Impact of Postshock Transcutaneous Pacing on Chest Compression Quality during Resuscitation: A Simulation-Based Pilot Study

Background. Successful defibrillation is commonly followed by a transient nonperfusing state. To provide perfusion in this stagnant phase, chest compressions are recommended irrespective of arrhythmia termination. Implantable cardioverters-defibrillators (ICD) used immediately after delivery of the shock are capable of pacing the heart, and this feature is commonly activated in these devices. Potential utility of external, transcutaneous postshock pacing in patients with SCA in shockable rhythms has not been determined. This study aimed at presenting an impact of a short-term external postshock pacing (ePSP) on a quality of chest compressions (CC) without compromising them. Methods. The study was designed as a high-fidelity simulation study. Twenty triple-paramedic teams were invited. Participants were asked to take part in a 10-minute adult cardiac arrest scenario with ventricular fibrillation. In the first simulation, paramedics had to resume compressions after each shock (control group). In the second, simultaneous with compressions, one of the rescuers started transcutaneous pacing (TCP) with a current output of 200 mA and a pacer rate of 80 ppm. TCP was finished after 30 seconds (experimental group). The primary outcomes were chest compression fraction (CCF), mean depth and rate of compressions, percent of fully recoiled compressions, and percent of compressions of correct depth and their rate. Results. In both experimental and control group, CCF, mean depth, and rate were similar (84.65 ± 3.67 vs. 85.45 ± 4.95, p = 0.54 ; 55.75 ± 3.40 vs. 55.25 ± 2.73, p = 0.63 ; 122.70 ± 4.92 vs. 120.80 ± 6.00, p = 0.25 , respectively). In turn, percent of CC performed in correct depth, rate, and recoil was unsatisfactory in both groups (51.00 ± 17.40 vs. 52.60 ± 18.72, p = 0.76 ; 122.70 ± 4.92 vs. 120.80 ± 6.00, p = 0.25 , respectively). Small differences were not statistically significant. Moreover, appropriate hand-positioning was observed more frequently in the control group, and this was the only significant difference (95.60 ± 5.32 vs. 99.30 ± 1.59, p = 0.006 ). Conclusion. This difference was statistically significant ( p < 0.01 ). Introducing an ePSP does not influence relevantly the quality of CC.

Short-term immediate post-shock pacing in adult advanced life support – a feasibility study of modified ALS algorithm

Introduction It is well known that the majority of patients remains transiently pulseless after successfull defibrillation shock during routine advanced cardiovascular life support (ACLS). The post-shock asystole is longer than 120 seconds in as many as 25% of patients. Not only asystole, but also profound postshock bradycardia and high degree AV blocks are described as common. The need for post-shock pacing (PSP) in adult ACLS is unknown, but there is extensive use of that feature in implantable cardioverters – defibrillators (ICD). PSP feature is widely used in these devices. The wide utilisation of PSP in ICD patients warrants the research towards any possible benefit of it during ACLS measures. Material and methods We performed high-fidelity simulation study including 60 paramedic at 20 scenarios. The participants were asked to perform routine resuscitation scenarios according to the AHA ACLS algorithm. In the control group paramedics had to resume compressions after each shock. In experimental group simultaneously with the compressions, transcutaneous pacing with 200 mA output and rate of 80 ppm was delivered. Several parameters were monitored: chest compression fraction, compressions depth and rate, percent of recoiled compression, compressions on correct depth, and other. Results There were no statistically significant differences between both groups in respect of compressions depth and rate, time needed to achieve advanced airway, initiate and achieve intravenous line, administer medications (Table 1). The detailed results are presented in Table 1. Discussion According to the best of the authors knowledge, this is the first study describing the feasibility of PSP in resuscitation. The quality of resuscitation depends on adherence to the protocol. Any additional element in the protocol can negatively affect the outcome. In the presented study we present that major ACLS steps are delivered without significant delay when PSP is utilised. Conclusions The implementation of PSP had no negative impact on adherence to ACLS protocol. The authors see the need for further intensive research in this area. Figure 1. Design of the study. Funding Acknowledgement Type of funding source: None

Successful transcutaneous pacing following ventricular standstill during anaesthetic induction in a dog with third-degree atrioventricular block

Third-degree atrioventricular block is a haemodynamically unstable bradycardia frequently resulting in signs of lethargy, weakness and collapse. In this reported case, a four year-four month-old male neutered Cavalier King Charles spaniel diagnosed with third-degree atrioventricular block was referred for transvenous permanent pacemaker implantation. During induction of general anaesthesia, the dog suffered cardiac arrest consistent with ventricular standstill, as indicated by cessation of ventricular electrical activity on the ECG monitor and the absence of a peripheral pulse. The prior placement of transthoracic pacing pads under sedation allowed for rapid commencement of temporary transcutaneous pacing and proved effective in achieving ventricular capture with re-establishment of cardiac output. The subsequent general anaesthesia for implantation of a permanent pacemaker was uneventful. This report considers the possible causes of ventricular escape rhythm suppression and highlights the importance of ensuring availability of a temporary pacing method from the outset when anaesthetising animals with unstable and symptomatic bradycardias.

Transcutaneous pacing: a life saviour

Doukky Rand colleagues acknowledged that Transcutaneous Cardiac Pacing is a temporary method of pacing which may be indicated in patients with symptoms of severe or hemodynamically unstable bradyarrhythmias. It is found to be extremely helpful in patients with reversible or transient conditions, such as digoxin toxicity and in atrioventricular block in the case of inferior wall myocardial infarction, or when transvenous pacing is not available or there are high chances of complications. Widened QRS complex indicates successful attempt followed by a distinct ST segment and broad T wave. The hemodynamic response to pacing is to be confirmed by the assessment of patient’s arterial pulse waveforms. Trancutaneous pacing is a boon to manage and treat intra op dangerous bradycardia.

MP42: Evaluating clinical and situational factors related to the likelihood of physician authorization for time-sensitive procedures during mandatory paramedic patches

Introduction: Delegation of controlled medical acts by physicians to paramedics is an important component of the prehospital care framework. Where directives indicate that physician input is needed before proceeding with certain interventions, online medical control (a “patch”) exists to facilitate communication between a paramedic and a Base Hospital Physician (BHP) to request an order to proceed with that intervention. The clinical and logistical setting will contribute to the decision to proceed with or withhold an intervention in the prehospital setting. The aim of this study was to examine the impact of various clinical and situational factors on the likelihood of a patch request being granted. Methods: Prehospital paramedic calls that included a mandatory patch point (excluding requests exclusively for termination of resuscitation and those records which were unavailable) were identified through review of all patch records from January 1, 2014 to December 31, 2017 for Paramedic Services in our region. Written Ambulance Call Reports (ACRs) and audio recordings of paramedic patches were obtained and reviewed. Results: 214 patch records were identified and screened for inclusion. 91 ACRs and audio patch records were included in the analysis. 51 of 91 (56%) patch requests were granted by the BHP. Of the 40 paramedic requests that were not granted, the most commonly cited reason was close proximity to hospital (22/40; 55%) followed by low likelihood of the intervention making a clinical impact in the prehospital setting (11/40; 27.5%). Requests for certain interventions were more likely to be granted than other requests. All requests to perform needle thoracostomy for possible tension pneumothorax, administer atropine for symptomatic bradycardia and treat hemodynamically unstable hyperkalemia were granted (2/2, 3/3 and 7/7, respectively), while requests for synchronized cardioversion (7/19; 37%) and transcutaneous pacing (2/6; 33%) were approved less than half of the time. Conclusion: This retrospective review suggests that requests to perform certain critical and potentially time sensitive interventions are more likely to be granted which calls into question the requirement for a mandatory patch point for these procedures. Furthermore, the interplay between proximity to hospital and the decision to proceed with an intervention potentially informs future modifications to directives to facilitate timely, safe and efficient care.