreted with caution. The validity of assessing study at Karolinska Institutet for video assessments. Further we thank CPR skills by use of full-scale simulators can also be questioned. To our Elisabeth Berg at the department of Learning, Informatics, Management knowledge no studies on this issue have been performed. On the other and Ethics as well as Tony Qureshi at the department for Clinical Science, hand, this technique for training and assessment is already implemented Intervention and Technology, both at Karolinska Institutet, for assistance for clinical training of skills and behaviours in various settings and with statistical methods. This study was fully financed by research grants scenarios [37]. from the Wallenberg Global Learning Network (WGLN), The Marianne and Marcus Wallenberg Foundation, Stockholm County Council and EU A focus of this training study was to standardize the scenarios in order to Research Programme Goal 1, Northern Sweden. evaluate how pre-training and subsequent full-scale training affected the participants. Full-scale simulator team training is costly and in very limited References supply, and therefore cannot be seen as a realistic future alternative for larger groups in society. In this study, in the absence of real-world 1. Herlitz J: National Swedish registry for cardiac arrest – Yearly report of RESUSCITATION T alternatives, full-scale simulation was mainly used as a way of creating a 2011. (in Swedish) Accessed 3 April 2012, at http://www.hlr.nu/sites/ hlr.nu/files/attachment/ Rapport%202011.pdf webcite reasonably realistic way of assessing transfer. 2. Nordberg P, Hollenberg J, Herlitz J, Rosenqvist M, Svensson L: Aspects on the increase in bystander CPR in Sweden and its Serious games for learning and training are receiving much attention. association with outcome. Resuscitation 2009; 80(3): 329-333.

However, transfer of CPR skills trained in serious games is difficult to oday 3. McNally B, Robb R, Mehta M, Vellano K, Valderrama AL, Yoon PW, test in authentic CPR. Thus, this exploratory quasi-transfer study was Sasson C, Crouch A, Bray Perez A, Merritt R, et al.: Out-of- Hospital designed to probe the potential future use for virtual worlds in emergency Cardiac Arrest Surveillance — Cardiac Arrest Registry to Enhance - SPRING 2015 medicine. Survival (CARES), United States, October 1, 2005–December 31, 2010. In Morbidity and mortality weekly report. vol. 60th edition. Edited by Moolenaar RL, Casey CG, Rutledge TF. Atlanta, GA: Office Conclusions of Surveillance, Epidemiology, and Laboratory Services, Center for Disease Control and Prevention, U.S. Department of Health and In this exploratory study we have demonstrated that conventionally trained Human Services; 2011. medical students who in addition received multiplayer virtual world CPR >>> 11 EDUCATION Evidence based airway

4. Edwards S, Siassakos D: Training teams and leaders to reduce 22. Hansen MM: Versatile, immersive, creative and dynamic virtual 3-D management in emergency resuscitation errors and improve patient outcome. Resuscitation healthcare learning environments: a review of the literature. J Med 2012; 83(1): 13-15. Internet Res 2008; 10(3): e26. medicine and resuscitation 5. Mancini ME, Soar J, Bhanji F, Billi JE, Dennett J, Finn J, Ma MH, 23. Heinrichs WL, Youngblood P, Harter PM, Dev P: Simulation for team Perkins GD, Rodgers DL, Hazinski MF, et al.: Part 12: Education, training and assessment: case studies of online training with virtual implementation, and teams: 2010 International Consensus on worlds. World J Surg 2008; 32(2): 161-170. Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 24. Bransford JD, Brown AL, Pellegrino JW, Anderson JR, Berliner D, Science With Treatment Recommendations. Circulation 2010; 122(16 Cooney MS, Eisenkraft A, Gelman R, Ginsburg HP, Glaser R, et al.: Suppl 2): S539-S581. Learning: from speculation to science. In How people learn: brain, 6. Hunziker S, Johansson AC, Tschan F, Semmer NK, Rock L, Howell mind, experience, and school. Edited by Bransford JD, Brown AL, MD, Marsch S: Teamwork and leadership in cardiopulmonary Cocking RR, Donovan MS, Pellegrino JW. Washington D.C: resuscitation. J Am Coll Cardiol 2011; 57(24): 2381-2388. 25. McKendree J: e-Learning. In Understanding medical education: 7. Tschan F, Vetterli M, Semmer NK, Hunziker S, Marsch SC: Activities evidence, theory, and practice. Edited by Swanwick T. Chichester, during interruptions in cardiopulmonary resuscitation: a simulator West Sussex, UK: John Wiley & Sons; 2010:151-163. study. Resuscitation 2011; 82(11): 1419-1423. 26. Creutzfeldt J, Hedman L, Medin C, Heinrichs WL, Felländer-Tsai L: 8. 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Brit J Educ Technol 2005; 36(3): 439-451. 30. International Liaison Committee on Resuscitation: 2005 International 13. Richardson A, Hazzard M, Challman SD, Morgenstein AM, consensus on cardiopulmonary resuscitation and emergency Bruechner JK: A “Second Life” for gross anatomy: applications for cardiovascular care science with treatment recommendations. Part multiuser virtual environments in teaching the anatomical sciences. 2: adult basic life support. Resuscitation 2005; 67(2-3): 187-201. Anat Sci Educ 2011; 4(1): 39-43. 31. Abella BS, Edelson DP, Kim S, Retzer E, Myklebust H, Barry AM, 14. Wiecha J, Heyden R, Sternthal E, Merialdi M: Learning in a virtual O’Hearn N, Hoek TL, Becker LB: CPR quality improvement during world: experience with using second life for medical education. in-hospital cardiac arrest using a real-time audiovisual feedback J Med Internet Res 2010; 12(1): e1. system. Resuscitation 2007; 73(1): 54-61. 15. 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RESUSCITATION T 17. Dev P, Heinrichs WL, Youngblood P: CliniSpace: a multiperson 3D 34. Hazinski MF, Nolan JP, Billi JE, Böttiger BW, Bossaert L, de Caen AR, online immersive training environment accesible through a browser. Deakin CD, Drajer S, Eigel B, Hickey RW, et al.: 2010 International Stud Health Technol Inform 2011; 163: 173-179. consensus on cardiopulmonary resuscitation and emergency 18. Oblinger DG: The next generation of educational engagement. cardiovascular care science with treatment recommendations. J Interact Media in Educ 2004;, 8: Accessed 4 December 2012, Circulation 2010; 122(16 Suppl 2): S250-S581. at www-jime.open.ac.uk/article/2004-8-oblinger/199 webcite 35. Christenson J, Andrusiek D, Everson-Stewart S, Kudenchuk P,

oday 19. Taekman JM, Shelley K: Virtual environments in healthcare: Hostler D, Powell J, Callaway CW, Bishop D, Vaillancourt C, Davis immersion, disruption, and flow. Int Anesthesiol Clin 2010; 48(3): D, et al.: Chest compression fraction determines survival in patients - SPRING 2015 101-121. with out-of-hospital ventricular fibrillation. Circulation 2009; 120(13): 1241-1247. 20. Akl EA, Pretorius RW, Sackett K, Erdley WS, Bhoopathi PS, Alfarah Z, Schunemann HJ: The effect of educational games on medical 36. Kahol K, Vankipuram M, Smith ML: Cognitive simulators for medical students’ learning outcomes: a systematic review: BEME Guide No education and training. J Biomed Inform 2009; 42(4): 593-604. 14. Med Teach 2010; 32(1): 16-27. 37. Berkenstadt H, Ziv A, Gafni N, Sidi A: The validation process 21. Andreatta PB, Maslowski E, Petty S, Shim W, Marsh M, Hall T, Stern of incorporating simulation-based accreditation into the S, Frankel J: Virtual reality triage training provides a viable solution anesthesiology Israeli national board exams. Isr Med Assoc J 2006; lnteract with us for disaster-preparedness. Acad Emerg Med 2010; 17(8): 870-876. 8(10): 728-733.

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        

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nosebleeds (epistaxis) and accumulation of air in Incidences of all three diseases were Ensuring a cool recovery soft tissues (peri-orbital emphysema). diminished in patients treated with pharyngeal from cardiac arrest cooling: SIRS incidences in the pharyngeal Pharyngeal cooling method cooling group amounted to 31% of  Pharyngeal cooling was begun during chest patients compared with 57% in the control, Researchers at Okayama University in collaboration with several medical centres in compression as soon as patients entered the coagulopathy incidences were lower in the first Japan have demonstrated the safety and efficacy emergency room or on return of spontaneous three days and thrombocytopaenia incidences  of a hypothermal treatment – pharyngeal cooling – circulation (ROSC) if ROSC returned before dropped to zero compared with 17% of the  for cardiac arrest patients. entering the emergency room. control group  Cooling the brain is known to prevent In the current study pharyngeal cooling was Reference   neurological problems in patients recovering administered using a pharyngeal cuff, a vinyl Yoshimasa Takeda, Takahisa Kawashima,  from cardiac arrest. However most of the current chloride tubular structure fitted into the upper Kazuya Kiyota, Shigeto Oda,Naoki Morimoto, methods for therapeutic hypothermia may not be oesophagus and pharynx. Saline solution at a Hitoshi Kobata, Hisashi Isobe, Mitsuru Honda,  initiated before return of spontaneous circulation. temperature of 5°C was perfused into the cuff at a Satoshi Fujimi, Jun Onda, Seishi I, Tetsuya rate of 500 ml min−1 and pressure of 50 cm H O. Sakamoto, Masami Ishikawa, Hiroshi Nakano,  2 Researchers at Okayama University investigated Daikai Sadamitsu, Masanobu Kishikawa, The temperature was chosen to be above Kosaku Kinoshita, Tomoharu Yokoyama,  a method for cooling the area at the top of   the throat – the pharynx - because the arteries freezing so that ice did not form, and treatment Masahiro Harada, Michio Kitaura, Kiyoshi that supply the head with oxygenated blood duration was also limited to 2 hours to avoid Ichihara, Hiroshi Hashimoto Beng, Hidekazu     run nearby. Cooling this area should be a damage from the cold. The pressure was chosen Tsuji Beng, Takashi Yorifuji, Osamu Nagano,

good approach to cooling the brain but so to be below 60 cm H2O to avoid neuropathy – Hiroshi Katayama,Yoshihito Ujike and Kiyoshi   far there have been no complete studies to nerve damage – which has been reported with Morita, “Feasibility study of immediate determine whether pharyngeal cooling could be the use of equipment similar to the cuff. pharyngeal cooling initiation in cardiacarrest   administered effectively or whether it may lead to patients after arrival at the emergency room” other adverse side effects. Low mechanical damage to the pharynx was     thought to be largely due to similarities between The researchers alongside people working in the cuff and other medical instruments, as Facilitation: the practical   emergency and critical care clinics set up a trial clinicians administering the treatment were approach by ALSG  for 108 cardiac arrest patients. The medical familiar with using similar equipment.     staff administered treatments with or without The Advanced Life Support Group is pleased to be  pharyngeal cooling to patients at random, Choice of patients attending Life Connections 2015. Now in our 21st   and subsequently recorded success rates of Patients aged 14-89 years old were considered year as an international medical education charity resuscitation and physiological conditions, eligible for the study within 15 minutes of dedicated to saving life by providing training, we  including temperature both at the body core and collapse if they had suffered cardiogenic cardiac are hosting a conference plenary on the eagerly   in the head near the ear (tympanic temperature), arrest or had been resuscitated from non- awaited ILCOR update.  mechanical or temperature damage to the cardiogenic arrest by medical personnel.    pharynx, inflammation and blood platelet levels. A shortage of human resources meant that not We are also delighted to be able to offer all eligible patients were used in the study. a course on day one of the conference The results of the trial indicated effective cooling Of the 818 patients that met the criteria, 113 on Facilitation: the practical approach. All     of tympanic temperatures, with no observed were enrolled on the study. The researchers conference delegates interested in learning   adverse side effects. In addition, incidences of believe that the relatively small size of the fraction about or improving their role play and inflammation and blood-clotting disorders were of eligible patients that were enrolled does not simulation facilitation skills would be welcome    reduced in patients receiving pharyngeal cooling. affect the quality of the study data because the to apply for a place on this one day course. As the researchers report, “In conclusion, it random selection for treatment with or without Prior to attending the course delegates will be appears that the initiation of pharyngeal cooling pharyngeal cooling was undertaken after required to complete a series of e-modules RESUSCITATION T      is safe and feasible before and shortly after enrolment, and exclusion from the study after on our Virtual Learning Environment. During  recovery of spontaneous circulation in the enrolment was very low. the day you will build on your understanding     emergency room.” of group dynamics, feedback and running  Inflammation and blood clotting disorders role plays and simulations and will have the Background post cardiac arrest opportunity to practise the elements essential     oday Hypothermia treatments and limitations Systemic Inflammatory Response Syndrome to successful small group facilitation.

Previous clinical data has indicated that quickly (SIRS) has been highlighted as an important - SPRING 2015    achieving therapeutic hypothermia is one factor linked to illnesses following cardiac arrest Places are limited to 16 so please book now at of the most important factors for improving that include brain and heart injury and restricted http://www.lifeconnections.uk.com/conference-     neurological outcomes for cardiac arrest blood supplies to tissue. Poor blood clotting details/  patients. Approaches to achieving therapeutic (coagulopathy) is observed with whole body cooling and severe brain damage and low levels   hypothermia include intravenous infusion of cold We look forward to welcoming you at Life fluid, which can increase re-arrest rates, and of platelets (thrombocytopaenia) can impair Connections and wish you an enjoyable   nasal cooling which is prone to cause extreme blood clotting. conference experience.

15 www.atacc.co.uk

ATACC De-coding The Future Embrace the words & wisdom of some of the greatest modern minds in healthcare.

“ Why are resuscitationists & Over the two days of this The pace will be fast and dynamic, crit care doctors doing the same conference the ATACC Faculty moving across a diverse and exciting resuscitation as the skin doctors? “ will take us on a journey from range of topics such as Lodox Scott Weingart, 2014 the present day to somewhere scanning, new vehicle technology & around 10 years into the future. essential changes in extrication, the next generation of heamostatics, “ I believe we have a responsibility Carefully selected for their knowledge 21st century tele-medicine, xenon to stay at the cutting edge of and also their ability to present in a anaesthesia. resuscitation, and I want to passionate and inspirational style, Education has always played huge part share what I learn.“ these are the doctors, scientists and in ATACC and we have always strived Cliff Reid, Sydney HEMS specialists who are creating the to adopt and develop the very latest future today. educational technology, such as our “ The first principle of Leadership Gareth Davies, Mark Wilson, ProMedSim immersive simulator. Prof is Excellence. The most important Prof Simon Carley, Mike Tipton, Carley will tell us where we go next and thing for an educational leader James Tooley, Prof Mike McNicholas how we might get there best prepared. is that they are clinically credible. and Paul Trafford from the UK will join After the initial management of trauma Prof Simon Carley Raed Arafat, Ian Dunbar, SAMU, we are left to recover and rehabilitate, Sydney HEMS and ATACC from across but as we move forward we will look at the globe will create one of the greatest “ Why repair when we could the very latest in ‘bionic’ style aids and Faculties to gather in the UK within these regenerate - We’re developing 3D-printing. But that is only the start fields of emergency care and recovery. a material that has the right as we then move into the world of stem DE-CODING THE FUTURE OF porosity and architecture to Inspired by the recent RAGE Podcasts cell, tissue regrowth and regenerative form new tissue.” of Weingart, Swami and others the medicine. If this session doesn’t truly ANAESTHESIA TRAUMA AND CRITICAL CARE Prof Kevin Shakesheff conference will open with an incredible astound you then nothing will. session that takes a fresh look at The whole conference will be delivered 21/10/15 – 22/10/15 LIFE CONNECTIONS 2015 resuscitation in terms of aggressive and presented in a fresh and unique management, neuro-protection, KETTERING CONFERENCE CENTRE style, which hopes to capture the re-animation and recovery with the passion of the speakers, the delegates overall aim of greatly improving the and the ATACC Faculty. Come and join current dreadfully poor outcomes us as we decode the future of trauma, from cardiac arrest. Date: resuscitation and critical care. 21 – 22 October 2015 Sessions will then move through the new technology that is going to For more information or to Place: potentially radically change our trauma book your place for this event Kettering Conference Centre & critical care practice. Some exists please visit: now and has been slow to get widely www.lifeconnections.uk.com For more information or to book your place for this event please visit: Price : £250.00 adopted, whilst other devices and or call 01322 660 434 www.lifeconnections.uk.com or call 01322 660 434 therapies have barely left the lab yet.

www.atacc.co.uk www.atacc.co.uk

ATACC De-coding The Future Embrace the words & wisdom of some of the greatest modern minds in healthcare.

Over the two days of this conference the ATACC Faculty will take us on a journey from the present day to somewhere around 10 years into the future. Carefully selected for their knowledge and also their ability to present in a passionate and inspirational style, these are the doctors, scientists and specialists who are creating the future today.

RESUSCITATION TECHNOLOGY SESSIONS RECONSTRUCTION

DECODING THE FUTURE IMAGING THE FUTURE BRAIN REHABILITATION – THROUGH PHYSIOLOGY Speaker to be confirmed DOES COUNSELLING WORK? Prof Mike Tipton Lodox Surgeon Commander Professor of Human & Applied Physiology, Prof Neil Greenburg Consultant in survival & thermal medicine VETIGEL – STOPPING BLEEDING Defence Professor of Mental Health, Royal RAF and UK Sport, Portsmouth, UK Mr Joe Landolina Navy Institute of Psychiatry, King’s College London Biomedical Engineer, New York, US GOOD SAM & CROWD SOURCING Mr Mark Wilson TELE-MEDICINE THE NEXT STEP ROBOTICS Neurosurgeon & Prehospital Emergency Dr Raed Arafat Speaker to be confirmed Medicine Physician, London HEMS, UK Prehospital Critical Care Physician. Secretary of State-Head of the BIOMECHATRONICS SUSPENDED ANIMATION Department of Emergency Situations at Speaker to be confirmed Dr Gareth Davies Ministry of Internal Affairs - Romania Prehospital Emergency Medicine TOP GUN – PRESIDENTIAL DEBATE Physician, Medical Director London INERT GASES & THE FUTURE HEMS, UK OF ANAESTHESIA SMURD - ROMANIA Dr James Toolley Dr Raed Arafat ECMO IN THE STREETS – Paediatric Anaesthesia & Critical Care Re- ‘THE REANIMATEUR’ trieval Physician, UK SYDNEY HEMS - AUSTRALIA Dr Lionel Lamhaut, Dr John Glasheen Anaesthesiologist and Prehospital Critical Care Physician, SAMU, Paris PREVENTION SAMU – FRANCE VEHICLE DESIGN – WHEN WILL Dr Lionel Lamhaut EDUCATION CASUALTY CARE CATCH UP? Mr Ian Dunbar HEMS - LONDON MEDUCATION AND BEYOND International Rescue Consultant, Dr Gareth Davies Professor Simon Carley - Holmatro, Netherlands St Emlyns Professor of Emergency CARS THAT WON’T LET YOU CRASH REGENERATION Medicine, Manchester, UK Dr Paul Trafford Anaesthetics and Intensive Care STEM CELL-ORTHO SIMULATING THE FUTURE Consultant, Medical Advisor FIA Mr Sven Kili Dr Mark Forrest - ATACC Institute, Wirral, UK Senior Director, - Biosurgery and Cell Anaesthetics & Critical care Physician, Therapy & Regenerative Medicine at Medical Director ATACC and Cheshire MAKING 2 WHEELS SAFER Sanofi, Oxford UK Fire & Rescue, UK Dr John Hinds 3D PRINTING Anaesthetics and Prehospital Critical CREW COURSES – STAYING AHEAD Care Physician, Ireland Speaker to be confirmed Dr John Glasheen Emergency Medicine and Prehospital TISSUE REGENERATION Critical Care Retrieval Physician, Brisbane, Prof Kevin Shakesheff Australia Professor of Regnerative Medicine, Nottingham

www.atacc.co.uk For more information or to book your Date: 21 – 22 October 2015 place for this event please visit: Place: Kettering Conference Centre www.lifeconnections.uk.com Price : £250.00 EVIDENCE or call 01322 660 434 ATACC De-coding The Future Consensus Paper on Out-of-Hospital Over the two days of this conference the ATACC Faculty will take us on a journey Cardiac Arrest in England from the present day to somewhere around 10 years into the future. Carefully selected for their knowledge and also their ability to present in a passionate and inspirational style, Date: 16th October 2014 these are the doctors, scientists and specialists who are creating the future today. Revision Date: 16th October 2015

RESUSCITATION TECHNOLOGY SESSIONS RECONSTRUCTION Introduction Evidence-based interventions to improve The purpose of this paper is to bring some clarity to the analysis of rates from OHCA: DECODING THE FUTURE IMAGING THE FUTURE BRAIN REHABILITATION – data associated with out-of-hospital cardiac arrest (OHCA) in England. Countries with the highest rates of OHCA survival are those which have THROUGH PHYSIOLOGY Speaker to be confirmed DOES COUNSELLING WORK? This will help us to agree the scale of the problem, ensure that realistic strengthened all 4 links in the chain of survival: Prof Mike Tipton Lodox Surgeon Commander targets for improvement can be set and the impact of interventions Professor of Human & Applied Physiology, Prof Neil Greenburg assessed. Consultant in survival & thermal medicine VETIGEL – STOPPING BLEEDING Defence Professor of Mental Health, Royal RAF and UK Sport, Portsmouth, UK Mr Joe Landolina Navy Institute of Psychiatry, King’s College Incidence of OHCA in England London Biomedical Engineer, New York, US In England in 2013 the Emergency Medical Services (EMS) attempted GOOD SAM & CROWD SOURCING to resuscitate approximately 28,000 cases of OHCA.1 There are many Mr Mark Wilson TELE-MEDICINE THE NEXT STEP ROBOTICS more cases of OHCA where the EMS do not attempt resuscitation Neurosurgeon & Prehospital Emergency Dr Raed Arafat Speaker to be confirmed because on their arrival the EMS assess the victim to be beyond Medicine Physician, London HEMS, UK resuscitation. This is because the victim has been dead for several Prehospital Critical Care Physician. Secretary of State-Head of the BIOMECHATRONICS hours, or has suffered severe trauma which is not compatible with life, The current rate of initial bystander CPR in England is reported as being SUSPENDED ANIMATION Department of Emergency Situations at Speaker to be confirmed or because the opportunity to start resuscitation was not taken sooner 43%7 (compared, for example to 73% in Stavanger, Norway during Dr Gareth Davies Ministry of Internal Affairs - Romania while the EMS were on their way. If more bystanders had the confidence 2006-2008). However, this includes some situation where the bystander Prehospital Emergency Medicine and skills to call 999 quickly, deliver effective cardiopulmonary TOP GUN – PRESIDENTIAL DEBATE initiated CRP without having to be instructed to do so, as well as Physician, Medical Director London resuscitation (CPR) until the EMS arrive, and when appropriate use a INERT GASES & THE FUTURE situations where the bystander initiated CPR following the instructions of HEMS, UK public access defibrillator, the number of cases where the EMS could OF ANAESTHESIA SMURD - ROMANIA the emergency medical dispatcher after calling 999. The latter situation attempt resuscitation would increase. Dr James Toolley Dr Raed Arafat may result in a delay of up to several minutes before the victim receives ECMO IN THE STREETS – Paediatric Anaesthesia & Critical Care Re- CPR. Such delays could be minimised if more members of the public Approximately 80% of OHCAs occur at home and 20% in public ‘THE REANIMATEUR’ trieval Physician, UK were able and willing to recognise cardiac arrest and attempt CPR SYDNEY HEMS - AUSTRALIA places.2 Only about 20% are in a “shockable rhythm” (i.e. treatable Dr Lionel Lamhaut, immediately. Dr John Glasheen 2 Anaesthesiologist and Prehospital Critical by defibrillation) by the time the EMS arrive. Survival is much more PREVENTION likely when a shockable rhythm is present.3 The proportion of people Care Physician, SAMU, Paris There is limited data on the current rate of bystander defibrillation with a SAMU – FRANCE in shockable rhythm could be increased if more cardiac arrest victims public access defibrillator (PAD) following an OHCA. One study in the VEHICLE DESIGN – WHEN WILL Dr Lionel Lamhaut received immediate and effective CPR from bystanders. South of England reported bystander defibrillation in 1.74% of OHCA EDUCATION CASUALTY CARE CATCH UP? cases.8 When someone has a cardiac arrest, every minute without CPR Mr Ian Dunbar HEMS - LONDON Therefore more immediate 999 calls and immediate CPR given by and defibrillation reduces their chances of survival by 7-10 per cent.9,10,11 MEDUCATION AND BEYOND International Rescue Consultant, Dr Gareth Davies bystanders could increase the number of people who receive CPR Rates of bystander CPR and PAD use in the UK are believed to be low Holmatro, Netherlands Professor Simon Carley - by the EMS. This will increase the number of people who are given a for a number of reasons: St Emlyns chance of surviving, and ultimately increase the number of people who 4 RESUSCITATION T Professor of Emergency CARS THAT WON’T LET YOU CRASH REGENERATION do survive when they are given CPR. • Failure to recognise cardiac arrest Medicine, Manchester, UK Dr Paul Trafford • Lack of knowledge of what to do Anaesthetics and Intensive Care STEM CELL-ORTHO Survival rates from OHCA in England: • Fear of causing harm (such as breaking the victim’s ribs) or being SIMULATING THE FUTURE Consultant, Medical Advisor FIA Mr Sven Kili The average overall survival to hospital discharge from 28,000 EMS Institute, Wirral, UK harmed (acquiring infection from a stranger when giving rescue breaths) Dr Mark Forrest - ATACC Senior Director, - Biosurgery and Cell treated OHCA in England is 8.6%.1 This is significantly lower than for

• Fear of being sued oday Anaesthetics & Critical care Physician, Therapy & Regenerative Medicine at populations in other developed countries: North Holland 21%5, Seattle Sanofi, Oxford UK Medical Director ATACC and Cheshire MAKING 2 WHEELS SAFER 20%6 and Norway 25%.3 Although these figures have to be interpreted • Lack of knowledge of the location of PADs Fire & Rescue, UK - SPRING 2015 Dr John Hinds with caution as there are some differences in the way that figures are • No access to a PAD at the time of the cardiac arrest 3D PRINTING Anaesthetics and Prehospital Critical presented, there is a clear potential to improve survival rates in the UK. CREW COURSES – STAYING AHEAD Care Physician, Ireland Speaker to be confirmed As the chain of survival illustrates, a person is most likely to survive an Dr John Glasheen Improving survival rates from OHCA is a major propriety for the OHCA in the following circumstances: Emergency Medicine and Prehospital TISSUE REGENERATION Resuscitation Council (UK), the British Heart Foundation and the Critical Care Retrieval Physician, Brisbane, Prof Kevin Shakesheff NHS England. This was identified by the Department of Health in the • Their cardiac arrest is either witnessed by a bystander or the victim is Australia Professor of Regnerative Medicine, Cardiovascular Disease Outcomes Strategy (2013). discovered immediately after collapsing Nottingham 19 www.atacc.co.uk EVIDENCE

• The bystander calls 999 immediately least until a defibrillator arrives (and often also immediately following defibrillation) if the person is to survive. This is true even in the case • They bystander delivers effective CPR without delay of in-hospital cardiac arrests where defibrillators are more often readily • The cause of the cardiac arrest is a sudden disturbance of heart available. It should be noted that 80% of cardiac arrests occur at home rhythm, which may be caused by a heart attack or may be due to where defibrillators are not usually available, but calling 999 immediately another heart condition, sometimes an inherited heart condition and delivering effective CPR at home can still save lives. • The cardiac arrest is due to a “shockable” rhythm disturbance (ventricular fibrillation or ventricular tachycardia) Q. If we had more defibrillators in public places would more people survive an OHCA? • There is a PAD close by which another bystander can fetch

• The bystander uses the PAD without delay A. Public access defibrillators (PADs) are most likely to be used (and • The EMS arrive very quickly (within minutes of being called) used effectively) in places used or attended by large numbers of people. Cardiac arrest is more likely in some such places (for example large Frequently asked questions railway stations and airports) than in others.14 It makes sense to ensure that all such places have PADs readily available. In other places where

Q. What is the total number of cardiac arrests in England? cardiac arrests may occur less frequently and be more widely spread A. The total number of cardiac arrests in England is unknown. out it makes sense to try to have enough PADs to allow rapid access to a nearby defibrillator for as many cardiac arrest victims as possible. Before quoting any figure it is important to define what is meant by “cardiac arrest”. In everyone who dies (for example from advanced Public access defibrillators are an important part in the chain of survival conditions such as cancer or the final stages of severe lung disease, but they are not the only part. 80% of cardiac arrests occur at home, heart disease or kidney disease) the heart will stop as part of the where defibrillators are not usually available, but calling 999 immediately process of dying. Attempting to restart the heart with CPR would and delivering effective CPR at home can still save lives. Defibrillation provide no benefit in such situations. with a PAD can save lives from OHCA when the cardiac arrest rhythm is “shockable”. Currently only 20% of cardiac arrest victims are in A figure of 60,000 OHCAs per year in the UK is often quoted. This is a “shockable” rhythm when the EMS arrive. This figure could be probably derived from a report by the Ambulance Services Association12 increased if more cardiac arrest victims received immediate, effective which identified 57,345 OHCAs in 2006, of which 25,143 received CPR from bystanders. Prompt access to a PAD may allow treatment of attempted CPR by the EMS and 32,202 who did not. It is uncertain a shockable rhythm before the arrival of the EMS in situations where that how many of those 32,202 people would have received CPR from the opportunity would have been lost before their arrival. EMS if they had been called earlier and / or bystanders had given CPR whilst waiting for the EMS to arrive. The total figure of 60,000 is also Q. Is hands-only CPR as good as full CPR that includes mouth-to- compatible with the reported incidence of cardiac arrest in Europe of mouth ventilation? 1/1000 of the population per year.13 A. In a cardiac arrest, it is better for a bystander to do something The most important number to consider is the total number of cardiac rather than nothing. Some people are untrained or unwilling to deliver arrests from which the person may have a chance of surviving if someone “rescue breaths” (mouth-to-mouth ventilation). If the bystander is starts a resuscitation attempt immediately. This remains uncertain but is trained and willing to deliver rescue breaths effectively as well as chest likely to be greater than the number of cardiac arrests in which the EMS compressions they should do so as this remains the recommended currently attempt resuscitation (28,000 in England in 2013). treatment. If not, it is better to deliver “hands-only CPR” (i.e. chest compressions) immediately and without interruption, rather than doing Q. Why is it important to deliver CPR as well as defibrillation? nothing or attempting “rescue breathing” ineffectively. A. Each link in the chain of survival is important. Calling 999

RESUSCITATION T immediately ensures that emergency professional help is on the way as Q. Would every cardiac victim survive if they had effective CPR quickly as possible – the person is unlikely to survive without receiving and defibrillation? expert help as soon as possible at the scene, en route to hospital and after arrival. A. No. The most common cause of a cardiac arrest is a “heart attack” (acute myocardial infarction). In that situation survival will not only CPR increases the chances of surviving because it keeps some blood depend on being resuscitated from rhythm disturbance causing the oday circulation to vital organs such as the brain and the heart itself. It also cardiac arrest, but also on the amount of heart muscle that has been

- SPRING 2015 increases the likelihood of the heart remaining in a “shockable” rhythm damaged by the heart attack, how quickly the person receives treatment rather than deteriorating to a “non-shockable” rhythm (referred to in lay for that and how well they respond to treatment. terms as a “flat line”). This matters because a cardiac arrest victim is more likely to survive if their heart is in a “shockable” rhythm from which Survival from a cardiac arrest is also dependent on the underlying state it may be possible to shock them out of cardiac arrest with a defibrillator. of health of the victim. If the person already has important medical Given the random occurrence of cardiac arrest, it is relatively rare for conditions (for example severe lung or heart disease or advanced anyone to have a cardiac arrest right next to a defibrillator in a public cancer) when they suffer a cardiac arrest, their chance of CPR leading place. Delivering CPR promptly and effectively is therefore crucial, at to survival will be much less than if their health had been good. 20 EVIDENCE

Survival is also less likely in the event of major trauma and shock 10. Larsen MP, Eisenberg MS, Cummins RO et al. Predicting survival following blood loss caused by injury, for example in a road traffic from out-of-hospital cardiac arrest: a graphic model. Ann Emerg accident. Med 1993; 22:1652-8.

Q. How many public access defibrillators are in England? 11. Valenzuela TD, Roe DJ, Cretin S, Spaite DW, Larsen MP. Estimating effectiveness of cardiac arrest interventions: a logistic regression A. Nobody knows because there is no systematic arrangement in survival model. Circulation. 1997; 63:3308-3313. place to record the location of all PADs. In July 2014 the British Heart Foundation committed to fund the setting up of a national PAD database 12. Ambulance Service Association. National Out-of-Hospital Cardiac for use across the whole of the UK. However, this is only part of the Arrest Project 2006. solution. It is crucial to increase public awareness of: 13. de Vreede-Swagemakers JJ, Gorgels AP, Dubois-Arbouw WI et • Cardiac arrest al. Out-of-hospital cardiac arrest in the 1990s: a population based study in the Maastricht area on incidence, characteristics and • How to recognise it survival. J Am Coll Cardiol 1997; 30:1500-1505. • The need to call 999 immediately

• The need to start CPR immediately 14. Colquhoun M. National database of Automated External Defibrillator (AED) use. • The fact that PADs can be used safely by anyone https://www.resus.org.uk/pages/Reports/Report-National_ database_of_AED_use.pdf. If this happens we can expect more people to intervene quickly and effectively in the event of a cardiac arrest, resulting in more lives saved. Other relevant published papers: References Murakami Y, Iwami T, Kitamura T, Nishiyama C, Nishiuchi T, Hayashi Y, Kawamura T and the Utstein Osaka Project. Outcomes of Out- 1. www.england.nhs.uk/statistics/statistical-work-areas/ambulance- of-Hospital Cardiac Arrest by Public Location in the Public Access quality-indicators/ Defibrillation Era. JAMA 2014; doi: 10.1161/JAHA. 113.000533.

2. London Ambulance Service Cardiac Arrest Annual Report Wissenberg M, Lippert FK, Folke F, Weeke P, Hansen CM, Christensen F, 2012/2013 [www.londonambulance.nhs.uk] Jans H, Hansen PA, Lang-Jensen T, Olesen JB, Lindhardsen J, Fosbol EL, Nielsen SL, Gislason GH, Kober L, Torp-Pedersen C. Association of 3. Lindner TW,Soreide E, Nilsen OB, Torunn MW, Lossius HM. Good National Initiatives to Improve Cardiac Arrest Management With Rates outcome in every fourth resuscitation attempt is achievable – An of Bystander Intervention and Patient Survival After Out-Of-Hospital Utstein template report from the Stavanger region. Resuscitation Cardiac Arrest. JAMA. 2013; 310(13):1377-1384. doi: 10.1001/ 2011; 82:1508-13. JAMA.2013.278483.

4. Waalewijn RA, Tijssen JGP, Koster RW. Bystander initiated actions in out-of-hospital cardiopulmonary resuscitation: results from the Amsterdam Resuscitation study (ARREST). Resuscitation 2001; 50:273-279.

5. Grasner JT, Herlitz J, Koster RW, Rosell-Ortiz F, Stamatakis L, Bossaert L. Quality management in resuscitation – towards a European cardiac arrest registry (EuReCa). Resuscitation 2011;

82:989-94. RESUSCITATION T

6. Division of Medical Services Public Health – Seattle & King Country 2013 Annual Report to the King County Council. http://www.kingcountry.gov/healthservices/health/ems/reports.aspx. oday 7. Perkins GD. Data on file. OHCA database. - SPRING 2015 8. Deakin CD, Shewry E, Gray H, Public access defibrillation remains out of reach for most victims of out-of-hospital sudden cardiac arrest. Heart 2014; 100:619:623.

9. Holmberg M, Holmberg S, Herlitz J. Incidence, duration and survival of ventricular fibrillation in out-of-hospital cardiac arrest patients in Sweden. Resuscitation 2000; 44:7-17. 21 LIFE CONNECTIONS 2015 LIFE CONNECTIONS 2015 CONNECTING LIFE SAVERS WITH ONE COMMON GOAL CONNECTING LIFE SAVERS WITH ONE COMMON GOAL

Diary Date: Wednesday 21st & Thursday 22nd October 2015 MORE CHOICE, MORE VALUE, MORE CPD OPPORTUNITIES Kettering Conference Centre, Kettering, Northants NN15 6PB MORE 2 for 1 EARLY BIRD OFFERS

Life Connections 2015 will be taking place at the Resuscitation Conference taking place the following THURSDAY 22ND OCTOBER guides on Early Warning Scores, your skills in this area Kettering Conference Centre, Kettering, Northants, day (saving £36.00). will be tested during the day using various ALS case on October 21st and 22nd and, once again, has studies and scenarios. Early Bird offer – Book by Mar ATACC Conference st plenty to offer those wishing to keep up-to-date with ALSG Facilitation Course - The Practical ATACC "Decoding the Future" - Day 2. 31 to also secure a FREE delegate place on our new techniques and maintain their CPD portfolios, all Approach. Those interested in learning about or One day delegate rate £150. Paramedic Conference taking place the previous day at affordable delegate rates!!! improving their role play and simulation facilitation (value £48.00).

skills are welcome to apply for a place on this one Resuscitation Today Conference speakers For those taking advantage of our early bird 2 for 1 day course. Prior to attending the course delegates including Professor Sir Keith Porter, Jamie Todd and Meditech Global are repeating their Motorsport offer, Kettering has a wealth of reasonably priced will be required to complete a series of e-modulars Mike Davis are amongst those who will all be Medicine CPD Workshop, aimed at medics and rescue accommodation but book early! on the ALSG Virtual Learning Environment. Only 16 providing up to the minute presentations on topics of personnel involved with motorsport events. The day will delegate places are available at £140. Early Bird great interest to Resuscitation Officers such as, include Scene Safety, Airway Management and Programmes to date are as follows: Offer - Book by March 31st to also secure a FREE Incorporating Non-Technical Skills in Life Support Appropriate Casualty Extrication. 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ATACC "Decoding the Future" - This ground- Workshop which will include a general approach to £36). breaking 2 day course aims to explore the very latest paediatrics such as 'Spotting a Sick Child', 'Red medical advances in the fields of Resuscitation, Flags Pre-Hospital', and 'Pre-Hospital Pain Outreach Rescue Study Day - this organisation Trauma, Anaesthesia & Critical Care. A truly Management. Only 25 places are available at and the quality of their educational programmes need breathtaking list of International experts will present £60.00. Early Bird Offer - Book by March 31st to also no introduction, next year's topics include "Key both advanced current practice and also remarkable secure a FREE delegate place on our Resuscitation Principles of Patient Packaging under Varying evolving research that we are likely to see adopted Conference taking place the following day (value Constraints" - only 20 places are available at a £48). delegate rate of £72. Early Bird offer – Book by Mar over the next 5-10 years. st 31 to also secure a FREE delegate place on our Inspired by SMACC, TEDmed and in typical Jamie Todd of Pre-Hospital Care Paramedic Conference taking place the previous day innovative ATACC style this fast paced and Consultancy Ltd is running a one day NAEMT (value £48). stimulating conference is aimed at doctors, nurses Course ideal for First Responders, Fire Fighters and and other healthcare professionals at the cutting Police Officers. Only 16 places are available on Medipro Training are running a one day Minor edge of medicine. Join us in decoding the future of this course offered at £108 (50% below normal Injuries Workshop to include Musuloskeletal Trauma & Critical Care. course costs). Delegates will also receive a free Assessment and Management of the Ankle, Knee, NAEMT TFR Manual (worth £25) courtesy of Class Jamie Todd of Pre-Hospital Care Consultancy Shoulder, Wrist and Urinalysis Pre-Hospital. 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Keith Porter, Patrick Bourke, Jamie Todd, Dr Simon normal course costs). - Early Bird offer- book by Mar Le Clerc and Mike Davis are among this year's Meditech Global are running a Motorsport 31st to also secure a FREE delegate place on our speakers who will be giving presentations on a Medicine CPD Workshop, aimed at medics and Paramedic Conference taking place the previous day number of wide and varied topics such as: rescue personnel involved with motor sport events. (value £48). The day will include Scene Safety, Airway "The Importance of Non-Technical Skills in the Management and Appropriate Casualty Extrication. Paramedic Community", "Intubation without Thames Group are running a Cardiac Based Study Speakers will include; FIA Doctors and active motor traditional Laryngoscopy - Is this the Future?", Day on ECG Interpretation and have available 20 sport paramedics. "Shock May Hinder Bleeding - Cannon 1917. Only 25 places are available at delegate places at £90. 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All prices quoted are inclusive of VAT. To secure your 2 for 1 delegate place or to register for any of the above conferences/study days call the organisers office on Once finalised all Conference/Study Day Programmes 01322 660434 can be viewed on www.lifeconnections.uk.com LIFE CONNECTIONS 2015 LIFE CONNECTIONS 2015 CONNECTING LIFE SAVERS WITH ONE COMMON GOAL CONNECTING LIFE SAVERS WITH ONE COMMON GOAL

Diary Date: Wednesday 21st & Thursday 22nd October 2015 MORE CHOICE, MORE VALUE, MORE CPD OPPORTUNITIES Kettering Conference Centre, Kettering, Northants NN15 6PB MORE 2 for 1 EARLY BIRD OFFERS

All prices quoted are inclusive of VAT. To secure your 2 for 1 delegate place or to register for any of the above conferences/study days call the organisers office on Once finalised all Conference/Study Day Programmes 01322 660434 can be viewed on www.lifeconnections.uk.com medical EVIDENCE medical For this months reviews of resuscitation evidence we have used some Olaussen A, et al. of the latest papers from “life in the fast lane” this is one of the more influential blog sites used by the FOAM twitter community.

Fraser K et al. Return of consciousness during ongoing The Emotional and Cognitive Cardiopulmonary Impact of Unexpected Resuscitation: Simulated Patient Death A A systematic review Randomized Controlled Trial Resuscitation 2014; 86: 44-48. PMID 25447435

Chest. 2014; 145(5): 958-63. PMID: 24158305 • After introduction of mechanical CPR device CPR induced consciousness seems more prevalent. • What is the effect of simulation patient death on trainees? • Though CPR induced consciousness may be distressing for the • This study looks into the question and finds that medical students rescuers (and maybe the patient) it is often percieved as a good randomized to having their simulated patient die report increased prognostic sign of outcome. The current guidelines on advanced cognitive load and had poorer learning outcomes. cardiopulmonary resuscitation focus on delivering high quality • The authors caution that this doesn’t mean we shouldn’t have simulated chest compressions with minimal interruptions only pausing for patients die but that we need to plan for this outcome intelligently. rhythm check or if the patient shows signs of life. Thus CPR induced consciousness may be mistanken for signs of life interupting the • Recommended by: Anand Swaminathan sequence of CPR and influence the quality of care.

Many of us running clinical ALS scenarios may deliberately run into the • This systematic review only identified reports on 10 patients. negative effects reported in this paper... The incidence, implications and prognostic value of CPR-induced consciousness remains unknown and should be eveluated. Calle PA et al. • Recommended by: Søren Rudolph

Many anecdotes exist and again this fascinating area of research Inaccurate treatment will increase it’s profile with the ongoing development of quality resuscitation. The ethical side of the mechanically CPR dependant decisions of automated patient will also be debated in future. external defibrillators used by emergency medical THE CAPABILITY OF PROFESSIONAL services personnel: - AND LAY-RESCUERS TO ESTIMATE Incidence, cause and impact THE CHEST COMPRESSION-DEPTH on outcome TARGET: A SHORT, RANDOMIZED RESUSCITATION T Resuscitation 2015. PMID: 25556589 EXPERIMENT.

• This is an interesting and concerning paper. Author: van Tulder R • Two authors reviewed all rhythm analysis algorithm (RAA) from Resuscitation, [Epub ahead of print] patients who had an AED activated secondary to cardiac arrest. The authors found that in 16% of shockable rhythms (23 of 148) the AED Editors comment - One of the latest resuscitation papers published oday did not advise shock, often secondary to artefacts or “fine V-fib”.This recently is summarised below it is a really interesting study as it - SPRING 2015 article shows a concerning incidence of “failure to defibrillate” among suggests that estimation of depth is often poor by both professional OHCA receiving AEDs. and lay rescuers. • Recommended by: Daniel Cabrera In CPR, sufficient compression depth is essential. The American As researchers in resuscitation many of us may have encountered Heart Association (“at least 5cm”, AHA-R) and the European anomalies with data accuracy and downloads, and this is definitely Resuscitation Council (“at least 5cm, but not to exceed 6cm”, an area requiring further attention. ERC-R) recommendations differ, and both are hardly achieved. 25 EVIDENCE

This study aims to investigate the effects of differing target depth equipment for the standardization of the procedure. The same instructions on compression depth performances of professional and parameters were measured during a standard exercise testing protocol lay-rescuers. (spiroergometry) on a bicycle to analyze the aerobic endurance range of the participants. Data from the resuscitation protocols were correlated 110 professional-rescuers and 110 lay-rescuers were randomized (1:1, with those from spiroergometry to establish a simple standard 4 groups) to estimate the AHA-R or ERC-R on a paper sheet (given investigation procedure to check people at risk and to give minimum horizontal axis) using a pencil and to perform chest compressions requirements to perform CPR in Watts/kg. The study consisted of two according to AHA-R or ERC-R on a manikin. parts: 1 (n = 16) explored minimal workload cutoffs for the rescuer using the 1995 recommendations and 2 (n = 14) tested the latest 2010 Distance estimation and compression depth were the outcome variables. guidelines to compare both recommendations.

Professional-rescuers estimated the distance according to AHA-R When tested according to the 1995 guidelines, heart frequency of in 19/55 (34.5%) and to ERC-R in 20/55 (36.4%) cases (p=0.84). rescuers increased from 83.0 bpm (±11.3) at rest to 109.9 bpm (±12.6; Professional-rescuers achieved correct compression depth according P = 0.0004). The newer 2010 guidelines increased the workload to AHA-R in 39/55 (70.9%) and to ERC-R in 36/55 (65.4%) cases marginally more (n.s.). (p=0.97). Lay-rescuers estimated the distance correctly according to AHA-R in 18/55 (32.7%) and to ERC-R in 20/55 (36.4%) cases (p=0.59). CPR can be performed by healthy people within the range of aerobic Lay-rescuers yielded correct compression depth according to AHA-R in endurance. The minimal requirements for trainings are 1.6-1.8 W/ 39/55 (70.9%) and to ERC-R in 26/55 (47.3%) cases (p=0.02). kg body weight in standard cycling ergometry. People at risk should be trained very careful. Since there is no significant lower workload Professional and lay-rescuers have severe difficulties in correctly when following the 1995 recommendations, people at risk should be estimating distance on a sheet of paper. Professional-rescuers are able trained according to the latest recommendations. In the case of a to yield AHA-R and ERC-R targets likewise. real resuscitation, such trained individuals must additionally take into account any symptoms.

In lay-rescuers AHA-R was associated with significantly higher success rates. International archives of occupational and environmental health, 88(2):175-84. Epub 2014 May 30. The inability to estimate distance could explain the failure to appropriately perform chest compressions. For teaching lay-rescuers, the AHA-R with PreMedline Identifier: 24874840 no upper limit of compression depth might be preferable.

Workload during “Lay resuscitation is crucial for cardiopulmonary the survival of the patients with resuscitation out-of-hospital cardiac arrest.

Author: Küpper T Therefore, lay CPR should be 2015-02-01 a basic skill for everyone. With Editors comments - this is a great study - although small it suggests that CPR using modern 2010 guidelines is slightly harder to perform than the growing proportion of retired using guidelines of old. The use of telemetry and cycling based science people in the Western societies,

RESUSCITATION T and the use of physiological testing to test human ability to perform CPR is a great area for others to explore. Suggesting that many cardiac CPR performed by people with arrest sufferers may themselves live with a rescuer with pre existing disease and therefore at risk of over exertion themselves is interesting... preexisting diseases and at risk

Lay resuscitation is crucial for the survival of the patients with out-of-

oday of cardiac events is expected to hospital cardiac arrest. Therefore, lay CPR should be a basic skill for

- SPRING 2015 everyone. With the growing proportion of retired people in the Western grow. There is little knowledge societies, CPR performed by people with preexisting diseases and at risk of cardiac events is expected to grow. There is little knowledge about the workload during CPR about the workload during CPR and the minimum workload capacity of the rescuer. and the minimum workload

Pulse frequency, oxygen uptake, and CO2 elimination were measured capacity of the rescuer.” by telemetry, while CPR was performed using a manikin with digital 26 EVIDENCE NEWS

If they take on a management role, they Computed tomography findings “Hybrid” clinician-managers are often see it as something of a sideline of complications resulting from crucial to NHS improvement, – either they have been asked to “take cardiopulmonary resuscitation says research But Oxford a turn” (defined by Fitzgerald and her colleagues as passive professional academic warns that they need obligation), or they feel that they Yuta Kashiwagi, Tomoki Sasakawa, Akihito Tampo, need to “protect” the profession from Daisuke Kawata, Takeshi Nishiura, Naohiro Kokita, more support if change is to be Hiroshi Iwasaki, Satoshi Fujita implemented effectively encroaching managerialism (reactive professional obligation).

Introduction Saïd Business School, University of Oxford This retrospective study was conducted to “These ‘incidental’ hybrid managers evaluate injuries related to cardiopulmonary Service improvements and organisational typically use their roles to keep medical resuscitation (CPR) and their associated change in the NHS are more effective professional work separate from the factors using postmortem computed when led by clinicians with management demands of politics and management tomography (PMCT) and whole body CT responsibilities than by full-time managers, and to protect it from change,” explains after successful resuscitation. according to research by Professor Louise Fitzgerald. “They are not really interested Fitzgerald, Saïd Business School, University in service improvement, seeing it as a ‘box- Methods of Oxford. But these “hybrid” managers are ticking’ exercise. To effect real change, the currently struggling without support and The inclusion criteria were adult, non- NHS will have to identify these incidental training in management, which they need to traumatic, out-of-hospital cardiac arrest hybrids and find ways of either engaging help them succeed. patients who were transported to our them in genuine service improvement or emergency room between April 1, 2008 encouraging them to vacate the role for “The popular image that the NHS is overrun and March 31, 2013. Following CPR, PMCT others who wish to achieve this – those we by managers with no medical expertise is was performed in patients who died without have called ‘willing hybrids’.” inaccurate,” said Louise Fitzgerald, Visiting return of spontaneous circulation (ROSC). Professor (Organisational Change). “Hybrid Similarly, CT scans were performed in Willing hybrids often have to endure managers, who combine managerial patients who were successfully resuscitated accusations from their fellow professionals responsibilities with clinical or medical within 72hours after ROSC. The injuries of “going over to the dark side”, of duties, outnumber the full-time managers by associated with CPR were analysed becoming “a poacher turned gamekeeper… four to one. But many find the role a tough retrospectively on CT images. fraternising with the enemy”. Nevertheless, challenge, partly because of a historic they were proactive in seeking service conflict between how medical professionals Results improvements and used their roles view themselves and their roles and their During the study period, 309 patients who to disrupt and challenge unrealistic perception of management, and partly suffered out-of hospital cardiac arrest were and out-dated professionalism. “Our because they have not been taught how to transported to our emergency room and research showed that these hybrids were manage.” received CPR; 223 were enrolled in the interested in inter-professional teamwork, study. The CT images showed that 156 focused on delivering ‘the best service’ “Although our research has suggested that for patients collectively, in contrast to patients (70.0%) had rib fractures, and 18 it may be more important to learn how to the institutionalised lone professional patients (8.1%) had sternal fractures. Rib be a hybrid than to do management, even who focuses on individual patients” says fractures were associated with older age the most proactive hybrid managers can Fitzgerald. “They were willing to challenge (78.0 years vs. 66.0 years, p<0.01), longer be slowed down by a lack of knowledge duration of CPR (41min vs. 33min, p<0.01), professionals who ignored resource of basic issues – which can be taught,” RESUSCITATION T and lower rate of ROSC (26.3% vs. 55.3%, she said. “Better management training limitations and were willing to work with p<0.01). All sternal fractures occurred with alongside professional training, as well as government targets as a means of providing rib fractures and were associated with a improved financial rewards for those taking good patient care.” greater number of rib fractures, higher age, on a hybrid management role, would have and a lower rate of ROSC than rib fractures the benefits both of encouraging more • Hybrid managers tend to learn the oday only cases. Bilateral pneumothorax was professionals to become hybrids, and management side of their roles on the observed in two patients with rib fractures. job. This has an advantage in that they

making them more effective when they do.” - SPRING 2015 are not seen to distance themselves too Conclusions Fitzgerald has identified two key issues much from clinical or medical practice. PMCT is useful for evaluating complications that have an impact on the effectiveness of However, some do not feel supported in related to chest compression. Further hybrid managers in the NHS: their roles. Others are hampered by a investigations with PMCT are needed to lack of knowledge about management, reduce complications and improve the • Medical professionals in all fields identify particularly in specialised areas such as quality of CPR. themselves as medics first and foremost. change management. 27 EVIDENCE NEWS Resuscitation Today

initiation of ECMO of 56 (IQR 40-85) min. R efractory cardiac arrest Percutaneous coronary intervention was treated with mechanical performed on 11 (42%) and pulmonary “The CHEER protocol Conference CPR, hypothermia, ECMO embolectomy on 1 patient. Return of was developed for spontaneous circulation was achieved in 25 Programme and early reperfusion (the (96%) patients. Median duration of ECMO selected patients with CHEER trial). support was 2 (IQR 1-5) days, with 13/24 refractory in-hospital Thursday 22nd October 2015 (54%) of patients successfully weaned and out-of-hospital Stub D1, Bernard S2, Pellegrino V3, from ECMO support. Survival to hospital Kettering Conference Centre, Kettering, Northants NN15 6PB Smith K4, Walker T5, Sheldrake J3, discharge with full neurological recovery cardiac arrest and Hockings L3, Shaw J6, Duffy SJ6, (CPC score 1) occurred in 14/26 (54%) Burrell A7, Cameron P7,Smit DV3, patients. involves mechanical Time Presentation Speaker Position Kaye DM6. CPR, rapid intravenous Author information Conclusions: 08.30 – 09.30 Registration A protocol including E-CPR instituted administration of 30mL/ 09.30 – 09.45 Introduction Abstract by critical care physicians for refractory kg of ice-cold saline cardiac arrest which includes mechanical Professor in Clinical Introduction: CPR, peri-arrest therapeutic hypothermia to induce intra-arrest 09.45 – 10.30 Trauma…… 30 per cent More Lives Saved Professor Sir Keith Porter Traumatology, University Hospital, Birmingham Many patients who suffer cardiac arrest do and ECMO is feasible and associated with therapeutic hypothermia, not respond to standard cardiopulmonary a relatively high survival rate. 10.30 – 11.15 Tea/Coffee, Exhibition resuscitation. There is growing interest percutaneous Copyright © 2014 Elsevier Ireland Ltd. Intubation without Traditional Laryngoscopy Jamie Todd BSc Hons in utilizing veno-arterial extracorporeal cannulation of the 11.15 – 11.45 Principle Consultant membrane oxygenation assisted All rights reserved. – is this the Future? MCPara cardiopulmonary resuscitation (E-CPR) femoral artery and Emersive Simulation and Resuscitation in the management of refractory cardiac Keywords: 11.45 – 12.15 Rob Clark TBC vein by two critical Theories arrest. We describe our preliminary Cardiac arrest; Extracorporeal membrane experiences in establishing an E-CPR oxygenation; Resuscitation care physicians and 12.15 –13.30 Lunch and Exhibition program for refractory cardiac arrest in commencement of Incorporating Non-Technical Skills in Life 13.30 – 14.00 Mike Davis Facd Med Melbourne, Australia. veno-arterial ECMO.” Support Teaching Methods: 14.00 – 14.30 TBC TBC TBC The CHEER trial (mechanical CPR, Hypothermia, ECMO and Early Reperfusion) 14.30 –15.15 Tea/Coffee, Exhibition is a single center, prospective, observational study conducted at The Alfred Hospital. Designing Telemedicine Solutions for the The CHEER protocol was developed for 15.15 – 16.00 Remote Assessment of the Peri Arrest TBC TBC selected patients with refractory in-hospital Patient and out-of-hospital cardiac arrest and 16.00 – 16.30 New Resuscitation Guidelines TBC TBC involves mechanical CPR, rapid intravenous administration of 30mL/kg of ice-cold 16.30 – 17.00 New Resuscitation Guidelines Q&A TBC TBC saline to induce intra-arrest therapeutic hypothermia, percutaneous cannulation of the femoral artery and vein by two critical RESUSCITATION T care physicians and commencement of Topics & Speakers correct at the time of press but may be subject to change veno-arterial ECMO. Subsequently, patients with suspected coronary artery occlusion are transferred to the cardiac catheterization Delegate Rates: £48 inc VAT (Student rate: £36 inc VAT) laboratory for coronary angiography. Cost includes: delegate bag, refreshments and the opportunity to visit over 50 trade stands.

oday Therapeutic hypothermia (33°C) is st maintained for 24h in the intensive care unit. Early Bird Offer – Book by 31 March to secure a reduced delegate rate of £36.00 or pay £60.00 - SPRING 2015 to also attend the Paramedic Conference taking place the previous day (saving £36.00) Results: There were 26 patients eligible for the CHEER protocol (11 with OHCA, 15 with To register call 01322 660434 or visit IHCA). The median age was 52 (IQR 38-60) years. ECMO was established in 24 (92%), with a median time from collapse until www.lifeconnections.uk.com 28 Resuscitation Today Conference Programme Thursday 22nd October 2015 Kettering Conference Centre, Kettering, Northants NN15 6PB

Time Presentation Speaker Position

08.30 – 09.30 Registration

09.30 – 09.45 Introduction

Professor in Clinical 09.45 – 10.30 Trauma…… 30 per cent More Lives Saved Professor Sir Keith Porter Traumatology, University Hospital, Birmingham

10.30 – 11.15 Tea/Coffee, Exhibition

Intubation without Traditional Laryngoscopy Jamie Todd BSc Hons 11.15 – 11.45 Principle Consultant – is this the Future? MCPara

Emersive Simulation and Resuscitation 11.45 – 12.15 Rob Clark TBC Theories

12.15 –13.30 Lunch and Exhibition

Incorporating Non-Technical Skills in Life 13.30 – 14.00 Mike Davis Facd Med Support Teaching

14.00 – 14.30 TBC TBC TBC

14.30 –15.15 Tea/Coffee, Exhibition Designing Telemedicine Solutions for the 15.15 – 16.00 Remote Assessment of the Peri Arrest TBC TBC Patient

16.00 – 16.30 New Resuscitation Guidelines TBC TBC

16.30 – 17.00 New Resuscitation Guidelines Q&A TBC TBC

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

Delegate Rates: £48 inc VAT (Student rate: £36 inc VAT) Cost includes: delegate bag, refreshments and the opportunity to visit over 50 trade stands. st Early Bird Offer – Book by 31 March to secure a reduced delegate rate of £36.00 or pay £60.00 to also attend the Paramedic Conference taking place the previous day (saving £36.00) To register call 01322 660434 or visit www.lifeconnections.uk.com EQUIPMENT NEWS

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