Abstract Aim High-quality chest compressions are a critical component of the resuscitation of patients in cardiopulmonary arrest. Point-of-care ultrasound (POCUS) is used frequently during emergency department (ED) resuscitations, but there has been limited research assessing its benefits and harms during the delivery of cardiopulmonary resuscitation (CPR). We hypothesized that use of POCUS during cardiac arrest resuscitation adversely affects high-quality CPR by lengthening the duration of pulse checks beyond the current cardiopulmonary resuscitation guidelines recommendation of 10 s. Methods We conducted a prospective cohort study of adults in cardiac arrest treated in an urban ED between August 2015 and September 2016. Resuscitations were recorded using video equipment in designated resuscitation rooms, and the use of POCUS was documented and timed. A linear mixed-effects model was used to estimate the effect of POCUS on pulse check duration. Results Twenty-three patients were enrolled in our study. The mean duration of pulse checks with POCUS was 21.0 s (95% CI, 18–24) compared with 13.0 s (95% CI, 12–15) for those without POCUS. POCUS increased the duration of pulse checks and CPR interruption by 8.4 s (95% CI, 6.7–10.0 [p 0.0001]). Age, body mass index (BMI), and procedures did not significantly affect the duration of pulse checks. Conclusions The use of POCUS during cardiac arrest resuscitation was associated with significantly increased duration of pulse checks, nearly doubling the 10-s maximum duration recommended in current guidelines. It is important for acute care providers to pay close attention to the duration of interruptions in the delivery of chest compressions when using POCUS during cardiac arrest resuscitation. Autors: Hendrika Meischke, Ian S. Painter, Scott R. Stangenes, Marcia R. Weaver, Carol E. Fahrenbruch, Tom Rea, Anne M. Turner Autors: Maite A. Huis in 't Veld, Michael G. Allison, David S. Bostick, Kiondra R. Fisher, Olga G. Goloubeva, Michael D. Witting, Michael E. Winters Autors: Marine Riou, Stephen Ball, Teresa A. Williams, Austin Whiteside, Kay L. O’Halloran, Janet Bray, Gavin D. Perkins, Karen Smith, Peter Cameron, Daniel M. Fatovich, Madoka Inoue, Paul Bailey, Deon Brink, Judith Finn Autors: Martha Wolfskeil, Maxim Vanwulpen, Christophe Duchatelet, Koenraad G. Monsieurs, Said Hachimi-Idrissi Autors: Signe Riddersholm, Kristian Kragholm, Rikke Nørmark Mortensen, Marianne Pape, Carolina Malta Hansen, Freddy K. Lippert, Christian Torp-Pedersen, Christian F. Christiansen, Bodil Steen Rasmussen Autors: Takahisa Kawano, Brian Grunau, Frank X. Scheuermeyer, Koichiro Gibo, William Dick, Christopher B. Fordyce, Paul Dorian, Robert Stenstrom, Ronald Straight, Jim Christenson Autors: Veer D. Vithalani, Steven Q. Davis, Neal J. Richmond, MD Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions Association of bystander interventions and hospital length of stay and admission to intensive care unit in out-of-hospital cardiac arrest survivors Abstract Background The impact of bystander interventions on post-arrest hospital course is sparsely studied. We examined the association between bystander interventions and length of hospital stay and admission to intensive care unit (ICU) in one-day survivors after OHCA. Methods This cohort study linked data of 4641 one-day OHCA survivors from 2001 to 2014 to data on hospital length of stay and ICU admission. We examined associations between bystander efforts and outcomes using regression, adjusted for age, sex, comorbidities, calendar year and witnessed status. We divided bystander efforts into three categories: 1. No bystander interventions; 2.Bystander CPR only; 3. Bystander defibrillation with or without bystander CPR. Results For patients surviving to hospital discharge, hospital length of stay was 20 days for patients without bystander interventions, compared to 16 for bystander CPR, and 13 for bystander defibrillation. 82% of patients without bystander interventions were admitted to ICU compared to 77.2% for bystander CPR, and 61.2% for bystander defibrillation. In-hospital mortality was 60% in the first category compared to 40.5% and 21.7% in the two latter categories. In regression models, bystander CPR and bystander defibrillation were associated with a reduction of length of hospital stay of 21% (Estimate: 0.79 [95% CI: 0.72–0.86]) and 32% (Estimate: 0.68 [95% CI: 0.59–0.78]), respectively. Both bystander CPR (OR: 0.94 [95% CI: 0.91–0.97]) and bystander defibrillation (OR: 0.81 [0.76–0.85]), were associated with lower risk of ICU admission. Conclusions Bystander interventions were associated with reduced hospital length of stay and ICU admission, suggesting that these efforts improve recovery in OHCA survivors. Unrecognized failed airway management using a supraglottic airway device Abstract Background 911 Emergency Medical Services (EMS) systems utilize supraglottic devices for either primary advanced airway management, or for airway rescue following failed attempts at direct laryngoscopy endotracheal intubation. There is, however, limited data on objective confirmation of supraglottic airway placement in the prehospital environment. Furthermore, the ability of EMS field providers to recognize a misplaced airway is unknown. Methods Retrospective review of patients who underwent airway management using the King LTS-D supraglottic airway in a large urban EMS system, between 3/1/15-9/30/2015. Subjective success was defined as documentation of successful airway placement by the EMS provider. Objective success was confirmed by review of waveform capnography, with the presence of a 4-phase waveform greater than 5 mmHg. Sensitivity and specificity of the field provider’s assessment of success were then calculated. Results A total of 344 supraglottic airway attempts were reviewed. No patients met obvious death criteria. 269 attempts (85.1%) met criteria for both subjective and objective success. 19 attempts (5.6%) were recognized failures by the EMS provider. 47 (13.8%) airways were misplaced but unrecognized by the EMS provider. Four attempts (1.2%) were correctly placed but misidentified as failures, leading to the unnecessary removal and replacement of the airway. Sensitivity of the provider’s assessment was 98.5%; specificity was 28.7%. Conclusion The use of supraglottic airway devices results in unrecognized failed placement. Appropriate utilization and review of waveform capnography may remedy a potential blind-spot in patient safety, and systemic monitoring/feedback processes may therefore be used to prevent unrecognized misplaced airways. Prehospital sodium bicarbonate use could worsen long term survival with favorable neurological recovery among patients with out-of-hospital cardiac arrest Abstract Background Sodium bicarbonate (SB) is widely used for resuscitation in out-of- hospital cardiac arrest (OHCA); however, its effect on long term outcomes is unclear. Methods From 2005–2016, we prospectively conducted a province-wide population-based observational study including adult non-traumatic OHCA patients managed by paramedics. SB was administered by paramedics based on their clinical assessments. To examine the association of SB administration and survival and favorable neurological outcome to hospital discharge, defined as modified Rankin scale of 3 or less, we performed a multivariable logistic regression analysis: (1) within propensity score matched comparison groups, and; (2) within the full cohort with missing variables addressed by multiple imputation techniques. Results Of 15 601 OHCA patients, 13,865 were included in this study with 5165 (37.3%) managed with SB. In the SB treated group, 118 (2.3%) patients survived and 62 (1.2%) had favorable neurological outcomes to hospital discharge, compared to 1699 (19.8%) and 831 (10.6%) in the non-SB treated group, respectively. In the 1:1 propensity matched cohort including 5638 OHCA patients, SB was associated with decreased probability of outcomes (adjusted OR for survival: 0.64, 95% CI 0.45–0.91, and adjusted OR for favorable neurological outcome: 0.59, 95% CI 0.39–0.88, respectively). The association remained consistent in the multiply imputed cohort (adjusted OR 0.48, 95 CI 0.36–0.64, and adjusted OR 0.54, 95% CI 0.38–0.76, respectively). Conclusions In OHCA patients, prehospital SB administration was associated with worse survival rate and neurological outcomes to hospital discharge. Simulation training to improve 9-1-1 dispatcher identification of cardiac arrest: A randomized controlled trial Abstract Background The objective of this study was to test the effectiveness of simulation training, using actors to make mock calls, on improving Emergency Medical Dispatchers’ (EMDs) ability to recognize the need for, and reduce the time to, telephone-assisted CPR (T-CPR) in simulated and real cardiac arrest 9-1-1 calls. Methods We conducted a parallel prospective randomized controlled trial with n = 157 EMDs from thirteen 9-1-1 call centers. Study participants were randomized within each center to intervention (i.e., completing 4 simulation training sessions over 12-months) or control (status quo). After the intervention period, performance on 9 call processing skills and 2 time-intervals were measured in 2 simulation assessment calls for both arms. Six of the 13 call centers provided recordings of real cardiac arrest calls taken by study participants during the study period. Results Of the N = 128 EMDs who completed the simulation assessment, intervention participants (n = 66) performed significantly better on 6 of 9 call processing skills and started T-CPR 23 s faster (73 vs 91 s respectively, p 0.001) compared to participants in the control arm (n = 62). In real cardiac arrest calls, EMDs who completed 3 or 4 training sessions were more likely to recognize the need for T-CPR for more challenging cardiac arrest calls than EMDs who completed fewer than 3, including controls who completed no training (68% vs 53%, p = 0.018). Conclusions Simulation training improves call processing skills and reduces time to T-CPR in simulated call scenarios, and may improve the recognition of the need for T-CPR in more challenging real-life cardiac arrest calls. Detection and quantification of gasping during resuscitation for out-of-hospital cardiac arrest Abstract Aim To detect and quantify gasping during cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OHCA) patients and to investigate whether gasping is associated with increased return of spontaneous circulation (ROSC). Materials and methods A prospective observational study in patients resuscitated and mechanically or manually ventilated for OHCA by emergency physicians of Ghent University Hospital. After intubation, pressure catheters were inserted in the endotracheal tube (ETT) and pressures were measured at the proximal and distal ends of the ETT. Gasping was analysed with custom-developed software and volumes were calculated based on pressure differences between the catheters. Data are expressed as median (interquartile range). Results Data were collected in 292 resuscitated patients of whom 36.2% achieved ROSC. Seventy-six of 292 (26.0%) patients showed gasping on the pressure curves during resuscitation. The median gasping volume was 274 ml (196–434). The median gasping rate was 3.7 gasps/min (1.5–7.3). Gasping occurred significantly more in patients displaying ventricular fibrillation as the initial rhythm compared to patients with pulseless electrical activity, pulseless ventricular tachycardia or asystole. The median gasping rate was significantly higher in the ROSC group compared to the non-ROSC group (11.8 gasps/min (95% CI [4.2, 13.9]) and 2.8 gasps/min (95% CI [1.7, 3.9]) respectively (P 0.001)). A gasping rate of 7.3 gasps/min appeared to be the optimal criterion value to herald ROSC. Deeper negative pressures were associated with an increased incidence of ROSC (P = 0.011). There was no significant difference in ROSC between patients with gasping and those without. Conclusion The occurrence of gasping during CPR was high. Significant gasping volumes were measured. The presence or absence of gasping was not associated with ROSC, but higher gasping rate and deeper negative pressures were. ‘Tell me exactly what’s happened’: When linguistic choices affect the efficiency of emergency calls for cardiac arrest Abstract Background Clear and efficient communication between emergency caller and call-taker is crucial to timely ambulance dispatch. We aimed to explore the impact of linguistic variation in the delivery of the prompt “okay, tell me exactly what happened” on the way callers describe the emergency in the Medical Priority Dispatch System®. Methods We analysed 188 emergency calls for cases of paramedic-confirmed out-of-hospital cardiac arrest. We investigated the linguistic features of the prompt “okay, tell me exactly what happened” in relation to the format (report vs. narrative) of the caller’s response. In addition, we compared calls with report vs. narrative responses in the length of response and time to dispatch. Results Callers were more likely to respond with a report format when call-takers used the present perfect (“what’s happened”) rather than the simple past (“what happened”) (Adjusted Odds Ratio [AOR] 4.07; 95% Confidence Interval [95%CI] 2.05–8.28, p 0.001). Reports were significantly shorter than narrative responses (9 s vs. 18 s, p 0.001), and were associated with less time to dispatch (50 s vs. 58s, p = 0.002). Conclusion These results suggest that linguistic variations in the way the scripted sentences of a protocol are delivered can have an impact on the efficiency with which call-takers process emergency calls. A better understanding of interactional dynamics between caller and call-taker may translate into improvements of dispatch performance.