Improving Cardiopulmonary Resuscitation with a CPR Feedback Device and Refresher Simulations (CPR CARES Study)

The Journal of Emergency Medicine for identifying patients requiring early RC was compared with that of SBP of 90 mm Hg or less using McNemar’s test. Three hundred eighty-seven patients presented with an SBP of 71 mm Hg to 100 mm Hg and were included in the primary analyses; 70 patients (18%) required early RC. With the use of a P-LAC decision rule ($ 2.5 mmol/L) that yielded the same specificity as that of an SBP of 90 mm Hg or less, the observed sensitivities were 93% (95% confidence interval [CI] 84–98%) for P-LAC of 2.5 mmol/L or greater and 67% (95% CI 55–78%) for SBP of 90 mm Hg or less (McNemar’s test, p < 0.001). PLAC # 2.5 mmol/L had a negative predictive value of 97% (95% CI 93–99%), compared with 87% (95% CI 81–91%) for an SBP > 90 mm Hg, and the estimated area under the receiver operating characteristic curve associated with all possible PLAC cutoff points in these data was 0.78 (95% CI 0.73–0.83), which was statistically significantly superior to that of SBP (0.59; 95% CI 0.53–0.66) and shock index (SI) (0.66; 95% CI 0.60–0.74). In conclusion, this study demonstrated that a decision rule based on P-LAC of 2.5 mmol/L or greater was more sensitive than an SBP of 90 mm Hg or less for identifying the need for RC in trauma patients within 6 h of ED arrival. PLAC was superior to other early surrogates for hypoperfusion (SBP and SI) at predicting the need for RC in trauma patients with SBP of 71–100 mm Hg. Some limitations of this study were accuracy of measuring blood pressure in the prehospital setting, inability or forgetting to obtain a P-LAC in many study patients, and potential bias of the trauma team toward intervention once obtaining a lactate or other imaging studies. [Justin Westphalen, MD Denver Health Medical Center, Denver, CO] Comments: This study demonstrated that obtaining a prehospital lactate in trauma patients with SBP of 71–100 mm Hg may lead to improved triage to the appropriate level trauma center, guide early resuscitation efforts, and reduce the time to definitive care. , IMPROVING CARDIOPULMONARY RESUSCITATION WITH A CPR FEEDBACK DEVICE AND REFRESHER SIMULATIONS (CPR CARES STUDY). Cheng A, Brown LL, Duff JP, et al. JAMA Pediatr 2015;169: 137–44. The quality of cardiopulmonary resuscitation (CPR) affects outcomes after pediatric cardiopulmonary arrest (CPA). Previous studies demonstrate that even after basic or advanced life support classes, health care professionals fail to retain the skills in performing effective chest compressions (CC) and fail to consistently perform CPR within American Heart Association guidelines during CPA. This was a multi-center, prospective, randomized, clinical, 2  2 factorial design, pediatric simulation-based trial, and therefore sought to determine if ‘‘just-intime’’ (JIT), brief CPR visual feedback (VisF) training with video-based instruction prior to CPA (defined as a training session conducted directly prior to and at/near the site of potential intervention), or real-time VisF during CPR either alone or in combination, could improve CPR quality. The primary outcome

787 measure was CC depth, with secondary outcome measures being CC rate and CC fraction (percentage of time compressions done during resuscitation), averaged over the course of a 12min simulated CPA event. Results of the trial showed that overall, CPR quality was poor, with CCs with adequate depth found to be only 12.7% for control, 37.9% for JIT training alone, 33.4% for VisF during CPA alone, and 48% for JIT training plus VisF during CPR. For both CC depth and rate, the investigators determined that either JIT training or VisF alone, or combined JIT training and VisF, was significantly better compared to the control (no JIT training or VisF). For CC depth, JIT training showed a 19.9% absolute increase in compliance (95% confidence interval [CI] 11.1–28.7%; p < 0.001), and VisF a 15.4% absolute increase (95% CI 6.6–24.2%, p = 0.0001). For CC rate, JIT training showed a 12.0% absolute increase over control (95% CI 0.8–23.2%, p = 0.04), and VisF a 40.1% absolute increase (95% CI 28.8–51.3%; p < 0.001). Combined JIT training + VisF showed the highest rates of compliance in both CC depth and rate, but the increase over JIT training or VisF alone was not statistically significant. Control, JIT training, VisF, and combined JIT training and VisF all showed similar CC fractions. The investigators concluded that JIT training alone, VisF training alone, or combined JIT training and VisF improve quality of CPR during CPA compared to control. [Skylar Johnson, MD Denver Health Medical Center, Denver, CO] Comment: This study makes a great case for implementing either JIT training or VisF during CPA in emergency departments (EDs) to improve CPR quality. It would seem that the generalizability of JIT training might be limited because it would be difficult to frequently and consistently have JIT training in EDs prior to possible interventions. , THE AFFORD CLINICAL DECISION AID TO IDENTIFY EMERGENCY DEPARTMENT PATIENTS WITH ATRIAL FIBRILLATION AT LOW RISK FOR 30-DAY ADVERSE EVENTS. Barrett TW, Storrow AB, Jenkins CA, et al. Am J Cardiol 2015;115:763–70. This study from Vanderbilt University Medical Center in Nashville, Tennessee sought to derive and internally validate the first emergency department (ED)-based clinical decision aid to identify patients with atrial fibrillation (AF) who are at low risk for 30-day adverse events. There is a high rate of hospitalizations after ED evaluation for AF with considerable variation among admission frequency between different countries, yet the 30-day risk of stroke and death after an ED visit for primary AF is relatively low, with an incidence of 1–3%. The authors of this study postulated that the lack of accurate risk stratification may contribute to the substantial variation in ED admissions. Therefore, the authors conducted a prospective observational cohort study utilizing a previously reportedupon decision aid created by the authors for estimating 30-day adverse event risk based on a retrospective cohort of patients with AF (Atrial Fibrillation and Flutter Outcome Risk