Resus Today Summer 2021

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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

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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

WWW.RESUSTODAY.COM

DEDICATED TO THE AMBULANCE SERVICE AND ITS SUPPLIERS

October 2020

Discover the Quantum

DIFFERENCE

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

RESUSCITATION TODAY - SUMMER 2021

Blood &

Fl

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Wa

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in

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Sy

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ENHANCE PAEDIATRIC SIMULATION WITH REALITi

Train critical skills required for your most vulnerable patients

FAST | EFFECTIVE | SAFE | INTUITIVE | LIGHTWEIGHT | POWERFUL

EXCLUSIVE TO

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