Abstract 11964: Citizen Responders Provide Emotional Support for Relatives to Out-of-Hospital Cardiac Arrest Patients

Introduction: A citizen responder (CR) system to activate volunteer citizens by a smartphone application (HeartRunner) to nearby cardiac arrests was implemented in 2017 in the Capital Region of Denmark. Participating in resuscitation may not only involve provision of cardio-pulmonary resuscitation (CPR) but also include provision of emotional support for relatives to the cardiac arrest patient. We examined the proportion of CR who reported provision of support to relatives to out-of-hospital cardiac arrest (OHCA) patients during resuscitation attempt. Hypothesis: We hypothesized that CR not only deliver CPR but also provide emotional support to relatives of OHCA patients. Methods: All CR activated by the HeartRunner app received a follow-up questionnaire 90 minutes after the alarm including questions about how CRs participated in resuscitation and whether they provided emotional support to relatives present during the resuscitation attempt. All surveys from March 12, 2020 to June 1, 2021, from CR who accepted an alarm and arrived at the cardiac arrest location were included. Results: A total of 1,868 CR responded to the survey (median age 37 years (IQR 28-37). Half (54.4%) were male and 23.9% health care professionals. CRs arrived before the emergency medical services (EMS) in almost 1/3 (28.9%) of OHCA cases with CR activation, with 227 CRs (41.9%) performing CPR and 139 (25.7%) attaching an automated external defibrillator. In total, more than 433 CRs (23.2%) reported provision of support for relatives at the OHCA location. Even though a higher proportion of support was observed among CR who arrived before the EMS, almost 12% reported provision of support to relatives even when arriving after EMS (Figure). Conclusions: Citizen responders provide not only resuscitative efforts but offer emotional support to relatives to OHCA patients. Citizen responders may be an important resource for both EMS personnel and relatives who are present at the cardiac arrest scene.

Fetal Congenital Diaphragmatic Hernia and Hydramnios in a Quarter Horse Mare

Hydramnios is an excessive accumulation of fluid within the amniotic compartment. It is a rare condition in mares, often associated with fetal anomalies. Hydrops of fetal membranes predisposes to the rupture of the prepubic tendon, and many authors suggest the induction of parturition to preserve mare’s reproductive career. This report presents the case of a 15-year-old multiparous Quarter Horse mare, referred at 268 days of gestation for suspected hydrops. Repeated ultrasonographic exams confirmed an increase in the depth of the amniotic fluid and reduced fetal viability. During the hospitalization, the mare developed a partial rupture of the prepubic tendon. In this case, a conservative approach was elected, and the mare was treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and an abdominal support bandage. At 327 days of gestation, the mare gave birth to a foal with APGAR score 1. The resuscitation attempt was unsuccessful, and the foal died immediately. A post-mortem examination diagnosed a congenital diaphragmatic hernia (CDH) with pleuroperitoneal diaphragmatic eventration.

Collaboration between emergency physicians and citizen responders in out-of-hospital cardiac arrest resuscitation

Background Citizen responder programmes dispatch volunteer citizens to initiate resuscitation in nearby out-of-hospital cardiac arrests (OHCA) before the Emergency Medical Services (EMS) arrival. Little is known about the interaction between citizen responders and EMS personnel during the resuscitation attempt. In the Capital Region of Denmark, emergency physicians are dispatched to all suspected OHCAs. The aim of this study was to evaluate how emergency physicians perceived the collaboration with citizen responders during resuscitation attempts. Method This cross-sectional study was conducted through an online questionnaire. It included all 65 emergency physicians at Copenhagen EMS between June 9 and December 13, 2019 (catchment area 1.8 million). The questionnaire examined how emergency physicians perceived the interaction with citizen responders at the scene of OHCA (use of citizen responders before and after EMS arrival, citizen responders’ skills in cardiopulmonary resuscitation (CPR), and challenges in this setting). Results The response rate was 87.7% (57/65). Nearly all emergency physicians (93.0%) had interacted with a citizen responder at least once. Of those 92.5%(n = 49) considered it relevant to activate citizen responders to OHCA resuscitation, and 67.9%(n = 36) reported the collaboration as helpful. When citizen responders arrived before EMS, 75.5%(n = 40) of the physicians continued to use citizen responders to assist with CPR or to carry equipment. Most (84.9%, n = 45) stated that citizen responders had the necessary skills to perform CPR. Challenges in the collaboration were described by 20.7%(n = 11) of the emergency physicians and included citizen responders being mistaken for relatives, time-consuming communication, or crowding problems during resuscitation. Conclusion Emergency physicians perceived the collaboration with citizen responders as valuable, not only for delivery of CPR, but were also considered an extra helpful resource providing non-CPR related tasks such as directing the EMS to the arrest location, carrying equipment and taking care of relatives.

The clinical effects of CPR meter on chest compression quality: a QI project

The clinical effects of CPR meter on chest compression quality: a QI project. Christopher Picard, Richard Drew, Domhnall O’Dochartaigh, Matthew J Douma, Candice Keddie, Colleen Norris. Background: High-quality chest compressions are the cornerstone of resuscitation. Training guidelines require CPR feedback, and pre-clinical data shows that feedback devices improve chest compression quality; but devices are not being used in many emergency departments, and their impact on clinical care is less well understood. Some services use defibrillator generated reports for quality improvement, but these measurements may be limited in scope and have not been rigorously compared to other tools. Methods: Laerdal CPRMeter 2 chest compression feedback devices were purchased using funds made available by a zone QI initiative. Initial training for implementation consisted of staff performing one minute of blinded chest compression using the feedback device, followed by one minute of chest compression unblinded. Staff were shown the raw percentage of chest compressions meeting target depth, release, and rate under both conditions as well as overall improvement. Following initial orientation, devices were incorporated into clinical care and all subsequent staff simulation and training. Clinically, use of the feedback device and completion or QI tracking forms was not mandated but was encouraged by drawing code participant names from completed forms for a free ACLS or PALS course. Data from all codes were automatically collected by the LifePak 20, data from any resuscitation using the Laerdal CPRmeter 2 were also automatically recorded when the device was used: these data were downloaded weekly. Completed questionnaire forms were submitted to the Clinical Educators and extracted as received. Evaluation Methods: Chest compression quality data was collected in two ways: first, using a Laerdal CPRMeter2, second, by downloading and analyzing cardiac arrest data from a LifePak20 defibrillator using CodeStatTM software. Device data were matched and synthesized by an emergency department CNE using Microsoft excel and IBM SPSS 26. Descriptive statistics (mean and standard deviations) are used to describe the data. Differences in chest compression quality and duration of resuscitations between resuscitation that did or did not use a feedback device or a backboard were compared using independent t-testing. Differences in chest compressions at the target depth, release, and rate between the numbers of staff involved were assessed using ANOVA. Agreement between devices (CPRMeter2 and LifePak) used during the resuscitations were evaluated using paired t-testing, Pearson correlations, and Bland-Altman plots. All tests were two-tailed with predetermined significance levels set at a=0.05. Results: Data collection occurred between August 2019 and December 2020. There were a total of 50 cardiac arrests included, 36 had questionnaire data returned, 36 had data collected from the CPR meter 2, 24 had data collected from the LifePak, and 10 had data collected using all three methods. The average duration of resuscitation (number of chest compressions) was 1079.56 (SD=858.25); there was no difference in the duration of resuscitation (number of chest compressions) between resuscitations using versus not using CPR feedback devices (p=0.673). Resuscitations utilizing chest compression feedback had a higher percentage of chest compressions at the target rate compared to resuscitations not using feedback (74.08% vs 42.18%, p=0.007). Resuscitations that utilized a backboard had a higher percentage of chest compressions at target depth (72.92% vs 48.73%, p=0.048). There were no differences noted in the duration of resuscitation attempt (p=0.167) or percentages of chest compressions at the target depth (p=0.181), release (p=0.538), or rate (p=0.656) between resuscitations with different sized teams (4-5, 6-7, 8-9, >10 staff involved). There was a strong positive correlation (r=0.771, p=0.005, n=11) between the two measurement methods and chest compression rates, and no statistically significant difference in measured scores (p=0.999), with 100% of values falling within the Bland-Altman confidence intervals of 36.72 and -36.72, n=11. Interpretation of the levels of agreement between these two device measures methods should be done cautiously however, given the small sample size and wide confidence intervals. Implications 1) Incorporation of visual chest compression feedback and use of a backboard are fast andaffordable and significantly improved the percentage of chest compression at the target rateand depth. 2) There was no correlation between the size of the resuscitation team and the percentage ofchest compressions at the target depth, release or rate; nor was the feedback device useassociated with the duration of the resuscitation attempt. 3) The implications of improvement with the CPR meter suggests that areas or service not usingfeedback should consider implementing its use to achieve the target compression rate. 4) Compared to LifePak feedback alone the CPRMeter2 will also allow services to target depthand release targets as well as rate.

Association of Psychological Distress, Contextual Factors, and Individual Differences Among Citizen Responders

Background Little is known about the psychological risks of dispatched citizen responders who have participated in resuscitation attempts. Methods and Results A cross‐sectional survey study was performed with 102 citizen responders who participated in a resuscitation attempt from July 23, 2018, to August 22, 2018, in the Capital Region of Denmark. Psychological distress, defined as symptoms of posttraumatic stress disorder, was assessed 3 weeks after the resuscitation attempt and measured with the Impact of Event Scale‐Revised. Perceived stress was measured with the Perceived Stress Scale. Individual differences were assessed as the personality traits of agreeableness, conscientiousness, extraversion, neuroticism, and openness to experience with the Big Five Inventory, general self‐efficacy, and coping mechanisms (Brief Coping Orientation to Problems Experienced Inventory). Associations between continuous variables were examined with the Pearson correlation. The associations between psychological distress levels and contextual factors and individual differences were analyzed in multivariable linear regression models to determine factors independently associated with psychological distress levels. The mean overall posttraumatic stress disorder score was 0.65 of 12; the mean perceived stress score was 7.61 of 40. The most common coping mechanisms were acceptance and emotional support. Low perceived stress was significantly associated with high general self‐efficacy, and high perceived stress was significantly associated with high scores on neuroticism and openness to experience. Non–healthcare professionals were less likely to report symptoms of posttraumatic stress disorder. Conclusions Citizen responders who participated in resuscitation reported low levels of psychological distress. Individual differences were significantly associated with levels of psychological distress and should be considered when engaging citizen responders in resuscitation.

Immediate intravenous epinephrine versus early intravenous epinephrine for in-hospital cardiopulmonary arrest

Background Intravenous epinephrine has been a key treatment in cardiopulmonary arrest since the early 1960s. The ideal timing for the first dose of epinephrinee is uncertain. We aimed to investigate the association of immediate epinephrine administration (within 1-min of recognition of cardiac arrest) with return of spontaneous circulation (ROSC) up to 24-h. Methods This was a multicenter retrospective analysis of patients who underwent cardiopulmonary resuscitation. We included the following patients: 1) ≥18 years-old, 2) non-shockable rhythms, 3) received intravenous epinephrine during cardiopulmonary resuscitation, 4) witnessed in-hospital arrest and 5) first resuscitation attempt (for patients requiring more than one resuscitation attempt). We excluded patients who suffered from traumatic arrest, were pregnant, had shockable rhythms, arrested in the operating room, with Do-Not-Resuscitate (DNR) order, and patient aged 17 years-old or less. Results A total of 360 patients were included in the analysis. Median age was 62 years old and median epinephrine administration time was two minutes. We found that immediate epinephrine administration (within 1-min) is associated with higher rates of ROSC up to 24-h (OR = 1.25, 95% CI; [1.01–1.56]), compared with early epinephrine (≥2-min) administration. After adjusting for confounding covariates, earlier administration of epinephrine predicted higher rates of ROSC sustained for up to 24-h (OR 1.33 95%CI [1.13–1.55]). Conclusions Immediate administration of epinephrine in conjunction with high-quality CPR is associated with higher rates of ROSC.

Temporal Trends of Out-of-Hospital Cardiac Arrests Without Resuscitation Attempt by Emergency Medical Services

Background: Significant improvements in survival from out-of-hospital cardiac arrest (OHCA) have been reported; however, these are based only on data from OHCA in whom resuscitation is initiated by emergency medical services (EMS). We aimed to assess the characteristics and temporal trends of OHCA without resuscitation attempt by EMS. Methods: Prospective population-based study between 2011 and 2016 in the Greater Paris area (6.7 million inhabitants). All cases of OHCA were included in collaboration with EMS units, 48 different hospitals, and forensic units. Results: Among 15 207 OHCA (mean age 70.7±16.9 years, 61.6% male), 5486 (36.1%) had no resuscitation attempt by EMS. Factors that were independently associated with increase in likelihood of no resuscitation attempt included: age of patients (odds ratio, 1.06 per year [95% CI, 1.05–1.06], P <0.001), female sex (odds ratio, 1.21 [95% CI, 1.10–1.32], P =0.002), OHCA at home location (odds ratio, 3.38 [95%CI, 2.86–4.01], P <0.001), and absence of bystander (odds ratio, 1.94 [95% CI, 1.74–2.16], P <0.001). Overall, the annual number of OHCA increased by 9.1% (from 2923 to 3189, P =0.028). This increase was related to an increase of the annual number of OHCA without resuscitation attempt by EMS by 26.3% (from 993 to 1253, P =0.012), while the annual number of OHCA with resuscitation attempt by EMS did not significantly change (from 1930 to 1936, P =0.416). Considering only cases with resuscitation attempt, survival rate at hospital discharge increased (from 7.3% to 9.5%, P =0.02). However, when considering all OHCA, survival improvement did not reach statistical significance (from 4.8% to 5.7%, P =0.17). Conclusions: We demonstrated an increase of the total number of OHCA related to an increase of the number of OHCA without resuscitation attempt by EMS. This increasing proportion of OHCA without resuscitation attempt attenuates improvement in survival rates achieved in EMS-treated patients.

Abstract 368: Does Filtered Rhythm Technology Lead to Increased Inappropriate Manual Defibrillation?

Introduction: Defibrillation of ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) is an effective treatment for patients with cardiac arrest (CA). Identifying the rhythm during cardiopulmonary resuscitation (CPR) can be difficult with the rhythm obscured by chest compression artifact. “Rhythm” checks are usually recommended, but this interrupts the resuscitation attempt. Filtered rhythm technology such as See-Thru CPR aims to reduce these interruptions by filtering out chest compression artifact, leading to easier visualization of the underlying heart rhythm without stopping CPR. Hypothesis: While See-Thru CPR is effective at improving chest compression fraction, inappropriate shocks of non-VF/VT rhythms are still common. Methods: This is a retrospective review of an internal database of all cardiac arrests occurring within a two-hospital academic hospital system between July 2012 and September 2019. The local CPR algorithm trains responders to utilize See-Thru CPR to minimize interruptions and increase the chest compression fraction (the average chest compression fraction is > 90%). The database includes all inpatient and emergency room CA and includes patient demographics, cardiac and resuscitation data including CPR parameter data when available, and outcomes. Cardiac arrests with CPR data were reviewed and all defibrillation attempts were identified and analyzed. Pre and post-shock rhythm were identified by reviewing the preceding rhythm strip, and the rhythm following the defibrillation delivery. Results: Three hundred thirty-six patients had CA with complete CPR data containing defibrillation attempts. These 336 patients had 1199 defibrillations delivered. Between 1 - 39 shocks were delivered during each event. The majority of defibrillations were delivered correctly for VF/VT (916/1199, 76%), however 23.6% of defibrillations were inappropriate - PEA in 232 attempts (19%) and asystole in 51 (4%). Of these inappropriate shocks, 23 converted to either VF/VT or ROSC, while the rest maintained a non-VF/VT rhythm. Conclusions: Defibrillation while using See-Thru CPR for inappropriate shocks is common. Further studies will be needed to show the clinical effects of shocking non-VF/VT rhythms.