今日の臨床サポート

心肺停止

著者: 田中敏春 JA 新潟厚生連 上越総合病院 救急科

監修: 箕輪良行 みさと健和病院 救急総合診療研修顧問

著者校正/監修レビュー済:2019/09/06
患者向け説明資料

概要・推奨   

  1. 医療従事者は、すべての成人心肺停止状態の患者に対して胸骨圧迫を実施するべきである(推奨度1)。
  1. 心肺停止状態の傷病者には、特に質の高い胸骨圧迫が重要であり、胸骨圧迫からCPRを開始する(推奨度1)。
  1. 質の高い胸骨圧迫とは、約100回~120/分のテンポで、約5cmの深さで行うことである(推奨度1)。
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  1. 気管挿管チューブの正確な位置確認のために最も信頼性が高い方法は、“波形表示呼気CO2モニター(PETCO2)”である(推奨度1)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
田中敏春 : 特に申告事項無し[2021年]
監修:箕輪良行 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、画像の出典を変更した。 

まとめ

疾患情報(疫学・病態)  
  1. 突然の心肺停止は、その予防において重要な進歩がみられるものの、依然として世界各国における主要な死亡原因となっている[1]
  1. 米国では、院外での心肺停止の推定発生件数は年間10万人あたり約50~55人とされる[2]
  1. 院内での心肺停止発生件数は、入院患者1,000人あたり3~6人とされ、そのうち約25%に無脈性心室性不整脈(心室細動、無脈性心室頻拍)がみられる[3]
  1. ほとんどの成人における心肺停止は、心原性かつ突発性である。一方、小児における心肺停止は、その多くが呼吸原性である。
  1. 突然の心肺停止の約80%が冠動脈疾患によるものとされ、冠動脈疾患および慢性低左心機能を既往に持つ患者では突然の心肺停止のリスクが増大する。
  1. 米国での院外で目撃された突然の心肺停止に陥った傷病者に対する生存退院率は平均5%である[2]
  1. 院外で心肺停止状態となった成人で、居合わせた人(バイスタンダー)による心肺蘇生法(CPR)を受けた人の割合は、わずか約20~30%である[4][5]
 
  1. 状態が悪化しつつある患者が心肺停止に移行することを早期介入によって予防するために、院内で迅速対応チーム(rapid response team:RRT)または救急医療チーム(medical emergency team:MET)の設置は一般病棟における成人の心肺停止発生率低下に有効である(推奨度2)。
  1. 院内での心停止前迅速対応システムの構築:
  1. 状態が悪化しつつある患者が心肺停止に移行することを早期介入によって予防するために、院内で迅速対応チーム(rapid response team:RRT)または救急医療チーム(medical emergency team:MET)の設置は一般病棟における成人の心肺停止発生率低下に有効である。
  1. これらのチームは、病院スタッフが患者の状態悪化を認知した時点で患者のベッドサイドに緊急招集され、携行しているモニタリング装置、蘇生器具、薬剤等で早期に介入する。1件の病棟でのランダム化試験[6]および複数の観察研究で、これらシステムの導入に伴い院内心肺停止発生率が有意に低下したことを示した[7]
 
  1. 呼吸循環補助装置を用いたCPR(ECPR)のルーチン使用について推奨するに足る十分なエビデンスはないが、ECPRをただちに使用できる状況では、一部の心停止(予想される心停止の原因が回復し得る場合)患者に対してECPRを考慮してもよいかも知れない(推奨度2)。
  1. 1件の前向きランダム化試験では、CPR中の気管挿管患者において搬送用自動人工呼吸器の使用により、バッグマスク器具と類似の換気と酸素供給がもたらされ、その間に医療チームは他の作業を実施することができると報告されている[8]
  1. 1件の同時対照を用いた症例蓄積研究および1件の多施設前向きランダム化比較試験では、CPR中の機械的ピストン圧迫器具(LUCASなど) または荷重分散式バンド器具(AutoPulseなど)の使用による生存率における有益性は示されなかった[9][10]
  1. 2件の前向き研究では、従来のCPRに反応しない院外心停止に対しPCPSによる循環補助と34℃の低体温療法を組み合わせた場合、12~52%の症例で神経学的転帰が良好であった[11][12]
  1. 複数の症例集積研究と観察研究で体外循環装置を用いてのCPRは、従来のCPRと比較した場合に生存率が向上する可能性が示されたが、ランダム化臨床試験の報告例は無い[13][14]
  1. 院内発生の心肺停止患者172例を対象に、傾向スコアマッチングを用いて検討した前向き観察研究では、10分超のCPRを受けた患者でECPRを実施された場合のROSC達成率が従来のCPR群よりも高く、生存退院率、30日生存率、1年後生存率(追跡調査による)も改善したが、神経学的予後には差を認めなかった[13]
  1. 院内発生の心肺停止患者120例と対照群を検討した後ろ向き観察研究では、ECPRのほうが従来のCPRより退院時と追跡6カ月後の生存率と神経学的予後がわずかに優れていた[15]
  1. 20分を超える従来のCPRを実施されたがROSCしなかった院外心肺停止患者162例を対象とした前向きコホートから得たデータを傾向スコアマッチングして解析した結果では、ECPRのほうが神経学的な障害を残さない3カ月後生存率が高くなることが示された[16]
  1. 病院到着後に従来のALSを15分超実施されたがROSCしなかった場合にECPRを実施された454例を対象とした前向き観察研究では、心停止の1カ月後、6カ月後の神経学的予後がECPRにより改善したことが示された[17]
  1. 心原性の心停止後に10分超のCPRと引き続いてECPRを実施された院内発生心肺停止患者118例を対象にした傾向スコアマッチングによる後ろ向き観察研究では、退院時、フォローアップ30日後あるいは1年後に、従来のCPRと比較して生存率および神経学的予後に対する有益性を認めなかった[18]
  1. 以上より、心肺停止患者に対して呼吸循環補助装置を用いたCPRのルーチン実施は推奨されない。ただし、心停止による循環停止時間が比較的短く、心停止の原因を解除することが見込まれる場合(偶発性低体温、薬物中毒、STEMIなど)には、ECPR(主にPCPS)を考慮してもよいかも知れない。
 
  1. 心肺蘇生に家族を立ち会わせることは推奨される(推奨度2)。
  1. 調査によれば、家族が蘇生の場面に立ち会うことについて医療従事者の間でもさまざまな意見がある[19][20]
  1. 家族を蘇生中に立ち会わせることについての懸念事項は、蘇生現場を見ることで家族が混乱したり、蘇生手順に干渉したりすることであるが、そうした文献報告例はない。
  1. 複数の調査によれば、家族の大多数は、家族の最期に立ち会い、別れを告げることが慰めになるため蘇生中に立ち会うことを希望していると考えられる[21][22]
  1. 家族の立ち会いが有害となることを示すデータはなく、かつ有益であることをデータが示唆しており、蘇生中に家族を立ち会わせることは望ましい。蘇生チームのメンバーは、蘇生中に家族が立ち会うことに配慮すべきであり、家族に状況を説明し安心させる役割を担う必要がある。
問診・診察のポイント  
  1. 心肺停止患者に対しては、効果的な胸骨圧迫(強く・速く・絶え間なく)を実施する。

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文献 

著者: Thomas D Rea, Michael Helbock, Stephen Perry, Michele Garcia, Don Cloyd, Linda Becker, Mickey Eisenberg
雑誌名: Circulation. 2006 Dec 19;114(25):2760-5. doi: 10.1161/CIRCULATIONAHA.106.654715. Epub 2006 Dec 11.
Abstract/Text BACKGROUND: The most recent resuscitation guidelines have sought to improve the interface between defibrillation and cardiopulmonary resuscitation; the survival impact of these changes is unknown, however. A year before issuance of the most recent guidelines, we implemented protocol changes that provided a single shock without rhythm reanalysis, stacked shocks, or postdefibrillation pulse check, and extended the period of cardiopulmonary resuscitation from 1 to 2 minutes. We hypothesized that survival would be better with the new protocol.
METHODS AND RESULTS: The present study took place in a community with a 2-tiered emergency medical services response and an established system of cardiac arrest surveillance, training, and review. The investigation was a cohort study of persons who had bystander-witnessed out-of-hospital ventricular fibrillation arrest because of heart disease, comparing a prospectively defined intervention group (January 1, 2005, to January 31, 2006) with a historical control group that was treated according to previous guidelines of rhythm reanalysis, stacked shocks, and postdefibrillation pulse checks (January 1, 2002, to December 31, 2004). The primary outcome was survival to hospital discharge. The proportion of treated arrests that met inclusion criteria was similar for intervention and control periods (15.4% [134/869] versus 16.6% [374/2255]). Survival to hospital discharge was significantly greater during the intervention period compared with the control period (46% [61/134] versus 33% [122/374], P=0.008) and corresponded to a decrease in the interval from shock to start of chest compressions (28 versus 7 seconds). Adjustment for covariates did not alter the survival association.
CONCLUSIONS: These results suggest the new resuscitation guidelines will alter the interface between defibrillation and cardiopulmonary resuscitation and in turn may improve outcomes.

PMID 17159062  Circulation. 2006 Dec 19;114(25):2760-5. doi: 10.1161/C・・・
著者: Graham Nichol, Elizabeth Thomas, Clifton W Callaway, Jerris Hedges, Judy L Powell, Tom P Aufderheide, Tom Rea, Robert Lowe, Todd Brown, John Dreyer, Dan Davis, Ahamed Idris, Ian Stiell, Resuscitation Outcomes Consortium Investigators
雑誌名: JAMA. 2008 Sep 24;300(12):1423-31. doi: 10.1001/jama.300.12.1423.
Abstract/Text CONTEXT: The health and policy implications of regional variation in incidence and outcome of out-of-hospital cardiac arrest remain to be determined.
OBJECTIVE: To evaluate whether cardiac arrest incidence and outcome differ across geographic regions.
DESIGN, SETTING, AND PATIENTS: Prospective observational study (the Resuscitation Outcomes Consortium) of all out-of-hospital cardiac arrests in 10 North American sites (8 US and 2 Canadian) from May 1, 2006, to April 30, 2007, followed up to hospital discharge, and including data available as of June 28, 2008. Cases (aged 0-108 years) were assessed by organized emergency medical services (EMS) personnel, did not have traumatic injury, and received attempts at external defibrillation or chest compressions or resuscitation was not attempted. Census data were used to determine rates adjusted for age and sex.
MAIN OUTCOME MEASURES: Incidence rate, mortality rate, case-fatality rate, and survival to discharge for patients assessed or treated by EMS personnel or with an initial rhythm of ventricular fibrillation.
RESULTS: Among the 10 sites, the total catchment population was 21.4 million, and there were 20,520 cardiac arrests. A total of 11,898 (58.0%) had resuscitation attempted; 2729 (22.9% of treated) had initial rhythm of ventricular fibrillation or ventricular tachycardia or rhythms that were shockable by an automated external defibrillator; and 954 (4.6% of total) were discharged alive. The median incidence of EMS-treated cardiac arrest across sites was 52.1 (interquartile range [IQR], 48.0-70.1) per 100,000 population; survival ranged from 3.0% to 16.3%, with a median of 8.4% (IQR, 5.4%-10.4%). Median ventricular fibrillation incidence was 12.6 (IQR, 10.6-5.2) per 100,000 population; survival ranged from 7.7% to 39.9%, with a median of 22.0% (IQR, 15.0%-24.4%), with significant differences across sites for incidence and survival (P<.001).
CONCLUSION: In this study involving 10 geographic regions in North America, there were significant and important regional differences in out-of-hospital cardiac arrest incidence and outcome.

PMID 18812533  JAMA. 2008 Sep 24;300(12):1423-31. doi: 10.1001/jama.30・・・
著者: T D Valenzuela, D J Roe, S Cretin, D W Spaite, M P Larsen
雑誌名: Circulation. 1997 Nov 18;96(10):3308-13.
Abstract/Text BACKGROUND: The study objective was to develop a simple, generalizable predictive model for survival after out-of-hospital cardiac arrest due to ventricular fibrillation.
METHODS AND RESULTS: Logistic regression analysis of two retrospective series (n=205 and n=1667, respectively) of out-of-hospital cardiac arrests was performed on data sets from a Southwestern city (population, 415,000; area, 406 km2) and a Northwestern county (population, 1,038,000; area, 1399 km2). Both are served by similar two-tiered emergency response systems. All arrests were witnessed and occurred before the arrival of emergency responders, and the initial cardiac rhythm observed was ventricular fibrillation. The main outcome measure was survival to hospital discharge. Patient age, initiation of CPR by bystanders, interval from collapse to CPR, interval from collapse to defibrillation, bystander CPR/collapse-to-CPR interval interaction, and collapse-to-CPR/collapse-to-defibrillation interval interaction were significantly associated with survival. There was not a significant difference between observed survival rates at the two sites after control for significant predictors. A simplified predictive model retaining only collapse to CPR and collapse to defibrillation intervals performed comparably to the more complicated explanatory model.
CONCLUSIONS: The effectiveness of prehospital interventions for out-of-hospital cardiac arrest may be estimated from their influence on collapse to CPR and collapse to defibrillation intervals. A model derived from combined data from two geographically distinct populations did not identify site as a predictor of survival if clinically relevant predictor variables were controlled for. This model can be generalized to other US populations and used to project the local effectiveness of interventions to improve cardiac arrest survival.

PMID 9396421  Circulation. 1997 Nov 18;96(10):3308-13.
著者: SOS-KANTO study group
雑誌名: Lancet. 2007 Mar 17;369(9565):920-6. doi: 10.1016/S0140-6736(07)60451-6.
Abstract/Text BACKGROUND: Mouth-to-mouth ventilation is a barrier to bystanders doing cardiopulmonary resuscitation (CPR), but few clinical studies have investigated the efficacy of bystander resuscitation by chest compressions without mouth-to-mouth ventilation (cardiac-only resuscitation).
METHODS: We did a prospective, multicentre, observational study of patients who had out-of-hospital cardiac arrest. On arrival at the scene, paramedics assessed the technique of bystander resuscitation. The primary endpoint was favourable neurological outcome 30 days after cardiac arrest.
FINDINGS: 4068 adult patients who had out-of-hospital cardiac arrest witnessed by bystanders were included; 439 (11%) received cardiac-only resuscitation from bystanders, 712 (18%) conventional CPR, and 2917 (72%) received no bystander CPR. Any resuscitation attempt was associated with a higher proportion having favourable neurological outcomes than no resuscitation (5.0%vs 2.2%, p<0.0001). Cardiac-only resuscitation resulted in a higher proportion of patients with favourable neurological outcomes than conventional CPR in patients with apnoea (6.2%vs 3.1%; p=0.0195), with shockable rhythm (19.4%vs 11.2%, p=0.041), and with resuscitation that started within 4 min of arrest (10.1%vs 5.1%, p=0.0221). However, there was no evidence for any benefit from the addition of mouth-to-mouth ventilation in any subgroup. The adjusted odds ratio for a favourable neurological outcome after cardiac-only resuscitation was 2.2 (95% CI 1.2-4.2) in patients who received any resuscitation from bystanders.
INTERPRETATION: Cardiac-only resuscitation by bystanders is the preferable approach to resuscitation for adult patients with witnessed out-of-hospital cardiac arrest, especially those with apnoea, shockable rhythm, or short periods of untreated arrest.

PMID 17368153  Lancet. 2007 Mar 17;369(9565):920-6. doi: 10.1016/S0140・・・
著者: Taku Iwami, Takashi Kawamura, Atsushi Hiraide, Robert A Berg, Yasuyuki Hayashi, Tatsuya Nishiuchi, Kentaro Kajino, Naohiro Yonemoto, Hidekazu Yukioka, Hisashi Sugimoto, Hiroyuki Kakuchi, Kazuhiro Sase, Hiroyuki Yokoyama, Hiroshi Nonogi
雑誌名: Circulation. 2007 Dec 18;116(25):2900-7. doi: 10.1161/CIRCULATIONAHA.107.723411. Epub 2007 Dec 10.
Abstract/Text BACKGROUND: Previous animal and clinical studies suggest that bystander-initiated cardiac-only resuscitation may be superior to conventional cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrests. Our hypothesis was that both cardiac-only bystander resuscitation and conventional bystander CPR would improve outcomes from out-of-hospital cardiac arrests of < or = 15 minutes' duration, whereas the addition of rescue breathing would improve outcomes for cardiac arrests lasting > 15 minutes.
METHODS AND RESULTS: We carried out a prospective, population-based, observational study involving consecutive patients with emergency responder resuscitation attempts from May 1, 1998, through April 30, 2003. The primary outcome measure was 1-year survival with favorable neurological outcome. Multivariable logistic regression analysis was performed to evaluate the relationship between type of CPR and outcomes. Among the 4902 witnessed cardiac arrests, 783 received conventional CPR, and 544 received cardiac-only resuscitation. Excluding very-long-duration cardiac arrests (> 15 minutes), the cardiac-only resuscitation yielded a higher rate of 1-year survival with favorable neurological outcome than no bystander CPR (4.3% versus 2.5%; odds ratio, 1.72; 95% CI, 1.01 to 2.95), and conventional CPR showed similar effectiveness (4.1%; odds ratio, 1.57; 95% CI, 0.95 to 2.60). For the very-long-duration arrests, neurologically favorable 1-year survival was greater in the conventional CPR group, but there were few survivors regardless of the type of bystander CPR (0.3% [2 of 624], 0% [0 of 92], and 2.2% [3 of 139] in the no bystander CPR, cardiac-only CPR, and conventional CPR groups, respectively; P<0.05).
CONCLUSIONS: Bystander-initiated cardiac-only resuscitation and conventional CPR are similarly effective for most adult out-of-hospital cardiac arrests. For very prolonged cardiac arrests, the addition of rescue breathing may be of some help.

PMID 18071072  Circulation. 2007 Dec 18;116(25):2900-7. doi: 10.1161/C・・・
著者: George Priestley, Wendy Watson, Arash Rashidian, Caroline Mozley, Daphne Russell, Jonathan Wilson, Judith Cope, Dianne Hart, Diana Kay, Karen Cowley, Jayne Pateraki
雑誌名: Intensive Care Med. 2004 Jul;30(7):1398-404. doi: 10.1007/s00134-004-2268-7. Epub 2004 Apr 27.
Abstract/Text OBJECTIVE: The purpose of the study was to investigate the effects of introducing a critical care outreach service on in-hospital mortality and length of stay in a general acute hospital.
DESIGN: A pragmatic ward-randomised trial design was used, with intervention introduced to all wards in sequence. No blinding was possible.
SETTING: Sixteen adult wards in an 800-bed general hospital in the north of England.
PATIENTS AND PARTICIPANTS: All admissions to the 16 surgical, medical and elderly care wards during 32-week study period were included (7450 patients in total, of whom 2903 were eligible for the primary comparison).
INTERVENTIONS: Essential elements of the Critical Care Outreach service introduced during the study were a nurse-led team of nurses and doctors experienced in critical care, a 24-h service, emphasis on education, support and practical help for ward staff.
MEASUREMENTS AND RESULTS: The main outcome measures were in-hospital mortality and length of stay. Outreach intervention reduced in-hospital mortality compared with control (two-level odds ratio: 0.52 (95% CI 0.32-0.85). A possible increased length of stay associated with outreach was not fully supported by confirmatory and sensitivity analyses.
CONCLUSIONS: The study suggests outreach reduces mortality in general hospital wards. It may also increase length of stay, but our findings on this are equivocal.

PMID 15112033  Intensive Care Med. 2004 Jul;30(7):1398-404. doi: 10.10・・・
著者: Saad Al-Qahtani, Hasan M Al-Dorzi, Hani M Tamim, Sajid Hussain, Lian Fong, Saadi Taher, Bandar Abdulmohsen Al-Knawy, Yaseen Arabi
雑誌名: Crit Care Med. 2013 Feb;41(2):506-17. doi: 10.1097/CCM.0b013e318271440b.
Abstract/Text OBJECTIVE: The effectiveness of rapid response teams remains controversial. However, many studied rapid response teams were not intensivist-led, had limited involvement beyond the initial activations, and did not provide post-ICU follow-up. The objective of this study was to examine the impact of implementing an intensivist-led multidisciplinary extended rapid response team on hospital-wide cardiopulmonary arrests and mortality.
DESIGN: This was a pre-post rapid response team implementation study.
SETTING: : Tertiary care academic center in Saudi Arabia.
PATIENTS: A total of 98,391 patients in the 2-yr pre-rapid response team and 157,804 patients in the 3-yr post-rapid response team implementation were evaluated.
INTERVENTION: The rapid response team was activated by any health care provider based on pre-defined criteria and a four-member intensivist-led multidisciplinary rapid response team responded to provide the necessary management and disposition. The rapid response team function was extended to provide follow-up until clinical stabilization. In addition, the rapid response team provided a mandatory post-ICU follow-up for a minimum of 48 hrs.
MEASUREMENTS AND MAIN RESULTS: The primary outcomes were cardiopulmonary arrests and mortality. After rapid response team implementation, non-ICU cardiopulmonary arrests decreased from 1.4 to 0.9 per 1,000 hospital admissions (relative risk, 0.68; 95% confidence interval, 0.53-0.86; p = 0.001) and total hospital mortality decreased from 22.5 to 20.2 per 1,000 hospital admissions (relative risk, 0.90; 95% confidence interval, 0.85-0.95; p < 0.0001). For patients who required admission to the ICU, there was a significant reduction in the Acute Physiology and Chronic Health Evaluation II scores after rapid response team implementation from 29.3 ± 9.3 to 26.9 ± 8.5 (p < 0.0001), with reduction in hospital mortality from 57.4% to 48.7% (relative risk, 0.85; 95% confidence interval, 0.78-0.92; p < 0.0001). Do-not-resuscitate orders for ward referrals increased from 0.7 to 1.7 per 1,000 hospital admissions (relative risk, 2.58; 95% confidence interval, 1.95-3.42; p < 0.0001) and decreased for patients admitted to ICU from the wards from 30.5% to 26.1% (relative risk, 0.86; 95% confidence interval, 0.74-0.99; p = 0.03). Additionally, ICU readmission rate decreased from 18.6 to 14.3 per 100 ICU alive discharges (relative risk, 0.77; 95% confidence interval, 0.66-0.89; p < 0.0001) and post-ICU hospital mortality from 18.2% to 14.8% (relative risk, 0.85; 95% confidence interval, 0.72-0.99; p = 0.04).
CONCLUSION: The implementation of rapid response team was effective in reducing cardiopulmonary arrests and total hospital mortality for ward patients, improving the outcomes of patients who needed ICU admission and reduced readmissions and mortality of patients who were discharged from the ICU.

PMID 23263618  Crit Care Med. 2013 Feb;41(2):506-17. doi: 10.1097/CCM.・・・
著者: Steven J Weiss, Amy A Ernst, Ray Jones, Margaret Ong, Todd Filbrun, Chad Augustin, Mike Barnum, Todd G Nick
雑誌名: South Med J. 2005 Oct;98(10):970-6. doi: 10.1097/01.smj.0000182177.01436.70.
Abstract/Text PURPOSE: The primary objective of this study was to compare Emergency Medical Technicians-Paramedics (EMT-P) perceptions of the usefulness of an automatic transport ventilator (ATV) compared with bag valve (BV) ventilation for intubated patients.
METHODS: Cardiopulmonary resuscitation or assisted ventilation patients were randomly assigned by day to the ATV or BV arm of the study. Questionnaires were completed by the EMT-Ps at the conclusion of each patient enrollment. EMT-Ps were asked to rate the modality used (ATV versus BV) on ease of use, time of setup, expedition of transport, additional tasks completed, documentation, overall patient care, and patient comfort.
RESULTS: Twenty-eight patients were entered into the study, 14 in the BV arm and 14 in the ATV arm. There were significant differences in favor of the ATV in ability to accomplish additional tasks (P = 0.01), ability to document (P = 0.04), and ability to provide patient care (P = 0.03)
CONCLUSIONS: EMT-Ps were able to accomplish more tasks, document more completely, and provide better patient care with the use of the ATV.

PMID 16295811  South Med J. 2005 Oct;98(10):970-6. doi: 10.1097/01.smj・・・
著者: Christer Axelsson, Johan Nestin, Leif Svensson, Asa B Axelsson, Johan Herlitz
雑誌名: Resuscitation. 2006 Oct;71(1):47-55. doi: 10.1016/j.resuscitation.2006.02.011. Epub 2006 Aug 30.
Abstract/Text AIM: To evaluate the outcome among patients suffering from out-of-hospital cardiac arrest (OHCA) after the introduction of mechanical chest compression (MCC) compared with standard cardiopulmonary resuscitation (SCPR) in two emergency medical service (EMS) systems.
METHODS: The inclusion criterion was witnessed OHCA. The exclusion criteria were age < 18 years, the following judged etiologies behind OHCA: trauma, pregnancy, hypothermia, intoxication, hanging and drowning or return of spontaneous circulation (ROSC) prior to the arrival of the advanced life support (ALS) unit. Two MCC devices were allocated during six-month periods between four ALS units for a period of two years (cluster randomisation).
RESULTS: In all, 328 patients fulfilled the criteria for participation and 159 were allocated to the MCC tier (the device was used in 66% of cases) and 169 to the SCPR tier. In the MCC tier, 51% had ROSC (primary end-point) versus 51% in the SCPR tier. The corresponding values for hospital admission alive (secondary end-point) were 38% and 37% (NS). In the subset of patients in whom the device was used, the percentage who had ROSC was 49% versus 50% in a control group matched for age, initial rhythm, aetiology, bystander-/crew-witnessed status and delay to CPR. The percentage of patients discharged alive from hospital after OHCA was 8% versus 10% (NS) for all patients and 2% versus 4%, respectively (NS) for the patients in the subset (where the device was used and the matched control population).
CONCLUSION: In this pilot study, the results did not support the hypothesis that the introduction of mechanical chest compression in OHCA improves outcome. However, there is room for further improvement in the use of the device. The hypothesis that this will improve outcome needs to be tested in further prospective trials.

PMID 16945472  Resuscitation. 2006 Oct;71(1):47-55. doi: 10.1016/j.res・・・
著者: Al Hallstrom, Thomas D Rea, Michael R Sayre, James Christenson, Andy R Anton, Vince N Mosesso, Lois Van Ottingham, Michele Olsufka, Sarah Pennington, Lynn J White, Stephen Yahn, James Husar, Mary F Morris, Leonard A Cobb
雑誌名: JAMA. 2006 Jun 14;295(22):2620-8. doi: 10.1001/jama.295.22.2620.
Abstract/Text CONTEXT: High-quality cardiopulmonary resuscitation (CPR) may improve both cardiac and brain resuscitation following cardiac arrest. Compared with manual chest compression, an automated load-distributing band (LDB) chest compression device produces greater blood flow to vital organs and may improve resuscitation outcomes.
OBJECTIVE: To compare resuscitation outcomes following out-of-hospital cardiac arrest when an automated LDB-CPR device was added to standard emergency medical services (EMS) care with manual CPR.
DESIGN, SETTING, AND PATIENTS: Multicenter, randomized trial of patients experiencing out-of-hospital cardiac arrest in the United States and Canada. The a priori primary population was patients with cardiac arrest that was presumed to be of cardiac origin and that had occurred prior to the arrival of EMS personnel. Initial study enrollment varied by site, ranging from late July to mid November 2004; all sites halted study enrollment on March 31, 2005.
INTERVENTION: Standard EMS care for cardiac arrest with an LDB-CPR device (n = 554) or manual CPR (n = 517).
MAIN OUTCOME MEASURES: The primary end point was survival to 4 hours after the 911 call. Secondary end points were survival to hospital discharge and neurological status among survivors.
RESULTS: Following the first planned interim monitoring conducted by an independent data and safety monitoring board, study enrollment was terminated. No difference existed in the primary end point of survival to 4 hours between the manual CPR group and the LDB-CPR group overall (N = 1071; 29.5% vs 28.5%; P = .74) or among the primary study population (n = 767; 24.7% vs 26.4%, respectively; P = .62). However, among the primary population, survival to hospital discharge was 9.9% in the manual CPR group and 5.8% in the LDB-CPR group (P = .06, adjusted for covariates and clustering). A cerebral performance category of 1 or 2 at hospital discharge was recorded in 7.5% of patients in the manual CPR group and in 3.1% of the LDB-CPR group (P = .006).
CONCLUSIONS: Use of an automated LDB-CPR device as implemented in this study was associated with worse neurological outcomes and a trend toward worse survival than manual CPR. Device design or implementation strategies require further evaluation.
TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00120965.

PMID 16772625  JAMA. 2006 Jun 14;295(22):2620-8. doi: 10.1001/jama.295・・・
著者: K Nagao, N Hayashi, K Kanmatsuse, K Arima, J Ohtsuki, K Kikushima, I Watanabe
雑誌名: J Am Coll Cardiol. 2000 Sep;36(3):776-83.
Abstract/Text OBJECTIVES: The purpose of this study was to evaluate the efficacy of an alternative cardiopulmonary cerebral resuscitation (CPCR) using emergency cardiopulmonary bypass (CPB), coronary reperfusion therapy and mild hypothermia.
BACKGROUND: Good recovery of patients with out-of-hospital cardiac arrest is still inadequate. An alternative therapeutic method for patients who do not respond to conventional CPCR is required.
METHODS: A prospective preliminary study was performed in 50 patients with out-of-hospital cardiac arrest meeting the inclusion criteria. Patients were treated with standard CPCR and, if there was no response, by emergency CPB plus intra-aortic balloon pumping. Immediate coronary angiography for coronary reperfusion therapy was performed in patients with suspected acute coronary syndrome. Subsequently, in patients with systolic blood pressure above 90 mm Hg and Glasgow coma scale score of 3 to 5, mild hypothermia (34 C for at least two days) was induced by coil cooling. Neurologic outcome was assessed by cerebral performance categories at hospital discharge.
RESULTS: Thirty-six of the 50 patients were treated with emergency CPB, and 30 of 39 patients who underwent angiography suffered acute coronary artery occlusion. Return of spontaneous circulation and successful coronary reperfusion were achieved in 92% and 87%, respectively. Mild hypothermia could be induced in 23 patients, and 12 (52%) of them showed good recovery. Factors related to a good recovery were cardiac index in hypothermia and the presence of serious complications with hypothermia or CPB.
CONCLUSIONS: The alternative CPCR demonstrated an improvement in the incidence of good recovery. Based upon these findings, randomized studies of this hypothermia are needed.

PMID 10987599  J Am Coll Cardiol. 2000 Sep;36(3):776-83.
著者: Ken Nagao, Kimio Kikushima, Kazuhiro Watanabe, Eizo Tachibana, Yoshiteru Tominaga, Katsushige Tada, Mitsuru Ishii, Nobutaka Chiba, Asuka Kasai, Taketomo Soga, Masakazu Matsuzaki, Kei Nishikawa, Yutaka Tateda, Harumi Ikeda, Tsukasa Yagi
雑誌名: Circ J. 2010 Jan;74(1):77-85. Epub 2009 Nov 27.
Abstract/Text BACKGROUND: Therapeutic hypothermia for comatose survivors of out-of-hospital cardiac arrest has demonstrated neurological benefits. Although early cooling during cardiac arrest enhances efficacy in animal studies, few clinical studies are available.
METHODS AND RESULTS: The 171 patients who failed to respond to conventional cardiopulmonary resuscitation were studied prospectively. Patients underwent emergency cardiopulmonary bypass (CPB) plus intra-aortic balloon pumping, with subsequent percutaneous coronary intervention (PCI) if needed. Mild hypothermia (34 degrees C for 3 days) was induced during cardiac arrest or after return of spontaneous circulation. Of the 171 patients, 21 (12.3%) had a favorable neurological outcome at hospital discharge. An unadjusted rate of favorable outcome decreased in a stepwise fashion for increasing quartiles of collapse-to-34 degrees C interval (P=0.016). An adjusted odds ratio for favorable outcome after collapse-to-CPB interval was 0.89 (95% confidence interval (CI) 0.82-0.97) and after CPB-to-34 degrees C interval, 0.99 (95%CI 0.98-0.99) when collapse-to-34 degrees C interval was divided into 2 components. Favorable neurological accuracy of a collapse-to-CPB interval at a cutoff of 55.5 min and CPB-to-34 degrees C interval at a cutoff of 21.5 min was 85.4% and 89.5%, respectively.
CONCLUSIONS: Early attainment of a core temperature had neurological benefits for patients with out-of-hospital cardiac arrest who underwent CPB and PCI. (Circ J 2010; 74: 77 - 85).

PMID 19942784  Circ J. 2010 Jan;74(1):77-85. Epub 2009 Nov 27.
著者: Yih-Sharng Chen, Jou-Wei Lin, Hsi-Yu Yu, Wen-Je Ko, Jih-Shuin Jerng, Wei-Tien Chang, Wen-Jone Chen, Shu-Chien Huang, Nai-Hsin Chi, Chih-Hsien Wang, Li-Chin Chen, Pi-Ru Tsai, Sheoi-Shen Wang, Juey-Jen Hwang, Fang-Yue Lin
雑誌名: Lancet. 2008 Aug 16;372(9638):554-61. doi: 10.1016/S0140-6736(08)60958-7. Epub 2008 Jul 4.
Abstract/Text BACKGROUND: Extracorporeal life-support as an adjunct to cardiac resuscitation has shown encouraging outcomes in patients with cardiac arrest. However, there is little evidence about the benefit of the procedure compared with conventional cardiopulmonary resuscitation (CPR), especially when continued for more than 10 min. We aimed to assess whether extracorporeal CPR was better than conventional CPR for patients with in-hospital cardiac arrest of cardiac origin.
METHODS: We did a 3-year prospective observational study on the use of extracorporeal life-support for patients aged 18-75 years with witnessed in-hospital cardiac arrest of cardiac origin undergoing CPR of more than 10 min compared with patients receiving conventional CPR. A matching process based on propensity-score was done to equalise potential prognostic factors in both groups, and to formulate a balanced 1:1 matched cohort study. The primary endpoint was survival to hospital discharge, and analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00173615.
FINDINGS: Of the 975 patients with in-hospital cardiac arrest events who underwent CPR for longer than 10 min, 113 were enrolled in the conventional CPR group and 59 were enrolled in the extracorporeal CPR group. Unmatched patients who underwent extracorporeal CPR had a higher survival rate to discharge (log-rank p<0.0001) and a better 1-year survival than those who received conventional CPR (log rank p=0.007). Between the propensity-score matched groups, there was still a significant difference in survival to discharge (hazard ratio [HR] 0.51, 95% CI 0.35-0.74, p<0.0001), 30-day survival (HR 0.47, 95% CI 0.28-0.77, p=0.003), and 1-year survival (HR 0.53, 95% CI 0.33-0.83, p=0.006) favouring extracorporeal CPR over conventional CPR.
INTERPRETATION: Extracorporeal CPR had a short-term and long-term survival benefit over conventional CPR in patients with in-hospital cardiac arrest of cardiac origin.

PMID 18603291  Lancet. 2008 Aug 16;372(9638):554-61. doi: 10.1016/S014・・・
著者: Katsutoshi Tanno, Yasushi Itoh, Yoshihiro Takeyama, Satoshi Nara, Kazuhisa Mori, Yasufumi Asai
雑誌名: Am J Emerg Med. 2008 Jul;26(6):649-54. doi: 10.1016/j.ajem.2007.09.019.
Abstract/Text OBJECTIVE: The aim of this study is to describe the effect emergency cardiopulmonary bypass (CPB) for resuscitation on the survival rate of patients.
METHODS: The study population was composed of persons 16 years or older who had out-of-hospital cardiac arrest and were transferred to the Sapporo Medical University Hospital from the scene between January 1, 2000, and September 30, 2004. Children younger than 16 years and persons who were dead were excluded. Data were collected according to the Utstein style. Survival rates and cerebral performance category were analyzed using chi(2) analysis for the patients with presumed cardiac etiology. Cardiopulmonary bypass was applied to patients who showed no response with standard advanced cardiac life support. The interval from collapse and other noncardiac etiologies were considered criteria for exclusion.
RESULTS: Of the 919 patient medical records reviewed, CPB was performed in 92 patients. Of the 919 patients, 398 were of presumed cardiac etiology (n = 66 for CPB), 48 patients survived, and 24 patients (n = 7 for CPB) had a good cerebral outcome (cerebral performance category score 1). With CPB, the rate of survival at 3 months increased significantly (22.7% vs 9.9%, P < .05), but the rate of good cerebral outcome (10.6% vs 5.1%, P = .087) showed a positive trend.
CONCLUSION: The use of CPB for arrest patients was associated with reduced mortality. It did not increase good neurologic outcome significantly. Still, 7 cases with intact central nervous system would have been lost without CPB.

PMID 18606315  Am J Emerg Med. 2008 Jul;26(6):649-54. doi: 10.1016/j.a・・・
著者: Tae Gun Shin, Jin-Ho Choi, Ik Joon Jo, Min Seob Sim, Hyoung Gon Song, Yeon Kwon Jeong, Yong-Bien Song, Joo-Yong Hahn, Seung Hyuk Choi, Hyeon-Cheol Gwon, Eun-Seok Jeon, Kiick Sung, Wook Sung Kim, Young Tak Lee
雑誌名: Crit Care Med. 2011 Jan;39(1):1-7. doi: 10.1097/CCM.0b013e3181feb339.
Abstract/Text OBJECTIVE: We investigated whether the survival of patients with inhospital cardiac arrest could be extended by extracorporeal cardiopulmonary resuscitation supported with extracorporeal membrane oxygenation compared with those of conventional cardiopulmonary resuscitation.
DESIGN: : A retrospective, single-center, observational study.
SETTING: A tertiary care university hospital.
PATIENTS: We retrospectively analyzed a total of 406 adult patients with witnessed inhospital cardiac arrest receiving cardiopulmonary resuscitation for >10 mins from January 2003 to June 2009 (85 in the extracorporeal cardiopulmonary resuscitation group and 321 in the conventional cardiopulmonary resuscitation group).
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: The primary end point was a survival discharge with minimal neurologic impairment. Propensity score matching was used to balance the baseline characteristics and cardiopulmonary resuscitation variables that could potentially affect prognosis. In the matched population (n = 120), the survival discharge rate with minimal neurologic impairment in the extracorporeal cardiopulmonary resuscitation group was significantly higher than that in the conventional cardiopulmonary resuscitation group (odds ratio of mortality or significant neurologic deficit, 0.17; 95% confidence interval, 0.04-0.68; p = .012). In addition, there was a significant difference in the 6-month survival rates with minimal neurologic impairment (hazard ratio, 0.48; 95% confidence interval, 0.29-0.77; p = .003; p <.001 by stratified log-rank test). In the subgroup based on cardiac origin, extracorporeal cardiopulmonary resuscitation also showed benefits for survival discharge (odds ratio, 0.19; 95% confidence interval, 0.04-0.82; p = .026) and 6-month survival with minimal neurologic impairment (hazard ratio, 0.56; 95% confidence interval, 0.33-0.97; p = .038; p = .013 by stratified log-rank test).
CONCLUSIONS: Extracorporeal cardiopulmonary resuscitation showed a survival benefit over conventional cardiopulmonary resuscitation in patients who received cardiopulmonary resuscitation for >10 mins after witnessed inhospital arrest, especially in cases with cardiac origins.

PMID 21057309  Crit Care Med. 2011 Jan;39(1):1-7. doi: 10.1097/CCM.0b0・・・
著者: Kunihiko Maekawa, Katsutoshi Tanno, Mamoru Hase, Kazuhisa Mori, Yasufumi Asai
雑誌名: Crit Care Med. 2013 May;41(5):1186-96. doi: 10.1097/CCM.0b013e31827ca4c8.
Abstract/Text OBJECTIVE: Encouraging results of extracorporeal cardiopulmonary resuscitation for patients with refractory cardiac arrest have been shown. However, the independent impact on the neurologic outcome remains unknown in the out-of-hospital population. Our objective was to compare the neurologic outcome following extracorporeal cardiopulmonary resuscitation and conventional cardiopulmonary resuscitation and determine potential predictors that can identify candidates for extracorporeal cardiopulmonary resuscitation among patients with out-of-hospital cardiac arrest of cardiac origin.
DESIGN: Post hoc analysis of data from a prospective observational cohort.
SETTING: A tertiary care university hospital in Sapporo, Japan (January 2000 to September 2004).
PATIENTS: A total of 162 adult patients with witnessed cardiac arrest of cardiac origin who had undergone cardiopulmonary resuscitation for longer than 20 minutes (53 in the extracorporeal cardiopulmonary resuscitation group and 109 in the conventional cardiopulmonary resuscitation group).
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: The primary endpoint was neurologically intact survival at three months after cardiac arrest. We used propensity score matching to reduce selection bias and balance the baseline characteristics and clinical variables that could potentially affect outcome. This matching process selected 24 patients from each group. The impact of extracorporeal cardiopulmonary resuscitation was estimated in matched patients. Intact survival rate was higher in the matched extracorporeal cardiopulmonary resuscitation group than in the matched conventional cardiopulmonary resuscitation group (29.2% [7/24] vs. 8.3% [2/24], log-rank p = 0.018). According to the predictor analysis, only pupil diameter on hospital arrival was associated with neurologic outcome (adjusted hazard ratio, 1.39 per 1-mm increase; 95% confidence interval, 1.09-1.78; p = 0.008).
CONCLUSIONS: Extracorporeal cardiopulmonary resuscitation can improve neurologic outcome after out-of-hospital cardiac arrest of cardiac origin; furthermore, pupil diameter on hospital arrival may be a key predictor to identify extracorporeal cardiopulmonary resuscitation candidates.

PMID 23388518  Crit Care Med. 2013 May;41(5):1186-96. doi: 10.1097/CCM・・・
著者: Tetsuya Sakamoto, Naoto Morimura, Ken Nagao, Yasufumi Asai, Hiroyuki Yokota, Satoshi Nara, Mamoru Hase, Yoshio Tahara, Takahiro Atsumi, SAVE-J Study Group
雑誌名: Resuscitation. 2014 Jun;85(6):762-8. doi: 10.1016/j.resuscitation.2014.01.031. Epub 2014 Feb 12.
Abstract/Text BACKGROUND: A favorable neurological outcome is likely to be achieved in out-of-hospital cardiac arrest (OHCA) patients with ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) on the initial electrocardiogram (ECG). However, in patients without pre-hospital restoration of spontaneous circulation despite the initial VF/VT, the outcome is extremely low by conventional cardiopulmonary resuscitation (CPR). Extracorporeal CPR (ECPR) may enhance cerebral blood flow and recovery of neurological function. We prospectively examined how ECPR for OHCA with VF/VT would affect neurological outcomes.
METHODS AND RESULTS: The design of this trial was a prospective, observational study. We compared differences of outcome at 1 and 6 months after OHCA between ECPR group (26 hospitals) and non-ECPR group (20 hospitals). Primary endpoints were the rate of favorable outcomes defined by the Glasgow-Pittsburgh Cerebral Performance and Overall Performance Categories (CPC) 1 or 2 at 1 and 6 months after OHCA. Based on intention-to-treat analysis, CPC 1 or 2 were 12.3% (32/260) in the ECPR group and 1.5% (3/194) in the non-ECPR group at 1 month (P<0.0001), and 11.2% (29/260) and 2.6% (5/194) at 6 months (P=0.001), respectively. By per protocol analysis, CPC 1 or 2 were 13.7% (32/234) in the ECPR group and 1.9% (3/159) in the non-ECPR group at 1 month (P<0.0001), and 12.4% (29/234) and 3.1% (5/159) at 6 months (P=0.002), respectively.
CONCLUSIONS: In OHCA patients with VF/VT on the initial ECG, a treatment bundle including ECPR, therapeutic hypothermia and IABP was associated with improved neurological outcome at 1 and 6 months after OHCA.

Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
PMID 24530251  Resuscitation. 2014 Jun;85(6):762-8. doi: 10.1016/j.res・・・
著者: Jou-Wei Lin, Ming-Jiuh Wang, Hsi-Yu Yu, Chih-Hsien Wang, Wei-Tien Chang, Jih-Shuin Jerng, Shu-Chien Huang, Nai-Kuan Chou, Nai-Hsin Chi, Wen-Je Ko, Ya-Chen Wang, Shoei-Shen Wang, Juey-Jen Hwang, Fang-Yue Lin, Yih-Sharng Chen
雑誌名: Resuscitation. 2010 Jul;81(7):796-803. doi: 10.1016/j.resuscitation.2010.03.002. Epub 2010 Apr 21.
Abstract/Text AIM: Extracorporeal cardiopulmonary resuscitation (ECPR) has been shown to have survival benefit over conventional CPR (CCPR) in patients with in-hospital cardiac arrest of cardiac origin. We compared the survival of patients who had return of spontaneous beating (ROSB) after ECPR with the survival of those who had return of spontaneous circulation (ROSC) after conventional CPR.
METHODS: Propensity score-matched cohort of adults with in-hospital prolonged CPR (>10min) of cardiac origin in a university-affiliated tertiary extracorporeal resuscitation center were included in this study. Fifty-nine patients with ROSB after ECPR and 63 patients with sustained ROSC by CCPR were analyzed. Main outcome measures were survival at hospital discharge, 30 days, 6 months, and one year, and neurological outcome.
RESULTS: There was no statistical difference in survival to discharge (29.1% of ECPR responders vs. 22.2% of CCPR responders, p=0.394) and neurological outcome at discharge and one year later. In the propensity score-matched groups, 9 out of 27 ECPR patients survived to one month (33.3%) and 7 out of 27 CCPR patients survived (25.9%). Survival analysis showed no survival difference (HR: 0.856, p=0.634, 95% CI: 0.453-1.620) between the groups, either at 30 days or at the end of one year (HR: 0.602, p=0.093, 95% CI: 0.333-1.088).
CONCLUSIONS: This study failed to demonstrate a survival difference between patients who had ROSB after institution of ECMO and those who had ROSC after conventional CPR. Further studies evaluating the role of ECMO in conventional CPR rescued patients are warranted.

PMID 20413202  Resuscitation. 2010 Jul;81(7):796-803. doi: 10.1016/j.r・・・
著者: E T Boie, G P Moore, C Brummett, D R Nelson
雑誌名: Ann Emerg Med. 1999 Jul;34(1):70-4.
Abstract/Text STUDY OBJECTIVES: No large study has addressed whether parents want to be present when invasive procedures are performed on their children in the emergency department. We conducted a survey to address this question.
METHODS: The study used a self-administered, written survey consisting of 5 pediatric scenarios with increasing level of procedural invasiveness. Parents in an urban, teaching hospital ED waiting area were asked to participate.
RESULTS: Of 407 persons asked to participate, 400 (98%) completed the survey. The number of parents expressing a desire to be present during a procedure performed on their child was 387 (97.5%) for venipuncture of the extremity, 375 (94.0%) for laceration repair, 341 (86.5%) for lumbar puncture, and 317 (80.9%) for endotracheal intubation. For a major resuscitation scenario, 316 (80.7%) wished to be present if their child were conscious during the resuscitation, 277 (71.4%) wanted to be present if their child were unconscious during the resuscitation, whereas 322 (83.4%) indicated a desire to be present if their child were likely to die during the resuscitation. Of the 400, 261 (65.3%) wished to be present for all 5 scenarios. Only 26 (6.5%) wanted the physician to determine parental presence in all 5 scenarios.
CONCLUSION: Most parents surveyed would want to be present when invasive procedures are performed on their children. With increasing procedural invasiveness, parental desire to be present decreased. However, most parents would want to be in attendance if their child were likely to die, and nearly all parents want to participate in the decision about their presence.

PMID 10381997  Ann Emerg Med. 1999 Jul;34(1):70-4.
著者: S Adams, M Whitlock, R Higgs, P Bloomfield, P J Baskett
雑誌名: BMJ. 1994 Jun 25;308(6945):1687-9.
Abstract/Text
PMID 8025465  BMJ. 1994 Jun 25;308(6945):1687-9.
著者: R Boyd
雑誌名: Resuscitation. 2000 Feb;43(3):171-6.
Abstract/Text Witnessed resuscitation is the process of active 'medical' resuscitation in the presence of family members. Witnessed resuscitation though not as yet wide spread in practice is becoming established. Early reports of programs designed to promote such a process first appeared in the early 1980s. More recent work appears to show both public support and a desire for inclusion in the resuscitation process. Some research has been produced that indicates both satisfaction and psychological benefit for those relatives enabled to witness. Limited work only, exists pertaining to the effects on health care providers and these reports currently do not show any significant deleterious effects. Approval of witnessed resuscitation programs is not universal amongst all groups of health care workers. Concerns about the ethics of witnessed resuscitation and its medico-legal implications have been raised. The quality of the initial witnessed resuscitation reports is however variable and there is a great need for further work to validate the initial findings particularly in the areas of psychological stressors in staff and risk management implications.

PMID 10711485  Resuscitation. 2000 Feb;43(3):171-6.
著者: R J Offord
雑誌名: Intensive Crit Care Nurs. 1998 Dec;14(6):288-93.
Abstract/Text Witnessing the attempted resuscitation of a loved one is likely to be traumatic and distressing. However, because the majority of patients requiring cardiopulmonary resuscitation (CPR) die, this raises the question, within the hospital environment, of whether relatives should be invited to be present. There is a distinct lack of nursing research available on this subject, particularly with regard to the possible long-term effects on relatives. Much of the information is anecdotal and focuses on the positive aspects of this practice. With particular reference to the intensive care unit (ICU), the discussion in this paper includes not only family presence during CPR from the perspective of the patient, relatives and healthcare professionals, but also the potential legal implications. Recommendations for nursing practice are offered.

PMID 10196912  Intensive Crit Care Nurs. 1998 Dec;14(6):288-93.
著者: Mary Fran Hazinski, Jerry P Nolan, John E Billi, Bernd W Böttiger, Leo Bossaert, Allan R de Caen, Charles D Deakin, Saul Drajer, Brian Eigel, Robert W Hickey, Ian Jacobs, Monica E Kleinman, Walter Kloeck, Rudolph W Koster, Swee Han Lim, Mary E Mancini, William H Montgomery, Peter T Morley, Laurie J Morrison, Vinay M Nadkarni, Robert E O'Connor, Kazuo Okada, Jeffrey M Perlman, Michael R Sayre, Michael Shuster, Jasmeet Soar, Kjetil Sunde, Andrew H Travers, Jonathan Wyllie, David Zideman
雑誌名: Circulation. 2010 Oct 19;122(16 Suppl 2):S250-75. doi: 10.1161/CIRCULATIONAHA.110.970897.
Abstract/Text
PMID 20956249  Circulation. 2010 Oct 19;122(16 Suppl 2):S250-75. doi: ・・・
著者: Thomas D Rea, Andrea J Cook, Ian G Stiell, Judy Powell, Blair Bigham, Clifton W Callaway, Sumeet Chugh, Tom P Aufderheide, Laurie Morrison, Thomas E Terndrup, Tammy Beaudoin, Lynn Wittwer, Dan Davis, Ahamed Idris, Graham Nichol, Resuscitation Outcomes Consortium Investigators
雑誌名: Ann Emerg Med. 2010 Mar;55(3):249-57. doi: 10.1016/j.annemergmed.2009.09.018. Epub 2009 Nov 27.
Abstract/Text STUDY OBJECTIVE: Survival after out-of-hospital cardiac arrest depends on the links in the chain of survival. The Utstein elements are designed to assess these links and provide the basis for comparing outcomes within and across communities. We assess whether these measures sufficiently predict survival and explain outcome differences.
METHODS: We used an observational, prospective data collection, case-series of adult persons with nontraumatic out-of-hospital cardiac arrest from December 1, 2005, through March 1, 2007, from the multisite, population-based Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. We used logistic regression, receiver operating curves, and measures of variance to estimate the extent to which the Utstein elements predicted survival to hospital discharge and explained outcome variability overall and between 7 Resuscitation Outcomes Consortium sites. Analyses were conducted for all emergency medical services-treated cardiac arrests and for the subset of bystander-witnessed patient arrests because of presumed cardiac cause presenting with ventricular fibrillation or ventricular tachycardia.
RESULTS: Survival was 7.8% overall (n=833/10,681) and varied from 4.6% to 14.7% across Resuscitation Outcomes Consortium sites. Among bystander-witnessed ventricular fibrillation or ventricular tachycardia, survival was 22.1% overall (n=323/1459) and varied from 12.5% to 41.0% across sites. The Utstein elements collectively predicted 72% of survival variability among all arrests and 40% of survival variability among bystander-witnessed ventricular fibrillation. The Utstein elements accounted for 43.6% of the between-site survival difference among all arrests and 22.3% of the between-site difference among the bystander-witnessed ventricular fibrillation subset.
CONCLUSION: The Utstein elements predict survival but account for only a modest portion of outcome variability overall and between Resuscitation Outcomes Consortium sites. The results underscore the need for ongoing investigation to better understand characteristics that influence cardiac arrest survival.

Copyright (c) 2009. Published by Mosby, Inc.
PMID 19944488  Ann Emerg Med. 2010 Mar;55(3):249-57. doi: 10.1016/j.an・・・
著者: P Hew, B Brenner, J Kaufman
雑誌名: J Emerg Med. 1997 May-Jun;15(3):279-84.
Abstract/Text Recently, a reluctance of lay and medical personnel to perform mouth-to-mouth resuscitation (MMR) in hospital and community settings has been documented, with 45% of respondents declining to perform MMR on a stranger. In the present study, we examined whether the perceived risk and fear of contracting infectious diseases diminishes the willingness of paramedics and emergency medical technicians (EMTs) to perform MMR. Seventy-seven EMTs and 27 paramedics responded to a questionnaire, administered by one of two physicians, containing mock cardiac arrest scenarios that were designed to assess willingness to perform MMR as a citizen responder. Faced with a situation in which an adult stranger required MMR, 57% of the participating EMTs and all of the paramedics stated that they would refuse to perform MMR. None of the paramedics and only 32.5% of the EMTs stated that they would perform MMR on a man in a gay neighborhood. In addition, 23% of the EMTs and 37% of the paramedics indicated that they would refuse to perform MMR on a child. White respondents were more willing than nonwhite respondents to perform MMR. Twenty-nine percent of the prehospital-care providers had been in situations requiring MMR in the community, and 40% either had walked away or did only external compression. Of those participating paramedics and EMTs who had performed MMR in emergency situations, only 45% indicated that they would do so again. The respondents indicated that they would not be willing to administer MMR because of the fear of contracting infectious agents, especially the human immunodeficiency virus. Despite the proven effectiveness of MMR in saving lives, paramedics and EMTs are highly reluctant to perform MMR as citizen responders. Their perceived risks of contracting infectious agents during MMR are high, despite the low actual risks. We recommend that instruction in cardiopulmonary resuscitation for providers of pre-hospital care, the medical community, and the general public should emphasize the benefits of providing MMR, the actual low risks of contracting infectious diseases during administration of MMR, and the use of widely available and effective barrier masks to minimize any risks due to administration of MMR.

PMID 9258774  J Emerg Med. 1997 May-Jun;15(3):279-84.
著者: Tetsuhisa Kitamura, Taku Iwami, Takashi Kawamura, Ken Nagao, Hideharu Tanaka, Vinay M Nadkarni, Robert A Berg, Atsushi Hiraide, implementation working group for All-Japan Utstein Registry of the Fire and Disaster Management Agency
雑誌名: Lancet. 2010 Apr 17;375(9723):1347-54. doi: 10.1016/S0140-6736(10)60064-5. Epub 2010 Mar 2.
Abstract/Text BACKGROUND: The American Heart Association recommends cardiopulmonary resuscitation (CPR) by bystanders with chest compression only for adults who have cardiac arrests, but not for children. We assessed the effect of CPR (conventional with rescue breathing or chest compression only) by bystanders on outcomes after out-of-hospital cardiac arrests in children.
METHODS: In a nationwide, prospective, population-based, observational study, we enrolled 5170 children aged 17 years and younger who had an out-of-hospital cardiac arrest from Jan 1, 2005, to Dec 31, 2007. Data collected included age, cause, and presence and type of CPR by bystander. The primary endpoint was favourable neurological outcome 1 month after an out-of-hospital cardiac arrest, defined as Glasgow-Pittsburgh cerebral performance category 1 or 2.
FINDINGS: 3675 (71%) children had arrests of non-cardiac causes and 1495 (29%) cardiac causes. 1551 (30%) received conventional CPR and 888 (17%) compression-only CPR. Data for type of CPR by bystander were not available for 12 children. Children who were given CPR by a bystander had a significantly higher rate of favourable neurological outcome than did those not given CPR (4.5% [110/2439] vs 1.9% [53/2719]; adjusted odds ratio [OR] 2.59, 95% CI 1.81-3.71). In children aged 1-17 years who had arrests of non-cardiac causes, favourable neurological outcome was more common after bystander CPR than no CPR (5.1% [51/1004] vs 1.5% [20/1293]; OR 4.17, 2.37-7.32). However, conventional CPR produced more favourable neurological outcome than did compression-only CPR (7.2% [45/624] vs 1.6% [six of 380]; OR 5.54, 2.52-16.99). In children aged 1-17 years who had arrests of cardiac causes, favourable neurological outcome was more common after bystander CPR than no CPR (9.5% [42/440] vs 4.1% [14/339]; OR 2.21, 1.08-4.54), and did not differ between conventional and compression-only CPR (9.9% [28/282] vs 8.9% [14/158]; OR 1.20, 0.55-2.66). In infants (aged <1 year), outcomes were uniformly poor (1.7% [36/2082] with favourable neurological outcome).
INTERPRETATION: For children who have out-of-hospital cardiac arrests from non-cardiac causes, conventional CPR (with rescue breathing) by bystander is the preferable approach to resuscitation. For arrests of cardiac causes, either conventional or compression-only CPR is similarly effective.
FUNDING: Fire and Disaster Management Agency and the Ministry of Education, Culture, Sports, Science and Technology (Japan).

Copyright 2010 Elsevier Ltd. All rights reserved.
PMID 20202679  Lancet. 2010 Apr 17;375(9723):1347-54. doi: 10.1016/S01・・・
著者: M P Larsen, M S Eisenberg, R O Cummins, A P Hallstrom
雑誌名: Ann Emerg Med. 1993 Nov;22(11):1652-8.
Abstract/Text STUDY OBJECTIVE: To develop a graphic model that describes survival from sudden out-of-hospital cardiac arrest as a function of time intervals to critical prehospital interventions.
PARTICIPANTS: From a cardiac arrest surveillance system in place since 1976 in King County, Washington, we selected 1,667 cardiac arrest patients with a high likelihood of survival: they had underlying heart disease, were in ventricular fibrillation, and had arrested before arrival of emergency medical services (EMS) personnel.
METHODS: For each patient, we obtained the time intervals from collapse to CPR, to first defibrillatory shock, and to initiation of advanced cardiac life support (ACLS).
RESULTS: A multiple linear regression model fitting the data gave the following equation: survival rate = 67%-2.3% per minute to CPR-1.1% per minute to defibrillation-2.1% per minute to ACLS, which was significant at P < .001. The first term, 67%, represents the survival rate if all three interventions were to occur immediately on collapse. Without treatment (CPR, defibrillatory shock, or definitive care), the decline in survival rate is the sum of the three coefficients, or 5.5% per minute. Survival rates predicted by the model for given EMS response times approximated published observed rates for EMS systems in which paramedics respond with or without emergency medical technicians.
CONCLUSION: The model is useful in planning community EMS programs, comparing EMS systems, and showing how different arrival times within a system affect survival rate.

PMID 8214853  Ann Emerg Med. 1993 Nov;22(11):1652-8.
著者: Paul S Chan, Harlan M Krumholz, Graham Nichol, Brahmajee K Nallamothu, American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators
雑誌名: N Engl J Med. 2008 Jan 3;358(1):9-17. doi: 10.1056/NEJMoa0706467.
Abstract/Text BACKGROUND: Expert guidelines advocate defibrillation within 2 minutes after an in-hospital cardiac arrest caused by ventricular arrhythmia. However, empirical data on the prevalence of delayed defibrillation in the United States and its effect on survival are limited.
METHODS: We identified 6789 patients who had cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia at 369 hospitals participating in the National Registry of Cardiopulmonary Resuscitation. Using multivariable logistic regression, we identified characteristics associated with delayed defibrillation. We then examined the association between delayed defibrillation (more than 2 minutes) and survival to discharge after adjusting for differences in patient and hospital characteristics.
RESULTS: The overall median time to defibrillation was 1 minute (interquartile range, <1 to 3 minutes); delayed defibrillation occurred in 2045 patients (30.1%). Characteristics associated with delayed defibrillation included black race, noncardiac admitting diagnosis, and occurrence of cardiac arrest at a hospital with fewer than 250 beds, in an unmonitored hospital unit, and during after-hours periods (5 p.m. to 8 a.m. or weekends). Delayed defibrillation was associated with a significantly lower probability of surviving to hospital discharge (22.2%, vs. 39.3% when defibrillation was not delayed; adjusted odds ratio, 0.48; 95% confidence interval, 0.42 to 0.54; P<0.001). In addition, a graded association was seen between increasing time to defibrillation and lower rates of survival to hospital discharge for each minute of delay (P for trend <0.001).
CONCLUSIONS: Delayed defibrillation is common and is associated with lower rates of survival after in-hospital cardiac arrest.

Copyright 2008 Massachusetts Medical Society.
PMID 18172170  N Engl J Med. 2008 Jan 3;358(1):9-17. doi: 10.1056/NEJM・・・
著者: Ian G Stiell, George A Wells, Brian Field, Daniel W Spaite, Lisa P Nesbitt, Valerie J De Maio, Graham Nichol, Donna Cousineau, Josée Blackburn, Doug Munkley, Lorraine Luinstra-Toohey, Tony Campeau, Eugene Dagnone, Marion Lyver, Ontario Prehospital Advanced Life Support Study Group
雑誌名: N Engl J Med. 2004 Aug 12;351(7):647-56. doi: 10.1056/NEJMoa040325.
Abstract/Text BACKGROUND: The Ontario Prehospital Advanced Life Support (OPALS) Study tested the incremental effect on the rate of survival after out-of-hospital cardiac arrest of adding a program of advanced life support to a program of rapid defibrillation.
METHODS: This multicenter, controlled clinical trial was conducted in 17 cities before and after advanced-life-support programs were instituted and enrolled 5638 patients who had had cardiac arrest outside the hospital. Of those patients, 1391 were enrolled during the rapid-defibrillation phase and 4247 during the subsequent advanced-life-support phase. Paramedics were trained in standard advanced life support, which includes endotracheal intubation and the administration of intravenous drugs.
RESULTS: From the rapid-defibrillation phase to the advanced-life-support phase, the rate of admission to a hospital increased significantly (10.9 percent vs. 14.6 percent, P<0.001), but the rate of survival to hospital discharge did not (5.0 percent vs. 5.1 percent, P=0.83). The multivariate odds ratio for survival after advanced life support was 1.1 (95 percent confidence interval, 0.8 to 1.5); after an arrest witnessed by a bystander, 4.4 (95 percent confidence interval, 3.1 to 6.4); after cardiopulmonary resuscitation administered by a bystander, 3.7 (95 percent confidence interval, 2.5 to 5.4); and after rapid defibrillation, 3.4 (95 percent confidence interval, 1.4 to 8.4). There was no improvement in the rate of survival with the use of advanced life support in any subgroup.
CONCLUSIONS: The addition of advanced-life-support interventions did not improve the rate of survival after out-of-hospital cardiac arrest in a previously optimized emergency-medical-services system of rapid defibrillation. In order to save lives, health care planners should make cardiopulmonary resuscitation by citizens and rapid-defibrillation responses a priority for the resources of emergency-medical-services systems.

Copyright 2004 Massachusetts Medical Society
PMID 15306666  N Engl J Med. 2004 Aug 12;351(7):647-56. doi: 10.1056/N・・・
著者: A P Hallstrom, J P Ornato, M Weisfeldt, A Travers, J Christenson, M A McBurnie, R Zalenski, L B Becker, E B Schron, M Proschan, Public Access Defibrillation Trial Investigators
雑誌名: N Engl J Med. 2004 Aug 12;351(7):637-46. doi: 10.1056/NEJMoa040566.
Abstract/Text BACKGROUND: The rate of survival after out-of-hospital cardiac arrest is low. It is not known whether this rate will increase if laypersons are trained to attempt defibrillation with the use of automated external defibrillators (AEDs).
METHODS: We conducted a prospective, community-based, multicenter clinical trial in which we randomly assigned community units (e.g., shopping malls and apartment complexes) to a structured and monitored emergency-response system involving lay volunteers trained in cardiopulmonary resuscitation (CPR) alone or in CPR and the use of AEDs. The primary outcome was survival to hospital discharge.
RESULTS: More than 19,000 volunteer responders from 993 community units in 24 North American regions participated. The two study groups had similar unit and volunteer characteristics. Patients with treated out-of-hospital cardiac arrest in the two groups were similar in age (mean, 69.8 years), proportion of men (67 percent), rate of cardiac arrest in a public location (70 percent), and rate of witnessed cardiac arrest (72 percent). No inappropriate shocks were delivered. There were more survivors to hospital discharge in the units assigned to have volunteers trained in CPR plus the use of AEDs (30 survivors among 128 arrests) than there were in the units assigned to have volunteers trained only in CPR (15 among 107; P=0.03; relative risk, 2.0; 95 percent confidence interval, 1.07 to 3.77); there were only 2 survivors in residential complexes. Functional status at hospital discharge did not differ between the two groups.
CONCLUSIONS: Training and equipping volunteers to attempt early defibrillation within a structured response system can increase the number of survivors to hospital discharge after out-of-hospital cardiac arrest in public locations. Trained laypersons can use AEDs safely and effectively.

Copyright 2004 Massachusetts Medical Society
PMID 15306665  N Engl J Med. 2004 Aug 12;351(7):637-46. doi: 10.1056/N・・・
著者: J J Clark, M P Larsen, L L Culley, J R Graves, M S Eisenberg
雑誌名: Ann Emerg Med. 1992 Dec;21(12):1464-7.
Abstract/Text STUDY OBJECTIVE: To discover the frequency of agonal respirations in cardiac arrest calls, the ways callers describe them, and discharge rates associated with agonal respirations.
DESIGN: We reviewed taped recordings of calls reporting cardiac arrests and emergency medical technician and paramedic incident reports for 1991. Arrests after arrival of emergency medical services were excluded.
SETTING: King County, Washington, excluding the city of Seattle.
PARTICIPANTS: Four hundred forty-five persons with out-of-hospital cardiac arrests receiving emergency medical services.
INTERVENTIONS: Telephone CPR, emergency medical technicians-defibrillation, and advanced life support by paramedics.
MEASUREMENTS AND MAIN RESULTS: Any attempts at breathing described by callers were identified, as well as whether agonal respirations could be heard by dispatcher, emergency medical technicians, or paramedics. Agonal respirations occurred in 40% of 445 out-of-hospital cardiac arrests. Callers described agonal breathing in a variety of ways. Agonal respirations were present in 46% of arrests caused by cardiac etiology compared with 32% in other etiologies (P < .01). Fifty-five percent of witnessed arrests had agonal activity compared with 16% of unwitnessed arrests (P < .001). Agonal respirations occurred in 56% of arrests with a rhythm of ventricular fibrillation compared with 34% of cases with a nonventricular fibrillation rhythm (P < .001). Twenty-seven percent of patients with agonal respirations were discharged alive compared with 9% without them (P < .001).
CONCLUSION: There is a high incidence of agonal activity associated with out-of-hospital cardiac arrest. Presence of agonal respirations is associated with increased survival. These findings have implications for public CPR training programs and emergency dispatcher telephone CPR programs.

PMID 1443844  Ann Emerg Med. 1992 Dec;21(12):1464-7.
著者: Frederic Lapostolle, Philippe Le Toumelin, Jean Marc Agostinucci, Jean Catineau, Frederic Adnet
雑誌名: Acad Emerg Med. 2004 Aug;11(8):878-80.
Abstract/Text UNLABELLED: The American Heart Association recently abolished the carotid pulse check during cardiopulmonary resuscitation for lay rescuers, but not for health care providers.
OBJECTIVES: The aim of the study was to evaluate health care providers' performance, degree of conviction, and influencing factors in checking the carotid pulse.
METHODS: Sixty-four health care providers were asked to check the carotid pulse for 10 or 30 seconds on a computerized mannequin simulating three levels of pulse strength (normal, weak, and absent). Health care providers were asked whether they felt a pulse and how certain were they that they felt a pulse. Performance was evaluated, as well as degree of conviction about the answer, using a visual analog scale. Data were compared by using a general linear model procedure.
RESULTS: In the pulseless situations, the answers were correct in 58% and 50% when checking the pulse for 10 and 30 seconds, respectively. In the situation with a weak pulse, the answer was correct in 83% when checking the pulse for 10 seconds. In situations with a normal pulse, the answers were correct in 92%, 84%, and 84%, respectively, when checking the pulse for 10 (twice) and 30 seconds. The exactitude of the answer was correlated with the pulse strength (p < 0.05). The degree of conviction about the answer was correlated with the exactitude of the answer (p < 0.01) and the pulse strength (p < 0.0001).
CONCLUSIONS: These results question the routine use of the carotid pulse check during cardiopulmonary resuscitation, including for health care providers.

PMID 15289196  Acad Emerg Med. 2004 Aug;11(8):878-80.
著者: Michael R Sayre, Robert A Berg, Diana M Cave, Richard L Page, Jerald Potts, Roger D White, American Heart Association Emergency Cardiovascular Care Committee
雑誌名: Circulation. 2008 Apr 22;117(16):2162-7. doi: 10.1161/CIRCULATIONAHA.107.189380. Epub 2008 Mar 31.
Abstract/Text
PMID 18378619  Circulation. 2008 Apr 22;117(16):2162-7. doi: 10.1161/C・・・
著者: Henry E Wang, Scott J Simeone, Matthew D Weaver, Clifton W Callaway
雑誌名: Ann Emerg Med. 2009 Nov;54(5):645-652.e1. doi: 10.1016/j.annemergmed.2009.05.024. Epub 2009 Jul 2.
Abstract/Text STUDY OBJECTIVE: Emergency cardiac care guidelines emphasize treatment of cardiopulmonary arrest with continuous uninterrupted cardiopulmonary resuscitation (CPR) chest compressions. Paramedics in the United States perform endotracheal intubation on nearly all victims of out-of-hospital cardiopulmonary arrest. We quantified the frequency and duration of CPR chest compression interruptions associated with paramedic endotracheal intubation efforts during out-of-hospital cardiopulmonary arrest.
METHODS: We studied adult out-of-hospital cardiopulmonary arrest treated by an urban and a rural emergency medical services agency from the Resuscitation Outcomes Consortium during November 2006 to June 2007. Cardiac monitors with compression sensors continuously recorded rescuer CPR chest compressions. A digital audio channel recorded all resuscitation events. We identified CPR interruptions related to endotracheal intubation efforts, including airway suctioning, laryngoscopy, endotracheal tube placement, confirmation and adjustment, securing the tube in place, bag-valve-mask ventilation between intubation attempts, and alternate airway insertion. We identified the number and duration of CPR interruptions associated with endotracheal intubation efforts.
RESULTS: We included 100 of 182 out-of-hospital cardiopulmonary arrests in the analysis. The median number of endotracheal intubation-associated CPR interruption was 2 (interquartile range [IQR] 1 to 3; range 1 to 9). The median duration of the first endotracheal intubation-associated CPR interruption was 46.5 seconds (IQR 23.5 to 73 seconds; range 7 to 221 seconds); almost one third exceeded 1 minute. The median total duration of all endotracheal intubation-associated CPR interruptions was 109.5 seconds (IQR 54 to 198 seconds; range 13 to 446 seconds); one fourth exceeded 3 minutes. Endotracheal intubation-associated CPR pauses composed approximately 22.8% (IQR 12.6-36.5%; range 1.0% to 93.4%) of all CPR interruptions.
CONCLUSION: In this series, paramedic out-of-hospital endotracheal intubation efforts were associated with multiple and prolonged CPR interruptions.

PMID 19573949  Ann Emerg Med. 2009 Nov;54(5):645-652.e1. doi: 10.1016/・・・
著者: Masanao Kobayashi, Akira Fujiwara, Hiroshi Morita, Yasuhisa Nishimoto, Takayuki Mishima, Masahiko Nitta, Toshimasa Hayashi, Toshihiro Hotta, Yasuyuki Hayashi, Eisou Hachisuka, Kenji Sato
雑誌名: Resuscitation. 2008 Sep;78(3):333-9. doi: 10.1016/j.resuscitation.2008.03.230. Epub 2008 Jun 17.
Abstract/Text AIM: To examine the current status and problems of resuscitation management in Japan as demonstrated at the 2006 and 2007 Osaka Senri medical rallies.
METHODS: Using manikins, the quality of resuscitation was evaluated in 33 teams that participated in the medical rallies. The challenge was to deliver defibrillation shocks for ventricular fibrillation; data were recorded using the Laerdal PC Skill Reporting System (Norway). The teams were first subjectively (visually) evaluated by a panel of judges and these evaluations were later reaffirmed using video records.
RESULTS: An approximately 30s delay was observed between the time of contact and initiation of chest compression in the teams that adopted the American Heart Association (AHA) method compared with those that adopted the European Resuscitation Council (ERC) method. Although the overall quality of chest compressions was very good, in several instances, the hand positions were inappropriate and complete chest recoil was not achieved. The left paddle was incorrectly positioned by all teams. Only 15.8% of the teams were able to deliver shocks with less than 10s of interruption between the chest compressions. Regarding interruption of chest compressions at confirmation of correct tracheal tube placement, among the eight teams that adopted the AHA method, pauses of more than 10s were confirmed in five (62.5%).
CONCLUSIONS: Significant differences in performance between the AHA and ERC methods were observed. The ERC guidelines were more rational and suitable in terms of actual application than the AHA guidelines.

PMID 18562075  Resuscitation. 2008 Sep;78(3):333-9. doi: 10.1016/j.res・・・
著者: Benjamin S Abella, Nathan Sandbo, Peter Vassilatos, Jason P Alvarado, Nicholas O'Hearn, Herbert N Wigder, Paul Hoffman, Kathleen Tynus, Terry L Vanden Hoek, Lance B Becker
雑誌名: Circulation. 2005 Feb 1;111(4):428-34. doi: 10.1161/01.CIR.0000153811.84257.59.
Abstract/Text BACKGROUND: Recent data highlight a vital link between well-performed cardiopulmonary resuscitation (CPR) and survival after cardiac arrest; however, the quality of CPR as actually performed by trained healthcare providers is largely unknown. We sought to measure in-hospital chest compression rates and to determine compliance with published international guidelines.
METHODS AND RESULTS: We developed and validated a handheld recording device to measure chest compression rate as a surrogate for CPR quality. A prospective observational study of adult cardiac arrests was performed at 3 hospitals from April 2002 to October 2003. Resuscitations were witnessed by trained observers using a customized personal digital assistant programmed to store the exact time of each chest compression, allowing offline calculation of compression rates at serial time points. In 97 arrests, data from 813 minutes during which chest compressions were delivered were analyzed in 30-second time segments. In 36.9% of the total number of segments, compression rates were <80 compressions per minute (cpm), and 21.7% had rates <70 cpm. Higher chest compression rates were significantly correlated with initial return of spontaneous circulation (mean chest compression rates for initial survivors and nonsurvivors, 90+/-17 and 79+/-18 cpm, respectively; P=0.0033).
CONCLUSIONS: In-hospital chest compression rates were below published resuscitation recommendations, and suboptimal compression rates in our study correlated with poor return of spontaneous circulation. CPR quality is likely a critical determinant of survival after cardiac arrest, suggesting the need for routine measurement, monitoring, and feedback systems during actual resuscitation.

PMID 15687130  Circulation. 2005 Feb 1;111(4):428-34. doi: 10.1161/01.・・・
著者: Dana P Edelson, Benjamin S Abella, Jo Kramer-Johansen, Lars Wik, Helge Myklebust, Anne M Barry, Raina M Merchant, Terry L Vanden Hoek, Petter A Steen, Lance B Becker
雑誌名: Resuscitation. 2006 Nov;71(2):137-45. doi: 10.1016/j.resuscitation.2006.04.008. Epub 2006 Sep 18.
Abstract/Text BACKGROUND: Cardiopulmonary resuscitation (CPR) and electrical defibrillation are the primary treatment options for ventricular fibrillation (VF). While recent studies have shown that providing CPR prior to defibrillation may improve outcomes, the effects of CPR quality remain unclear. Specifically, the clinical effects of compression depth and pauses in chest compression prior to defibrillation (pre-shock pauses) are unknown.
METHODS: A prospective, multi-center, observational study of adult in-hospital and out-of-hospital cardiac resuscitations was conducted between March 2002 and December 2005. An investigational monitor/defibrillator equipped to measure compression characteristics during CPR was used.
RESULTS: Data were analyzed from 60 consecutive resuscitations in which a first shock was administered for VF. The primary outcome was first shock success defined as removal of VF for at least 5s following defibrillation. A logistic regression analysis demonstrated that successful defibrillation was associated with shorter pre-shock pauses (adjusted odds ratio 1.86 for every 5s decrease; 95% confidence interval 1.10-3.15) and higher mean compression depth during the 30s of CPR preceding the pre-shock pause (adjusted odds ratio 1.99 for every 5mm increase; 95% confidence interval 1.08-3.66).
CONCLUSIONS: The quality of CPR prior to defibrillation directly affects clinical outcomes. Specifically, longer pre-shock pauses and shallow chest compressions are associated with defibrillation failure. Strategies to correct these deficiencies should be developed and consideration should be made to replacing current-generation automated external defibrillators that require long pre-shock pauses for rhythm analysis.

PMID 16982127  Resuscitation. 2006 Nov;71(2):137-45. doi: 10.1016/j.re・・・
著者: Ahamed H Idris, Danielle Guffey, Paul E Pepe, Siobhan P Brown, Steven C Brooks, Clifton W Callaway, Jim Christenson, Daniel P Davis, Mohamud R Daya, Randal Gray, Peter J Kudenchuk, Jonathan Larsen, Steve Lin, James J Menegazzi, Kellie Sheehan, George Sopko, Ian Stiell, Graham Nichol, Tom P Aufderheide, Resuscitation Outcomes Consortium Investigators
雑誌名: Crit Care Med. 2015 Apr;43(4):840-8. doi: 10.1097/CCM.0000000000000824.
Abstract/Text OBJECTIVE: Guidelines for cardiopulmonary resuscitation recommend a chest compression rate of at least 100 compressions/min. A recent clinical study reported optimal return of spontaneous circulation with rates between 100 and 120/min during cardiopulmonary resuscitation for out-of-hospital cardiac arrest. However, the relationship between compression rate and survival is still undetermined.
DESIGN: Prospective, observational study.
SETTING: Data is from the Resuscitation Outcomes Consortium Prehospital Resuscitation IMpedance threshold device and Early versus Delayed analysis clinical trial.
PARTICIPANTS: Adults with out-of-hospital cardiac arrest treated by emergency medical service providers.
INTERVENTIONS: None.
MEASUREMENTS MAIN RESULTS: Data were abstracted from monitor-defibrillator recordings for the first five minutes of emergency medical service cardiopulmonary resuscitation. Multiple logistic regression assessed odds ratio for survival by compression rate categories (<80, 80-99, 100-119, 120-139, ≥140), both unadjusted and adjusted for sex, age, witnessed status, attempted bystander cardiopulmonary resuscitation, location of arrest, chest compression fraction and depth, first rhythm, and study site. Compression rate data were available for 10,371 patients; 6,399 also had chest compression fraction and depth data. Age (mean±SD) was 67±16 years. Chest compression rate was 111±19 per minute, compression fraction was 0.70±0.17, and compression depth was 42±12 mm. Circulation was restored in 34%; 9% survived to hospital discharge. After adjustment for covariates without chest compression depth and fraction (n=10,371), a global test found no significant relationship between compression rate and survival (p=0.19). However, after adjustment for covariates including chest compression depth and fraction (n=6,399), the global test found a significant relationship between compression rate and survival (p=0.02), with the reference group (100-119 compressions/min) having the greatest likelihood for survival.
CONCLUSIONS: After adjustment for chest compression fraction and depth, compression rates between 100 and 120 per minute were associated with greatest survival to hospital discharge.

PMID 25565457  Crit Care Med. 2015 Apr;43(4):840-8. doi: 10.1097/CCM.0・・・
著者: David Hostler, Jon C Rittenberger, Ronald Roth, Clifton W Callaway
雑誌名: Resuscitation. 2007 Sep;74(3):446-52. doi: 10.1016/j.resuscitation.2007.01.022. Epub 2007 Mar 23.
Abstract/Text OBJECTIVE: Chest compressions are interrupted during cardiopulmonary resuscitation (CPR) due to human error, for ventilation, for rhythm analysis and for rescue shocks. Earlier data suggest that the recommended 15:2 compression to ventilation (C:V) ratio results in frequent interruptions of compressions during CPR. We evaluated a protocol change from the recommended C:V ratio of 15:2-30:2 during CPR in our municipal emergency medical system.
METHODS: Municipal firefighters (N=875) from a single city received didactic and practical training emphasizing the importance of continuous chest compressions and recommending a 30:2 C:V ratio. Both before and after the training, digital ECG and voice records from all first-responder cases of out-of-hospital cardiac arrest were examined off-line to quantify chest compressions. The number of chest compressions delivered and the number and duration of pauses in chest compressions were compared by t-test for the first three 1min intervals when CPR was recommended.
RESULTS: More compressions were delivered during minutes 1, 2, and 3 during CPR with the 30:2 C:V ratio (78+/-29, 80+/-30, 74+/-26) than with the 15:2C:V ratio (53+/-24, 57+/-24, 51+/-26) (p<0.001). Fewer pauses for ventilation occurred during each minute with the 30:2 C:V ratio (1.7+/-1.2, 2.2+/-1.2, 1.8+/-1.0) than with the 15:2C:V ratio (3.4+/-2.6, 4.7+/-7.2, 4.0+/-2.9) (p< or =0.01). Degradation of the final ECG to asystole occurred less frequently after the protocol change (asystole pre 67.1%, post 56.8%, p<0.05). The incidence of return of spontaneous circulation was not altered following the protocol change.
CONCLUSIONS: Retraining first responders to use a C:V ratio of 30:2 instead of the traditional 15:2 during out-of-hospital cardiac arrest increased the number of compressions delivered per minute and decreased the number of pauses for ventilation. These data are new as they produced persistent and quantifiable changes in practitioner behavior during actual resuscitations.

PMID 17383069  Resuscitation. 2007 Sep;74(3):446-52. doi: 10.1016/j.re・・・
著者: Silje Odegaard, Elisabeth Saether, Petter Andreas Steen, Lars Wik
雑誌名: Resuscitation. 2006 Dec;71(3):335-40. doi: 10.1016/j.resuscitation.2006.05.012. Epub 2006 Oct 27.
Abstract/Text The new CPR guidelines emphasise chest compression depth and have increased the compression:ventilation ratio to cause less time intervals without chest compressions. How this change may influence the quality of chest compressions is not documented. Sixty-eight volunteers among travellers at Oslo international airport and a senior citizen centre performed 5 min of CPR on a manikin with compression:ventilation ratios 15:2, 30:2 or continuous chest compressions. Median age was 37.5 years (range 15-87), 59% were men, and 71% reported CPR training median 8 years (3-15) previously. Three of 22, 4 of 23 and 3 of 23 subjects in the 15:2, 30:2 and continuous compressions groups respectively stopped before 5 min had passed. Mean compression depth was 41 +/- 11, 45 +/- 8 and 30 +/- 8 mm, respectively. Depth was reduced as a function of time in the continuous compression group. Number of compressions per minute was 40 +/- 9, 43 +/- 14 and 73 +/- 24 and percent no flow time 49 +/- 13%, 38 +/- 20% and 1 +/- 2%, respectively. In conclusion, continuous chest compressions without ventilations gave significantly more chest compressions per minute, but with decreased compression quality. No flow time for 30:2 was significantly less than for 15:2.

PMID 17069958  Resuscitation. 2006 Dec;71(3):335-40. doi: 10.1016/j.re・・・
著者: Dana E Niles, Robert M Sutton, Vinay M Nadkarni, Andrew Glatz, Mathias Zuercher, Matthew R Maltese, Joar Eilevstjønn, Benjamin S Abella, Lance B Becker, Robert A Berg
雑誌名: Resuscitation. 2011 Dec;82 Suppl 2:S23-6. doi: 10.1016/S0300-9572(11)70147-2.
Abstract/Text BACKGROUND: Cardiopulmonary resuscitation (CPR) guidelines recommend complete release between chest compressions (CC).
OBJECTIVE: Evaluate the hemodynamic effects of leaning (incomplete chest wall release) during CPR and the prevalence of leaning during CPR.
RESULTS: In piglet ventricular fibrillation cardiac arrests, 10% and 20% (1.8 kg and 3.6 kg, respectively), leaning during CPR increased right atrial pressures, decreased coronary perfusion pressures, and decreased cardiac index and left ventricular myocardial blood flow by nearly 50%. In contrast, residual leaning of a 260 g accelerometer/force feedback device did not adversely affect cardiac index or myocardial blood flow. Among 108 adult in-hospital CPR events, leaning ≥ 2.5 kg was demonstrable in 91% of the events and 12% of the evaluated CC. For 12 children with in-hospital CPR, 28% of CC had residual leaning ≥ 2.5 kg and 89% had residual leaning ≥ 0.5 kg.
CONCLUSIONS: Leaning during CPR increases intrathoracic pressure, decreases coronary perfusion pressure, and decreases cardiac output and myocardial blood flow. Leaning is common during CPR.

Copyright © 2011 Elsevier B.V. All rights reserved.
PMID 22208173  Resuscitation. 2011 Dec;82 Suppl 2:S23-6. doi: 10.1016/・・・
著者: Demetris Yannopoulos, Scott McKnite, Tom P Aufderheide, Gardar Sigurdsson, Ronald G Pirrallo, David Benditt, Keith G Lurie
雑誌名: Resuscitation. 2005 Mar;64(3):363-72. doi: 10.1016/j.resuscitation.2004.10.009.
Abstract/Text INTRODUCTION: Recent data suggest that generation of negative intrathoracic pressure during the decompression phase of CPR improves hemodynamics, organ perfusion and survival.
HYPOTHESIS: Incomplete chest wall recoil during the decompression phase of standard CPR increases intrathoracic pressure and right atrial pressure, impedes venous return, decreases compression-induced aortic pressures and results in a decrease of mean arterial pressure, coronary and cerebral perfusion pressure.
METHODS: Nine pigs in ventricular fibrillation (VF) for 6 min, were treated with an automated compression/decompression device with a compression rate of 100 min(-1), a depth of 25% of the anterior-posterior diameter, and a compression to ventilation ratio of 15:2 with 100% decompression (standard CPR) for 3 min. Compression was then reduced to 75% of complete decompression for 1 min of CPR and then restored for another 1 min of CPR to 100% full decompression. Coronary perfusion pressure (CPP) was calculated as the diastolic (aortic (Ao)-right atrial (RA) pressure). Cerebral perfusion pressure (CerPP) was calculated multiple ways: (1) the positive area (in mmHg s) between aortic pressure and intracranial pressure (ICP) waveforms, (2) the coincident difference in systolic and diastolic aortic and intracranial pressures (mmHg), and (3) CerPP = MAP--ICP. ANOVA was used for statistical analysis and all values were expressed as mean +/- S.E.M. The power of the study for an alpha level of significance set at 0.05 was >0.90.
RESULTS: With CPR performed with 100%-75%-100% of complete chest wall recoil, respectively, the CPP was 23.3 +/- 1.9, 15.1 +/- 1.6, 16.6 +/- 1.9, p = 0.003; CerPP was: (1) area: 313.8 +/- 104, 89.2 +/- 39, 170.5 +/- 42.9, p = 0.03, (2) systolic aortic minus intracranial pressure difference: 22.8 +/- 3.6, 16.5 +/- 4, 23.7 +/- 4.5, p = n.s., and diastolic pressure difference: 5.7 +/- 3, -2.4 +/- 2.4, 3.2 +/- 2.5, p = 0.04 and (3) mean: 14.3 +/- 3, 7 +/- 2.9, 12.4 +/- 2.9, p = 0.03, diastolic aortic pressure was 28.1 +/- 2.5, 20.7 +/- 1.9, 20.9 +/- 2.1, p = 0.0125; ICP during decompression was 22.8 +/- 1.7, 23 +/- 1.5, 19.7 +/- 1.7, p = n.s. and mean ICP was 37.1 +/- 2.3, 35.5 +/- 2.2, 35.2 +/- 2.4, p = n.s.; RA diastolic pressure 4.8 +/- 1.3, 5.6 +/- 1.2, 4.3 +/- 1.2 p = 0.1; MAP was 52 +/- 2.9, 43.3 +/- 3, 48.3 +/- 2.9, p = 0.04; decompression endotracheal pressure, -0.7 +/- 0.1, -0.3 +/- 0.1, -0.75 +/- 0.1, p = 0.045.
CONCLUSIONS: Incomplete chest wall recoil during the decompression phase of CPR increases endotracheal pressure, impedes venous return and decreases mean arterial pressure, and coronary and cerebral perfusion pressures.

PMID 15733767  Resuscitation. 2005 Mar;64(3):363-72. doi: 10.1016/j.re・・・
著者: Alexis F Turgeon, Pierre C Nicole, Claude A Trépanier, Sylvie Marcoux, Martin R Lessard
雑誌名: Anesthesiology. 2005 Feb;102(2):315-9.
Abstract/Text BACKGROUND: Cricoid pressure (CP) is applied during induction of anesthesia to prevent regurgitation of gastric content and pulmonary aspiration. However, it has been suggested that CP makes tracheal intubation more difficult. This double-blind randomized study evaluated the effect of CP on orotracheal intubation by direct laryngoscopy in adults.
METHODS: Seven hundred adult patients undergoing general anesthesia for elective surgery were randomly assigned to have a standardized CP (n = 344) or a sham CP (n = 356) during laryngoscopy and intubation. After anesthesia induction and complete muscle relaxation, a 30-s period was allowed to complete intubation with a Macintosh No. 3 laryngoscope blade. The primary endpoint was the rate of failed intubation at 30 s. The secondary endpoints included the intubation time, the Cormack and Lehane grade of laryngoscopic view, and the Intubation Difficulty Scale score.
RESULTS: Groups were similar for demographic data and risk factors for difficult intubation. The rates of failed intubation at 30 s were comparable for the two groups: 15 of 344 (4.4%) and 13 of 356 (3.7%) in the CP and sham CP groups, respectively (P = 0.70). The grades of laryngoscopic view and the Intubation Difficulty Scale score were also comparable. Median intubation time was slightly longer in the CP group than in the sham CP group (11.3 and 10.4 s, respectively, P = 0.001).
CONCLUSIONS: CP applied by trained personnel does not increase the rate of failed intubation. Hence CP should not be avoided for fear of increasing the difficulty of intubation when its use is indicated.

PMID 15681945  Anesthesiology. 2005 Feb;102(2):315-9.
著者: U McNelis, A Syndercombe, I Harper, J Duggan
雑誌名: Anaesthesia. 2007 May;62(5):456-9. doi: 10.1111/j.1365-2044.2007.05019.x.
Abstract/Text Tracheal tube impingement is common during gum elastic bougie facilitated intubation and a 90 degrees anti-clockwise rotation of the tube usually relieves it. We detail a case where this manoeuvre failed in the presence of cricoid pressure. We investigated the effect of cricoid pressure on gum elastic bougie facilitated intubation in 120 patients randomly allocated to receive sham cricoid pressure (n = 60) or 30 N cricoid pressure (n = 60). Impingement occurred in 23/60 (38%) with sham cricoid pressure and 36/60 (60%) with 30 N cricoid pressure (p < 0.025). Only females showed an increase in impingement with cricoid pressure: 29% sham cricoid pressure vs 63% 30 N cricoid pressure, p < 0.01, whereas the impingement in males was approximately 60% in both groups. Ninety degree anti-clockwise rotation of the tube was successful in all 23 patients (100%) with sham cricoid pressure and in 32/36 patients (89%) with 30 N cricoid pressure. Releasing cricoid pressure relieved the obstruction in the four cases where 90 degrees anti-clockwise rotation of the tube failed. Impingement is common and 90 degrees anti-clockwise rotation is highly effective in both the presence and absence of cricoid pressure. In a small number of cases, cricoid pressure may cause the manoeuvre to fail.

PMID 17448056  Anaesthesia. 2007 May;62(5):456-9. doi: 10.1111/j.1365-・・・
著者: E L Hartsilver, R G Vanner
雑誌名: Anaesthesia. 2000 Mar;55(3):208-11.
Abstract/Text Cricoid pressure may cause airway obstruction. We investigated whether this is related to the force applied and to the technique of application. We recorded expired tidal volumes and inflation pressures during ventilation via a face-mask and oral airway in 52 female patients who were anaesthetised and about to undergo elective surgery. An inspired tidal volume of 900 ml was delivered using a ventilator. Ventilation was assessed under five different conditions: no cricoid pressure, backwards cricoid pressure applied with a force of 30 N, cricoid pressure applied in an upward and backward direction with a force of 30 N, backwards cricoid pressure with a force of 44 N and through a tracheal tube. An expired tidal volume of < 200 ml was taken to indicate airway obstruction. Airway obstruction did not occur without cricoid pressure, but did occur in one patient (2%) with cricoid pressure at 30 N, in 29 patients (56%) with 30 N applied in an upward and backward direction and in 18 (35%) patients with cricoid pressure at 44 N. Cricoid pressure applied with a force of 44 N can cause airway obstruction but if cricoid pressure is applied with a force of 30 N, airway obstruction occurs less frequently (p = 0.0001) unless the force is applied in an upward and backward direction.

PMID 10671836  Anaesthesia. 2000 Mar;55(3):208-11.
著者: G Hocking, F L Roberts, M E Thew
雑誌名: Anaesthesia. 2001 Sep;56(9):825-8.
Abstract/Text We studied the effect of cricoid pressure and lateral tilt on airway patency during ventilation by facemask in a simulated obstetric setting. The lungs of 50 patients were ventilated by facemask and Guedel airway using a Nuffield Penlon 200 ventilator and Bain system with standard settings. Expired tidal volumes and peak inspiratory pressures were recorded for 10 breaths in each of four combinations: supine with no cricoid pressure, supine with cricoid pressure, 15 degrees lateral tilt with no cricoid pressure and 15 degrees lateral tilt with cricoid pressure. The timing of cricoid pressure was randomised and blinded to all observers. In both supine and tilted positions, cricoid pressure produced a reduction in tidal volume (p < 0.001) and an increase in peak inspiratory pressure (p < 0.001). Cricoid pressure with lateral tilt did not produce any additional airway obstruction to that in the supine position. Complete airway obstruction (tidal volume < 200 ml) resulted on three occasions, all with cricoid pressure applied.

PMID 11531665  Anaesthesia. 2001 Sep;56(9):825-8.
著者: Anouk P van Alem, Fred W Chapman, Paula Lank, Augustinus A M Hart, Rudolph W Koster
雑誌名: Resuscitation. 2003 Jul;58(1):17-24.
Abstract/Text BACKGROUND: Evidence suggests that biphasic waveforms are more effective than monophasic waveforms for defibrillation in out-of-hospital cardiac arrest (OHCA), yet their performance has only been compared in un-blinded studies.
METHODS AND RESULTS: We compared the success of biphasic truncated exponential (BTE) and monophasic damped sine (MDS) shocks for defibrillation in OHCA in a prospective, randomised, double blind clinical trial. First responders were equipped with MDS and BTE automated external defibrillators (AEDs) in a random fashion. Patients in ventricular fibrillation (VF) received BTE or MDS first shocks of 200 J. The ECG was recorded for subsequent analysis continuously. The success of the first shock as a primary endpoint was removal of VF and required a return of an organized rhythm for at least two QRS complexes, with an interval of <5 s, within 1 min after the first shock. The secondary endpoint was termination of VF at 5 s. VF was the initial recorded rhythm in 120 patients in OHCA, 51 patients received BTE and 69 received MDS shocks. The success rate of 200 J first shocks was significantly higher for BTE than for MDS shocks, 35/51 (69%) and 31/69 (45%), P=0.01. In a logistic regression model the odds ratio of success for a BTE shock was 4.01 (95% CI 1.01-10.0), adjusted for baseline cardiopulmonary resuscitation, VF-amplitude and time between collapse and first shock. No difference was found with respect to the secondary endpoint, termination of VF at 5 s (RR 1.07 95% CI: 0.99-1.11) and with respect to survival to hospital discharge (RR 0.73 95% CI: 0.31-1.70).
CONCLUSION: BTE-waveform AEDs provide significantly higher rates of successful defibrillation with return of an organized rhythm in OHCA than MDS waveform AEDs.

PMID 12867305  Resuscitation. 2003 Jul;58(1):17-24.
著者: Laurie J Morrison, Paul Dorian, Jennifer Long, Marian Vermeulen, Brian Schwartz, Bruce Sawadsky, Jamie Frank, Bruce Cameron, Robert Burgess, Jennifer Shield, Paul Bagley, Vivien Mausz, James E Brewer, Bruce B Lerman, Steering Committee, Central Validation Committee, Safety and Efficacy Committee
雑誌名: Resuscitation. 2005 Aug;66(2):149-57. doi: 10.1016/j.resuscitation.2004.11.031.
Abstract/Text BACKGROUND: Although biphasic defibrillation waveforms appear to be superior to monophasic waveforms in terminating VF, their relative benefits in out-of-hospital resuscitation are incompletely understood. Prior comparisons of defibrillation waveform efficacy in out-of-hospital cardiac arrest (OHCA) are confined to patients presenting in a shockable rhythm and resuscitated by first responder (basic life support). This effectiveness study compared monophasic and biphasic defibrillation waveform for conversion of ventricular arrhythmias in all OHCA treated with advance life support (ALS).
METHODS AND RESULTS: This prospective randomized controlled trial compared the rectilinear biphasic (RLB) waveform with the monophasic damped sine (MDS) waveform, using step-up energy levels. The study enrolled OHCA patients requiring at least one shock delivered by ALS providers, regardless of initial presenting rhythm. Shock success was defined as conversion at 5s to organized rhythm after one to three escalating shocks. We report efficacy results for the cohort of patients treated by ALS paramedics who presented with an initially shockable rhythm who had not received a shock from a first responder (MDS: n=83; RLB: n=86). Shock success within the first three ascending energy shocks for RLB (120, 150, 200J) was superior to MDS (200, 300, 360J) for patients initially presenting in a shockable rhythm (52% versus 34%, p=0.01). First shock conversion was 23% and12%, for RLB and MDS, respectively (p=0.07). There were no significant differences in return of spontaneous circulation (47% versus 47%), survival to 24h (31% versus 27%), and survival to discharge (9% versus 7%). Mean 24h survival rates of bystander witnessed events showed differences between waveforms in the early circulatory phase at 4-10 min post event (mean (S.D.) RLB 0.45 (0.07) versus MDS 0.31 (0.06), p=0.0002) and demonstrated decline as time to first shock increased to 20 min.
CONCLUSION: Shock success to an organized rhythm comparing step-up protocol for energy settings demonstrated the RLB waveform was superior to MDS in ALS treatment of OHCA. Survival rates for both waveforms are consistent with current theories on the circulatory and metabolic phases of out-of-hospital cardiac arrest.

PMID 15992986  Resuscitation. 2005 Aug;66(2):149-57. doi: 10.1016/j.re・・・
著者: T Schneider, P R Martens, H Paschen, M Kuisma, B Wolcke, B E Gliner, J K Russell, W D Weaver, L Bossaert, D Chamberlain
雑誌名: Circulation. 2000 Oct 10;102(15):1780-7.
Abstract/Text BACKGROUND: In the present study, we compared an automatic external defibrillator (AED) that delivers 150-J biphasic shocks with traditional high-energy (200- to 360-J) monophasic AEDs.
METHODS AND RESULTS: AEDs were prospectively randomized according to defibrillation waveform on a daily basis in 4 emergency medical services systems. Defibrillation efficacy, survival to hospital admission and discharge, return of spontaneous circulation, and neurological status at discharge (cerebral performance category) were compared. Of 338 patients with out-of-hospital cardiac arrest, 115 had a cardiac etiology, presented with ventricular fibrillation, and were shocked with an AED. The time from the emergency call to the first shock was 8.9+/-3.0 (mean+/-SD) minutes.
CONCLUSIONS: The 150-J biphasic waveform defibrillated at higher rates, resulting in more patients who achieved a return of spontaneous circulation. Although survival rates to hospital admission and discharge did not differ, discharged patients who had been resuscitated with biphasic shocks were more likely to have good cerebral performance.

PMID 11023932  Circulation. 2000 Oct 10;102(15):1780-7.
著者: John Carpenter, Thomas D Rea, John A Murray, Peter J Kudenchuk, Mickey S Eisenberg
雑誌名: Resuscitation. 2003 Nov;59(2):189-96.
Abstract/Text BACKGROUND: The importance of the defibrillation waveform on the evolving post-shock cardiac rhythm is uncertain. The primary objective of this study was to evaluate cardiac rhythms following the first defibrillation shock, comparing biphasic truncated exponential (BTE), monophasic damped sinusoidal (MDS), and monophasic truncated exponential (MTE) waveforms in patients experiencing out-of-hospital ventricular fibrillation cardiac arrest (OHCA).
METHODS: We reviewed the automated external defibrillator (AED) and emergency medical services (EMS) records of 366 patients who suffered OHCA and were treated with defibrillation shocks by first-tier emergency responders between 1 January 1999 and 31 August 2002 in King County, Washington. The post first shock rhythms were determined at 5, 10, 20, 30, and 60 s and compared according to defibrillation waveform.
RESULTS: The MDS and BTE waveforms were associated with significantly higher frequency of defibrillation than the MTE waveform, though only the BTE association persisted to 30 and 60 s. No difference in defibrillation rates was detected between MDS and BTE waveforms. By 60 s, an organized rhythm was present in a greater proportion for BTE (40.0%) compared with MDS (25.4%, P=0.01) or MTE (26.5%, P=0.07).
CONCLUSION: In this retrospective cohort investigation, MDS and BTE waveforms had higher first shock defibrillation rates than the MTE waveform, while patients treated with the BTE waveform were more likely to develop an organized rhythm within 60 s of the initial shock. The results of this investigation, however, do not provide evidence that these surrogate advantages are important for improving survival. Additional investigation is needed to improve the understanding of the role of waveform and its potential interaction with other clinical factors in order to optimize survival in OHCA.

PMID 14625109  Resuscitation. 2003 Nov;59(2):189-96.
著者: B E Gliner, R D White
雑誌名: Resuscitation. 1999 Jul;41(2):133-44.
Abstract/Text OBJECTIVE: Following out-of-hospital defibrillation attempts, electrocardiographic instability challenges accurate assessment of defibrillation efficacy and post-shock rhythm. Presently, there is no precise definition of defibrillation efficacy in the out-of-hospital setting that is consistently used. The objective of this study was to characterize out-of-hospital cardiac arrest rhythms following low-energy biphasic and high-energy monophasic shocks in order to precisely define defibrillation efficacy and establish uniform criteria for the evaluation of shock performance.
METHODS: Automatic external defibrillators (AEDs) delivering 150 J impedance-compensating biphasic or 200-360 J monophasic damped sine waveform shocks were observed in a combined police and paramedic program. ECGs from 29 biphasic patients and 87 monophasic patients were classified as organized, asystole or VF at post-shock times of 3, 5, 10, 20 and 60 s.
RESULTS: Post-shock time (P<0.0001) and shock waveform type (P = 0.02) affected the classification of post-shock rhythm. At each analysis time, there were more patients in VF following high-energy monophasic shocks than following 150 J biphasic shocks (P<0.0001). The percentage of patients in VF increased with post-shock time. The rate of VF recurrence was not a function of shock type, indicating that refibrillation is largely a function of the patient's underlying cardiac disease.
CONCLUSION: Defibrillation should uniformly be defined as termination of VF for a minimum of 5-s after shock delivery. Rhythms should be reported at 5-s after shock delivery to assess early effects of the defibrillation shock and at 60-s after shock delivery to assess the interaction of the defibrillation therapy and factors such as post-shock myocardial dysfunction and the patient's underlying cardiac disease.

PMID 10488935  Resuscitation. 1999 Jul;41(2):133-44.
著者: Kimberly Freeman, Gregory W Hendey, Marc Shalit, Geoff Stroh
雑誌名: Prehosp Emerg Care. 2008 Apr-Jun;12(2):152-6. doi: 10.1080/10903120801907240.
Abstract/Text STUDY OBJECTIVE: To compare the outcomes of out-of hospital cardiac arrest (OHCA) victims treated with monophasic truncated exponential (MTE) versus biphasic truncated exponential (BTE) defibrillation in an urban EMS system.
METHODS: We conducted a retrospective review of electronic prehospital and hospital records for victims of OHCA between August 2000 and July 2004, including two years before and after implementation of biphasic defibrillators by the Fresno County EMS agency. Main outcome measures included: return of spontaneous circulation (ROSC), number of defibrillations required for ROSC, survival to hospital discharge, and discharge to home versus an extended care facility.
RESULTS: There were 485 cases of cardiac arrest included. Baseline characteristics between the monophasic and biphasic groups were similar. ROSC was achieved in 77 (30.6%, 95% CI 25.2-36.5%) of 252 patients in the monophasic group, and in 70 (30.0% 95% CI 24.5-36.2%) of 233 in the biphasic group (p= .92). Survival to hospital discharge was 12.3% (95% CI 8.8-17%) for monophasic and 10.3% (95% CI 7.0-14.9%) for biphasic (p= .57). Discharge to home was accomplished in 20 (7.9%, 95% CI 5.1-12.0%) of the monophasic, and in 15 (6.4%, 95% CI 3.9-10.4%) of the biphasic group (p= .60). More defibrillations were required to achieve ROSC (3.5 vs. 2.6, p= .015) in the monophasic group.
CONCLUSIONS: We found no difference in ROSC or survival to hospital discharge between MTE and BTE defibrillation in the treatment of OHCA, although fewer defibrillations were required to achieve ROSC in those treated with biphasic defibrillation.

PMID 18379909  Prehosp Emerg Care. 2008 Apr-Jun;12(2):152-6. doi: 10.1・・・
著者: Thomas D Rea, Mickey S Eisenberg, Greg Sinibaldi, Roger D White
雑誌名: Resuscitation. 2004 Oct;63(1):17-24. doi: 10.1016/j.resuscitation.2004.03.025.
Abstract/Text BACKGROUND: The potential impact of efforts to improve the chain of survival for out-of-hospital sudden cardiac arrest (SCA) is unclear in part because estimates of the incidence of treatable cases of SCA are uncertain. The aim of the investigation was to determine a representative national incidence of emergency medical services (EMS)-treated all-rhythm and ventricular fibrillation (VF) SCA as well as survival.
METHODS: We used Medline to identify peer-reviewed articles published between 1 January 1980 and 31 March 2003 that reported a US community's EMS SCA experience. Inclusion criteria required the study to include at least 25 cases, report the total number of all-rhythm and/or ventricular fibrillation arrests, and provide information about population size and study duration. Incidence was computed by dividing the total number of SCA events by the product of the community's population and the study duration.
RESULTS: Reports from 35 communities met the inclusion criteria. A total of 35,801 all-rhythm EMS-treated cardiac arrests occurred during 62.11 million person-years of observation resulting in an overall incidence of 54.99 per 100,000 person-years. The incidence of ventricular fibrillation-rhythm SCA was 21.32 per 100,000 person-years. Sensitivity analyses generally produced similar results. Applying these results to the US population, 155,000 persons would experience EMS-treated all-rhythm SCA and 60,000 persons would experience EMS-treated ventricular fibrillation-rhythm SCA annually in the US. Survival was 8.4% for all-rhythm and 17.7% for ventricular fibrillation SCA.
CONCLUSION: The results provide a framework to assess opportunities and limitations of EMS care with regard to the public health burden of SCA.

PMID 15451582  Resuscitation. 2004 Oct;63(1):17-24. doi: 10.1016/j.res・・・
著者: Salvatore Silvestri, George A Ralls, Baruch Krauss, Josef Thundiyil, Steven G Rothrock, Amy Senn, Eric Carter, Jay Falk
雑誌名: Ann Emerg Med. 2005 May;45(5):497-503. doi: 10.1016/j.annemergmed.2004.09.014.
Abstract/Text STUDY OBJECTIVE: We evaluate the association between out-of-hospital use of continuous end-tidal carbon dioxide (ETCO2) monitoring and unrecognized misplaced intubations within a regional emergency medical services (EMS) system.
METHODS: This was a prospective, observational study, conducted during a 10-month period, on all patients arriving at a regional Level I trauma center emergency department who underwent out-of-hospital endotracheal intubation. The regional EMS system that serves the trauma service area is composed of multiple countywide systems containing numerous EMS agencies. Some of the EMS agencies had independently implemented continuous ETCO2 monitoring before the start of the study. The main outcome measure was the unrecognized misplaced intubation rate with and without use of continuous ETCO2 monitoring.
RESULTS: Two hundred forty-eight patients received out-of-hospital airway management, of whom 153 received intubation. Of the 153 patients, 93 (61%) had continuous ETCO2 monitoring, and 60 (39%) did not. Forty-nine (32%) were medical patients, 104 (68%) were trauma patients, and 51 (33%) were in cardiac arrest. The overall incidence of unrecognized misplaced intubations was 9%. The rate of unrecognized misplaced intubations in the group for whom continuous ETCO2 monitoring was used was zero, and the rate in the group for whom continuous ETCO2 monitoring was not used was 23.3% (95% confidence interval 13.4% to 36.0%).
CONCLUSION: No unrecognized misplaced intubations were found in patients for whom paramedics used continuous ETCO2 monitoring. Failure to use continuous ETCO2 monitoring was associated with a 23% unrecognized misplaced intubation rate.

PMID 15855946  Ann Emerg Med. 2005 May;45(5):497-503. doi: 10.1016/j.a・・・
著者: Stefek Grmec
雑誌名: Intensive Care Med. 2002 Jun;28(6):701-4. doi: 10.1007/s00134-002-1290-x. Epub 2002 Apr 30.
Abstract/Text OBJECTIVES: Verification of endotracheal tube placement is of vital importance, since unrecognized esophageal intubation can be rapidly fatal (death, brain damage). The aim of our study was to compare three different methods for immediate confirmation of tube placement: auscultation, capnometry and capnography in emergency conditions in the prehospital setting.
DESIGN AND SETTING: Prospective study in the prehospital setting.
PATIENTS AND INTERVENTIONS: All adult patients (>18 years) were intubated by an emergency physician in the field. Tube position was initially evaluated by auscultation. Then, capnometry was performed with infrared capnometry and capnography with infrared capnography. The examiners looked for the characteristic CO(2) waveform and value of end-tidal carbon dioxide (EtCO(2)) in millimeters of mercury. Determination of final tube placement was performed by a second direct visualization with laryngoscope. Data are mean +/- SD and percentages.
MEASUREMENTS AND RESULTS: Over a 4year period, 345 patients requiring emergency intubation were included. Indications for intubation included cardiac arrest ( n=246; 71%) and non-arrest conditions ( n=99; 29%). In nine (2.7%) patients, esophageal tube placement occurred. The esophageal intubations were followed by successful endotracheal intubations without complications. The capnometry (sensitivity and specificity 100%) and capnography (sensitivity and specificity 100%) were better than auscultation (sensitivity 94% and specificity 83%) in confirming endotracheal tube placement in non-arrest patients ( p<0.05). Capnometry was highly specific (100%) but not sensitive (88%) for correct endotracheal intubation in patients with cardiopulmonary arrest (capnometry versus auscultation and capnometry versus capnography, p<0.05).
CONCLUSION: Capnography is the most reliable method to confirm endotracheal tube placement in emergency conditions in the prehospital setting.

PMID 12107674  Intensive Care Med. 2002 Jun;28(6):701-4. doi: 10.1007/・・・
著者: Taku Takeda, Koichi Tanigawa, Hitoshi Tanaka, Yuri Hayashi, Eiichi Goto, Keiichi Tanaka
雑誌名: Resuscitation. 2003 Feb;56(2):153-7.
Abstract/Text We studied prospectively the reliability of clinical methods, end-tidal carbon dioxide (ETCO(2)) detection, and the esophageal detector device (EDD) for verifying tracheal intubation in 137 adult patients in the emergency department. Immediately after intubation, the tracheal tube position was tested by the EDD and ETCO(2) monitor, followed by auscultation of the chest. The views obtained at laryngoscopy were classified according to the Cormack grade. Of the 13 esophageal intubations that occurred, one false-positive result occurred in the EDD test and auscultation. In the non-cardiac arrest patients (n=56), auscultation, the ETCO(2), and EDD test correctly identified 89.3, 98.2*, and 94.6%* of tracheal intubations, respectively (*, P<0.05 vs. the cardiac arrest patients). In the cardiac arrest patients (n=81), auscultation, the ETCO(2), and the EDD tests correctly identified 92.6**, 67.9, and 75.3% of tracheal intubations, respectively (**, P<0.05 vs. EDD and ETCO(2)). The frequencies of Cormack grade 1 or 2 were 83.9% in the non-cardiac arrest, and 95.1% in the cardiac arrest patients. In conclusion, the ETCO(2) monitor is the most reliable method for verifying tracheal intubation in non-cardiac arrest patients. During cardiac arrest and cardiopulmonary resuscitation, however, negative results by the ETCO(2) or the EDD are not uncommon, and clinical methods are superior to the use of these devices.

PMID 12589988  Resuscitation. 2003 Feb;56(2):153-7.
著者: K Tanigawa, T Takeda, E Goto, K Tanaka
雑誌名: Anesth Analg. 2001 Feb;92(2):375-8.
Abstract/Text We performed this prospective study to evaluate the efficacy of esophageal detector devices (EDDs), both the bulb and the syringe-type, to indicate positioning of endotracheal tubes (ETTs) in out-of-hospital cardiac arrest patients. Forty-eight adult patients with out-of-hospital cardiac arrest were enrolled. Immediately after tracheal intubation and ETT cuff inflation in the emergency department, the patients were allocated randomly to two cross-over groups. In Group 1 (n = 24), patients underwent a bulb test and a syringe test in sequence. In Group 2 (n = 24), patients underwent a syringe test and a bulb test in sequence. End-tidal carbon dioxide (ETCO(2)) was also monitored. In 56 attempts at tracheal intubation, the bulb, the syringe, and ETCO(2) indicated all eight esophageal intubations. In 48 tracheal intubations, the bulb test correctly indicated 34 tracheal intubations (sensitivity, 70.8%). The syringe test identified 35 tracheal intubations (sensitivity, 72.9%). The results of both tests agreed in 33 tracheal intubations. ETCO(2) was detected in 31 tracheal intubations (sensitivity, 64.6%). No statistical difference was found among the tests. EDDs were less sensitive in detecting tracheal intubation for out-of-hospital cardiac arrest patients. Therefore, proper clinical judgment in conjunction with these devices should be used to confirm ETT placement in these difficult situations.

PMID 11159235  Anesth Analg. 2001 Feb;92(2):375-8.
著者: K Tanigawa, T Takeda, E Goto, K Tanaka
雑誌名: Anesthesiology. 2000 Dec;93(6):1432-6.
Abstract/Text BACKGROUND: To determine the sensitivity and specificity of the self-inflating bulb (SIB) to verify tracheal intubation in out-of-hospital cardiac arrest patients.
METHODS: Sixty-five consecutive adult patients with out-of-hospital cardiac arrest were enrolled. Patients were provided chest compression and ventilation by either ba-valve-mask or the esophageal tracheal double-lumen airway by ambulance crews when they arrived at the authors' department. Immediately after intubation in the emergency department, the endotracheal tube position was tested by the SIB and end-tidal carbon dioxide (ETCO2) monitor using an infrared carbon dioxide analyzer. We observed the SIB reinflating for 10 s, and full reinflation within 4 s was defined as a positive result (tracheal intubation).
RESULTS: Five esophageal intubations occurred, and the SIB correctly identified all esophageal intubations. Of the 65 tracheal intubations, the SIB correctly identified 47 tubes placed in the trachea (72.3%). Delayed but full reinflation occurred in one tracheal intubation during the 10-s observation period. Fifteen tracheal intubations had incomplete reinflation during the observation period, and two tracheal intubations did not achieve any reinflation. Thirty-nine tracheal intubations were identified by ETCO2 (60%). When the SIB test is combined with the ETCO2 detection, 59 tracheal intubations were identified with a 90.8% sensitivity.
CONCLUSIONS: The authors found a high incidence of false-negative results of the SIB in out-of-hospital cardiac arrest patients. Because no single test for verifying endotracheal tube position is reliable, all available modalities should be tested and used in conjunction with proper clinical judgment to verify tracheal intubation in cases of out-of-hospital cardiac arrest.

PMID 11149438  Anesthesiology. 2000 Dec;93(6):1432-6.
著者: Stephen A Bernard, Timothy W Gray, Michael D Buist, Bruce M Jones, William Silvester, Geoff Gutteridge, Karen Smith
雑誌名: N Engl J Med. 2002 Feb 21;346(8):557-63. doi: 10.1056/NEJMoa003289.
Abstract/Text BACKGROUND: Cardiac arrest outside the hospital is common and has a poor outcome. Studies in laboratory animals suggest that hypothermia induced shortly after the restoration of spontaneous circulation may improve neurologic outcome, but there have been no conclusive studies in humans. In a randomized, controlled trial, we compared the effects of moderate hypothermia and normothermia in patients who remained unconscious after resuscitation from out-of-hospital cardiac arrest.
METHODS: The study subjects were 77 patients who were randomly assigned to treatment with hypothermia (with the core body temperature reduced to 33 degrees C within 2 hours after the return of spontaneous circulation and maintained at that temperature for 12 hours) or normothermia. The primary outcome measure was survival to hospital discharge with sufficiently good neurologic function to be discharged to home or to a rehabilitation facility.
RESULTS: The demographic characteristics of the patients were similar in the hypothermia and normothermia groups. Twenty-one of the 43 patients treated with hypothermia (49 percent) survived and had a good outcome--that is, they were discharged home or to a rehabilitation facility--as compared with 9 of the 34 treated with normothermia (26 percent, P=0.046). After adjustment for base-line differences in age and time from collapse to the return of spontaneous circulation, the odds ratio for a good outcome with hypothermia as compared with normothermia was 5.25 (95 percent confidence interval, 1.47 to 18.76; P=0.011). Hypothermia was associated with a lower cardiac index, higher systemic vascular resistance, and hyperglycemia. There was no difference in the frequency of adverse events.
CONCLUSIONS: Our preliminary observations suggest that treatment with moderate hypothermia appears to improve outcomes in patients with coma after resuscitation from out-of-hospital cardiac arrest.

PMID 11856794  N Engl J Med. 2002 Feb 21;346(8):557-63. doi: 10.1056/N・・・
著者: Hypothermia after Cardiac Arrest Study Group
雑誌名: N Engl J Med. 2002 Feb 21;346(8):549-56. doi: 10.1056/NEJMoa012689.
Abstract/Text BACKGROUND: Cardiac arrest with widespread cerebral ischemia frequently leads to severe neurologic impairment. We studied whether mild systemic hypothermia increases the rate of neurologic recovery after resuscitation from cardiac arrest due to ventricular fibrillation.
METHODS: In this multicenter trial with blinded assessment of the outcome, patients who had been resuscitated after cardiac arrest due to ventricular fibrillation were randomly assigned to undergo therapeutic hypothermia (target temperature, 32 degrees C to 34 degrees C, measured in the bladder) over a period of 24 hours or to receive standard treatment with normothermia. The primary end point was a favorable neurologic outcome within six months after cardiac arrest; secondary end points were mortality within six months and the rate of complications within seven days.
RESULTS: Seventy-five of the 136 patients in the hypothermia group for whom data were available (55 percent) had a favorable neurologic outcome (cerebral-performance category, 1 [good recovery] or 2 [moderate disability]), as compared with 54 of 137 (39 percent) in the normothermia group (risk ratio, 1.40; 95 percent confidence interval, 1.08 to 1.81). Mortality at six months was 41 percent in the hypothermia group (56 of 137 patients died), as compared with 55 percent in the normothermia group (76 of 138 patients; risk ratio, 0.74; 95 percent confidence interval, 0.58 to 0.95). The complication rate did not differ significantly between the two groups.
CONCLUSIONS: In patients who have been successfully resuscitated after cardiac arrest due to ventricular fibrillation, therapeutic mild hypothermia increased the rate of a favorable neurologic outcome and reduced mortality.

PMID 11856793  N Engl J Med. 2002 Feb 21;346(8):549-56. doi: 10.1056/N・・・
著者: Niklas Nielsen, Jørn Wetterslev, Tobias Cronberg, David Erlinge, Yvan Gasche, Christian Hassager, Janneke Horn, Jan Hovdenes, Jesper Kjaergaard, Michael Kuiper, Tommaso Pellis, Pascal Stammet, Michael Wanscher, Matt P Wise, Anders Åneman, Nawaf Al-Subaie, Søren Boesgaard, John Bro-Jeppesen, Iole Brunetti, Jan Frederik Bugge, Christopher D Hingston, Nicole P Juffermans, Matty Koopmans, Lars Køber, Jørund Langørgen, Gisela Lilja, Jacob Eifer Møller, Malin Rundgren, Christian Rylander, Ondrej Smid, Christophe Werer, Per Winkel, Hans Friberg, TTM Trial Investigators
雑誌名: N Engl J Med. 2013 Dec 5;369(23):2197-206. doi: 10.1056/NEJMoa1310519. Epub 2013 Nov 17.
Abstract/Text BACKGROUND: Unconscious survivors of out-of-hospital cardiac arrest have a high risk of death or poor neurologic function. Therapeutic hypothermia is recommended by international guidelines, but the supporting evidence is limited, and the target temperature associated with the best outcome is unknown. Our objective was to compare two target temperatures, both intended to prevent fever.
METHODS: In an international trial, we randomly assigned 950 unconscious adults after out-of-hospital cardiac arrest of presumed cardiac cause to targeted temperature management at either 33°C or 36°C. The primary outcome was all-cause mortality through the end of the trial. Secondary outcomes included a composite of poor neurologic function or death at 180 days, as evaluated with the Cerebral Performance Category (CPC) scale and the modified Rankin scale.
RESULTS: In total, 939 patients were included in the primary analysis. At the end of the trial, 50% of the patients in the 33°C group (235 of 473 patients) had died, as compared with 48% of the patients in the 36°C group (225 of 466 patients) (hazard ratio with a temperature of 33°C, 1.06; 95% confidence interval [CI], 0.89 to 1.28; P=0.51). At the 180-day follow-up, 54% of the patients in the 33°C group had died or had poor neurologic function according to the CPC, as compared with 52% of patients in the 36°C group (risk ratio, 1.02; 95% CI, 0.88 to 1.16; P=0.78). In the analysis using the modified Rankin scale, the comparable rate was 52% in both groups (risk ratio, 1.01; 95% CI, 0.89 to 1.14; P=0.87). The results of analyses adjusted for known prognostic factors were similar.
CONCLUSIONS: In unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, hypothermia at a targeted temperature of 33°C did not confer a benefit as compared with a targeted temperature of 36°C. (Funded by the Swedish Heart-Lung Foundation and others; TTM ClinicalTrials.gov number, NCT01020916.).

PMID 24237006  N Engl J Med. 2013 Dec 5;369(23):2197-206. doi: 10.1056・・・
著者: Frank W Moler, Faye S Silverstein, Richard Holubkov, Beth S Slomine, James R Christensen, Vinay M Nadkarni, Kathleen L Meert, Amy E Clark, Brittan Browning, Victoria L Pemberton, Kent Page, Seetha Shankaran, Jamie S Hutchison, Christopher J L Newth, Kimberly S Bennett, John T Berger, Alexis Topjian, Jose A Pineda, Joshua D Koch, Charles L Schleien, Heidi J Dalton, George Ofori-Amanfo, Denise M Goodman, Ericka L Fink, Patrick McQuillen, Jerry J Zimmerman, Neal J Thomas, Elise W van der Jagt, Melissa B Porter, Michael T Meyer, Rick Harrison, Nga Pham, Adam J Schwarz, Jeffrey E Nowak, Jeffrey Alten, Derek S Wheeler, Utpal S Bhalala, Karen Lidsky, Eric Lloyd, Mudit Mathur, Samir Shah, Theodore Wu, Andreas A Theodorou, Ronald C Sanders, J Michael Dean, THAPCA Trial Investigators
雑誌名: N Engl J Med. 2015 May 14;372(20):1898-908. doi: 10.1056/NEJMoa1411480. Epub 2015 Apr 25.
Abstract/Text BACKGROUND: Therapeutic hypothermia is recommended for comatose adults after witnessed out-of-hospital cardiac arrest, but data about this intervention in children are limited.
METHODS: We conducted this trial of two targeted temperature interventions at 38 children's hospitals involving children who remained unconscious after out-of-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose patients who were older than 2 days and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C). The primary efficacy outcome, survival at 12 months after cardiac arrest with a Vineland Adaptive Behavior Scales, second edition (VABS-II), score of 70 or higher (on a scale from 20 to 160, with higher scores indicating better function), was evaluated among patients with a VABS-II score of at least 70 before cardiac arrest.
RESULTS: A total of 295 patients underwent randomization. Among the 260 patients with data that could be evaluated and who had a VABS-II score of at least 70 before cardiac arrest, there was no significant difference in the primary outcome between the hypothermia group and the normothermia group (20% vs. 12%; relative likelihood, 1.54; 95% confidence interval [CI], 0.86 to 2.76; P=0.14). Among all the patients with data that could be evaluated, the change in the VABS-II score from baseline to 12 months was not significantly different (P=0.13) and 1-year survival was similar (38% in the hypothermia group vs. 29% in the normothermia group; relative likelihood, 1.29; 95% CI, 0.93 to 1.79; P=0.13). The groups had similar incidences of infection and serious arrhythmias, as well as similar use of blood products and 28-day mortality.
CONCLUSIONS: In comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year. (Funded by the National Heart, Lung, and Blood Institute and others; THAPCA-OH ClinicalTrials.gov number, NCT00878644.).

PMID 25913022  N Engl J Med. 2015 May 14;372(20):1898-908. doi: 10.105・・・
著者: Dermot R Doherty, Christopher S Parshuram, Isabelle Gaboury, Aparna Hoskote, Jacques Lacroix, Marisa Tucci, Ari Joffe, Karen Choong, Rosemarie Farrell, Desmond J Bohn, James S Hutchison, Canadian Critical Care Trials Group
雑誌名: Circulation. 2009 Mar 24;119(11):1492-500. doi: 10.1161/CIRCULATIONAHA.108.791384. Epub 2009 Mar 9.
Abstract/Text BACKGROUND: Hypothermia therapy improves mortality and functional outcome after cardiac arrest and birth asphyxia in adults and newborns. The effect of hypothermia therapy in infants and children with cardiac arrest is unknown.
METHODS AND RESULTS: A 2-year, retrospective, 5-center study was conducted, and 222 patients with cardiac arrest were identified. Seventy-nine (35.6%) of these patients met eligibility criteria for the study (age >40 weeks postconception and <18 years, cardiac arrest >3 minutes in duration, survival for > or = 12 hours after return of circulation, and no birth asphyxia). Twenty-nine (36.7%) of these 79 patients received hypothermia therapy and were cooled to 33.7+/-1.3 degrees C for 20.8+/-11.9 hours. Hypothermia therapy was associated with higher mortality (P=0.009), greater duration of cardiac arrest (P=0.005), more resuscitative interventions (P<0.001), higher postresuscitation lactate levels (P<0.001), and use of extracorporeal membrane oxygenation (P<0.001). When adjustment was made for duration of cardiac arrest, use of extracorporeal membrane oxygenation, and propensity scores by use of a logistic regression model, no statistically significant differences in mortality were found (P=0.502) between patients treated with hypothermia therapy and those treated with normothermia. Also, no differences in hypothermia-related adverse events were found between groups.
CONCLUSIONS: Hypothermia therapy was used in resuscitation scenarios that are associated with greater risk of poor outcome. In an adjusted analysis, the effectiveness of hypothermia therapy was neither supported nor refuted. A randomized controlled trial is needed to rigorously evaluate the benefits and harms of hypothermia therapy after pediatric cardiac arrest.

PMID 19273725  Circulation. 2009 Mar 24;119(11):1492-500. doi: 10.1161・・・
著者: Jainn-Jim Lin, Shao-Hsuan Hsia, Huei-Shyong Wang, Ming-Chou Chiang, Kuang-Lin Lin
雑誌名: Pediatr Neurol. 2013 Apr;48(4):285-90. doi: 10.1016/j.pediatrneurol.2012.12.021.
Abstract/Text Brain injury after resuscitation is associated with high morbidity and mortality in children. Therapeutic hypothermia has theoretical benefits on brain preservation. It has been shown to be effective in improving neurological outcomes after adult ventricular arrhythmia-induced cardiac arrest and neonatal asphyxia. However, there have only been a few reports about therapeutic hypothermia after pediatric resuscitation. We conducted this retrospective cohort study in a tertiary pediatric intensive care unit between January 2010 and June 2012. All children from 2 months to 18 years of age with resuscitation and a history of at least 3 minutes of chest compressions with survival for 12 hours or more after return of circulation were eligible. Forty-three patients met the eligibility criteria for the study. Forty-two patients (97.6%) were asphyxial in etiology; 29 (67.4%) of them occurred out-of-hospital. Excluding one child with cardiac etiology, the overall survival rate to hospital discharge was 57.1%. Fourteen (33.3%) patients received hypothermia therapy and were cooled to 33°C for 72 hours. The survival rate was higher in the therapeutic hypothermia group (11/14, 78.6%) than in the normothermia group (13/28, 46.4%). In conclusion, therapeutic hypothermia was associated with increased survival rate after pediatric resuscitation.

Copyright © 2013 Elsevier Inc. All rights reserved.
PMID 23498561  Pediatr Neurol. 2013 Apr;48(4):285-90. doi: 10.1016/j.p・・・
著者: Ian G Jacobs, Judith C Finn, George A Jelinek, Harry F Oxer, Peter L Thompson
雑誌名: Resuscitation. 2011 Sep;82(9):1138-43. doi: 10.1016/j.resuscitation.2011.06.029. Epub 2011 Jul 2.
Abstract/Text BACKGROUND: There is little evidence from clinical trials that the use of adrenaline (epinephrine) in treating cardiac arrest improves survival, despite adrenaline being considered standard of care for many decades. The aim of our study was to determine the effect of adrenaline on patient survival to hospital discharge in out of hospital cardiac arrest.
METHODS: We conducted a double blind randomised placebo-controlled trial of adrenaline in out-of-hospital cardiac arrest. Identical study vials containing either adrenaline 1:1000 or placebo (sodium chloride 0.9%) were prepared. Patients were randomly allocated to receive 1 ml aliquots of the trial drug according to current advanced life support guidelines. Outcomes assessed included survival to hospital discharge (primary outcome), pre-hospital return of spontaneous circulation (ROSC) and neurological outcome (Cerebral Performance Category Score - CPC).
RESULTS: A total of 4103 cardiac arrests were screened during the study period of which 601 underwent randomisation. Documentation was available for a total of 534 patients: 262 in the placebo group and 272 in the adrenaline group. Groups were well matched for baseline characteristics including age, gender and receiving bystander CPR. ROSC occurred in 22 (8.4%) of patients receiving placebo and 64 (23.5%) who received adrenaline (OR=3.4; 95% CI 2.0-5.6). Survival to hospital discharge occurred in 5 (1.9%) and 11 (4.0%) patients receiving placebo or adrenaline respectively (OR=2.2; 95% CI 0.7-6.3). All but two patients (both in the adrenaline group) had a CPC score of 1-2.
CONCLUSION: Patients receiving adrenaline during cardiac arrest had no statistically significant improvement in the primary outcome of survival to hospital discharge although there was a significantly improved likelihood of achieving ROSC.

Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
PMID 21745533  Resuscitation. 2011 Sep;82(9):1138-43. doi: 10.1016/j.r・・・
著者: C Vandycke, P Martens
雑誌名: Resuscitation. 2000 Aug 1;45(3):161-6.
Abstract/Text In the management of cardiac arrest there is ongoing controversy concerning the optimal dose of epinephrine. To obtain the best available evidence regarding the current optimal dose, we performed a meta-analysis. We searched the Medline database online and reviewed citations in relevant articles to identify studies that met preset inclusion criteria (prospective, randomized, double-blind). Five trials were identified. The pooled odds ratio for return of spontaneous circulation favours the experimental dose. The pooled odds ratio for hospital discharge failed to demonstrate a statistically significant beneficial effect of high and/or escalating doses of epinephrine in comparison with standard dose of epinephrine. The possibility that patients who have already sustained irreversible neurologic injury will be resuscitated carries potential adverse social and economic implications.

PMID 10959014  Resuscitation. 2000 Aug 1;45(3):161-6.
著者: Francis Kim, Graham Nichol, Charles Maynard, Al Hallstrom, Peter J Kudenchuk, Thomas Rea, Michael K Copass, David Carlbom, Steven Deem, W T Longstreth, Michele Olsufka, Leonard A Cobb
雑誌名: JAMA. 2014 Jan 1;311(1):45-52. doi: 10.1001/jama.2013.282173.
Abstract/Text IMPORTANCE: Hospital cooling improves outcome after cardiac arrest, but prehospital cooling immediately after return of spontaneous circulation may result in better outcomes.
OBJECTIVE: To determine whether prehospital cooling improves outcomes after resuscitation from cardiac arrest in patients with ventricular fibrillation (VF) and without VF.
DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial that assigned adults with prehospital cardiac arrest to standard care with or without prehospital cooling, accomplished by infusing up to 2 L of 4°C normal saline as soon as possible following return of spontaneous circulation. Adults in King County, Washington, with prehospital cardiac arrest and resuscitated by paramedics were eligible and 1359 patients (583 with VF and 776 without VF) were randomized between December 15, 2007, and December 7, 2012. Patient follow-up was completed by May 1, 2013. Nearly all of the patients resuscitated from VF and admitted to the hospital received hospital cooling regardless of their randomization.
MAIN OUTCOMES AND MEASURES: The primary outcomes were survival to hospital discharge and neurological status at discharge.
RESULTS: The intervention decreased mean core temperature by 1.20°C (95% CI, -1.33°C to -1.07°C) in patients with VF and by 1.30°C (95% CI, -1.40°C to -1.20°C) in patients without VF by hospital arrival and reduced the time to achieve a temperature of less than 34°C by about 1 hour compared with the control group. However, survival to hospital discharge was similar among the intervention and control groups among patients with VF (62.7% [95% CI, 57.0%-68.0%] vs 64.3% [95% CI, 58.6%-69.5%], respectively; P = .69) and among patients without VF (19.2% [95% CI, 15.6%-23.4%] vs 16.3% [95% CI, 12.9%-20.4%], respectively; P = .30). The intervention was also not associated with improved neurological status of full recovery or mild impairment at discharge for either patients with VF (57.5% [95% CI, 51.8%-63.1%] of cases had full recovery or mild impairment vs 61.9% [95% CI, 56.2%-67.2%] of controls; P = .69) or those without VF (14.4% [95% CI, 11.3%-18.2%] of cases vs 13.4% [95% CI,10.4%-17.2%] of controls; P = .30). Overall, the intervention group experienced rearrest in the field more than the control group (26% [95% CI, 22%-29%] vs 21% [95% CI, 18%-24%], respectively; P = .008), as well as increased diuretic use and pulmonary edema on first chest x-ray, which resolved within 24 hours after admission.
CONCLUSION AND RELEVANCE: Although use of prehospital cooling reduced core temperature by hospital arrival and reduced the time to reach a temperature of 34°C, it did not improve survival or neurological status among patients resuscitated from prehospital VF or those without VF.
TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00391469.

PMID 24240712  JAMA. 2014 Jan 1;311(1):45-52. doi: 10.1001/jama.2013.2・・・
著者: M Callaham, C D Madsen, C W Barton, C E Saunders, J Pointer
雑誌名: JAMA. 1992 Nov 18;268(19):2667-72.
Abstract/Text OBJECTIVE: To determine the relative efficacy of high- vs standard-dose catecholamines in initial treatment of prehospital cardiac arrest.
DESIGN: Randomized, prospective, double-blind clinical trial.
SETTING: Prehospital emergency medical system of a major US city.
PATIENTS: All adults in nontraumatic cardiac arrest, treated by paramedics, who would receive epinephrine according to American Heart Association advanced cardiac life support guidelines.
INTERVENTIONS: High-dose epinephrine (HDE, 15 mg), high-dose norepinephrine bitartrate (NE, 11 mg), or standard-dose epinephrine (SDE, 1 mg) was blindly substituted for advanced cardiac life support doses of epinephrine.
MAIN OUTCOME MEASURES: Restoration of spontaneous circulation in the field, admission to hospital, hospital discharge, and Cerebral Performance Category score.
RESULTS: Of 2694 patients with cardiac arrests during the study period, resuscitation was attempted on 1062 patients. Of this total, 816 patients met study criteria and were enrolled. In the entire cardiac arrest population, 63% of the survivors were among the 11% of patients who were defibrillated by first responders. The three drug treatment groups were similar for all independent variables. Thirteen percent of patients receiving HDE regained a pulse in the field vs 8% of those receiving SDE (P = .01), and 18% of HDE patients were admitted to the hospital vs 10% of SDE patients who were admitted to the hospital (P = .02). Similar trends for NE were not significant. There were 18 survivors; 1.7% of HDE patients and 2.6% of NE patients were discharged from the hospital compared with 1.2% of SDE patients, but this was not significant (P = .37; beta = .38). There was a nonsignificant trend for Cerebral Performance Category scores to be worse for HDE (3.2) and NE patients (3.7) than for SDE patients (2.3) (P = .10; beta = .31). No significant complications were identified. High-dose epinephrine did not produce longer hospital or critical care unit stays.
CONCLUSIONS: High-dose epinephrine significantly improves the rate of return of spontaneous circulation and hospital admission in patients who are in prehospital cardiac arrest without increasing complications. However, the increase in hospital discharge rate is not statistically significant, and no significant trend could be determined for neurological outcome. No benefit of NE compared with HDE was identified. Further study is needed to determine the optimal role of epinephrine in prehospital cardiac arrest.

PMID 1433686  JAMA. 1992 Nov 18;268(19):2667-72.
著者: P Y Gueugniaud, P Mols, P Goldstein, E Pham, P Y Dubien, C Deweerdt, M Vergnion, P Petit, P Carli
雑誌名: N Engl J Med. 1998 Nov 26;339(22):1595-601. doi: 10.1056/NEJM199811263392204.
Abstract/Text BACKGROUND: Clinical trials have not shown a benefit of high doses of epinephrine in the management of cardiac arrest. We conducted a prospective, multicenter, randomized study comparing repeated high doses of epinephrine with repeated standard doses in cases of out-of-hospital cardiac arrest.
METHODS: Adult patients who had cardiac arrest outside the hospital were enrolled if the cardiac rhythm continued to be ventricular fibrillation despite the administration of external electrical shocks, or if they had asystole or pulseless electrical activity at the time epinephrine was administered. We randomly assigned 3327 patients to receive up to 15 high doses (5 mg each) or standard doses (1 mg each) of epinephrine according to the current protocol for advanced cardiac life support.
RESULTS: In the high-dose group, 40.4 percent of 1677 patients had a return of spontaneous circulation, as compared with 36.4 percent of 1650 patients in the standard-dose group (P=0.02); 26.5 percent of the patients in the high-dose group and 23.6 percent of those in the standard-dose group survived to be admitted to the hospital (P=0.05); 2.3 percent of the patients in the high-dose group and 2.8 percent in the standard-dose group survived to be discharged from the hospital (P=0.34). There was no significant difference in neurologic status according to treatment among those discharged. High-dose epinephrine improved the rate of successful resuscitation in patients with asystole, but not in those with ventricular fibrillation.
CONCLUSIONS: In our study, long-term survival after cardiac arrest outside the hospital was no better with repeated high doses of epinephrine than with repeated standard doses.

PMID 9828247  N Engl J Med. 1998 Nov 26;339(22):1595-601. doi: 10.105・・・
著者: Vinodh Bhagyalakshmi Nanjayya, Vineet Nayyar
雑誌名: Resuscitation. 2012 Jun;83(6):699-704. doi: 10.1016/j.resuscitation.2011.12.004. Epub 2011 Dec 14.
Abstract/Text INTRODUCTION: The role of immediate coronary angiography and percutaneous coronary intervention (angio±PCI), amongst comatose survivors of out-of-hospital cardiac arrest is unclear. This study was undertaken to evaluate if immediate angio±PCI compared to no initial intervention improves neurological outcome at hospital discharge amongst comatose survivors of out-of-hospital pulseless ventricular tachycardia (pVT) or ventricular fibrillation (VF).
METHODS: All patients admitted to Intensive Care Unit (ICU) following an out-of-hospital VF/pVT arrest from 1/1/2003 to 31/12/2008 were included. Outcome of patients who underwent immediate angio±PCI was compared to those who did not undergo any intervention before admission to ICU. Good outcome was defined as survival to hospital discharge with Cerebral Performance Category (CPC) score of 1 or 2.
RESULTS: Thirty-five patients (30 Males, 5 Females, mean age 60.3±10.1), underwent angio±PCI prior to ICU admission. A further 35 patients (20 Males, 15 Females, mean age 61.1±17.6 years) were admitted directly to ICU without undergoing any intervention. Forty percent (14/35) of patients who had immediate coronary intervention survived to hospital discharge with a good outcome compared to 31% (11/35) patients who did not undergo any intervention. After adjusting for other covariates, the probability of good outcome at hospital discharge was related to severity of illness (SAPS-II) score at ICU admission (adj OR=0.87, 95% CI 0.81-0.94, p<0.01). Immediate angio±PCI compared to no intervention was associated with an improved outcome but this difference was statistically not significant (adj OR 1.32, 95% CI 0.26-7.87, p=0.78).
CONCLUSION: Immediate angio±PCI in comatose survivors of out-of-hospital VF/pVT arrest did not lead to better neurological outcome at hospital discharge.

Crown Copyright © 2011. Published by Elsevier Ireland Ltd. All rights reserved.
PMID 22178796  Resuscitation. 2012 Jun;83(6):699-704. doi: 10.1016/j.r・・・
著者: Joshua C Reynolds, Clifton W Callaway, Samar R El Khoudary, Charity G Moore, René J Alvarez, Jon C Rittenberger
雑誌名: J Intensive Care Med. 2009 May-Jun;24(3):179-86. doi: 10.1177/0885066609332725. Epub 2009 Mar 25.
Abstract/Text OBJECTIVES: Determine if clinical parameters of resuscitated patients predict coronary angiography (CATH) performance and if receiving CATH after cardiac arrest is associated with outcome.
INTRODUCTION: CATH is associated with survival in patients suffering out-of-hospital cardiac arrest (OHCA) from ventricular fibrillation or ventricular tachycardia(VF/VT). Its effect on outcome in other cohorts is unknown.
METHODS: Chart review of resuscitated cardiac arrest patients between 2005 and 2007.
EXCLUSION CRITERIA: immediate withdrawal of care, hemodynamic collapse, or neurologic exam under sedation. Clinical parameters included Glasgow Coma Scale (GCS) arrest location, presenting rhythm, age, and acute ischemic ECG changes (new left bundle branch block or ST-elevation myocardial infarction-STEMI). Logistic regression identified clinical parameters predicting CATH. The association between CATH and good outcome (discharge home or to acute rehabilitation facility) was determined using logistic regression adjusting for likelihood of receiving CATH via propensity score.
RESULT: Of the 241 patients, 96 (40%) received CATH. Significant disease (>or=70% stenosis) of >or=1 coronary arteries was identified in 69% of patients including 57% of patients without acute ischemic ECG changes. Unadjusted predictors of CATH were sex, method of arrival, OHCA, presenting rhythm, acute ischemic ECG changes, and GCS. Propensity adjusted logistic regression demonstrated an association between CATH and good outcome (OR 2.16; 95% CI 1.12, 4.19; P<0.02).
CONCLUSION: CATH is more likely to be performed in certain patients and identifies a significant number of high-grade stenoses in this population. Receiving CATH was independently associated with good outcome.

PMID 19321536  J Intensive Care Med. 2009 May-Jun;24(3):179-86. doi: 1・・・
著者: Justin A Strote, Charles Maynard, Michele Olsufka, Graham Nichol, Michael K Copass, Leonard A Cobb, Francis Kim
雑誌名: Am J Cardiol. 2012 Feb 15;109(4):451-4. doi: 10.1016/j.amjcard.2011.09.036. Epub 2011 Nov 17.
Abstract/Text Despite reports of patients with resuscitated sudden cardiac arrest (rSCA) receiving acute cardiac catheterization, the efficacy of this strategy is largely unknown. We hypothesized that acute cardiac catheterization of patients with rSCA would improve survival to hospital discharge. A retrospective cohort of 240 patients with out-of-hospital rSCA caused by ventricular tachycardia or fibrillation was identified from 11 institutions in Seattle, Washington from 1999 through 2002. Patients were grouped into those receiving acute catheterization within 6 hours (≤6-hour group, n = 61) and those with deferred catheterization at >6 hours or no catheterization during the index hospitalization (>6-hour group, n = 179). Attention was directed to survival to hospital discharge, neurologic status, extent of coronary artery disease, presenting electrocardiographic findings, and symptoms before arrest. Propensity-score methods were used to adjust for the likelihood of receiving acute catheterization. Survival was greater in patients who underwent acute catheterization (72% in the ≤6-hour group vs 49% in the >6-hour group, p = 0.001). Percutaneous coronary intervention was performed in 38 of 61 patients (62%) in the ≤6-hour group and 13 of 170 patients (7%) in the >6-hour group (p <0.0001). Neurologic status was similar in the 2 groups. A significantly larger percentage of patients in the acute catheterization group had symptoms before cardiac arrest and had ST-segment elevation on electrocardiogram after resuscitation. Age, bystander cardiopulmonary resuscitation, daytime presentation, history of percutaneous coronary intervention or stroke, and acute ST-segment elevation were positively associated with receiving cardiac catheterization. In conclusion, in this series of patients who sustained out-of-hospital cardiac arrest, acute catheterization (<6 hours of presentation) was associated with improved survival.

Copyright © 2012 Elsevier Inc. All rights reserved.
PMID 22100026  Am J Cardiol. 2012 Feb 15;109(4):451-4. doi: 10.1016/j.・・・
著者: Aline Bouwes, Jan M Binnekade, Michael A Kuiper, Frank H Bosch, Durk F Zandstra, Arnoud C Toornvliet, Hazra S Biemond, Bas M Kors, Johannes H T M Koelman, Marcel M Verbeek, Henry C Weinstein, Albert Hijdra, Janneke Horn
雑誌名: Ann Neurol. 2012 Feb;71(2):206-12. doi: 10.1002/ana.22632.
Abstract/Text OBJECTIVE: This study was designed to establish the reliability of neurologic examination, neuron-specific enolase (NSE), and median nerve somatosensory-evoked potentials (SEPs) to predict poor outcome in patients treated with mild hypothermia after cardiopulmonary resuscitation (CPR).
METHODS: This multicenter prospective cohort study included adult comatose patients admitted to the intensive care unit (ICU) after CPR and treated with hypothermia (32-34°C). False-positive rates (FPRs 1 - specificity) with their 95% confidence intervals (CIs) were calculated for pupillary light responses, corneal reflexes, and motor scores 72 hours after CPR; NSE levels at admission, 12 hours after reaching target temperature, and 36 hours and 48 hours after collapse; and SEPs during hypothermia and after rewarming. The primary outcome was poor outcome, defined as death, vegetative state, or severe disability (Glasgow Outcome Scale 1-3) after 6 months.
RESULTS: Of 391 patients included, 53% had a poor outcome. Absent pupillary light responses (FPR 1; 95% CI, 0-7) or absent corneal reflexes (FPR 4; 95% CI, 1-13) 72 hours after CPR, and absent SEPs during hypothermia (FPR 3; 95% CI, 1-7) and after rewarming (FPR 0; 95% CI, 0-18) were reliable predictors. Motor scores 72 hours after CPR (FPR 10; 95% CI, 6-16) and NSE levels were not.
INTERPRETATION: In patients with persisting coma after CPR and therapeutic hypothermia, use of motor score or NSE, as recommended in current guidelines, could possibly lead to inappropriate withdrawal of treatment. Poor outcomes can reliably be predicted by testing brainstem reflexes 72 hours after CPR and performing SEP.

Copyright © 2011 American Neurological Association.
PMID 22367993  Ann Neurol. 2012 Feb;71(2):206-12. doi: 10.1002/ana.226・・・
著者: T Cronberg, M Rundgren, E Westhall, E Englund, R Siemund, I Rosén, H Widner, H Friberg
雑誌名: Neurology. 2011 Aug 16;77(7):623-30. doi: 10.1212/WNL.0b013e31822a276d. Epub 2011 Jul 20.
Abstract/Text OBJECTIVE: Therapeutic hypothermia (TH) is a recommended treatment for survivors of cardiac arrest. Prognostication is complicated since sedation and muscle relaxation are used and established indicators of a poor prognosis are lacking. This prospective, observational study describes the pattern of commonly used prognostic markers in a hypothermia-treated cohort of cardiac arrest patients with prolonged coma.
METHODS: Among 111 consecutive patients, 19 died, 58 recovered, and 34 were in coma 3 days after normothermia (4.5 days after cardiac arrest), defined as prolonged coma. All patients were monitored with continuous amplitude-integrated EEG and repeated samples of neuron-specific enolase (NSE) were collected. In patients with prolonged coma, somatosensory evoked potentials (SSEP) and brain MRI were performed. A postmortem brain investigation was undertaken in patients who died.
RESULTS: Six of the 17 patients (35%) with NSE levels <33 μg/L at 48 hours regained the capacity to obey verbal commands. By contrast, all 17 patients with NSE levels >33 failed to recover consciousness. In the >33 NSE group, all 10 studied with MRI had extensive brain injury on diffusion-weighted images, 12/16 lacked cortical responses on SSEP, and all 6 who underwent autopsy had extensive severe histologic damage. NSE levels also correlated with EEG pattern, but less uniformly, since 11/17 with NSE <33 had an electrographic status epilepticus (ESE), only one of whom recovered. A continuous EEG pattern correlated to NSE <33 and awakening.
CONCLUSIONS: NSE correlates well with other markers of ischemic brain injury. In patients with no other signs of brain injury, postanoxic ESE may explain a poor outcome.

PMID 21775743  Neurology. 2011 Aug 16;77(7):623-30. doi: 10.1212/WNL.0・・・
著者: Jennifer E Fugate, Eelco F M Wijdicks, Jay Mandrekar, Daniel O Claassen, Edward M Manno, Roger D White, Malcolm R Bell, Alejandro A Rabinstein
雑誌名: Ann Neurol. 2010 Dec;68(6):907-14. doi: 10.1002/ana.22133.
Abstract/Text OBJECTIVE: To evaluate the predictive value of neurologic prognostic indicators for patients treated with hypothermia after surviving cardiopulmonary arrest.
METHODS: Patients who survived cardiopulmonary arrest were prospectively collected from June 2006 to October 2009. Detailed neurologic examinations were performed. Serum neuron specific enolase (NSE) measurements, brain imaging findings, somatosensory evoked potentials, and electroencephalogram (EEG) results were recorded. EEG patterns were blindly dichotomized with malignant patterns consisting of burst-suppression, generalized suppression, status epilepticus, and nonreactivity. Outcome measure of in-hospital mortality was assessed.
RESULTS: A total of 192 patients (103 hypothermic, 89 nonhypothermic) were studied. The absence of pupillary light responses, corneal reflexes, and an extensor or absent motor response at Day 3 after cardiac arrest remained accurate predictors of poor outcome after therapeutic hypothermia (p < 0.0001 for all). Myoclonic status epilepticus was invariably associated with death (p = 0.0002). Malignant EEG patterns and global cerebral edema on head computed tomography (CT) were associated with death in both populations (p < 0.001). NSE > 33 ng/ml levels measured 1-3 days after cardiac arrest remained associated with poor outcome (p = 0.017), but had a false-positive rate of 29.3% (95% confidence interval [CI] 0.164-0.361).
INTERPRETATION: Clinical examination (brainstem reflexes, motor response, and presence of myoclonus) at Day 3 after cardiac arrest remains an accurate predictor of outcome after therapeutic hypothermia. Sedative medications in both hypothermic and nonhypothermic patients may confound the clinical exam. NSE > 33 ng/ml has a high false-positive rate in patients treated with hypothermia and should be interpreted with caution.

PMID 21061401  Ann Neurol. 2010 Dec;68(6):907-14. doi: 10.1002/ana.221・・・
著者: Edgar A Samaniego, Michael Mlynash, Anna Finley Caulfield, Irina Eyngorn, Christine A C Wijman
雑誌名: Neurocrit Care. 2011 Aug;15(1):113-9. doi: 10.1007/s12028-010-9412-8.
Abstract/Text BACKGROUND: Therapeutic hypothermia is commonly used in comatose survivors' post-cardiopulmonary resuscitation (CPR). It is unknown whether outcome predictors perform accurately after hypothermia treatment.
METHODS: Post-CPR comatose survivors were prospectively enrolled. Six outcome predictors [pupillary and corneal reflexes, motor response to pain, and somatosensory-evoked potentials (SSEP) >72 h; status myoclonus, and serum neuron-specific enolase (NSE) levels <72 h] were systematically recorded. Poor outcome was defined as death or vegetative state at 3 months. Patients were considered "sedated" if they received any sedative drugs ≤ 12 h prior the 72 h neurological assessment.
RESULTS: Of 85 prospectively enrolled patients, 53 (62%) underwent hypothermia. Furthermore, 53 of the 85 patients (62%) had a poor outcome. Baseline characteristics did not differ between the hypothermia and normothermia groups. Sedative drugs at 72 h were used in 62 (73%) patients overall, and more frequently in hypothermia than in normothermia patients: 83 versus 60% (P = 0.02). Status myoclonus <72 h, absent cortical responses by SSEPs >72 h, and absent pupillary reflexes >72 h predicted poor outcome with a 100% specificity both in hypothermia and normothermia patients. In contrast, absent corneal reflexes >72 h, motor response extensor or absent >72 h, and peak NSE >33 ng/ml <72 h predicted poor outcome with 100% specificity only in non-sedated patients, irrespective of prior treatment with hypothermia.
CONCLUSIONS: Sedative medications are commonly used in proximity of the 72-h neurological examination in comatose CPR survivors and are an important prognostication confounder. Patients treated with hypothermia are more likely to receive sedation than those who are not treated with hypothermia.

PMID 20680517  Neurocrit Care. 2011 Aug;15(1):113-9. doi: 10.1007/s120・・・
著者: E D Bailey, G C Wydro, D C Cone
雑誌名: Prehosp Emerg Care. 2000 Apr-Jun;4(2):190-5.
Abstract/Text The National Association of EMS Physicians (NAEMSP) supports out-of-hospital termination of resuscitation for adult, nontraumatic cardiac arrest patients who have not responded to full resuscitative efforts. The following factors should be considered in establishing termination of resuscitation protocols: 1) Termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical. 2) Unwitnessed cardiac arrest with delayed initiation of cardiopulmonary resuscitation (CPR) beyond 6 minutes and delayed defibrillation beyond 8 minutes has a poor prognosis. 3) In the absence of "do not resuscitate" or advanced directives, a full resuscitative effort including CPR, definitive airway management, medication administration, defibrillation if necessary, and at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines should be performed prior to declaring the patient dead. 4) A patient whose rhythm changes to, or remains in, ventricular fibrillation or ventricular tachycardia should have continued resuscitative efforts. Patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation. 5) Logistic factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. 6) Online medical direction should be established prior to termination of resuscitation. The decision to terminate efforts should be a consensus between the on-scene paramedic and the online physician. 7) The on-scene providers and family should have access to resources, such as clergy, crisis workers, and social workers. 8) Quality review is necessary to ensure appropriate application of the termination protocol, law enforcement notification, medical examiner or coroner involvement, and family counseling.

PMID 10782611  Prehosp Emerg Care. 2000 Apr-Jun;4(2):190-5.
著者: Marc Eckstein, Samuel J Stratton, Linda S Chan
雑誌名: Acad Emerg Med. 2005 Jan;12(1):65-70. doi: 10.1197/j.aem.2004.07.020.
Abstract/Text OBJECTIVE: To determine the rate of termination of resuscitative efforts for out-of-hospital cardiac arrest patients and whether variability exists among different base hospitals providing online medical control (OLMC).
METHODS: This was an observational one-year study that included all adult patients in the city of Los Angeles with nontraumatic, out-of-hospital cardiac arrests with attempted resuscitative efforts by paramedics. OLMC was provided by 13 base hospitals. The main outcome measure was the incidence of termination of resuscitative efforts on scene as directed by OLMC.
RESULTS: Of 1,700 patients, 151 (9%) had resuscitative efforts terminated on scene via direction by OLMC. Patients pronounced on scene were statistically more likely to be older, be found in an extended care facility, have an unwitnessed arrest, and present in asystole. Two base hospitals were more likely to terminate resuscitative efforts via OLMC than all others. Incidence at base hospital A was 37% (odds ratio, 18.6; 95% confidence interval = 11.7 to 30.0; p < 0.0001); incidence at base hospital B was 14% (odds ratio, 3.3; 95% confidence interval = 1.9 to 5.5; p < 0.0001), and incidence at all other base hospitals was 5%. Cardiac arrest patients handled by base hospital A were more likely to be found in ventricular fibrillation; those patients handled by base hospital B had shorter emergency medical services response times and were more likely to be found in an extended care facility. All other characteristics of cardiac arrest patients were not significantly different among the base hospitals.
CONCLUSIONS: There is significant variability in Los Angeles, depending on the particular base hospital that provides OLMC, in pronouncement of death and termination of resuscitative efforts for medical cardiac arrest in the field. Given potential ethical, logistical, and economic concerns, efforts to assure consistency in the practice of discontinuing resuscitative efforts in the field is warranted.

PMID 15635140  Acad Emerg Med. 2005 Jan;12(1):65-70. doi: 10.1197/j.ae・・・
著者: Laurie J Morrison, Laura M Visentin, Alex Kiss, Rob Theriault, Don Eby, Marian Vermeulen, Jonathan Sherbino, P Richard Verbeek, TOR Investigators
雑誌名: N Engl J Med. 2006 Aug 3;355(5):478-87. doi: 10.1056/NEJMoa052620.
Abstract/Text BACKGROUND: We prospectively evaluated a clinical prediction rule to be used by emergency medical technicians (EMTs) trained in the use of an automated external defibrillator for the termination of basic life support resuscitative efforts during out-of-hospital cardiac arrest. The rule recommends termination when there is no return of spontaneous circulation, no shocks are administered, and the arrest is not witnessed by emergency medical-services personnel. Otherwise, the rule recommends transportation to the hospital, in accordance with routine practice.
METHODS: The study included 24 emergency medical systems in Ontario, Canada. All patients 18 years of age or older who had an arrest of presumed cardiac cause and who were treated by EMTs trained in the use of an automated external defibrillator were included. The patients were treated according to standard guidelines. Characteristics of diagnostic tests for the prediction rule were calculated. These characteristics include sensitivity, specificity, and positive and negative predictive values.
RESULTS: Follow-up data were obtained for all 1240 patients. Of 776 patients with cardiac arrest for whom the rule recommended termination, 4 survived (0.5 percent). The rule had a specificity of 90.2 percent for recommending transport of survivors to the emergency department and had a positive predictive value for death of 99.5 percent when termination was recommended. Implementation of this rule would result in a decrease in the rate of transportation from 100 percent of patients to 37.4 percent. The addition of other criteria (a response interval greater than eight minutes or a cardiac arrest not witnessed by a bystander) would further improve both the specificity and positive predictive value of the rule but would result in the transportation of a larger proportion of patients.
CONCLUSIONS: The use of a clinical prediction rule for the termination of resuscitation may help clinicians decide whether to terminate basic life support resuscitative efforts in patients having an out-of-hospital cardiac arrest.

Copyright 2006 Massachusetts Medical Society.
PMID 16885551  N Engl J Med. 2006 Aug 3;355(5):478-87. doi: 10.1056/NE・・・
著者: M Gilbert, R Busund, A Skagseth, P A Nilsen, J P Solbø
雑誌名: Lancet. 2000 Jan 29;355(9201):375-6. doi: 10.1016/S0140-6736(00)01021-7.
Abstract/Text In a victim of very deep accidental hypothermia, 9 h of resuscitation and stabilisation led to good physical and mental recovery. This potential outcome should be borne in mind for all such victims.

PMID 10665559  Lancet. 2000 Jan 29;355(9201):375-6. doi: 10.1016/S0140・・・
著者: Ravindranath Tiruvoipati, Senthil K Balasubramanian, Espeed Khoshbin, Leonidas Hadjinikolaou, Andrzej W Sosnowski, Richard K Firmin
雑誌名: ASAIO J. 2005 Jul-Aug;51(4):474-6.
Abstract/Text Cardiopulmonary bypass is usually used for rewarming and for providing cardiac support in patients with severe hypothermia and cardiovascular instability. We report the first case of accidental severe hypothermia associated with prolonged cardiac arrest that was successfully managed by venovenous extracorporeal membrane oxygenation.

PMID 16156316  ASAIO J. 2005 Jul-Aug;51(4):474-6.

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