Resus Today Summer 2021

Volume 8 No. 2
Summer 2021
Resuscitation Today
A Resource for all involved in the Teaching and Practice of Resuscitation
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CONTENTS
CONTENTS
Resuscitation Today
4 EDITORS COMMENT
6 FEATURE Drowning
10 FEATURE The Future of Point of Care Ultrasound (POCUS)
Training
13 FEATURE New technologies and Artificial Intelligence in
Emergency Medicine: tools to improve Cardio-
Pulmonary Resuscitation (CPR)
This issue edited by:
David Halliwell
MSc Paramedic
c/o Media Publishing Company
Greenoaks
Lockhill
Upper Sapey, Worcester, WR6 6XR
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RESUSCITATION TODAY - SUMMER 2021
3

EDITORS COMMENT
EDITORS COMMENT
The latest Resuscitation guidelines have been released, new slide sets for
courses, new books / manuals and an ever growing evidence base. This has
been welcomed by the Resus community and we will plan to review the teaching
materials in the next edition of this journal.
As a community we are seeing a shift towards “high quality“ resuscitation, through the use of CPR
feedback devices, controlling rate and depth of human (manual) CPR.
RESUSCITATION TODAY - SUMMER 2021
“As a
community we
are seeing a
shift towards
“high quality“
resuscitation,
through the
use of CPR
feedback
devices,
controlling
rate and depth
of human
(manual)
CPR.”
We are seeing a continued growth of mechanical CPR - especially since covid19 - and now we
are seeing an increased interest in Ventilation Monitoring - controlling Volume and Rate of CPR to
reduce Hyperventilation.
In this edition of the journal Dr Abdo Koury shares his insight into the EOlife device and its
use of Artificial Intelligence to support Improved Ventilation and reduce death by “Rescuer
Hyperventilation” - ventilation monitoring appears to be a huge area for us to consider in 2021.
Adam Gent has provided this journal with a review of the science of drowning for this journal - at
the time of writing there have been 14 deaths by drowning in the past week in the U.K. and we are
grateful to Adam for this opportunity to review our drowning science knowledge.
David Halliwell
MSc Paramedic
4

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FEATURE
DROWNING
Adam Gent
20th January 2021
To begin with, lets just forget “near-drowning”, “dry drowning”, “wet
drowning”, “freshwater drowning”, “saltwater drowning” and “secondary
drowning”. (1)
These terms are outdated and no longer accepted by The World
Health Organization (2), the United Kingdom Resuscitation Council (3),
International Liaison Committee on Resuscitation (4) , the Wilderness
Medical Society (5) , the International Lifesaving Federation (6), the
American Heart Association (7) who all discourage the use of these
terms.
Unfortunately, these terms still slip past the editors of major medical
journals, allowing their use to be perpetuated. These terms are most
pervasive in the nonmedical press and social media to add an illusion of
gravitas, where the term drowning seems to be synonymous with death.
The currently accepted definition of drowning from the World Congress
on Drowning (8) is:
“Drowning is the process of experiencing respiratory impairment from
submersion or immersion in a liquid.”
Key to this are:
Sudden immersion in cold water causes an immediate fall in skin
temperature which triggers several body reflexes (9) collectively (and
annoyingly) known as the “cold-shock” response, and they last for
just the first few minutes after falling in.
The “cold-shock” responses include:
1) instantaneous gasping for air
2) sudden increase in breathing rate
3) sudden increase in heart rate
4) sudden increase in blood pressure
5) dramatic decrease in breath-holding time (from around 60
seconds to just 20-25 seconds (10).
A combination of gasping and a decreased ability to hold ones
breath causes the casualty to inhale water. And this is the
fundamental cause of drowning – respiratory distress.
Inhaling water appears to cause laryngospasm in the first instance
(although this is debated) but real problem occur when water enters
the lower airway, in particular the alveoli; only a small amount of
water is required to cause significant problems – less than 4ml/kg
(11, 12).
RESUSCITATION TODAY - SUMMER 2021
• Drowning is a process, not the end result. The definition of drowning
does not include death.
• There must be respiratory impairment. If a casualty is rescued from
the water with no respiratory distress, they did not drown or ‘near
drowned’, they were simply rescued.
• Submersion occurs where the whole body is submersed, including
the airway. Immersion is where the body is within a liquid but not
covering the airway.
• Drowning is limited to liquids. Casualties submersed in powders
(which behave as free flowing fluids) are asphyxiated.
Once it is determined a drowning incident has occurred, there are 3
possible outcomes:
• Mortality (death)
• Morbity (illness or injury)
• No morbidity
Drowned casualties either die as a result of respiratory impairment, are
rescued with consequential illness or injury following their respiratory
impairment or have no lasting illness or injury.
The Process of drowning
Stage 1: Cold water Immersion Response (0-2 minutes):
• Regardless of the salinity of the water, the inflammatory response
leads to increased permeability of alveoli capillary membrane and
exacerbates fluid, plasma and electrolyte shifts into the alveoli
resulting in pulmonary oedema leading to decreased oxygen and
carbon dioxide exchange and some bronchospasm.
• Water in the alveoli also causes surfactant washout and
dysfunction and leading to reduced lung compliance and alveoli
collapse.
The fundamental cause of death from drowning is hypoxia, leading to
arrhythmias and cardiac arrest.
It is or this very simple reason that lifejackets and PFD save lives by
keeping the airway above the water during the first few minutes of
uncontrolled breathing.
Shallow Water Blackout
A combination of inhaled water and hyperventilation might, at this
stage cause shallow water blackout:
Ordinarily as we hold our breath our oxygen levels are decreasing
whilst our carbon dioxide levels are increasing. The desire to
breathe is triggered by elevated CO2 levels which usually occurs
before our O2 levels drop below a particular threshold at which point
we go unconscious or ‘blackout’.
6

FEATURE
very cold water this can take over an hour to achieve. If the
casualty was not wearing a life jacket of PFD, it is likely they died
of drowning rather than hypothermia. If the casualty’s airway is
protected by a life-jacket and they are breathing normally, they
are not a Drowned casualty, they are a hypothermic casualty and
should be treated as such.
To rescue or not?
National Operation Guidance decision tool (14) based on the work
of Dr Mike Tipton (15) is a model is designed to give casualties
every reasonable chance of rescue and resuscitation and is
balanced against the risk of harm to responders when carrying out
rescues.
Image source: Wikipedia. CC BY-SA 4.0, File:Shallow water blackout
diagram 1 revised.svg
If the casualty has been hyperventilating, they have a normal amount
of oxygen in their blood stream but vastly reduced CO2 levels. As
they attempt to hold their breathe, they reach the low 02 threshold
of blackout before their raising C02 levels have triggered a desire to
breath.
The length of time submerged and the temperature of the water are
the two main factors determining survivability; generally, the longer
a casualty is submerged and the warmer the water, the lower the
chances of survival. Other factors affecting survivability include the
age and/or size of the casualty, as smaller and/or younger people
can survive longer than larger people or adults.
1. Start The Clock
The main factors are the length of time the casualty has been
submerged and the water temperature. It is not possible to know
for certain when a casualty became submerged, so the clock
should start when the first attendance arrives on scene. It should
not be assumed that the person has been submerged for longer
than this.
2. Risk Assess
A risk assessment should balance the likelihood of casualty
survival and the likelihood and severity of harm to rescuers.
The decision will consider whether an immediate rescue can be
started or if one should await specialist resources.
Image source: Wikipedia. CC BY-SA 4.0 File:Shallow water blackout
diagram 2 revised.svg
3. At 30 minutes
further Risk Assessment should be considered given the reduced
likelihood of survival against the danger to rescuers which may
be increased (darkness, cold, exposure, fatigue, changing tides
or river levels).
Stage 2: Functional Disability (2-30 minutes)
If the casualty has survived the ‘cold-shock’, rapid cooling of the
muscles reduces contractility preventing normal muscle movement;
the casualty may be unable to swim or may have lost manual dexterity
preventing them from grasping rescue lines or ordinarily climbing out.
It is this loss of muscle control which is why drowning may not appear
ass drowning:
1. Except in rare circumstances, drowning people are physiologically
unable to call out for help due to uncontrolled breathing.
2. A drowning casualty may not wave for help, favouring suing their
arms to keep their airway above the water.
Stage 3: Hypothermia (> 30 minutes).
After prolonged exposure, the casualty will become hypothermic.
Unconsciousness can be expected around 30-32oc but even in
If the water is ‘icy-cold’ (below 7oc) the casualty should be
considered survivable, although the likelihood of survival reduces
as time passes. If not, the operation should move to recovery of
the body, if safe.
4. At 60 minutes
If rescue operations have continued at 60 minutes a further
assessment should be made. If the water is ‘icy-cold’ and
the casualty is known to be young and/or small they should
be considered survivable, although again their chances are
further reducing as time passes. The risk assessment should be
revisited to decide if rescue should continue or if the incident
should switch to body recovery.
5. At 90 minutes
After 90 the decision should be taken to switch to body recovery
because the circumstances are regarded as no longer survivable.
RESUSCITATION TODAY - SUMMER 2021
7

FEATURE
RESUSCITATION TODAY - SUMMER 2021
Image source: National operational Guidance: Water Rescue and Flooding”. National Central Programme Office.
https://www.ukfrs.com/pdf/print/node%3A20802 Accessed on 9th January 2021
8

FEATURE
Rescue
• Avoid entry into the water whenever possible. If entry into the water is
essential, use a buoyant rescue aid or flotation device.
• Remove the victim from the water and start resuscitation as quickly
and safely as possible.
• Cervical spine injury is uncommon in drowning victims (approximately
0.5%). Spinal immobilisation is difficult in the water and delays
removal from the water and adequate resuscitation of the victim.
• Consider cervical spine immobilisation if there is a history of diving,
water slide use, signs of severe injury, or signs of alcohol intoxication.
• Despite potential spinal injury, if the victim is pulseless and apnoeic
remove them from the water as quickly as possible (even if a back
support device is not available) whilst attempting to limit neck flexion
and extension.
• Try to remove the victim from the water in a horizontal position to
minimise the risks of post-immersion hypotension and cardiovascular
collapse.
Ventilation (3)
• Prompt initiation of rescue breathing or positive pressure ventilation
increases survival. If possible supplement ventilation with oxygen.
• Give five initial ventilations as soon as possible.
• Rescue breathing can be initiated whilst the victim is still in shallow
water provided the safety of the rescuer is not compromised.
• If the victim is in deep water, open their airway and if there is no
spontaneous breathing start in-water rescue breathing if trained to do so.
• In-water resuscitation is possible, but should ideally be performed
with the support of a buoyant rescue aid.
• If normal breathing does not start spontaneously, and the victim is <
5 min from land, continue rescue breaths while towing. If more than
an estimated 5 min from land, give rescue breaths over 1 min, then
bring the victim to land as quickly as possible without further attempts
at ventilation.
Regurgitation (3)
• Expect the casualty to vomit.
• If regurgitation occurs, turn the victim’s mouth to the side and remove
the regurgitated material
• There is no need to clear the airway of aspirated water as this is
absorbed rapidly into the central circulation.
• Do not use abdominal thrusts or tip the victim head down to remove
water from the lungs or stomach.
Chest compressions (3)
• As soon as the victim is removed from the water, check for breathing.
If the victim is not breathing (or is making agonal gasps), start chest
compressions immediately.
• Continue CPR in a ratio of 30 compressions to 2 ventilations.
• Most drowning victims will have sustained cardiac arrest secondary to
hypoxia. In these patients, compression-only CPR is likely to be less
effective and standard CPR should be used.
Post Rescue Care
After Drop
A phenomena known as “After Drop” can occur as a result of aggressive
rewarming; peripheral vasodilation can lead to a redistribution of blood
and a drop in core temperature. This can occur during treatment or
even after recovery. This can be prevented by moderated warming
techniques; If the casualty has vital signs, is insulated and immobile,
there is no rush to actively warm them.
Curcum Rescue Collapse
Particularly evident in immersion hypothermia casualties, ‘Curcum
Rescue Collapse’ has been attributed to the aggressive repositioning
of the casualty from a floating horizontal position to vertical as they
were winched out of the sea using a hoist. Standing up quickly can
cause orthostatic hypotension; a drop in blood pressure as the vascular
system cannot constrict fast enough in the lower limbs and abdomen
to squeeze oxygenated blood up to the brain; this is noticeable by the
‘head rush’ or feeling of light-headedness as the brain is momentarily
deprived of oxygen.
Combined with the immediate loss of hydrostatic pressure which was
being exerted on the body whilst the casualty was immersed, this
drop in blood pressure can reduce cerebral perfusion to the point of
unconsciousness and cardiac perfusion to the point of cardiac arrest.
Both immersion and severely hypothermic casualties are now rescued
horizontally and as such, should remain in this position until rescue.
References
1. Hawkings JC, Sempsrott J and Schmidt A (2016) “Drowning in a Sea of
Misinformation: Dry Drowning and Secondary Drowning” Emergency medicine
News. https://journals.lww.com/em-news/blog/BreakingNews/pages/post.
aspx?PostID=377 Accessed 19th January 2021
2. https://www.who.int/en/news-room/fact-sheets/detail/drowning
3. UK Resuscitation Council (2019) “Cardiac Arrest in Special Circumstances” in
Advanced Life Support Guidelines. Ch 12. 113:142
4. Idris AH, Berg RA, Bierens J, Bossaert L, Branche CM et al (2003)
“Recommended Guidelines for Uniform Reporting of Data From Drowning”.
Circulation. 108[20]:2565
5. Schmidt AC, Sempsrott JR, Hawkins SC, Arastu AS, Cushing TA, Auerbach PS. (2016)
“Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of
Drowning”. Wilderness and Environmental Medicine. June;27(2):236-51.
6. Szpilman D, Pearn J, Queiroga AC (2019) “Medical Position Statement MPS
22 – Research Needs for Drowning”. International Lifesaving Fderation Rescue
Commission 28/08/2019. https://www.ilsf.org/wp-content/uploads/2020/01/
MPS-22-2019-Research-Needs-for-Drowning.pdf Accessed 19th January 2021
7. American Heart Association (2005) “Drowning”. Circulation. 112(2) Supp. 13.
IV-133-IV-135.
8. International Lifesaving (2015) “World Conference on Drowning Prevention 2015
– Malaysia: Program and Proceedings”. ILS. https://www.ilsf.org/wp-content/
uploads/2018/11/WCDP2015_ProgramProceedingsLR.pdf Accessed 19th
January 2021
9. Datta A and Tipton M (2006) “Respiratory responses to cold water immersion:
neural pathways, interactions, and clinical consequences awake and asleep”.
Journal of Applied Physiology. 100:6, 2057-2064
10. Giesbrecht G. (2000) “Cold stress, near drowning and accidental hypothermia: A
review”. Aviation, Space, and Environmental Medicine. 71. 733-52.
11. Matthew JA. (2016) “Submersion and Diving-Related Illnesses”. In: David S.
(eds) Clinical Pathways in Emergency Medicine. Springer, New Delhi.
12. Schmidt AC, Sempsrott JR, Hawkins SC, Arastu AS, Cushing TA, Auerbach PS. (2016)
“Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of
Drowning”. Wilderness and Environmental Medicine. Jun;27(2):236-51.
13. Vittone M and Francesco A. (2006) “Drowning doesn’t look like drowning”.
On Scene – the Journal of of U. S. Coast Guard Search and Rescue. Fall. P.14.
https://mariovittone.com/wp-content/uploads/2010/05/OSFall06.pdf Accessed
19th January 2021
14. National operational Guidance: Water Rescue and Flooding”. National Central
Programme Office. https://www.ukfrs.com/pdf/print/node%3A20802 Accessed
on 9th January 2021
15. Tipton MJ, Golden FS. (2011) “A proposed decision-making guide for the
search, rescue and resuscitation of submersion (head under) victims based on
expert opinion”. Resuscitation. Jul;82(7):819-24
RESUSCITATION TODAY - SUMMER 2021
9

FEATURE
THE FUTURE OF POINT OF CARE
ULTRASOUND (POCUS) TRAINING
Authors: Dr Andrew Tagg & Mr Benjamin Krynski
About the authors: Dr Tagg is the Medical Director of Real Response, and an adult and paediatric emergency and retrieval
specialist in Melbourne. Benjamin Krynski is an ALS paramedic in Sydney and Co-Founder of Real Response.
Introduction
The extended Focused Assessment with Sonography of Trauma
(e-FAST) scan is a key part of the resuscitationists diagnostic toolkit
(Kirkpatric et al. 2004). Rapid sonographic assessment of the chest for
the presence of a pneumothorax can lead to life-saving interventions
whilst the presence, or absence, of free fluid in the abdomen or pelvis
can change the immediate disposition of the patient.
RESUSCITATION TODAY - SUMMER 2021
There are many opportunities for learning this core skill in the hospital
environment. Repeat practice, guided by a skilled clinician, means that
the skill of image acquisition can be taught to anyone. These images
can then be reviewed remotely to facilitate making a diagnosis.
The ability to perform a timely e-FAST scan degrades with time and
there are concerns over the ability of any one practitioner to maintain
their skills (Edgar et al. 2019). There is some evidence that visualizing
a task can strengthen one’s ability to perform the task. The firing of
bidirectional visuo-motor and motor-visual mirror neurons has been
demonstrated in a number of sports including climbing (Boschker and
Bakker, 2002), soccer (Horn, Williams, and Scott, 2002) and cricket
(Breslin et al., 2005)
We wanted to test the hypothesis that novices could obtain the visuomotor
skill of e-FAST image acquisition using enhanced visualization
through the medium of immersive virtual reality (IVR). If successful, it
could lower the barrier of entry for POCUS education enhancing the
number of trained staff who can perform an e-FAST assessment.
The Model
Using off the shelf hardware (Oculus Quest 2) as the delivery
device the challenge was to create a virtual simulacrum of patient,
pathology and ultrasound probes. Development and 3D modelling
was completed with Unity, Marmoset toolbag and Substance
painter, all commercially available platforms. Development was led
by Real Response based in Melbourne, Australia and supported by
Healthcare Australia.
The Lumify POCUS was chosen for the device to be 3D rendered
and embedded into the immersive virtual world and training scenario.
The tablet, phased array, curvilinear and linear transducers were
modelled.
The Scenario
The environment of an Australian Army MRH-90 Taipan helicopter
was created and upon starting the scenario users are transported
to the MedEvac bay where they receive a handover from a medic
asking them to perform a e-FAST assessment on their patient to
determine potential internal injury.
The user is then expected to perform a e-FAST assessment using
the Lumify ensuring they hold the transducer appropriately and in
the correct location to acquire a high quality image and perform an
interpretation. The user is assessed on their interpretation of the
image acquired.
10

FEATURE
Instructor Guidance
Instructors can remotely observe the user and offer real-time guidance
and verbal direction. Through offering remote/virtual guidance by a
skilled clinician, IVR for POCUS training may reduce the barrier of
entry allowing a greater number of clinicians to become competent
in the e-FAST assessment. These may include remote GP’s, nurses,
paramedics, military medics and off-shore/industrial medics.
The next stage of research will be to assess the ability and timeliness
of a cohort of novices to acquire suitable images as compared to those
learning passively from video.
Summary
The ability to perform and interpret an e-FAST scan is just one small
part of the complex virtual simulation package that Real Response
hopes to deliver. The post-COVID world poses a number of challenges
to traditional face-to-face courses. With national and international travel
curtailed we are becoming used to technology enhanced learning in the
virtual Zoom classroom. Perhaps now is the right time to step into the
virtual simulation space too?
References:
Boschker, M. S., and Bakker, F. C. (2002). Inexperienced sport climbers
might perceive and utilize new opportunities for action by merely
observing a model. Percept Mot Skills, 95(1), 3-9.
Breslin, G., Hodges, N. J., Williams, A. M., Curran, W., and Kremer, J.
(2005). Modelling relative motion to facilitate intra-limb coordination.
Hum Mov Sci, 24(3), 446-463.
Edgar, L., Fraccaro, L., Park, L., MacIsaac, J., Pageau, P., Ramnanan,
C. and Woo, M., 2019. MP16: Which PoCUS skills are retained over
time for medical students?. Canadian Journal of Emergency Medicine,
21(S1), pp.S47-S48.
Horn, R. R., Williams, A. M., & Scott, M. A. (2002). Learning from
demonstrations: the role of visual search during observational learning
from video and point-light models. J Sports Sci, 20(3), 253-269.
Kirkpatrick, A.W., Sirois, M., Laupland, K.B., Liu, D., Rowan, K., Ball,
C.G., Hameed, S.M., Brown, R., Simons, R., Dulchavsky, S.A. and
Hamiilton, D.R., 2004. Hand-held thoracic sonography for detecting
post-traumatic pneumothoraces: the Extended Focused Assessment
with Sonography for Trauma (EFAST). Journal of Trauma and Acute Care
Surgery, 57(2), pp.288-295.
Rodríguez, Á.L., Cheeran, B., Koch, G., Hortobágyi, T. and Fernandez-del-
Olmo, M., 2014. The role of mirror neurons in observational motor learning: an
integrative review. European Journal of Human Movement, (32), pp.82-103.
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RESUSCITATION TODAY - SUMMER 2021
11

FEATURE
North West resuscitation expert explains
new 2021 Resuscitation Guidelines
The Resuscitation Council
(UK) (RCUK) has released its
latest set of guidelines for
the emergency treatment of
critically unwell patients.
The 2021 guidelines build on the
2015 guidelines and the latest
recommendations from the
European Resuscitation Council
(ERC), providing the best up-todate
evidence for clinical practice
in the UK, including the use of escalating and high levels of energy.
The guidelines also recognise that many cardiac arrests have
premonitory signs and are preventable. Anthony Freestone, RCUK
regional representative for the North West and advanced clinical
practitioner at Blackpool Teaching Hospitals NHS Foundation Trust,
explains: “The focus must always be on preventing cardiac arrest
from occurring. Greater emphasis on recognising and treating the
deteriorating patient should be every NHS Trust’s responsibility, in
line with other Guidelines such as NICE (CG50).
“With the growing recognition that many cardiac arrests can be
identified in advance, it makes sense to employ comprehensive
monitoring where possible to reduce mortality. Our defibrillator
supplier builds precision monitoring into its defibrillators, to assist in
peri and post arrest resuscitation stages.”
On the latest defibrillation and cardioversion guidelines, Mr Freestone
said: “Working in a Regional Cardiac Centre, with some of the best
and most qualified staff within the field, I feel that energy plays a
major part in resuscitation. In my experience for both defibrillation
and cardioversion, using the highest possible energy level is a clinical
necessity, a shock strategy re-enforced by both the RCUK and the
ERC in certain situations. The guidelines call for an ‘initial synchronised
shock at maximum defibrillator output’ to respond to atrial fibrillation,
as this arrythmia often requires greater levels of energy to terminate.
“Our Mindray defibrillators can rapidly charge and produce a biphasic
shock at up to 360J in five seconds, so we are ideally equipped to
meet this guideline.
“For fixed high energy versus escalating shocks protocols, this is
a very exciting time. The guidelines again highlight escalation of
energy after a failed shock, and for patients where refibrillation has
occurred, but now give us the option of starting within an energy
range, empowering Resuscitation Departments to think outside the
box when it comes to defibrillation energy requirements.”
The new guidelines clarify the RCUK’s position on capnography,
requiring it be used to monitor the quality of CPR.
“While defibrillation is important, we need to continue to push
for high quality CPR, where the only recommendation is for
capnography, which had previously always been more of a
consideration. The technology does more than just tell the user
to push harder, it’s an accurate display of how the resuscitation
attempt is going and can provide a real insight into performance and
feedback.” Mr Freestone comments.
“Our Mindray devices provide up to 360J, capnography and a full
range of peri and post arrest monitoring, which from a point of care
perspective enables the patient to have the best possible chance of
survival no matter the stage of resuscitation they are in.”
RESUSCITATION TODAY - SUMMER 2021
To find out more about Mindray’s
D3 and D6 Platinum range
defibrillators, just scan this QR code
or visit www.mindrayuk.com.
12

FEATURE
NEW TECHNOLOGIES AND ARTIFICIAL INTELLIGENCE
IN EMERGENCY MEDICINE: TOOLS TO IMPROVE
CARDIO-PULMONARY RESUSCITATION (CPR)
Abdo Khoury MD, MPH, MScDM
Department of Emergency Medicine and Critical Care, Besancon University Hospital, France
akhoury@chu-besancon.fr
In the field of cardiopulmonary resuscitation (CPR), one might think
that progress is more “laborious” than in other medical specialties,
but the reality is more complex. Naturally, one would always wish that
things move faster, certainly, especially in the last few years. Because
it is clear that we are facing a stagnation in the survival rate of patient
in cardiorespiratory arrest (CA). Survival to discharge slightly improved
from the seventies to reach 8.8% [1]. We must therefore remain patient
and determined. No choice: we must innovate and we can!
Recently, practitioners have, for example, thought to optimise chest
compressions by focusing on two parameters: the depth of the
compressions and their rhythm. Without forgetting to give time for
thoracic relaxation. Having a bystander initiating prompt CPR has led to
an increase in survival rate up to 11.3% [1]. All these optimisations have
already proven to have a positive impact on the survival rate, which is
our main objective. There is no doubt that the European Resuscitation
Council (ERC) Congress on Cardiac Arrest to be held in March 2021 (it
should have been held in Manchester from 20 to 22 October) promises
to be rich in new recommendations. The congress will certainly explore
other avenues: improving ventilation is surely one of them, and in recent
years many studies have been talking more and more about it.
Proof of this is that things are “on the move”, these recommendations -
or treatment protocols - are slowly but surely evolving. Although that to
date, many of my colleagues would tend to consider them as optimal.
The fact is that these international guidelines are relatively poorly
applied, especially on ventilation [2] And this is where the problem lies:
how to explain it?
Today, the recommendations focus on chest compressions, recalling
the uniformly accepted good practices: early warning, initiate chest
compressions and ventilate if trained to do so... As for ventilation,
which is of crucial importance, it has been proven long time ago, that
hyperventilation of 30 times/minute reduces the chance of survival
by a factor of 3 [3]. Hyperventilation increases the Mean Intrathoracic
Pressure thus decreasing the venous return to the heart and decreasing
the Coronary Arteries Perfusion Pressure (CPP) (fig 1). On the other
hand, ventilating 12 times/minute multiplies survival by 3 folds...
However, we still don’t know how to stick to the recommendations: the
scientific knowledge is up to date, but putting it into practice remains...
theoretical or even impossible.
Moreover, in this field we are now seeing a return to the fundamentals,
against a backdrop of specialist controversy: should we intubate or
ventilate, taken up by the famous “intubate or not”? Two systems
predominate: the Anglo-Saxon system based on mask ventilation with
rapid transport to the nearest hospital where the doctors will perform
advanced resuscitation, and the Franco-German system, with the
Figure 1. Hemodynamic Study (n=9). Changes in mean intrathoracic
pressure (MIP), coronary perfusion pressure (CPP), and right atrial
diastolic pressure (RA diastolic) with different ventilation rates during
resuscitation in a porcine model of cardiac arrest. Probability value

FEATURE
Figure 2. Percentage of hyperventilation (black), adequate ventilation
(grey) and hypoventilation (light grey) for professional categories
(n=280 tests for each ventilation technique).
ETT, endotracheal tube [6].
stability... In addition to this, there are other needs, very strong
regulatory constraints and clinical trials that are more difficult to carry
out in the field. Nevertheless, over the last twenty years, new fields of
research (digital, miniaturisation …) have enlarged our perspectives and
possibilities in healthcare innovations.
Figure 3. Comparison of mean tidal volume (a) and mean ventilation
rate (b) for each participant between conventional ventilation (O) and
ventilation with VFD (X) for Basic Life Support (BLS) and Advanced
Life Support (ALS) groups. n = 20 participants/group, ventilation was
performed during 5 min/participant [8].
become a reference in just a few years, has already inspired a number
of manufacturers and, above all, generated new projects in research
and development [9].
It is in this context that applied artificial intelligence could well
revolutionise practices, or at least shake them up. It seems to be
present everywhere: robots, glasses, microscopes, radios... or almost.
Indeed, it is far from having revealed its full potential in our branch,
and would even be cruelly lacking. If it is not a question of replacing
humans, but of “completing” them, of perfecting their gestures, then it
has a bright future in emergency medicine and CPR [7].
The time for breakthrough innovations may have come for emergency
medicine. With solutions designed by and for practitioners, and
validated by “field teams”. Significant progress which, besides relieving
part of the extremely heavy burden of first aid to some extent, should
save more lives. A real glimmer of hope in a particularly difficult context.
Bibliography
RESUSCITATION TODAY - SUMMER 2021
We only seem to be at the dawn of these advances... And the
applications are flourishing. For example, a team of engineers and I
led a project to design a completely innovative ventilation assistance
device. This small device, recently marketed by the French company
Archeon, is attached to oxygen insufflators to measure the quality of
ventilation during CPR: the right volume of air to be administered, the
optimum ventilation frequency, and it analyses the different variables,
depending on the patient’s profile [8]. Packed with electronics, its
“intelligence” results from the interpretation of 56,000 ventilation cycles,
with the aim of identifying a volume trend of optimal frequencies and to
tell, in real time, if we are within the standards. It starts to equip a large
number of ambulances and emergency services across the world.
EOlife ® Ventilation Feedback
Device (VFD)
We could just as easily mention the Lucas massage board, a real
find, pure product of mechanical engineering. To automate and
calibrate chest compressions gesture thanks to a machine, one had
to think about it! An astonishing device that has opened up beautiful
perspectives in terms of dealing with CPR. This system, which has
1. Yan S, Gan Y, Jiang N, Wang R, Chen Y, Luo Z, et al. The global survival rate
among adult out-of-hospital cardiac arrest patients who received cardiopulmonary
resuscitation: a systematic review and meta-analysis. Crit Care 2020;24:61.
2. Cordioli RL, Brochard L, Suppan L, Lyazidi A, Templier F, Khoury A, et al. How
Ventilation Is Delivered During Cardiopulmonary Resuscitation: An International
Survey. Respir Care 2018;63:1293–301.
3. Aufderheide TP, Sigurdsson G, Pirrallo RG, Yannopoulos D, McKnite S, von
Briesen C, et al. Hyperventilation-induced hypotension during cardiopulmonary
resuscitation. Circulation 2004;109:1960–5.
4. Sinning C, Ahrens I, Cariou A, Beygui F, Lamhaut L, Halvorsen S, et al. The cardiac
arrest centre for the treatment of sudden cardiac arrest due to presumed cardiac
cause - aims, function and structure: Position paper of the Association for Acute
CardioVascular Care of the European Society of Cardiology (AVCV), European
Association of Percutaneous Coronary Interventions (EAPCI), European Heart
Rhythm Association (EHRA), European Resuscitation Council (ERC), European
Society for Emergency Medicine (EUSEM) and European Society of Intensive Care
Medicine (ESICM). Eur Heart J Acute Cardiovasc Care 2020;9:S193–202.
5. Jabre P, Penaloza A, Pinero D, Duchateau F-X, Borron SW, Javaudin F, et al. Effect
of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary
Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory
Arrest: A Randomized Clinical Trial. JAMA 2018;319:779–87.
6. Sall FS, De Luca A, Pazart L, Pugin A, Capellier G, Khoury A. To intubate or not:
ventilation is the question. A manikin-based observational study. BMJ Open Respir
Res 2018;5:e000261.
7. Jiang F, Jiang Y, Zhi H, Dong Y, Li H, Ma S, et al. Artificial intelligence in
healthcare: past, present and future. Stroke Vasc Neurol 2017;2:230–43.
8. Khoury A, De Luca A, Sall FS, Pazart L, Capellier G. Ventilation feedback device
for manual ventilation in simulated respiratory arrest: a crossover manikin study.
Scand J Trauma Resusc Emerg Med 2019;27:93.
9. Strugo R, Wacht O, Kohn J. Mechanical CPR Devices: Where is the Science?
JEMS. 2019.https://www.jems.com/exclusives/mechanical-cpr-devices-where-isthe-science/
(accessed 10 Feb2021).
14

FEATURE
FREE EDUCATIONAL PODCASTS
In the knowledge that conferences and exhibitions may be difficult to attend we are delighted to
offer you the opportunity to listen to the following presentations listed on www.resustoday.com
FREE OF CHARGE with further presentations being added on a regular basis (average Podcast
time is 30 minutes):
Management of Traumatic Cardiac Arrest - Richard Lyons
The role of humour - Joel Symonds
Assessment Treatment - Paddy Morgan
Head Injuries - Dr Jonathan Hanson
Drowning and cold water - Paddy Morgan
Post Resuscitation Care - Paul Rees
The importance of sleep - Lisa Artist
This unique section on our web site also gives you the opportunity to see the following products being
demonstrated:
• I-view(tm) video laryyngoscope
• Water Rescue toddler
• EOlife Ventillation Monitor
• Quantum Life Warmer
Visit www.resustoday.com
We are also seeking further presentation/podcasts to add to this exciting new educational concept
therefore if you have anything to submit that would interest those working in Pre Hospital Care,
Resuscitation and Simulation please forward it to info@mediapublishingcompany.com
Volume 35 No. 5
IT’S FREE - IT’S EDUCATIONAL - IT’S REWARDING
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October 2020
Discover the Quantum
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THE Prehospital Blood &Fluid Warming Solution
Volume 30 No. 4
Winter 2020
Gastroenterology Today
New Ways of Working
within Endoscopy
One of the impacts of Covid-19 is
the way the NHS is accepting and
encouraging new ways of working.
But is this true in endoscopy?
In this edition, we look at insourcing
with 18 Week Support as a solution,
the actual experience of our nurses
and clinicians working on these
short-term contracts and explore
the differences in working life with
18 Week Support compared to their
day to day jobs in their home trusts.
Volume 7 No. 2
Autumn 2020
Resuscitation Today
A Resource for all involved in the Teaching and Practice of Resuscitation
Volume 2 No. 2
Autumn 2020
SimulationToday
A resource for all involved in the teaching and practice of simulation
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Train critical skills required for your most vulnerable patients
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