Journal: Resuscitation

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Abstract

Accuracy of Automatic Geolocalization of Smartphone Location during Emergency Calls - a Pilot Study.

Ecker H, Lindacher F, Dressen J, Wingen S, ... Böttiger BW, Wetsch WA
Introduction
Widespread use of smartphones allows automatic geolocalization (i.e., transmission of location data) in countless apps. Until now, this technology has not been routinely used in connection with an emergency call in which location data play a decisive role This study evaluated a new software automatically providing emergency medical service (EMS) dispatchers with a caller\'s geolocation. We hypothesized that this technology will provide higher accuracy, faster dispatching of EMS and a faster beginning of thoracic compressions in a cardiac arrest scenario.
Material and methods
Approval from the local Ethics Committee was obtained. 108 simulated emergency calls reporting a patient in cardiac arrest were conducted at 54 metropolitan locations, which were chosen according to a realistic pattern. At each location, a conventional emergency call, with an oral description of the location, was given first; subsequently, another call using an app with automatic geolocation was placed. Accuracy of localization, time to location, time to EMS dispatch and time to first thoracic compression were compared between both groups.
Results
The conventional emergency call was always successful (n = 54). Emergency call via app worked successfully in n = 46 cases (85.2%). Automatic geolocation was provided to EMS in all these n = 46 cases (100%). Deviation from estimated position to actual position was 1,173.5 ± 4,343.1 m for conventional and 65.6 ± 320.5 m for automatic geolocalization (p < 0.001). In addition, time to localization was significantly shorter using automatic geolocalization (34.7 vs. 71.7 s, p < 0.001). Time to first thoracic compression was significantly faster in the geolocalization group (83.0 vs. 122.6 s; p < 0.001).
Conclusions
This pilot study showed that automatic geolocalization leads to a significantly shorter duration of the emergency call, significantly shorter times until the beginning of thoracic compressions, and a higher precision in determining the location of an emergency.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 06 Nov 2019; epub ahead of print
Ecker H, Lindacher F, Dressen J, Wingen S, ... Böttiger BW, Wetsch WA
Resuscitation: 06 Nov 2019; epub ahead of print | PMID: 31706968
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Abstract

Functional outcomes associated with varying levels of targeted temperature management after out-of-hospital cardiac arrest - An INTCAR2 registry analysis.

Johnsson J, Wahlström J, Dankiewicz J, Annborn M, ... Seder DB, Nielsen N
Introduction
Targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) has been recommended in international guidelines since 2005. The TTM-trial published in 2013 showed no difference in survival or neurological outcome for patients randomised to 33 °C or 36 °C, and many hospitals have changed practice. The optimal utilization of TTM is still debated. This study aimed to analyse if a difference in temperature goal was associated with outcome in an unselected international registry population.
Methods
This is a retrospective observational study based on a prospective registry - the International Cardiac Arrest Registry 2. Patients were categorized as receiving TTM in the lower range at 32-34 °C (TTM-low) or at 35-37 °C (TTM-high). Primary outcome was good functional status defined as cerebral performance category (CPC) of 1-2 at hospital discharge and secondary outcome was adverse events related to TTM. A logistic regression model was created to evaluate the independent effect of temperature by correcting for clinical and demographic factors associated with outcome.
Results
Of 1710 patients included, 1242 (72,6%) received TTM-low and 468 (27,4%) TTM-high. In patients receiving TTM-low, 31.3% survived with good outcome compared to 28.8% in the TTM-high group. There was no significant association between temperature and outcome (p = 0.352). In analyses adjusted for baseline differences the OR for a good outcome with TTM-low was 1.27, 95% CI (0.94-1.73). Haemodynamic instability leading to discontinuation of TTM was more common in TTM-low.
Conclusions
No significant difference in functional outcome at hospital discharge was found in patients receiving lower- versus higher targeted temperature management.

Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.

Resuscitation: 06 Nov 2019; epub ahead of print
Johnsson J, Wahlström J, Dankiewicz J, Annborn M, ... Seder DB, Nielsen N
Resuscitation: 06 Nov 2019; epub ahead of print | PMID: 31706964
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Abstract

Initial serum cholesterol level as a potential marker for post cardiac arrest patient outcomes.

Chae MK, Lee SE, Min YG, Jung Park E
Aim
Cholesterol and lipoproteins have many roles during systemic inflammation in critically ill patients. Many previous studies have reported that low levels of cholesterol are associated with poor outcomes in these patients. The aim of this study was to investigate the association of initial total cholesterol with predicting neurologic outcome of post-cardiac arrest patients.
Methods
This was a retrospective observational study of out-of-hospital-cardiac arrest (OHCA) survivors who had serum cholesterol levels at admission. Multivariate regression analysis was performed to investigate total cholesterol and its association with neurologic outcome. Area under receiver operator characteristic curve (AUROC) was assessed and cut off values for predicting good or poor neurologic outcomes were analysed.
Results
A total of 355 patients were analysed. Lower total cholesterol was significantly associated with poor neurologic outcome [OR: 0.99 (95% CI: 0.98-0.99), p <  0.01] in the multivariate analysis. Cholesterol was also useful to screening for poor neurologic outcome [AUROC: 0.70 (95%CI: 0.63-0.77)]. Patients with cholesterol lower than 71 mg/dL had poor neurologic outcome with a specificity of 100%.
Conclusions
Initial cholesterol level is an easily obtained biomarker that showed association with neurologic outcomes of post cardiac arrest patients.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 07 Nov 2019; epub ahead of print
Chae MK, Lee SE, Min YG, Jung Park E
Resuscitation: 07 Nov 2019; epub ahead of print | PMID: 31711917
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Abstract

Electroencephalographic patterns preceding cardiac arrest in neonates following cardiac surgery.

Massey SL, Abend NS, Gaynor JW, Licht DJ, ... Xiao R, Naim MY
Aim
To identify EEG changes that could predict impending cardiac arrest (CA) in neonates with congenital heart disease undergoing postoperative continuous EEG monitoring.
Methods
Single-center observational study of neonates who underwent cardiac surgery and had CA postoperatively while undergoing EEG monitoring from 2012-2018. Clinical data were extracted from the medical record. EEG backgrounds were evaluated at defined time-points using standardized terminology.
Results
We assessed 22 neonates. The median gestational age was 38.7 weeks (IQR 37.6, 39), the median age at surgery was 5 days (IQR 2, 8), 12 patients (55%) underwent repair for hypoplastic left heart syndrome, and the median time from cardiac intensive care unit arrival postoperatively to CA was 9.5 h (IQR 7, 23). The initial EEG background was abnormal in 15 (68%). All 22 neonates (100%) had worsening of the EEG background prior to initiation of chest compressions for CA at a median of 3 min (IQR 1.5, 3). Eighteen neonates (82%) had an EEG change more than 1 min prior to chest compressions. The EEG backgrounds immediately prior to CA were continuous low voltage in 1 (5%), excessive discontinuity in 8 (36%), burst-suppression in 2 (9%), and low voltage suppression in 11 (50%).
Conclusion
EEG background was abnormal in 68% of neonates at EEG monitoring onset and worsened in all minutes before CA. EEG background changes may be an early sign of impending CA and indicative of developing cerebral dysfunction. Further study is needed to determine whether rapid identification of EEG changes could drive implementation of interventions to prevent CA.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:67-74
Massey SL, Abend NS, Gaynor JW, Licht DJ, ... Xiao R, Naim MY
Resuscitation: 30 Oct 2019; 144:67-74 | PMID: 31560988
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Abstract

Exercise related sudden cardiac death (SCD) in the young - Pre-mortal characterization of a Swedish nationwide cohort, showing a decline in SCD among athletes.

Wisten A, Börjesson M, Krantz P, Stattin EL
Aims
To study the frequency, etiology, and premortal abnormalities in exercise-related sudden cardiac death (SCD) in the young in Sweden.
Methods
All subjects with SCD in 10-35-year olds in Sweden during 2000-10, were included (n = 514). Information about each case was retrieved from death certifications, autopsy- and medical records. The number of SCD in athletes was compared to national figures from 1992-99.
Results
Exercise-related SCD occurred in 12% (62/514) of the SCD-population, a majority being men (56/62; 90%). Cardiopulmonary resuscitation (CPR) was started in 87% (54/62). In total, 48% (30/62), had a cardiac diagnosis, symptoms, family history and/or ECG-changes, before the fatal event. The most prevalent autopsy diagnosis was sudden arrhythmic death syndrome (15/62; 24%). The frequency of hypertrophic cardiomyopathy (HCM) and arrhythmogenic right ventricular cardiomyopathy (ARVC) was significantly higher in exercise-related SCD compared to non-exertional SCD. Exercise-related SCD was more common in athletes (21/29) than in non-athletes (41/485) (P < 0.0001). The total number of SCDs/year in athletes 15-35 years old, are approximately halved in 2000-10 compared to the years 1992-99.
Conclusion
The increased risk of exercise-related SCD in HCM and ARVC underlines the importance of early detection and eligibility recommendations. There is a major reduction in deaths among athletes in the 2000s, compared to the previous decade. These results may partly be explained by improved acute preparedness for sudden cardiac arrest (CPR, defibrillation), but as a substantial percentage have preceding risk factors, such as symptoms and ECG-abnormalities, increased cardiac screening and increased general awareness, may also play a role.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:99-105
Wisten A, Börjesson M, Krantz P, Stattin EL
Resuscitation: 30 Oct 2019; 144:99-105 | PMID: 31560990
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Abstract

Epinephrine for out of hospital cardiac arrest: a systematic review and meta-analysis of randomized controlled trials.

Vargas M, Buonanno P, Iacovazzo C, Servillo G
Objective
To evaluate the effectiveness of epinephrine, compared with control treatments, on survival at admission, ROSC, survival to discharge, and a favorable neurologic outcome in adult patients during OHCA.
Data source
MEDLINE and PubMed from inception to August 2018.
Study selection
Randomized controlled trials (RCTs) on adult patients after out-of-hospital cardiac arrest (OHCA) treated with epinephrine versus controls.
Data extraction
Independent, double-data extraction; risk of bias assessment with Cochrane Collaboration\'s criteria.
Data synthesis
15 RCTs representing 20 716 OHCA adult patients. When epinephrine was compared with a placebo/no drugs, survival to hospital discharge (RR: 1.34, 95% CI: 1.08 - 1.67), ROSC (RR: 2.03, 95% CI: 1.18 - 3.51) and survival to hospital admission (RR: 2.04, 95% CI: 1.22 - 3.43) were increased, but favorable neurologic outcome was not significantly different (RR: 1.22, 95% CI: 0.99 - 1.51). Patients treated with the high-dose epinephrine (HDE) had a higher rate of ROSC (standard-dose epinephrine (SDE) versus HDE, RR: 0.85, 95% CI: 0.74 - 0.97, p = 0.01) and increased survival to hospital admission (SDE versus HDE, RR: 0.86, 95% CI: 0.75 - 0.99, p = 0.04) compared with those treated with SDE. No considered treatments improved the neurological outcome after OHCA.
Conclusions
In OHCA, standard or high doses of epinephrine should be used because they improved survival to hospital discharge. There was also a clear advantage of using epinephrine over a placebo or no drugs in the considered outcomes.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 02 Nov 2019; epub ahead of print
Vargas M, Buonanno P, Iacovazzo C, Servillo G
Resuscitation: 02 Nov 2019; epub ahead of print | PMID: 31693924
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Abstract

Long-term trends in the epidemiology of out-of-hospital cardiac arrest precipitated by suspected drug overdose.

Alqahtani S, Nehme Z, Williams B, Bernard S, Smith K
Background
Little is known about the long-term trends in the incidence and outcomes of drug overdose out-of-hospital cardiac arrests (OHCA).
Method
Between 2000 and 2017, we retrospectively reviewed drug overdose OHCAs from the Victorian Ambulance Cardiac Arrest Registry. Incidence was assessed using linear regression, and the baseline characteristics and survival outcomes were assessed using nonparametric test for trend. Arrest factors associated with survival to hospital discharge were assessed using logistic regression. The 12-month functional recovery and health related quality of life for survivors was summarised using descriptive statistics.
Results
The incidence of emergency medical services (EMS)-attended and EMS-treated cases was 5.8 and 2.0 per 100,000 person-years, respectively, with no significant changes in trend over time. Return of spontaneous circulation increased from 23% to 34% (p for trend = 0.001), event survival increased from 23% to 30% (p for trend = 0.007), and survival to hospital discharge increased from 4% to 13% (p for trend = 0.03). Age, arrest witnessed by bystander or EMS, initial shockable rhythm or pulseless electrical activity, intubation, epinephrine and sodium bicarbonate administration were independently associated with survival. The adjusted-temporal trend for survival was not significant (per year increase; OR 1.02, 95% CI: 0.98, 1.07; p = 0.244). Of the 12-month survivors, 50% of the responders reported good functional recovery, and few reported severe problems with mobility, self-care, daily activity, pain, and anxiety/depression.
Conclusion
Although the incidence of drug overdose OHCA remained unchanged between 2000 and 2017, the rates of survival have significantly improved.

Crown Copyright © 2019. Published by Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:17-24
Alqahtani S, Nehme Z, Williams B, Bernard S, Smith K
Resuscitation: 30 Oct 2019; 144:17-24 | PMID: 31513862
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Abstract

Cardioplegia defibrillation of circulatory and metabolic phase ventricular fibrillation in a swine model.

Marill KA, Salcido DD, Sundermann ML, Koller AC, Menegazzi JJ
Introduction
We previously found potassium cardioplegia followed by rapid calcium reversal (Kplegia) can achieve defibrillation in a swine model of electrical phase of ventricular fibrillation (VF) comparable to standard care.
Hypothesis
Exploring 3 possible potassium dose and timing protocols, we hypothesize Kplegia may benefit resuscitation of longer duration untreated VF.
Methods
Three separate blinded randomized placebo-controlled trials were performed with electrically-induced VF untreated for durations of 6, 9, and 12min in a swine model. Experimental groups received infusion of 1 or 2 boluses of intravenous (IV) potassium followed by a single calcium reversal bolus. Potassium was replaced by saline in the control groups. Outcomes included: amplitude spectrum area (AMSA) during VF, resulting rhythms, number of defibrillations, return of spontaneous circulation (ROSC), and hemodynamics for 1h post ROSC. Binomial and interval data outcomes were compared with exact statistics. Serial interval data were assessed with mixed regression models.
Results
Twelve, 12, and 8 animals were included at 6, 9, and 12min VF durations for a total of 32. ROSC was achieved in: 4/6 Kplegia and 3/6 control animals in the 6min protocol, (p=1.00), 4/6 Kplegia and 2/6 control animals in the 9min protocol,(p=0.57), and 0/5 Kplegia and 1/3 control animals in the 12min protocol,(p=0.38). Two of 8 Kplegia animals achieved ROSC with chemical defibrillation alone.
Conclusions
The majority of animals achieved ROSC after up to 9min of untreated VF arrest using K plegia protocols. K plegia requires further optimization for both peripheral IV and intraosseous infusion, and to assess for superiority over standard care. Institutional Animal Care and Use Committee protocol #15127224.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:123-130
Marill KA, Salcido DD, Sundermann ML, Koller AC, Menegazzi JJ
Resuscitation: 30 Oct 2019; 144:123-130 | PMID: 31541693
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Abstract

A randomized trial of oropharyngeal airways to assist stabilization of preterm infants in the delivery room.

Kamlin COF, Schmölzer GM, Dawson JA, McGrory L, ... Hooper SB, Davis PG
Objective
Positive pressure ventilation (PPV) using a ventilation device and a face mask is recommended for compromised newborn infants in the delivery room (DR). Airway obstruction and face mask leak during PPV may contribute to failure of resuscitation. Using an oropharyngeal airway (OPA) may improve efficacy of mask PPV. To determine whether the use of an OPA with mask PPV in the DR during stabilization of infants <34 weeks\' gestational age, reduces the incidence of airway obstruction.
Intervention and measurements
An international two center unblinded randomized trial. Infants assessed by the clinical team to require PPV, were randomly assigned to receive PPV using a T Piece device with either a soft round face mask alone or in combination with an appropriately sized OPA. Resuscitation protocols were standardized. A hot-wire anemometer flow sensor measured respiratory function during the first five minutes of stabilization. The primary outcome was the incidence of airway obstruction, either complete (no gas flow) or partial (minimal gas flows resulting in expired tidal volumes <2 mL/kg).
Main results
A total of 137 infants were enrolled. Obstructed inflations were more frequently observed in infants stabilized with an OPA (81% vs. 64%; p = 0.03). Partial obstruction was more common in infants stabilized with an OPA (70% vs 54%; p = 0.04). There were no differences in mortality or respiratory outcomes for the whole cohort or in gestational age subgroups.
Conclusions
Airway obstruction is common in preterm infants receiving mask ventilation in the DR. Using an oropharyngeal airway significantly increases the incidence of airway obstruction.
Registered clinical trial
Australian and New Zealand Clinical Trials Register; ACTRN 12612000392864.

Crown Copyright © 2019. Published by Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:106-114
Kamlin COF, Schmölzer GM, Dawson JA, McGrory L, ... Hooper SB, Davis PG
Resuscitation: 30 Oct 2019; 144:106-114 | PMID: 31518615
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Abstract

Inadequate oxygen delivery index dose is associated with cardiac arrest risk in neonates following cardiopulmonary bypass surgery.

Futterman C, Salvin JW, McManus M, Lowry AW, ... Laussen PC, Gazit AZ
Aim
To evaluate the Inadequate oxygen delivery (IDO) index dose as a predictor of cardiac arrest (CA) in neonates following congenital heart surgery.
Methods
Retrospective cohort study in 3 US pediatric cardiac intensive units (1/2011- 8/2016). Calculated IDO index values were blinded to bedside clinicians and generated from data collected up to 30 days postoperatively, or until death or ECMO initiation. Control event data was collected from patients who did not experience CA or require ECMO. IDO dose was computed over a 120-min window up to 30 min prior to the CA and control events. A multivariate logistic regression prediction model including the IDO dose and presence or absence of a single ventricle (SV) was used. Model performance metrics were the odds ratio for each regression coefficient and receiver operating characteristic area under the curve (ROC AUC).
Results
Of 897 patients monitored during the study period, 601 met inclusion criteria: 29 patients had CA (33 events) and 572 patients were used for control events. Seventeen (59%) CA and 125 (26%) control events occurred in SV patients. Median age/weight at surgery and level of monitoring were similar in both groups. Median postoperative event time was 0.73 days [0.05-22.39] in CA patients and 0.82 days [0.08 25.11] in control patients. Odds ratio of the IDO dose coefficient was 1.008 (95% CI: 1.006-1.012, p = 0.0445), and 2.952 (95% CI: 2.952-3.258, p = 0.0079) in SV. The ROC AUC using both coefficients was 0.74 (95% CI: 0.73-0.75). These associations of IDO dose with CA risk remained robust, even when censored periods prior to arrest were 10 and 20 min.
Conclusion
In neonates post-CPB surgery, higher IDO index dose over a 120-min monitoring period is associated with increased risk of cardiac arrest, even when censoring data 10, 20 or 30 min prior to the CA event.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Aug 2019; 142:74-80
Futterman C, Salvin JW, McManus M, Lowry AW, ... Laussen PC, Gazit AZ
Resuscitation: 30 Aug 2019; 142:74-80 | PMID: 31325555
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Abstract

Kinetics of manual and automated mechanical chest compressions.

Colombo R, Fossali T, Ottolina D, Borghi B, ... Castelli A, Catena E
Aim
Early onset of adequate chest compression is mandatory for cardiopulmonary resuscitation (CPR) following cardiac arrest. Transmission of forces from chest strain to the heart may be variable between manual and mechanical chest compressions. Furthermore, automated mechanical chest devices can deliver an active decompression, thus improving the venous return to the heart. This pilot study investigated the kinetics of cardiac deformation during these two CPR methods.
Methods
Transesophageal echocardiographic analysis of the right ventricular wall behind the sternum during CPR was assessed during manual and mechanical chest compression in adult patients admitted to the emergency department for out-of-hospital cardiac arrest.
Results
9 patients had manual and 11 mechanical chest compression. Mechanical chest compression was characterized by greater right ventricular lateral wall displacement [with a median (IQR) of 3.7 (3.12-4.27) vs. 2.53 (2.27-2.6) cm, p < 0.0001], and lower rising time [123 (102-169) vs. 187 (164-215) msec, p = 0.002], relaxing time [109 (102-127) vs. 211 (133-252) msec, p = 0.0003], compression rate [100.6 (99.6-102.2) vs. 131.9 (125.4-151.4) bpm, p < 0.0001], with compression-decompression time ratio of [1.04 (0.86-1.1) vs. 0.86 (0.78-0.96), p = 0.046].
Conclusion
Mechanical compared to manual chest compression delivered a more rapid compression and decompression of the cardiac structures at an adequate rate, with broader inward-outward movement of the ventricular walls suggesting greater emptying and filling of the ventricles. Transesophageal echocardiography may be a useful tool to assess the adequacy of chest compression without CPR interruption.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 18 Oct 2019; epub ahead of print
Colombo R, Fossali T, Ottolina D, Borghi B, ... Castelli A, Catena E
Resuscitation: 18 Oct 2019; epub ahead of print | PMID: 31639462
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Abstract

The effect of a face mask for respiratory support on breathing in preterm infants at birth.

Kuypers KLAM, Lamberska T, Martherus T, Dekker J, ... Plavka R, Te Pas AB
Objective
Applying a mask on the face for respiratory support could induce a trigeminocardiac reflex leading to apnoea and bradycardia. We have examined the effect of applying a face mask on breathing and heart rate in preterm infants at birth.
Methods
Resuscitation videos of infants ≤ 32 weeks gestation recorded from 2010 until 2018 at the Leiden University Medical Centre and the General University Hospital in Prague were reviewed. All infants received respiratory support via face mask. Breathing and heart rate were noted before and after application of the face mask and over the first 5 min.
Results
Recordings of 429 infants were included (median (IQR) gestational age of 28 (27-30) weeks). In 368/429 (86%) infants breathing was observed before application of the face mask and 197/368 (54%) of these infants stopped breathing following application of the face mask. Apnoea occurred at a median of 5 (3-17) seconds after application of the face mask with a duration of 28 (22-34) seconds of the first minute. In a logistic regression model, the occurrence of apnoea after face mask application was inversely associated with gestational age (OR = 1.424 (1.281-1.583), p < 0.001). Infants who stopped breathing had a significantly lower heart rate 82 (66-123) vs 134 (97-151) bpm, p < 0.001) and oxygen saturation (49% (33-59) vs 66% (50-82), p < 0.001) over the first minute after face mask application, compared to infants who continued breathing.
Conclusion
Applying a face mask for respiratory support affects breathing in a large proportion (54%) of preterm infants and this effect is gestational age dependent.

Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:178-184
Kuypers KLAM, Lamberska T, Martherus T, Dekker J, ... Plavka R, Te Pas AB
Resuscitation: 30 Oct 2019; 144:178-184 | PMID: 31521774
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Abstract

Succeeding with rapid response systems - a never-ending process: A systematic review of how health-care professionals perceive facilitators and barriers within the limbs of the RRS.

Olsen SL, Søreide E, Hillman K, Hansen BS
Background
Meta-analyses show that hospital rapid response systems (RRS) are associated with reduced rates of cardiorespiratory arrest and mortality. However, many RRS fail to provide appropriate outcomes. Thus an improved understanding of how to succeed with a RRS is crucial. By understanding the barriers and facilitators within the limbs of a RRS, these can be addressed.
Objective
To explore the barriers and facilitators within the limbs of a RRS as described by health-care professionals working within the system.
Methods
The electronic databases searched were: EMBASE, MEDLINE, CINAHL, Epistemonikos, Cochrane, PsychInfo and Web of Science. Search terms were related to RRS and their facilitators and barriers. Studies were appraised guided by the CASP tool. Twenty-one qualitative studies were identified and subjected to content analysis.
Results
Clear leadership, interprofessional trust and collaboration seems to be crucial for succeeding with a RRS. Clear protocols, feedback, continuous evaluation and interprofessional training were highlighted as facilitators. Reprimanding down the hierarchy, underestimating the importance of call-criteria, alarm fatigue and a lack of integration with other hospital systems were identified as barriers.
Conclusion
To succeed with a RRS, the keys seem to lie in the administrative and quality improvement limbs. Clear leadership and continuous quality improvement provide the foundation for the continuing collaboration to manage deteriorating patients. Succeeding with a RRS is a never-ending process.

Copyright © 2019 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:75-90
Olsen SL, Søreide E, Hillman K, Hansen BS
Resuscitation: 30 Oct 2019; 144:75-90 | PMID: 31525405
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Abstract

Relationship between optic nerve sheath diameter measured by magnetic resonance imaging, intracranial pressure, and neurological outcome in cardiac arrest survivors who underwent targeted temperature management.

Kang C, Hong Min J, Park JS, You Y, ... Lee D, Chae MK
Aim
Studies on the prognostic performance of optic nerve sheath diameter (ONSD) in out-of-hospital cardiac arrest survivors (OHCA) have reported conflicting results. We aimed to investigate the usefulness of ONSD measured using magnetic resonance imaging (MRI) to estimate its association with intracranial pressure (ICP) and 6-month neurological outcomes in CA survivors treated with targeted temperature management (TTM).
Method
This retrospective study included 37 CA survivors who underwent TTM from January 2018 to December 2018. ICP was measured by lumbar catheter during TTM on Days 0, 1, 2, and 3. ONSD was measured using MRI on Days 0 and 3. The primary outcome was the correlation between ONSD and ICP associated with neurological outcomes obtained after 6 months.
Results
The median (interquartile range [IQR]) ONSD was not significantly different between the good and poor neurological outcome group on Day 0 (5.2 mm [4.8-5.8] vs 5.2 mm [4.8-5.6]; p = 0.948) and Day 3 (5.0 mm [4.8-5.2] vs 5.5 mm [4.4-5.9]; p = 0.105). ONSD and ICP had excellent correlation on Day 3 (r = 0.90, p < 0.001). ONSD showed excellent correlation with increased ICP (IICP) defined as ICP above 20 mmHg (r = 0.89, p < 0.001). ONSD cut-off of 5.99 mm was used with a sensitivity of 90.0% and specificity of 98.0% to identify IICP.
Conclusion
The ONSD on Days 0 or 3 did not show differences in neurological outcomes in OHCA patients treated with TTM. However, ONSD had an excellent correlation with ICP on Day 3 and with IICP. Further studies are required to confirm our results.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 15 Oct 2019; epub ahead of print
Kang C, Hong Min J, Park JS, You Y, ... Lee D, Chae MK
Resuscitation: 15 Oct 2019; epub ahead of print | PMID: 31628979
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Impact:
Abstract

Effects of dispatcher-initiated telephone cardiopulmonary resuscitation after out-of-hospital cardiac arrest: A nationwide, population-based, cohort study.

Shibahashi K, Ishida T, Kuwahara Y, Sugiyama K, Hamabe Y
Aim
This study aimed to investigate the effects of dispatcher-initiated telephone cardiopulmonary resuscitation (TCPR) in Japan using a nationwide population-based registry.
Methods
Adult Japanese patients with out-of-hospital cardiac arrest (OHCA; n = 582,483, age ≥18 years) were selected from a nationwide Utstein-style database (2010-2016) and divided into 3 groups: no bystander CPR (NCPR) before emergency medical service arrival (n = 448,606), bystander-initiated CPR (BCPR) performed without assistance (n = 46,964), and TCPR (n = 86,913). The primary outcome was a favourable neurological outcome 1 month after OHCA.
Results
After adjusting for potential confounders, and relative to the NCPR group, significantly better 1-month neurological outcomes were observed in the BCPR group (odds ratio: 2.25, 95% confidence interval: 2.15-2.36; P < 0.001) and in the TCPR group (odds ratio: 1.30, 95% confidence interval: 1.24-1.36; P < 0.001). The collapse-to-CPR time was independently associated with the 1-month outcomes, with a rate of <1% for 1-month favourable neurological outcomes if CPR was initiated >5 min after the collapse.
Conclusion
Patients who received TCPR had significantly better outcomes than those who did not receive CPR. However, the TCPR outcomes were less favourable than those in the BCPR group. Better protocol development and enhanced education are needed to improve dispatcher instructions in Japan, which may help lessen the gap between the BCPR and TCPR outcomes and further improve the outcomes after OHCA.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:6-14
Shibahashi K, Ishida T, Kuwahara Y, Sugiyama K, Hamabe Y
Resuscitation: 30 Oct 2019; 144:6-14 | PMID: 31499100
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Impact:
Abstract

Effect of smart devices on the quality of CPR training: A systematic review.

An M, Kim Y, Cho WK
Aim of the review
Use of smart devices to provide real-time cardiopulmonary resuscitation (CPR) feedback in the context of out-of-hospital cardiac arrest (OHCA) has considerable potential for improving survival. However, the findings of previous studies evaluating the effectiveness of these devices have been conflicting. Therefore, we conducted a systematic review of the literature to assess the utility of smart devices for improving the quality of CPR during CPR training.
Data sources
Thirteen electronic databases were searched. The articles were reviewed according to the eligibility criteria. CPR quality was evaluated based on the rates and depths of chest compression, and the proportion of adequate depth of chest compressions.
Results
Ultimately, 11 studies (5 randomised controlled trials, 1 randomised trial, and 5 randomised cross-over trials) were selected for this systematic review. Eight of these studies used smartphones and three used smartwatches. This review did not find an apparent benefit from smart device use during CPR in terms of maintaining the recommended compression rates and depths of chest compressions. However, all three smartwatch studies reported that the proportion of chest compressions of adequate depth was significantly improved with smartwatch use (smartwatch group vs. non-smartwatch group in the three studies: 65.01% vs. 45.15%, p = 0.01; 64.6% vs. 43.1%, p = 0.049; 98.7% vs. 79.3%, p = 0.002).
Conclusion
This review does not find durable evidence for usefulness of smart devices in CPR training. However, the smartwatches may improve the accuracy of chest compression depth. Future studies with larger sample sizes might be necessary before reaching a firm conclusion.

Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:145-156
An M, Kim Y, Cho WK
Resuscitation: 30 Oct 2019; 144:145-156 | PMID: 31325556
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Impact:
Abstract

The cardiac arrest survival score: A predictive algorithm for in-hospital mortality after out-of-hospital cardiac arrest.

Balan P, Hsi B, Thangam M, Zhao Y, ... Wang H, Doshi P
Background
Out-of-hospital cardiac arrest (OHCA) is associated with high mortality. Current methods for predicting mortality post-arrest require data unavailable at the time of initial medical contact. We created and validated a risk prediction model for patients experiencing OHCA who achieved return of spontaneous circulation (ROSC) which relies only on objective information routinely obtained at first medical contact.
Methods
We performed a retrospective evaluation of 14,892 OHCA patients in a large metropolitan cardiac arrest registry, of which 3952 patients had usable data. This population was divided into a derivation cohort (n = 2,635) and a verification cohort (n = 1,317) in a 2:1 ratio. Backward stepwise logistic regression was used to identify baseline factors independently associated with death after sustained ROSC in the derivation cohort. The cardiac arrest survival score (CASS) was created from the model and its association with in-hospital mortality was examined in both the derivation and verification cohorts.
Results
Baseline characteristics of the derivation and verification cohorts were not different. The final CASS model included age >75 years (odds ratio [OR] = 1.61, confidence interval [CI][1.30-1.99], p < 0.001), unwitnessed arrest (OR = 1.95, CI[1.58-2.40], p < 0.001), home arrest (OR = 1.28, CI[1.07-1.53], p = 0.008), absence of bystander CPR (OR = 1.35, CI[1.12-1.64], p = 0.003), and non-shockable initial rhythm (OR = 3.81, CI[3.19-4.56], p < 0.001). The area under the curve for the model derivation and model verification cohorts were 0.7172 and 0.7081, respectively.
Conclusion
CASS accurately predicts mortality in OHCA patients. The model uses only binary, objective clinical data routinely obtained at first medical contact. Early risk stratification may allow identification of more patients in whom timely and aggressive invasive management may improve outcomes.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:46-53
Balan P, Hsi B, Thangam M, Zhao Y, ... Wang H, Doshi P
Resuscitation: 30 Oct 2019; 144:46-53 | PMID: 31539610
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Impact:
Abstract

Effect of bystander CPR initiated by a dispatch centre following out-of-hospital cardiac arrest on 30-day survival: Adjusted results from the French National Cardiac Arrest Registry.

Noel L, Jaeger D, Baert V, Debaty G, ... Chouihed T,
Aim
Cardiac arrest (CA) was considered irreversible until 1960, when basic cardiopulmonary resuscitation (CPR) was defined. CPR guidelines include early recognition of CA, rapid and effective CPR, effective defibrillation strategies and organized post-resuscitation to ensure a strengthening of the survival chain. Bystanders are the key to extremely early management, which is associated with the early medical care provided by EMS. This study aims to assess the prognosis of a bystander\'s cardiac CPR when it is initiated by the Dispatch Centre (DC).
Methods
We included patients in 3 groups according to who initiated the CPR. The groups were matched according to multiple propensity partition methods. We presented our results in terms of 30-day survival and neurological prognosis.
Results
85,634 patients were included. Statistical study focused on 18,185 patients once the exclusion criteria were applied. 12,743 (70.1%) are men and the average age is 70.1 years. Survival at D30 was 5.11% in the absence of CPR, 8.86% with bystander initiation and 7.35% with DC initiation (p < 0.001). Survival at D30 with favourable neurologic prognosis (CPC 1-2) was 76.30%, 83.69% and 82.82%, respectively. Our results show a 3.75% increase in the chance of survival at D30 if CPR was initiated by bystanders compared to patients for whom CPR was not initiated, a 2.25% increase in survival in the group that received from CPR initiated by the DC compared to the group that did not receive CPR.
Conclusions
Bystander CPR initiated by the DC represents a suitable option following out-of-hospital cardiac arrest.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:91-98
Noel L, Jaeger D, Baert V, Debaty G, ... Chouihed T,
Resuscitation: 30 Oct 2019; 144:91-98 | PMID: 31499101
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Impact:
Abstract

Extracorporeal membrane oxygenation improves outcomes of accidental hypothermia without vital signs: A nationwide observational study.

Ohbe H, Isogai S, Jo T, Matsui H, Fushimi K, Yasunaga H
Aim
Patients with accidental hypothermia without vital signs increasingly receive venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, there is limited knowledge regarding the efficacy of this advanced rewarming method. We aimed to determine whether VA-ECMO improved outcomes in patients with accidental hypothermia without vital signs, using a large nationwide inpatient database in Japan.
Methods
Using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2017, we identified patients diagnosed with accidental hypothermia who received closed-chest cardiac massage in-hospital on the day of admission. Patients who received VA-ECMO on the day of admission were allocated to the VA-ECMO group, and those who received cardiopulmonary resuscitation (CPR) only were allocated to the conventional CPR group. The primary outcome was in-hospital mortality, and the secondary outcome was a Japan Coma Scale status of \"alert consciousness\" at discharge. Propensity score-matching analyses were performed to compare the outcomes.
Results
We identified 1661 eligible patients during the 81-month study period, and 318 (19%) received VA-ECMO on the day of admission. Crude in-hospital mortality was 65% in the VA-ECMO group and 84% in the conventional CPR group. Propensity score-matching analyses demonstrated significantly lower in-hospital mortality (risk difference: -13%; 95% confidence interval: -21% to -5.1%) and a higher proportion of \"alert consciousness\" at discharge (risk difference: 8.3%; 95% confidence interval: 1.9%-15%) in the VA-ECMO group compared with the conventional CPR group.
Conclusion
VA-ECMO was associated with higher survival and favourable neurological outcomes compared with conventional CPR alone in patients with accidental hypothermia without vital signs.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:27-32
Ohbe H, Isogai S, Jo T, Matsui H, Fushimi K, Yasunaga H
Resuscitation: 30 Oct 2019; 144:27-32 | PMID: 31513865
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Impact:
Abstract

The balance of thrombosis and hemorrhage in STEMI patients with or without associated cardiac arrest: an observational study.

Picard F, Llitjos JF, Diefenbronn M, Laghlam D, ... Dumas F, Varenne O
Background
Data is scarce on hemorrhagic and thrombotic complications in patients with ST-elevation myocardial infarction (STEMI) associated with out-of-hospital cardiac arrest (OHCA).
Methods
This is a monocentric, retrospective study conducted from January 2012 to December 2017 in a tertiary university hospital, which serves as a cardiac arrest center for a large urban area. Over the study period, all consecutive patients who were treated for STEMI with or without OHCA were included. Baseline characteristics, treatments, hemorrhagic and thrombotic events were compared between STEMI patients with and without OHCA. Univariate and multivariate analysis were performed in order to identify predictors of 30-day mortality, occurrence of major bleeding (MB), and early stent thrombosis (ST).
Results
A total of 549 patients treated for STEMI without OHCA and 146 patients for STEMI with OHCA were included. The incidence of definite ST and MB after coronary angioplasty was significantly higher in patients with OHCA (2.6% vs. 7.5%, p = 0.004 and 3.3% vs. 19.2%, p < 0.001, respectively). Independent predictors of MB in OHCA patients were anticoagulation therapy (HR = 3.11, 95%CI [1.22-7.98], p = 0.02) and the use of glycoprotein IIb/IIIa inhibitors (HR = 4.16, 95%CI [1.61-10.79], p = 0.003). Independent predictors of mortality in OHCA patients were age (HR = 1.05, 95%CI [1.02-1.09], p = 0.004) and ST (HR = 5.62, 95%CI [1.61-19.65], p = 0.007, with a protective effect of new anti-P2Y12 treatments (HR = 0.20, 95%CI [0.08-0.46], p < 0.001).
Conclusion
Patients treated for STEMI associated with OHCA are at higher-risk of ST and MB than those who did not experience cardiac arrest. In this subset of patients, prospective studies are needed to better evaluate the balance of thrombosis and hemorrhage.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 31 Oct 2019; epub ahead of print
Picard F, Llitjos JF, Diefenbronn M, Laghlam D, ... Dumas F, Varenne O
Resuscitation: 31 Oct 2019; epub ahead of print | PMID: 31682901
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Impact:
Abstract

One year experience with fast track algorithm in patients with refractory out-of-hospital cardiac arrest.

Adler C, Paul C, Michels G, Pfister R, ... Baldus S, Stangl R
Background
Overall prognosis in patients with out-of-hospital cardiac arrest (OHCA) remains poor, especially when return of spontaneous circulation (ROSC) cannot be achieved at the scene. It is unclear if rapid transport to the hospital with ongoing cardiopulmonary resuscitation (CPR) improves outcome in patients with refractory OHCA (rOHCA). The aim of this study was to evaluate the effect of a novel fast track algorithm (FTA) in patients with rOHCA.
Methods
This prospective single-center study analysed outcome in rOHCA patients treated with FTA. Historical patients before FTA-implementation served as controls. rOHCA was defined as: persistent shockable rhythm after three shocks and 300mg of amiodarone or persistent non-shockable rhythm and continuous CPR for 10min without ROSC after exclusion of treatable arrest causes.
Results
110 consecutive patients with rOHCA (mean age 56±14 years) were included. 40 patients (36%) were treated with FTA, 70 patients (64%) served as historical controls. Pre-hospital time was significantly shorter after FTA implementation (69±18 vs. 79±24min, p=0.02). Favourable neurological outcome (defined as cerebral performance categories Score 1 or 2) was significantly more frequent in FTA patients (27.5% vs. 11.4%, p=0.038). FTA-implementation showed a trend towards improved mortality (70.0% vs. 82.9%, p=0.151). Extracorporeal Life Support was similar between the two groups.
Conclusion
Our study suggests that a rapid transport algorithm with ongoing CPR is feasible, improves neurological outcome and may improve survival in carefully selected patients with rOHCA.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:157-165
Adler C, Paul C, Michels G, Pfister R, ... Baldus S, Stangl R
Resuscitation: 30 Oct 2019; 144:157-165 | PMID: 31401135
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Impact:
Abstract

Outcome after type A aortic dissection repair in patients with preoperative cardiac arrest.

Pan E, Wallinder A, Peterström E, Geirsson A, ... Gudbjartsson T, Jeppsson A
Aim of the study
Patients presenting with acute type A aortic dissection (ATAAD) and cardiac arrest before surgery are considered to have very poor prognosis, but limited data is available. We used a large database to evaluate the outcome of ATAAD patients with a cardiac arrest before surgery.
Methods
We evaluated 1154 surgically treated ATAAD patients from the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) database between 2005 and 2014. Patients with (n = 44, 3.8%) and without preoperative cardiac arrest were compared and variables univariably associated with mortality in the cardiac arrest group were identified. Median follow-up time was 2.7 years (interquartile range 0.5-5.5).
Results
Thirty-day mortality in the arrest and non-arrest group was 43.2% and 16.6%, respectively (odds ratio [OR] 3.83, CI 2.06-7.09; P < 0.001). In the nine patients with ongoing cardiopulmonary resuscitation when cardiopulmonary bypass was initiated, five died intraoperatively and one died after 65 days. In patients surviving the operation, stroke was significantly more common in the arrest group (48.4% vs 18.2%; OR 4.21, CI 2.05-8.67; P < 0.001). In total, 50.0% (22/44) of the arrest patients survived to the end of follow-up. Non-survivors in the arrest group more often had DeBakey type I dissection, cardiac tamponade, cardiac malperfusion and higher preoperative serum lactate (all P < 0.05).
Conclusions
Early mortality and complications after ATAAD surgery in patients with a preoperative cardiac arrest are high, but mid-term outcome after surviving the initial period is acceptable. Preoperative cardiac arrest should not be considered an absolute contraindication for a surgical ATAAD repair.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:1-5
Pan E, Wallinder A, Peterström E, Geirsson A, ... Gudbjartsson T, Jeppsson A
Resuscitation: 30 Oct 2019; 144:1-5 | PMID: 31505231
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Impact:
Abstract

Optimal timing of coronary intervention in patients resuscitated from cardiac arrest without ST-segment elevation myocardial infarction (NSTEMI): A systematic review and meta-analysis.

Barbarawi M, Zayed Y, Kheiri B, Barbarawi O, ... Bachuwa G, Alkotob ML
Objective
Performing immediate coronary angiography (CAG) in patients with a cardiac arrest and a non-ST-elevation myocardial infarction (NSTEMI) remains a highly debated topic. We performed a meta-analysis aiming to evaluate the influence of immediate, delayed, and no CAG in patients with cardiac arrest and NSTEMI.
Methods
A comprehensive literature review of Pubmed/MEDLINE, Cochrane Library, and Embase was performed for all studies that compared immediate CAG to delayed or no CAG in the setting of cardiac arrest and NSTEMI. The primary outcome was long-term mortality and secondary outcomes included short-term mortality and a Cerebral Performance Category (CPC) score of 1-2 at the longest follow-up period. A random-effects model was used to report odds ratios (ORs) with Bayesian 95% credible intervals (CrIs), and ORs with 95% confidence intervals (CIs) for both network and direct meta-analyses, respectively.
Results
11 studies were included in the final analysis: 8 observational, 1 post-hoc analysis and 2 randomized trials, totaling 3702 patients. The mean age was 63.8±12.8 years with 78% males. We found that immediate and delayed CAG were associated with lower long-term mortality when compared to no CAG (OR 0.21; 95% CrI 0.05-0.82) and (OR 0.11; 95% CrI 0.03-0.43), as well as lower short-term mortality (OR 0.17; 95% CrI 0.04-0.64) and (OR 0.07; 95% CrI 0.01-0.29), respectively. In addition, immediate and delayed CAG were associated with a significantly higher number of patients with a CPC score of 1-2 (OR 4.15; 95% CrI 1.10-16.10) and (OR 4.67; 95% CrI 1.53-15.12), respectively. There were no significant differences between immediate or delayed CAG regarding long-term mortality, short-term mortality, or favorable CPC score.
Conclusions
Among patients who survived cardiac arrest with an NSTEMI, CAG is associated with a higher rate of survival and favorable neurological outcomes compared with no CAG. There were no differences between immediate and delayed strategies.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:137-144
Barbarawi M, Zayed Y, Kheiri B, Barbarawi O, ... Bachuwa G, Alkotob ML
Resuscitation: 30 Oct 2019; 144:137-144 | PMID: 31580909
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Impact:
Abstract

Acute respiratory compromise on hospital wards: Association between recent ICU discharge and outcome.

Berg KM, Donnino MW, Andersen LW, Moskowitz A, Grossestreuer AV
Introduction
Acute respiratory compromise (ARC), respiratory distress requiring emergent assisted ventilation, has a mortality of 20-40%. The relationship between recent discharge from an intensive care unit (ICU) and outcomes of patients suffering ARC on hospital wards is not well known. We hypothesized that a significant percentage of ARC events would occur in patients recently discharged from an ICU, that these patients would have worse outcomes than those without prior ICU stays, and that weekend ICU discharge would be associated with higher than expected post-ICU ARC frequency.
Methods
Using the Get-With-The-Guidelines-Resuscitation ARC registry, we included adult, index ARC events occurring on hospital wards. Our primary analysis used multivariable logistic regression accounting for clustering by hospital to examine the association between prior ICU discharge and survival after an ARC event.
Results
Of 11,800 ARCs, 937 (8%) occurred within two calendar days and 1010 (9%) >two calendar days after an ICU discharge. Patients with ICU discharge within two days had higher survival compared to those with no prior ICU stay (odds ratio 1.28 (95% CI: 1.11-1.48, p = 0.001)). Survival was not different in those with an ICU discharge more than two days prior and no prior ICU stay. Patients with ARC within two days of ICU discharge were not more likely to have left the ICU on a weekend.
Conclusions
Contrary to our hypothesis, discharge from an ICU within two calendar days was associated with better odds for survival compared to no prior ICU discharge or ICU discharge more than two days prior.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:40-45
Berg KM, Donnino MW, Andersen LW, Moskowitz A, Grossestreuer AV
Resuscitation: 30 Oct 2019; 144:40-45 | PMID: 31513866
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Impact:
Abstract

Effectiveness of a community based out-of-hospital cardiac arrest (OHCA) interventional bundle: Results of a pilot study.

Jia Min Tay P, Pek PP, Fan Q, Ng YY, ... Peng Tham L, Ong MEH
Background
70% of Out-of-hospital cardiac arrests (OHCA) in Singapore occur in residential areas, and are associated with poorer outcomes. We hypothesized that an interventional bundle consisting of Save-A-life (SAL) initiative (cardiopulmonary resuscitation (CPR)/ automated external defibrillator (AED) training and public-housing AED installation), Dispatcher-Assisted CPR (DA-CPR) program and myResponder (mobile application) will improve OHCA survival.
Methods
This is pilot data from initial implementation of a stepped-wedge, before-after, real-world interventional bundle in six selected regions. Under the SAL initiative, 30,000 individuals were CPR/AED trained, with 360 AEDs installed. Data was obtained from Singapore\'s national OHCA Registry. We included all adult patients who experienced OHCA in Singapore from 2011 to 2016 within study regions, excluding EMS-witnessed cases and cases due to trauma/drowning/electrocution. Cases occurring before and after intervention were allocated as control and intervention groups respectively. Survival was assessed via multivariable logistic regression.
Results
1241 patients were included for analysis (Intervention: 361; Control: 880). The intervention group had higher mean age (70 vs 67 years), survival (3.3% [12/361] vs. 2.2% [19/880]), pre-hospital return of spontaneous circulation (ROSC) (9.1% [33/361] vs 5.1% [45/880]), bystander CPR (63.7% [230/361] vs 44.8% [394/880]) and bystander AED application (2.8% [10/361] vs 1.1% [10/880]). After adjusting for age, gender, race and significant covariates, the intervention was associated with increased odds ratio (OR) for survival (OR 2.39 [1.02-5.62]), pre-hospital ROSC (OR 1.94 [1.15-3.25]) and bystander CPR (OR 2.29 [1.77-2.96]).
Conclusion
The OHCA interventional bundle (SAL initiative, DA-CPR, myResponder) significantly improved survival and is being scaled up as a national program.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 25 Oct 2019; epub ahead of print
Jia Min Tay P, Pek PP, Fan Q, Ng YY, ... Peng Tham L, Ong MEH
Resuscitation: 25 Oct 2019; epub ahead of print | PMID: 31669756
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Impact:
Abstract

Basic life support training using shared mental models improves team performance of first responders on normal wards: A randomised controlled simulation trial.

Beck S, Doehn C, Funk H, Kosan J, ... Zöllner C, Kubitz JC
Introduction
Survival of in-hospital cardiac arrest (IHCA) depends on fast and effective action of the first responding team. Not only technical skills, but professional teamwork is required. Observational studies and theoretical models suggest that shared mental models of members improve teamwork. This study investigated if a training on shared mental models, improves team performance in simulated in-hospital cardiac arrest.
Methods
On the background of an introduction of mandatory Basic Life Support (BLS) training for clinical staff a randomized controlled trial was performed to compare two training methods. Staff from clinical departments was randomised to receive either a conventional instructor led training (control group) or an interventional training (intervention group). The interventional training was based on self-directed learning of the group in order to develop shared mental models. Primary outcome were mean scores of the team assessment scale (TAS) and the hands-off time. Secondary outcome were mean scores for quality of BLS.
Results
Performance of 75 teams of the interventional and 66 of the control group was analysed. The hands-off time was significantly lower in the interventional group (5.42% vs. 8.85%, p = 0.029). Scores of the TAS and the overall BLS score were high and not significantly different between the groups. Hands-off time correlated significantly negative with all TAS items.
Conclusion
BLS training for clinical staff which creates shared mental models reduces hands-off time in a simulated cardiac arrest scenario. Training methods establishing shared mental models of team members can be considered for effective team trainings without adding additional training time.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:33-39
Beck S, Doehn C, Funk H, Kosan J, ... Zöllner C, Kubitz JC
Resuscitation: 30 Oct 2019; 144:33-39 | PMID: 31505232
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Impact:
Abstract

Sudden Cardiac Arrest Survival in HEARTSafe Communities.

Cone DC, Burns K, Maciejewski K, Dziura J, ... Vellano K,
Background
The HEARTSafe Communities program promotes community efforts to improve systems for treating sudden cardiac arrest (SCA). The study hypothesis was that the rates of SCA survival to admission, discharge, and discharge with CPC score 1 or 2 are higher in HEARTSafe-designated communities than non-designated communities in Connecticut, USA. Secondary outcomes included bystander CPR and AED application.
Methods
The state Office of EMS supplied a list of towns that are HEARTSafe-designated, and dates of designation. The Cardiac Arrest Registry to Enhance Survival provided data for all SCA from 2013 to 2017 in the 70 participating towns. For each SCA, it was determined whether the town was HEARTSafe-designated at the time.
Results
Of 2922 SCA cases, 1569 (54%) occurred in towns that were HEARTSafe-designated. Patients in designated towns were 1.15 times more likely to have AEDs applied by bystanders, and 1.15 times more likely to have CPR started by bystanders, than were patients in non-designated towns, but these differences were not significance (p = 0.66 and 0.28). The likelihood of surviving to admission was 1.33 times higher (p = 0.02) in designated towns. The likelihood of surviving to discharge was 1.33 times higher, and of surviving to discharge with CPC 1 or 2 was 1.4 times higher, but these differences were not significant (p = 0.17 and 0.13).
Conclusion
SCA survival rates do not differ between HEARTSafe and non-HEARTSafe communities in Connecticut. SCA patients in HEARTSafe communities are no more likely to receive bystander AED application or bystander CPR.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 05 Nov 2019; epub ahead of print
Cone DC, Burns K, Maciejewski K, Dziura J, ... Vellano K,
Resuscitation: 05 Nov 2019; epub ahead of print | PMID: 31705910
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Impact:
Abstract

Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update of the Utstein Resuscitation Registry Template for In-Hospital Cardiac Arrest: A Consensus Report From a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia).

Nolan JP, Berg RA, Andersen LW, Bhanji F, ... Soar J,

Utstein-style reporting templates provide a structured framework with which to compare systems of care for cardiac arrest. The 2004 Utstein reporting template encompassed both out-of-hospital and in-hospital cardiac arrest. A 2015 update of the Utstein template focused on out-of-hospital cardiac arrest, which makes this update of the in-hospital template timely. Representatives of the International Liaison Committee on Resuscitation developed an updated in-hospital Utstein reporting template iteratively by meeting face-to-face, by teleconference, and by online surveys between 2013 and 2018. Data elements were grouped by hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. Elements were classified as core or supplemental by use of a modified Delphi process. Variables were described as core if they were considered essential. Core variables should enable reasonable comparisons between systems and are considered essential for quality improvement programs. Together with core variables, supplementary variables are considered useful for research.

Copyright © 2019 European Resuscitation Council, American Heart Association, Inc. Published by Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:166-177
Nolan JP, Berg RA, Andersen LW, Bhanji F, ... Soar J,
Resuscitation: 30 Oct 2019; 144:166-177 | PMID: 31536777
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Impact:
Abstract

Organ donation after resuscitation from cardiac arrest.

Elmer J, Molyneaux BJ, Shutterly K, Stuart SA, ... Darby JM, Weisgerber AR
Background
We compared the characteristics and outcomes of post-arrest donors to those of other donors, described the proportion of post-arrest decedents who donated, and compared their characteristics to post-arrest decedents who did not donate.
Methods
We performed a retrospective cohort study including patients who died at a single academic medical center from January 1, 2010 to February 28, 2019. We linked our registry of consecutive post-arrest patients to donation-related data from the Center for Organ Procurement and Recovery (CORE). We used data from CORE to identify donor eligibility, first person designation, family approaches to seek consent for donation, and approach outcomes. We determined number of organs procured and number transplanted, stratified by donor type (brain death donors (BDD) vs donors after circulatory determination of death (DCD)).
Results
There were 12,130 decedents; 1,525 (13%) were resuscitated from cardiac arrest. CORE staff approached families of 836 (260 (31%) post-arrest, 576 (69%) not post-arrest) to request donation. Post-arrest patients and families were more likely to authorize donation (172/260 (66%) vs 331/576 (57%), P = 0.02), and more likely to be DCDs (50/146 (34%) vs 55/289 (19%), P < 0.001). Overall, 4.1 ± 1.5 organs were procured and 2.9 ± 1.9 transplanted per BDD, which did not differ by post-arrest status, 3.2 ± 1.2 organs were procured and 1.8 ± 1.1 transplanted per DCD. Number of organs transplanted per DCD did not differ by post-arrest status. Unfavorable arrest characteristics were more common among post-arrest organ donors compared to non-donors.
Conclusion
Patients resuscitated from cardiac arrest with irrecoverable brain injury have excellent potential to become organ donors.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 21 Oct 2019; epub ahead of print
Elmer J, Molyneaux BJ, Shutterly K, Stuart SA, ... Darby JM, Weisgerber AR
Resuscitation: 21 Oct 2019; epub ahead of print | PMID: 31654724
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Impact:
Abstract

One-year outcome of patients admitted after cardiac arrest compared to other causes of ICU admission. An ancillary analysis of the observational prospective and multicentric FROG-ICU study.

Kimmoun A, Cariou A, Gayat E, Feliot E, ... Deye N,
Objective
While cardiac arrest (CA) patients discharged alive from intensive care unit (ICU) are considered to have good one-year survival but potential neurological impairment, comparisons with other ICU sub-populations non-admitted for CA purpose are still lacking. This study aimed to compare long-term outcome and health-related quality of life (HRQOL) between CA patients and patients admitted to ICU for all other causes.
Methods
In 1635 patients discharged alive from 21 European ICUs in an ancillary analysis of a prospective multicentric cohort, we compared CA causes of ICU admission to all other causes of ICU admissions (named non-CAs). The primary endpoint was one-year survival rate after ICU discharge. Secondary endpoints included HRQOL at 3, 6 and 12 months after ICU discharge using the outcome survey short form-36 (SF36). Propensity score matching was used to consider the probability of having CA.
Results
Of the 1635 patients, 1561 were included in this study comprised of 1447 non-CAs and 114 CAs. At one-year in the non-matched population, survival rate was greater in the CA group 89% versus the non-CA group 78% (log rank p = 0.0056). In the matched population, this difference persisted between CAs and non-CAs (log rank p = 0.049). The physical component summary of the SF36 scale was higher in the CA group than in the non-CA group at all time points in both non-matched and matched populations.
Conclusions
CA patients discharged alive from ICU have a better one-year survival and a better HRQOL specifically on physical functions than patients admitted to ICU for other causes.
Trial registration
ClinicalTrials.gov NCT01367093; registered on June 6, 2011.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 30 Oct 2019; epub ahead of print
Kimmoun A, Cariou A, Gayat E, Feliot E, ... Deye N,
Resuscitation: 30 Oct 2019; epub ahead of print | PMID: 31678408
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Impact:
Abstract

A local neighborhood volunteer network improves response times for simulated cardiac arrest.

Kern KB, Colberg TP, Wunder C, Newton C, Slepian MJ
Aim
Each minute is crucial in the treatment of out-of-hospital cardiac arrest (CA). Immediate chest compressions and early defibrillation are keys to good outcomes. We hypothesized that a coordinated effort of alerting trained local neighborhood volunteers (vols) simultaneously with 911 activation of professional EMS providers would result in substantial decreases in call-to-arrival times, leading to earlier CPR and defibrillation.
Methods
We developed a program of simultaneously alerting CPR- and AED-trained neighborhood vols and the local EMS system for CA events in a retirement residential neighborhood in Southern Arizona, encompassing approximately 440 homes. The closest EMS station is 3.3 miles from this neighborhood. Within this neighborhood, 15 vols and the closest EMS station were involved in multiple days of mock CA notifications and responses.
Results
The two groups differed significantly in distance to the mock CA event and in response times. The volunteers averaged 0.3 ± 0.2 miles from the mock CA incidences while the closest EMS station averaged 3.4 ± 0.1 miles away (p < 0.0001). Response times (time from call to arrival) also differed. Two volunteers, one bringing an AED, averaged 1 min 38 s ± 53 s in Phase 1, while it took the EMS service an average of 7 min 20 s ± 1 min 13 s to arrive on scene; p < 0.0001.
Conclusion
Local neighborhood volunteers were geographically closer and arrived significantly sooner at the mock CA scene than did the EMS service. The approximate time savings from call to arrival with the volunteers was 4-6 min.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:131-136
Kern KB, Colberg TP, Wunder C, Newton C, Slepian MJ
Resuscitation: 30 Oct 2019; 144:131-136 | PMID: 31580910
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Impact:
Abstract

Effect of team-based cardiopulmonary resuscitation training for emergency medical service providers on pre-hospital return of spontaneous circulation in out-of-hospital cardiac arrest patients.

Park JH, Moon S, Cho H, Ahn E, Kim TK, Bobrow BJ
Objective
This study aimed to assess whether team-based cardiopulmonary resuscitation (CPR) training for emergency medical service (EMS) providers improved the pre-hospital return of spontaneous circulation (ROSC) rates of non-traumatic adult out-of-hospital cardiac arrest (OHCA) patients.
Methods
This was a before-and-after study an evaluating educational intervention for community EMS providers, which was conducted in Gyeonggi province, South Korea. Team-based CPR training was conducted from January to March 2016 for every level 1 and level 2 EMS provider in the study area. Non-traumatic EMS treated OHCA patients from July to December 2015 and from July to December 2016 were enrolled and used for the analysis. The primary outcome was pre-hospital ROSC rates before and after the training period. A multivariable logistic regression model with an interaction term (period × dispatch type) was used to determine the adjusted odds ratios (aORs) according to the dispatch type (single vs. multi-tiered).
Results
Of the 2125 OHCA cases included, 1072 (50.4%) and 1053 (49.6%) were categorized in the before- and after-training groups, respectively, and the pre-hospital ROSC rates were 6.6% and 12.6%, respectively. In the multivariable logistic regression analysis, the aOR for pre-hospital ROSC was 2.07 (95% CI, 1.32-3.25) in the after-training period. In the interaction model (period × type of dispatch), the aORs for pre-hospital ROSC were 2.00 (95% CI, 1.01-3.98) and 2.13 (95% CI, 1.20-3.79) in the single- and multi-tiered dispatch groups, respectively, during the after-training period.
Conclusion
Team-based CPR training for EMS providers in a large community EMS system improved the pre-hospital ROSC rates of OHCA patients.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:60-66
Park JH, Moon S, Cho H, Ahn E, Kim TK, Bobrow BJ
Resuscitation: 30 Oct 2019; 144:60-66 | PMID: 31550494
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Impact:
Abstract

Elimination of glutamate using CRRT for 72 h in patients with post-cardiac arrest syndrome: A randomized clinical pilot trial.

Nee J, Jörres A, Krannich A, Leithner C, ... Steppan S, Storm C
Aim
Glutamine and glutamate are major mediators of secondary brain cell death during post-cardiac arrest syndrome. As there is an equilibrium between brain tissue and plasma concentrations of glutamine and glutamate, their elimination from systemic circulation by extracorporeal blood purification may ultimately lead to reduced secondary cell death in the brain. We hypothesized that systemic glutamine and glutamate can be significantly reduced by continuous venovenous hemodiafiltration (CVVHDF).
Methods
This was a prospective, randomized clinical trial in post cardiac-arrest survivors evaluating standard of care or additional CVVHDF over 72 h immediately after admission. Glutamine and glutamate plasma concentrations were analyzed at eight time points in both groups. Primary endpoint was reduction of glutamine and glutamate plasma concentrations. The trial has been registered at clinical trial.gov (NCT02963298).
Results
In total, 41 patients were randomized over a period of 12 months (control n = 21, CVVHDF n = 20). The primary aim reduction of glutamine and glutamate plasma concentrations by CVVHDF, was not achieved; both groups-maintained concentrations within a normal range over the study period (glutamate: 4.7-11.1 mg/dL; glutamine: 0.2-3.7 mg/dL). However, post-filter concentrations of glutamine and glutamate in CRRT patients were significantly decreased as compared to pre-filter concentrations (glutamate: pre-filter median 8.85 mg/dL IQR 7.1-9.6; post-filter 0.95 mg/dL IQR 0.5-2; p < 0.001; glutamine: pre-filter 0.7 mg/dL IQR 0.6-1; post-filter 0.2 mg/dL IQR 0-0.2; p < 0.001).
Conclusion
In this trial, CVVHDF was not able to statistically significantly lower systemic plasma glutamine and glutamate levels. Post-cardiac arrest patients had plasma glutamine and glutamate levels within the normal range.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:54-59
Nee J, Jörres A, Krannich A, Leithner C, ... Steppan S, Storm C
Resuscitation: 30 Oct 2019; 144:54-59 | PMID: 31557520
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Impact:
Abstract

Stress and decision-making in resuscitation: A systematic review.

Groombridge CJ, Kim Y, Maini A, Smit V, Fitzgerald MC
Background
During resuscitation decisions are made frequently and based on limited information in a stressful environment.
Aim
This systematic review aimed to identify human factors affecting decision-making in challenging or stressful situations in resuscitation. The secondary aim was to identify methods of improving decision-making performance under stress.
Methods
The databases PubMed, EMBASE and The Cochrane Library were searched from their commencement to the 13th of April 2019. MeSH terms and key words were combined (Stress* OR \"human factor\") AND Decision. Articles were included if they involved decision makers in medicine where decisions were made under challenging circumstances, with a comparator group and an outcome measure relating to change in decision-making performance.
Results
22,368 records in total were initially identified, from which 82 full text studies were reviewed and 16 finally included. The included studies ranged from 1995 to 2018 and included a total of 570 participants. The studies were conducted in several different countries and settings, with participants of varying experience and backgrounds. Of the 16 studies, 5 were randomised controlled trials, 3 of which were deemed to have a high risk of bias. The stressors identified were (i) illness severity (ii) socio-evaluative, (iii) noise, (iv) fatigue. The mitigators identified were (i) cognitive aids including checklists, (ii) stress management training and (iii) meditation.
Conclusions
Human factors contributing to decision-making during resuscitation are identified and can be mitigated by tailored stress training and cognitive aids. Understanding these factors may have implications for clinician education and the development of decision-support tools.

Copyright © 2019 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 30 Oct 2019; 144:115-122
Groombridge CJ, Kim Y, Maini A, Smit V, Fitzgerald MC
Resuscitation: 30 Oct 2019; 144:115-122 | PMID: 31562904
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Impact:
Abstract

Systematic Review and Meta-Analysis of INTRAvascular Temperature Management versus Surface Cooling in COMATose Patients Resuscitated from Cardiac Arrest.

Bartlett E, Valenzuela T, Idris A, Deye N, ... Kirkegaard H, Nichol G
Objective
To systematically review the effectiveness and safety of intravascular temperature management (IVTM) versus surface cooling methods (SCM) for induced hypothermia (IH).
Methods
Systematic review and meta-analysis. English-language PubMed, Embase and the Cochrane Database of Systematic Reviews were searched on May 27, 2019. The quality of included observational studies was graded using the Newcastle-Ottawa Quality Assessment tool. The quality of included randomized trials was evaluated using the Cochrane Collaboration\'s risk of bias tool. Random effects modeling was used to calculate risk differences for each outcome. Statistical heterogeneity and publication bias were assessed using standard methods.
Eligibility
Observational or randomized studies comparing survival and/or neurologic outcomes in adults aged 18 years or greater resuscitated from out-of-hospital cardiac arrest receiving IH via IVTM versus SCM were eligible for inclusion.
Results
In total, 12 studies met inclusion criteria. These enrolled 1,573 patients who received IVTM; and 4,008 who received SCM. Survival was 55.0% in the IVTM group and 51.2% in the SCM group [pooled risk difference 2% (95% CI -1%, 5%)]. Good neurological outcome was achieved in 40.9% in the IVTM and 29.5% in the surface group [pooled risk difference 5% (95% CI 2%, 8%)]. There was a 6% (95% CI 11%, 2%) lower risk of arrhythmia with use of IVTM and 15% (95% CI 22%, 7%) decreased risk of overcooling with use of IVTM versus SCM. There was no significant difference in other evaluated adverse events between groups.
Conclusions
IVTM was associated with improved neurological outcomes vs. SCM among survivors resuscitated following cardiac arrest. These results may have implications for care of patients in the emergency department and intensive care settings after resuscitation from cardiac arrest.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 11 Nov 2019; epub ahead of print
Bartlett E, Valenzuela T, Idris A, Deye N, ... Kirkegaard H, Nichol G
Resuscitation: 11 Nov 2019; epub ahead of print | PMID: 31730898
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Impact:
Abstract

Identifying out-of-hospital cardiac arrest patients with no chance of survival: an independent validation of prediction rules.

Hreinsson JP, Thorvaldsson AP, Magnusson V, Fridriksson BT, Libungan BG, Karason S
Background
The Basic life support (BLS) and Advanced life support (ALS) are known prediction rules for termination of resuscitation (TOR) in out-of-hospital cardiac arrest (OHCA). Recently, a new rule was developed by Jabre et al. We aimed to independently validate and compare the predictive accuracy of these rules.
Methods
OHCA cases in Iceland from 2008-2017 from a population-based, prospectively registered database. Primary outcome was survival to discharge among patients that met all conditions of abovementioned rules: BLS (not witnessed by EMS personnel, no defibrillation nor ROSC before transport), ALS (BLS criteria plus not witnessed nor CPR by bystander) and Jabre (not witnessed by EMS personnel, initial rhythm non-shockable, no sustainable ROSC before third dose of adrenaline).
Results
Overall, 568 OHCA patients were included in validation of TOR rules. Mean age 67, males 74%, witnessed by EMS 11%, by bystander 66% that attempted CPR in 50%, transported to hospital 60%, overall survival 20%. All rules had high specificity for mortality, 99.6-100% (95%CI 95-100). The Jabre and BLS rules had similar sensitivity 47% (43-52) vs. 44% (40-49), respectively, the sensitivity of ALS was lower, 8% (5-11). Combined use of positive BLS and Jabre rules performed the best, identifying 88/226 (39%) of futile cases transported to hospital, specificity 100% (97-100) and sensitivity 59% (55-64).
Conclusions
The accuracy of the BLS and Jabre TOR rules to predict mortality after OHCA is very good and their combined use may be superior to the use of either one.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 07 Nov 2019; epub ahead of print
Hreinsson JP, Thorvaldsson AP, Magnusson V, Fridriksson BT, Libungan BG, Karason S
Resuscitation: 07 Nov 2019; epub ahead of print | PMID: 31711916
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Impact:
Abstract

Neonates with a 10-min Apgar score of zero: Outcomes by gestational age.

Zhong YJ, Claveau M, Yoon EW, Aziz K, ... Wintermark P,
Background
The current resuscitation guidelines for neonates recommend considering stopping resuscitation efforts if the heart rate remains undetectable after 10 min of adequate resuscitation. However, this recommendation does not take into account the gestational age (GA) of the neonates. We determined the outcomes of neonates with a 10-min Apgar score of zero (Apgar = 0) with respect to their GA.
Methods
In a retrospective matched cohort study, we studied neonates admitted to the Canadian Neonatal Network NICUs between 2010 and 2016 with an Apgar = 0. The neonates were divided into 3 subgroups according to their GA: (1) ≥36 weeks\', (2) 32-35 weeks\', and (3) <32 weeks\'. Each neonate with Apgar = 0 was matched 1:1 with neonates of same GA and sex but Apgar = 1-2 and Apgar = 3-5. Survival and brain injury were compared between matched groups.
Results
177 neonates had Apgar = 0. Survival to discharge was significantly different between GA groups [≥36 weeks\' 61% vs. 32-35 weeks\' 58% vs. <32 weeks\' 35%, p = 0.04]. Survival to discharge was similar to their matched cohort with Apgar = 1-2 for neonates born at ≥36 weeks\' (61% vs. 66%) and between 32 to 35 weeks\' (58% vs. 54%), but significantly different for neonates <32 weeks (35% vs. 61%, p = 0.04).
Conclusion
Neonates with Apgar = 0 had different outcomes depending on their GA. Less than half of neonates born at <32 weeks GA survived; however, a majority of neonates born at 32-35 weeks\' and ≥36 weeks\' GA survived at similar rates than their matched neonates with Apgar = 1-2.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:77-84
Zhong YJ, Claveau M, Yoon EW, Aziz K, ... Wintermark P,
Resuscitation: 29 Sep 2019; 143:77-84 | PMID: 31421194
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Impact:
Abstract

Cadaver models for cardiac arrest: A systematic review and perspectives.

Duhem H, Viglino D, Bellier A, Tanguy S, ... Chaffanjon P, Debaty G
Aim
To provide an overview of cadaver models for cardiac arrest and to identify the most appropriate cadaver model to improve cardiopulmonary resuscitation through a systematic review.
Methods
The search strategy included PubMed, Embase, Current contents, Pascal, OpenSIGLE and reference tracking. The search concepts included \"heart arrest\", \"cardiopulmonary resuscitation\" and \"cadavers\". All studies, published until February 2019, in English or French, on research or simulation in the field of cardiac arrest and using cadaver models were eligible for inclusion.
Results
Overall, 29 articles out of the 244 articles located were selected. The characteristics of the studies and the cadaver models were heterogenous. Indeed, 31% of the studies lacked a proper description of the model used and its specificities. Fresh cadavers were used in 55% of the studies and chest compressions were performed in 90%. This model was appreciated for its realism in terms of mechanical properties and tissue conservation. Thiel-embalmed cadavers also showed promising results concerning lung and chest compliance. The lack of circulation stood out as the strongest limitation of all types of human cadaver models.
Conclusion
Four types of cadaver models are used in cardiac arrest research. The great heterogeneity of these models coupled with unequal quality in reporting makes comparisons between studies difficult. There is a need for uniform reporting and standardisation of human cadaver models in cardiac arrest research.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:68-76
Duhem H, Viglino D, Bellier A, Tanguy S, ... Chaffanjon P, Debaty G
Resuscitation: 29 Sep 2019; 143:68-76 | PMID: 31412293
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Impact:
Abstract

The association between lipid profiles and the neurologic outcome in patients with out-of-hospital cardiac arrest.

Lee HY, Lee DH, Lee BK, Jeung KW, ... Min JH, Min YI
Background
Lipid profiles are known to be a risk factor for development of cardiovascular disease. However, the relationship between lipid profiles and outcome in out-of-hospital cardiac arrest (OHCA) survivors remains unclear. We aimed to examine the association between lipid profiles and neurologic outcome in OHCA survivors.
Methods
This retrospective observational study included adult (≥18 years) OHCA survivors between January 2016 and December 2018. We measured patients\' lipid profiles after return of spontaneous circulation (ROSC) including total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglyceride. The primary outcome was neurologic outcome at hospital discharge. Good neurologic outcome was defined cerebral performance categories 1 and 2.
Results
A total of 182 patients were included. Of them, 57 (31.3%) were discharged with good neurologic outcomes. Median serum levels of total cholesterol (178.0 vs. 123.0 mg/dL), HDL (44.0 vs. 31.0 mg/dL), and LDL (104.0 vs. 75.0 mg/dL) were significantly higher in patients with good neurologic outcome. The area under the curves of total cholesterol, HDL, LDL, and triglyceride were 0.742 (95% confidence interval [CI], 0.672-0.803), 0.729 (95% CI, 0.658-0.792), 0.683 (95% CI, 0.610-0.750), and 0.572 (95% CI, 0.497-0.645), respectively. Total cholesterol (odds ratio [OR], 1.013; 95% CI, 1.000-1.025; p = 0.043) and HDL (OR, 1.071; 95% CI, 1.021-1.123; p = 0.005) levels were associated with good neurologic outcomes.
Conclusions
The levels of total cholesterol and HDL after ROSC were associated with good neurologic outcomes in patients with OHCA, without considering the effect of other lipid profiles simultaneously.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 14 Oct 2019; 145:26-31
Lee HY, Lee DH, Lee BK, Jeung KW, ... Min JH, Min YI
Resuscitation: 14 Oct 2019; 145:26-31 | PMID: 31626864
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Impact:
Abstract

Timing of Brain Computed Tomography and Accuracy of Outcome Prediction after Cardiac Arrest.

Streitberger KJ, Endisch C, Ploner CJ, Stevens R, ... Storm C, Leithner C
Aim
Gray-white-matter ratio (GWR) calculated from head CT is a radiologic index of tissue changes associated with hypoxic-ischemic encephalopathy after cardiac arrest (CA). Evidence from previous studies indicates high specificity for poor outcome prediction at GWR thresholds of 1.10-1.20. We aimed to determine the relationship between accuracy of neurologic prognostication by GWR and timing of CT.
Methods
We included 195 patients admitted to the ICU following CA. GWR was calculated from CT radiologic densities in 16 regions of interest. Outcome was determined upon intensive care unit discharge using the cerebral performance category (CPC). Accuracy of outcome prediction of GWR was compared for 3 epochs (<6, 6-24, and >24 hrs after CA).
Results
125 (64%) patients had poor (CPC4-5) and 70 (36%) good outcome (CPC1-3). Irrespective of timing, specificity for poor outcome prediction was 100% at a GWR threshold of 1.10. Among 50 patients with both early and late CT, GWR decreased significantly over time (p = 0.002) in patients with poor outcome, sensitivity for poor outcome prediction was 12% (7-20%) with early CTs (<6 h) and 48% (38-58%) for late CTs (>24 h). Across all patients, sensitivity of early and late CT was 17% (9-28%) and 39% (28-51%), respectively.
Conclusion
A GWR below 1.10 predicts poor outcome (CPC 4-5) in patients after CA with high specificity irrespective of time of acquisition of CT. Because GWR decreases over time in patients with severe HIE, sensitivity for prediction of poor outcome is higher for late CTs (>24 h after CA) as compared to early CTs (<6 h after CA).

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Sep 2019; epub ahead of print
Streitberger KJ, Endisch C, Ploner CJ, Stevens R, ... Storm C, Leithner C
Resuscitation: 30 Sep 2019; epub ahead of print | PMID: 31585185
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Impact:
Abstract

The effects of route of admission to a percutaneous coronary intervention centre among patients with out-of-hospital cardiac arrest.

Suh J, Ahn KO, Shin SD
Aim
Patients with OHCA who are not transported directly to a percutaneous coronary intervention (PCI)-capable hospital may eventually undergo an inter-hospital transfer (IHT). The aim of the present study was to investigate the effects of route of admission to a PCI centre among patients with OHCA.
Methods
We included patients with OHCA of presumed cardiac aetiology that were admitted to a PCI centre between January 2015 and December 2016. The exposure variable was route of admission: direct versus indirect. The \'direct\' group was defined as patients who were transferred directly from the field to a PCI centre by emergency medical service (EMS) providers. The \'indirect\' group was defined as patients who underwent IHT from a non-PCI centre to a PCI centre. The primary outcome was neurological recovery. We evaluated the effects of route of admission using multivariable logistic regression analysis after adjusting for potential confounders.
Results
There were total of 4,363 eligible patients: 3,488 (78.2%) in the direct group and 975 (21.8%) in the indirect group. Neurologic recovery was better in the direct group (38.0%) than in the indirect group (29.0%). After adjusting for potential confounders, indirect admission was negatively associated with outcomes (adjusted odds ratio [aOR] 0.70; 95% confidence interval [CI] 0.58- 0.85).
Conclusions
The route of admission to a PCI centre is associated with neurological recovery among resuscitated patients with OHCA of presumed cardiac aetiology. This has implications for regionalized EMS transport and IHT protocols for patients with OHCA.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 10 Oct 2019; epub ahead of print
Suh J, Ahn KO, Shin SD
Resuscitation: 10 Oct 2019; epub ahead of print | PMID: 31610226
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Impact:
Abstract

Influence of comorbidity on survival after out-of-hospital cardiac arrest in the United States.

Pasupula DK, Bhat AG, Meera SJ, Siddappa Malleshappa SK
Aim
Association between survival rate and Elixhauser Comorbidity Index (ECI) among individuals suffering an out-of-hospital cardiac arrest (OHCA) in the United States (US).
Methods
We utilized the US National Emergency Department Sample (NEDS) dataset to retrospectively identify individuals experiencing OHCA between January 1, 2006 to December 31, 2015; using the International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9-CM) and Tenth Revision-Clinical Modification (ICD-10-CM) codes. Logistic regression analysis with twenty-nine ECIs as predictor variables were performed to compute for odds ratio (OR), after controlling for age and gender. Linear regression analysis performed to assess survival trend after clustering based on ECI. We also assessed the association of ECI with survival rate after stratifying patients based on cardiac rhythm (shockable versus non-shockable).
Results
We identified 1,282,520 (16.4%, survived-to-discharge) weighted observations presenting primarily after OHCA in the US during the study period. Annual percentage change (APC) in survival rate among OHCA patients with no ECI and those with >3 ECI was -1.53% (95% CI: -1.98% to -1.09%, P < 0.001) and 1.2% (95% CI: 0.69%-1.7%, P = 0.001), respectively. Adjusted OR for ECI was 1.31 (95% CI: 1.3-1.31, P < 0.001). Percentage change in the survival rate among shockable and non-shockable rhythm was 5.6% (95% CI: -3.9% to 15.13%, P = 0.127) and 1.04% (95% CI: 0.01%-2.07%, P = 0.05), respectively, with a unit increase in ECI.
Conclusion
In the US, OHCA patients with higher ECI have greater survival-to-discharge rate, demonstrating \"comorbidity paradox\".

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 09 Oct 2019; 145:21-25
Pasupula DK, Bhat AG, Meera SJ, Siddappa Malleshappa SK
Resuscitation: 09 Oct 2019; 145:21-25 | PMID: 31606397
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Impact:
Abstract

Stratifying comatose postanoxic patients for somatosensory evoked potentials using routine EEG.

Fredland A, Backman S, Westhall E
Introduction
Multimodal neurological prognostication is recommended for comatose patients after cardiac arrest. The absence of cortical N20-potentials in a somatosensory evoked potential (SSEP) examination reliably predicts poor outcome, but presence of N20-potentials have limited prognostic value. A benign routine electroencephalogram (EEG) may identify patients with a favourable prognosis who are likely to have present N20-potentials.
Objective
To investigate whether a routine EEG can identify patients where SSEP is unnecessary to perform.
Methods
In a multi-centre trial, comatose patients after cardiac arrest were randomised to a controlled temperature of 33 °C or 36 °C. A routine EEG was protocolised and SSEP performed at the clinicians\' discretion, both during normothermic conditions. EEGs were categorised into benign, malignant or highly malignant based on standardised terminology. A benign EEG was defined as a continuous normal-voltage background without abundant discharges. The N20-potentials were reported as absent (bilaterally) or present (bilaterally or unilaterally).
Results
Both EEG and SSEP were performed in 161 patients. EEG was performed before SSEP in 60%. A benign EEG was seen in 29 patients and 100% (CI 88-100%) had present N20-potentials. For the 69 patients with a malignant EEG and the 63 patients with a highly malignant EEG, 67% (CI 55-77%) and 44% (CI 33-57%) had present N20-potentials, respectively.
Conclusions
All patients with a benign EEG had present N20-potentials, suggesting that SSEP may be omitted in these patients to save resources. SSEP is useful in patients with a malignant or highly malignant EEG since these patterns are associated with both present and absent N20-potentials.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:17-21
Fredland A, Backman S, Westhall E
Resuscitation: 29 Sep 2019; 143:17-21 | PMID: 31394155
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Impact:
Abstract

Association of diastolic blood pressure with survival during paediatric cardiopulmonary resuscitation.

O\'Brien CE, Santos PT, Reyes M, Adams S, ... Koehler RC, Shaffner DH
Aim
To examine the relationship between survival and diastolic blood pressure (DBP) throughout resuscitation from paediatric asphyxial cardiac arrest.
Methods
Retrospective, secondary analysis of 200 swine resuscitations. Swine underwent asphyxial cardiac arrest and were resuscitated with predefined periods of basic and advanced life support (BLS and ALS, respectively). DBP was recorded every 30 s. Survival was defined as 20-min sustained return of spontaneous circulation (ROSC).
Results
During BLS, DBP peaked between 1-3 min and was greater in survivors (20.0 [11.3, 33.3] mmHg) than in non-survivors (5.0 [1.0, 10.0] mmHg; p < 0.001). After this transient increase, the DBP in survivors progressively decreased but remained greater than that of non-survivors after 10 min of resuscitation (9.0 [6.0, 13.8] versus 3.0 [1.0, 6.8] mmHg; p < 0.001). During ALS, the magnitude of DBP change after the first adrenaline (epinephrine) administration was greater in survivors (22.0 [16.5, 36.5] mmHg) than in non-survivors (6.0 [2.0, 11.0] mmHg; p < 0.001). Survival rate was greater when DBP improved by ≥26 mmHg after the first dose of adrenaline (20/21; 95%) than when DBP improved by ≤10 mmHg (1/99; 1%). The magnitude of DBP change after the first adrenaline administration correlated with the timetoROSC (r = -0.54; p < 0.001).
Conclusions
Survival after asphyxial cardiac arrest is associated with a higher DBP throughout resuscitation, but the difference between survivors and non-survivors was reduced after prolonged BLS. During ALS, response to adrenaline administration correlates with survival and time to ROSC. If confirmed clinically, these findings may be useful for titrating adrenaline during resuscitation and prognosticating likelihood of ROSC. Institutional Protocol Numbers: SW14M223 and SW17M101.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:50-56
O'Brien CE, Santos PT, Reyes M, Adams S, ... Koehler RC, Shaffner DH
Resuscitation: 29 Sep 2019; 143:50-56 | PMID: 31390531
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Impact:
Abstract

The performance of a new shock advisory algorithm to reduce interruptions during CPR.

Hu Y, Tang H, Liu C, Jing D, ... Zhang G, Xu J
Objective
To explore a new algorithm and strategy for rhythm analysis during chest compressions (CCs), and to improve the efficiency of cardiopulmonary resuscitation (CPR) by minimizing interruptions.
Methods
The clinical data and ECG of patients with sudden cardiac arrest (CA) from three hospitals in China were collected with Philips MRx monitor/defibrillators. The length of each analyzed ECG segment was 23 s, the first 11.5 s was selected to contain CPR compressions, the next 5 s had no compressions, and the last 6.5 s had no requirement. Three experienced emergency doctors annotated the ECG segments without compression artifacts. A two-step analysis through CPR (ATC) algorithm was applied to the selected data. The first step was analysis during chest compressions. If a shockable rhythm was not detected, compression-free analysis followed. The results of the ATC algorithm were compared with the annotations by the physicians, to determine the sensitivity and specificity of the algorithm.
Results
In total 166 CA patients were included with 100 out-of-hospital cardiac arrest (OHCA) patients and 66 in-hospital cardiac arrest (IHCA) patients. A total of 1578 ECG segments were analyzed, including 115 (7.3%) shockable rhythms, 1278 (81.0%) non-shockable rhythms, and 185 (11.7%) intermediate/unknown rhythms. The specificity of all non-shockable rhythms was 99.8% at the end of chest compressions, and 99.5% after analysis without compression artifact. 70.5% of ventricular fibrillation (VF) rhythms were detected by the end of chest compressions. After the CC-free analysis, 93.6% of VF was identified.
Conclusion
The ATC algorithm achieved sensitivity of 93.6% and specificity of 99.5% after the two-step analysis, and 70.5% of the patients with shockable rhythms did not require CC-free analysis. Such an approach has the potential to substantially reduce CC interruptions when identifying shockable rhythms.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:1-9
Hu Y, Tang H, Liu C, Jing D, ... Zhang G, Xu J
Resuscitation: 29 Sep 2019; 143:1-9 | PMID: 31377393
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Impact:
Abstract

Novel technologies for heart rate assessment during neonatal resuscitation at birth - A systematic review.

Johnson PA, Cheung PY, Lee TF, O\'Reilly M, Schmölzer GM
Background
6.5-9 million newborns worldwide require resuscitation at birth annually. During neonatal resuscitation, inaccurate or slow heart rate (HR) assessments may significantly increase risk of infant mortality or morbidity. Therefore fast, accurate, and effective HR assessment tools are critical for neonatal resuscitation.
Objective
To systematically review the literature about accuracy, latency, and efficacy of technologies for HR assessment during neonatal resuscitation.
Methods
Adhering to PRISMA guidelines, PubMed, EMBASE, and Google Scholar databases were systematically searched to identify studies related to technologies for HR assessment, which could be used to guide neonatal resuscitation.
Results
Forty-six studies evaluating HR assessment technologies for neonatal resuscitation were identified. In total, 16 studies (3/16 randomized trials and 13/16 observational studies) compared two or more HR assessment technologies to measure accuracy, latency, and efficacy. Of the trials, 1/3 had a low risk of bias while 2/3 had high risks. All observational studies had high risks of bias. Most studies considered infants not requiring resuscitation, constituting indirect evidence and lower certainty in the context of neonatal resuscitation. Two trials reported faster times to HR assessment using electrocardiogram with a mean(SD) 66(20) versus 114(39) s and a median(IQR) 24(19-39) versus 48(36-69) s (both p < 0.001), compared to pulse oximetry.
Conclusion
While electrocardiography is faster to assess HR at birth and more reliable to detect HR changes compared to other recommended technologies, practice should not exclusively rely on ECG. While novel technologies could support HR assessment, no studies validate their clinical efficacy during neonatal resuscitation.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:196-207
Johnson PA, Cheung PY, Lee TF, O'Reilly M, Schmölzer GM
Resuscitation: 29 Sep 2019; 143:196-207 | PMID: 31330200
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Impact:
Abstract

Out-of-hospital cardiac arrest in patients with psychiatric disorders - Characteristics and outcomes.

Barcella CA, Mohr GH, Kragholm K, Blanche P, ... Gislason GH, Søndergaard KB
Aims
To investigate whether the recent improvements in pre-hospital cardiac arrest-management and survival following out-of-hospital cardiac arrest (OHCA) also apply to OHCA patients with psychiatric disorders.
Methods
We identified all adult Danish patients with OHCA of presumed cardiac cause, 2001-2015. Psychiatric disorders were defined by hospital diagnoses up to 10 years before OHCA and analyzed as one group as well as divided into five subgroups (schizophrenia-spectrum disorders, bipolar disorder, depression, substance-induced mental disorders, other psychiatric disorders). Association between psychiatric disorders and pre-hospital OHCA-characteristics and 30-day survival were assessed by multiple logistic regression.
Results
Of 27,523 OHCA-patients, 4772 (17.3%) had a psychiatric diagnosis. Patients with psychiatric disorders had lower odds of 30-day survival (0.37 95% confidence interval 0.32-0.43) compared with other OHCA-patients. Likewise, they had lower odds of witnessed status (0.75 CI 0.70-0.80), bystander cardiopulmonary resuscitation (CPR) (0.77 CI 0.72-0.83), shockable heart rhythm (0.37 95% CI, 0.33-0.40), and return of spontaneous circulation (ROSC) at hospital arrival (0.66 CI 0.59-0.72). Similar results were seen in all five psychiatric subgroups. The difference in 30-day survival between patients with and without psychiatric disorders increased in recent years: from 8.4% (CI 7.0-10.0%) in 2006 to 13.9% (CI 12.4-15.4%) in 2015 and from 7.0% (4.3-10.8%) in 2006 to 7.0% (CI 4.5-9.7%) in 2015, respectively.
Conclusion
Patients with psychiatric disorders have lower survival following OHCA compared to non-psychiatric patients and the gap between the two groups has widened over time.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 29 Sep 2019; 143:180-188
Barcella CA, Mohr GH, Kragholm K, Blanche P, ... Gislason GH, Søndergaard KB
Resuscitation: 29 Sep 2019; 143:180-188 | PMID: 31325557
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Impact:
Abstract

Code blue pit crew model: A novel approach to in-hospital cardiac arrest resuscitation.

Spitzer CR, Evans K, Buehler J, Ali NA, Besecker BY
Background
Mortality from in-hospital cardiac arrests remains a large problem world-wide. In an effort to improve in-hospital cardiac arrest mortality, there is a renewed focus on team training and operations. Here, we describe the implementation of a \"pit crew\" model to provide in-hospital resuscitation care.
Methods
In order to improve our institution\'s code team organization, we implemented a pit crew resuscitation model. The model was introduced through computer-based modules and lectures and was reemphasized at our institution-based ACLS training and mock code events. To assess the effect of our model, we reviewed pre- and post-pit crew implementation data from five sources: defibrillator downloads, a centralized hospital database, mock codes, expert-led debriefings, and confidential surveys. Data with continuous variables and normal distribution were analyzed using a standard two-sample t-test. For yes/no categorical data either a Z-test for difference between proportions or Chi-square test was used.
Results
There were statistically significant improvements in compression rates post-intervention (mean rate 133.5 pre vs. 127.9 post, two-tailed, p = 0.02) and in adequate team communication (33% pre vs. 100% post; p = 0.05). There were also trends toward a reduction in the number of shockable rhythms that were not defibrillated (32.7% pre vs. 18.4% post), average time to shock (mean 1.96 min pre vs. 1.69 min post), and overall survival to discharge (31% pre vs. 37% post), though these did not reach statistical significance.
Conclusion
Implementation of an in-hospital, pit crew resuscitation model is feasible and can improve both code team communication as well as key ACLS metrics.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:158-164
Spitzer CR, Evans K, Buehler J, Ali NA, Besecker BY
Resuscitation: 29 Sep 2019; 143:158-164 | PMID: 31299222
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Impact:
Abstract

Intraosseous needles in pediatric cadavers: Rate of malposition.

Maxien D, Wirth S, Peschel O, Sterzik A, ... Reiser MF, Mück FG
Aim of the study
Intraosseous vascular access is a commonly conducted procedure especially in pediatric resuscitation. Very high success rates for intraosseous (IO) devices are reported. Aim of the study was to describe the rates of malposition of intraosseous needles (ION) in pediatric cadavers via post-mortem computed tomography (PMCT).
Methods
212 consecutive pediatric cadavers underwent PMCT, of which 38 cadavers had visible ION and were included in the study. They were divided into two subgroups depending on their age (n = 22 infant cadavers (age <1 year) and n = 16 child cadavers (age ≥1 year)). Two independent readers evaluated the number and position of ION.
Results
In 22 infant cadavers 34 ION were found. Malposition of at least one ION was visible in 14 subjects (64%), among which 7 cadavers (32%) even had no correctly placed ION, thus being without established vascular access. Overall, 16 of the 34 used ION devices (47%) were in malposition. 23 ION were found in 16 child cadavers. In 8 subjects (50%) at least one ION was malpositioned, among which 3 cadavers (19%) had no correctly placed ION, resulting in a complete absence of vascular access. Overall, 9 of the 23 ION devices (39%) were malpositioned.
Conclusion
Our study showed relatively high malposition rates for ION devices in pediatric cadavers which was not to be assumed regarding the success rates of 80% and higher in previous literature. This should be clarified by further studies in living patients.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Sep 2019; 145:1-7
Maxien D, Wirth S, Peschel O, Sterzik A, ... Reiser MF, Mück FG
Resuscitation: 30 Sep 2019; 145:1-7 | PMID: 31585187
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Impact:
Abstract

Short and long-term survival following an in-hospital cardiac arrest in a regional hospital cohort.

Doherty Z, Fletcher J, Fuzzard K, Kippen R, Knott C, O\'Sullivan B
Introduction
Evidence about the immediate survival from in-hospital cardiac arrest (IHCA) is well established, however, beyond discharge there is very little describing the long-term outcomes of these patients. Of the few existing studies, all have been conducted in metropolitan centres. Therefore, this study describes survival from IHCA in both the short and long-term in a large regional hospital cohort.
Method
A retrospective cohort study was conducted including all adult patients who suffered an IHCA between 1 February 2000 and 31 December 2017 in a large regional (non-metropolitan) hospital in Victoria, Australia. Characteristics of the arrest and patient were sourced from a prospectively collected database that captures all of the arrests occurring in the hospital. Mortality data after discharge were sourced from the state death registry, censored on 31 January 2018.
Results
A total of 629 patients were included in the study. Of these, 357 (57%) survived the event, and 213 (34%) survived to discharge. At one-year post-arrest 27% of the original cohort were still alive. The age of the patient, arrest rhythm, location and duration of resuscitation were all significantly associated with long-term survival.
Conclusion
Both short and long-term survival following an IHCA in a regional hospital are similar to previously described rates in metropolitan hospitals. Further research is required on the post-discharge correlates of long-term survival.

Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:134-141
Doherty Z, Fletcher J, Fuzzard K, Kippen R, Knott C, O'Sullivan B
Resuscitation: 29 Sep 2019; 143:134-141 | PMID: 31470101
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Impact:
Abstract

Coronary angiography and percutaneous coronary intervention in cardiac arrest survivors with non-shockable rhythms and no STEMI: A systematic review.

Harhash AA, Huang JJ, Howe CL, Hsu CH, Kern KB
Background
Emergency coronary angiography (CAG) and percutaneous coronary intervention (PCI) are thought to improve outcomes in cardiac arrest (CA) survivors with ST segment elevation myocardial infarction (STEMI) and those without STEMI but likely cardiac etiology (shockable rhythms). However, the role of CAG ± PCI in OHCA survivors with non-shockable rhythms and no STEMI post-resuscitation remains unclear.
Methods
We searched Ovid/MEDLINE, Embase, Scopus, the Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials.gov from inception to January 2019. Two reviewers independently screened titles and abstracts of all records retrieved in the database searches and full texts of all articles selected in the title/abstract screen, with disagreements resolved by consensus. Risk of bias was assessed using the Strobe checklist.
Results
Fourteen out of 1174 articles met criteria for full review. Only two studies including 152 patients with confirmed non-shockable rhythms and no STEMI post resuscitation met all criteria and were analyzed. One study reported 97 patients (of 1497 in the registry) underwent CAG and 24.7% underwent PCI. The second study reported 55 patients (of 545 in the cohort) underwent CAG and acute coronary lesions were found in 16.4% but only 9.1% underwent PCI and no survival benefit was demonstrated.
Conclusions
There is limited data describing the prevalence of CAD and the role of CAG ± PCI in CA survivors with non-shockable rhythms and no STEMI post-resuscitation. In the two studies meeting criteria for this systematic review, 16% of patients with non-shockable rhythms underwent PCI.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:106-113
Harhash AA, Huang JJ, Howe CL, Hsu CH, Kern KB
Resuscitation: 29 Sep 2019; 143:106-113 | PMID: 31442472
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Impact:
Abstract

Shorter defibrillation interval promotes successful defibrillation and resuscitation outcomes.

Roh YI, Jung WJ, Hwang SO, Kim S, ... Lee JS, Cha KC
Aim
Current cardiopulmonary resuscitation guidelines recommend performing defibrillation every 2 min during resuscitation. This study aimed to compare the rate of successful defibrillation using 1- and 2-min defibrillation intervals.
Methods
Twenty-six pigs were randomly assigned to 1- or 2-min interval groups. After inducing ventricular fibrillation (VF), we observed pigs for 2 min. Thereafter, basic life support was initiated with a 30:2 compression-to-ventilation ratio for 8 min. Defibrillation was performed with an energy of 2 J/kg at 10 min after VF and was repeated every 1 or 2 min according to randomization. Advanced cardiac life support, including continuous chest compression with ventilation every 6 s and intravenous injection of 1 mg epinephrine every 3 min, was performed until the return of spontaneous circulation (ROSC) or until 20 min after VF induction. Haemodynamic parameters and baseline arterial blood gas profiles were compared between groups. ROSC, 24 -h survival, and the neurologic deficit score (NDS) were evaluated at 24 h.
Results
Haemodynamic parameters during resuscitation and baseline arterial blood gas profiles did not differ between groups. ROSC was more frequently observed in the 1-min interval group (p = 0.047). Time to ROSC was not different between groups (p = 0.054). The 24 -h survival was higher (p = 0.047) and NDS at 24 h was lower (92 ± 175) in the 1-min interval group than in the 2-min interval group (272 ± 190) (p = 0.028).
Conclusions
Defibrillation success and resuscitation outcomes were superior when using a 1-min defibrillation interval in animal models of cardiac arrest.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:100-105
Roh YI, Jung WJ, Hwang SO, Kim S, ... Lee JS, Cha KC
Resuscitation: 29 Sep 2019; 143:100-105 | PMID: 31442471
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Impact:
Abstract

Trends in survival from out-of-hospital cardiac arrests defibrillated by paramedics, first responders and bystanders.

Nehme Z, Andrew E, Bernard S, Haskins B, Smith K
Background
Although survival from out-of-hospital cardiac arrest (OHCA) is increasing, little is known about the long-term trends in survival for patients defibrillated by first responders and bystanders.
Methods
Between 2000 and 2017, we included adult non-traumatic OHCA with an initial shockable rhythm from the Victorian Ambulance Cardiac Arrest Registry. Adjusted logistic regression analyses were used to assess trends in survival to hospital discharge according to whether the patient was initially shocked by paramedics, first responders or bystanders.
Results
Of the 10,451 initial shockable arrests, 796 (7.6%) and 526 (5.0%) were initially shocked by first responders and bystanders, respectively. Between 2000-02 and 2015-17, the proportion of cases initially shocked by first responders and bystanders increased from 3.8% to 8.2% and from 2.0% to 11.2%, respectively. Over the same period, survival to hospital discharge increased from 11.6% to 28.8% for cases initially shocked by paramedics, from 10.5% to 37.8% for cases initially shocked by first responders, and from 6.7% to 55.5% for cases initially shocked by bystanders (p trend <0.001 for all). In the adjusted analyses, patients initially shocked by first responders (AOR 1.40, 95% CI: 1.18, 1.67; p < 0.001) and bystanders (AOR 2.11, 95% CI: 1.72, 2.59; p < 0.001) were more likely to survive to hospital discharge than those initially shocked by paramedics. The odds of survival increased year-on-year by 8.1% for patients shocked by paramedics (p < 0.001), 6.1% for patients shocked by first responders (p = 0.004), and 11.8% for patients shocked by bystanders (p < 0.001).
Conclusion
OHCA patients initially defibrillated by bystanders yielded the largest improvements in survival over time.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:85-91
Nehme Z, Andrew E, Bernard S, Haskins B, Smith K
Resuscitation: 29 Sep 2019; 143:85-91 | PMID: 31430512
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Impact:
Abstract

Out of hospital cardiac arrest outcomes: Impact of weekdays vs weekends admission on survival to hospital discharge.

El Asmar A, Dakessian A, Bachir R, El Sayed M
Background
Cardiac arrests are a leading cause of mortality with survival of only 12%. In the United States, cardiac arrests were significantly more likely to occur on Saturdays. Hospitals experience a decrease in staffing on weekends. This study aims to assess the relationship between weekend vs weekday admission and outcomes of patients presenting with out of hospital cardiac arrests (OHCA) in the United States.
Methods
This retrospective study utilized the 2014 US National Emergency Department Sample (NEDS) database. Patients who sustained out of hospital cardiac arrests were included using ICD-9-CM codes. Descriptive analysis was conducted, followed by bivariate analysis to compare the collected variables by admission day. Multivariate analysis was done to assess the impact of weekday vs weekend admission on survival of cardiac arrests patients after adjusting for confounders.
Results
A total of 145,774 patients with cardiac arrest were included in this study. Mean age was 65.9 years with male predominance of 61.8%. Almost 71% of cardiac arrests took place on a weekday. As an overall outcome, only 5.7% patients survived to hospital discharge. After adjusting for significant confounders, patients presenting on weekends were less likely to survive compared to those admitted on weekdays (OR = 0.833, 95% CI: 0.727-0.954).
Conclusion
In this study, patients with OHCA admitted to the ED on weekends had slightly lower survival compared to those admitted on weekdays. Modifiable factors should be identified in future studies to reduce outcome discrepancies and improve survival in this patient population.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:29-34
El Asmar A, Dakessian A, Bachir R, El Sayed M
Resuscitation: 29 Sep 2019; 143:29-34 | PMID: 31401136
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Impact:
Abstract

Neurophysiology and neuroimaging accurately predict poor neurological outcome within 24 hours after cardiac arrest: The ProNeCA prospective multicentre prognostication study.

Scarpino M, Lolli F, Lanzo G, Carrai R, ... Grippo A,
Aims
To investigate the ability of 30-min electroencephalogram (EEG), short-latency somatosensory evoked potentials (SEPs) and brain computed tomography (CT) to predict poor neurological outcome (persistent vegetative state or death) at 6 months in comatose survivors of cardiac arrest within 24 h from the event.
Methods
Prospective multicentre prognostication study in seven hospitals. SEPs were graded according to the presence and amplitude of their cortical responses, EEG patterns were classified according to the American Clinical Neurophysiology Society terminology and brain oedema on brain CT was measured as grey/white matter (GM/WM) density ratio. Sensitivity for poor outcome prediction at 100% specificity was calculated for the three tests individually and in combination. None of the patients underwent withdrawal of life-sustaining treatments before the index event occurred.
Results
A total of 346/396 patients were included in the analysis. At 6 months, 223(64%) had poor neurological outcome; of these, 68 were alive in PVS. Bilaterally absent/absent-pathological amplitude cortical SEP patterns, a GM/WM ratio<1.21 on brain CT and isoelectric/burst-suppression EEG patterns predicted poor outcome with 100% specificity and sensitivities of 57.4%, 48.8% and 34.5%, respectively. At least one of these unfavourable patterns was present in 166/223 patients (74.4% sensitivity). Two unfavourable patterns were simultaneously present in 111/223 patients (49.7% sensitivity), and three patterns in 38/223 patients (17% sensitivity).
Conclusions
In comatose resuscitated patients, a multimodal approach based on results of SEPs, EEG and brain CT accurately predicts poor neurological outcome at 6 months within the first 24 h after cardiac arrest.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:115-123
Scarpino M, Lolli F, Lanzo G, Carrai R, ... Grippo A,
Resuscitation: 29 Sep 2019; 143:115-123 | PMID: 31400398
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Impact:
Abstract

Impact of electronic cardiac (ECG) monitoring on delivery room resuscitation and neonatal outcomes.

Shah BA, Wlodaver AG, Escobedo MB, Ahmed ST, ... Anderson MP, Szyld EG
Aim
In 2016, the neonatal resuscitation guidelines suggested electronic cardiac (ECG) monitoring to assess heart rate for an infant receiving positive pressure ventilation immediately after birth. Our aim was to study the impact of ECG monitoring on delivery room resuscitation interventions and neonatal outcomes.
Methods
Observational cohort study compared maternal, perinatal and infant characteristics, before (retrospective cohort, calendar year 2015) and after (prospective cohort, calendar year 2017) implementation of ECG monitoring in the delivery room. Association of ECG monitoring with delivery room resuscitation practice interventions and neonatal outcomes was assessed using unadjusted and adjusted multivariable regression analyses.
Results
Of 632 newly born infants who received positive pressure ventilation in the delivery room, ECG monitoring was performed in 369 (the prospective cohort) compared with no ECG monitoring in 263 (the retrospective cohort). Compared to neonates in the retrospective cohort, neonates with ECG monitoring had a significantly lower endotracheal intubation rate (36% vs 48%, P < .005) in the delivery room and higher 5-min Apgar scores (7 [5-8] vs 6 [5-8], P < .05). There was no difference in mortality (31 [8%] vs 23 [9%]), but infants who received ECG monitoring had increased odds of receiving chest compressions with an adjusted odds ratio of 3.6 (95% confidence interval: 1.4-9.5).
Conclusion
Introduction of ECG monitoring in the delivery room was associated with fewer endotracheal intubations, and an increase use of chest compressions with no difference in mortality.

Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:10-16
Shah BA, Wlodaver AG, Escobedo MB, Ahmed ST, ... Anderson MP, Szyld EG
Resuscitation: 29 Sep 2019; 143:10-16 | PMID: 31394156
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Impact:
Abstract

Factors associated with return to work among survivors of out-of-hospital cardiac arrest.

Kearney J, Dyson K, Andrew E, Bernard S, Smith K
Background
Although out-of-hospital cardiac arrest (OHCA) is a major cause of global mortality, survival rates have increased over the last decade. As such, there is an increasing need to explore long-term functional outcomes of survivors, such as return to work (RTW).
Methodology
We analysed baseline and 12-month follow-up data from the Victorian Ambulance Cardiac Arrest Registry for patients that arrested between 2010 and 2016 who were working prior to their arrest. We also conducted more detailed RTW interviews in a subset of OHCA survivors who arrested between July and September 2017. Factors associated with RTW were assessed using multivariable logistic regression analysis.
Results
A total of 884 previously working survivors were included in the analysis, 650 (73%) of whom RTW. Male sex (AOR 1.80; 95%CI: 1.10-2.94), arrests witnessed by emergency medical services (AOR 2.72; 95%CI: 1.50-9.25), discharge directly home from hospital (AOR 4.13; 95%CI: 2.38-7.18) and favourable 12-month health-related quality of life according to the EQ-5D were associated with RTW. Increasing age (AOR 0.97; 95%CI: 0.95-0.98), traumatic arrest aetiology (AOR 0.18; 95%CI: 0.04-0.77), and labour-intensive occupations (AOR 0.44; 95%CI: 0.29-0.66) were associated with decreased odds of RTW. Of the 23 OHCA survivors that participated in the more detailed RTW telephone-interview, 87% RTW. Flexible work hours or modified duties were offered to 74% of participants. Fatigue was the most frequently reported barrier to RTW.
Conclusion
This is the largest study to collectively examine factors associated with RTW among survivors of OHCA. Although larger qualitative studies are needed, our findings highlight which patients are at risk of not RTW and who may benefit from targeted rehabilitation strategies.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 16 Sep 2019; epub ahead of print
Kearney J, Dyson K, Andrew E, Bernard S, Smith K
Resuscitation: 16 Sep 2019; epub ahead of print | PMID: 31539607
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Impact:
Abstract

Optimal timing to measure optic nerve sheath diameter as a prognostic predictor in post-cardiac arrest patients treated with targeted temperature management.

Park JS, Cho Y, You Y, Min JH, ... Lee J, Lee IH
Aim
We evaluated the optimal timing of optic nerve sheath diameter (ONSD) measurement to predict neurologic outcome in post-cardiac arrest patients treated with target temperature management (TTM).
Methods
This was a prospective single-centre observational study from April 2018 to March 2019. Good outcome was defined as the Glasgow-Pittsburgh cerebral performance categories (CPC) 1 or 2, and poor outcome as a CPC between 3 and 5. ONSD was measured initially after return of spontaneous circulation (ROSC) (ONSD), at 24 h (ONSD), 48 h (ONSD), and 72 h (ONSD) using ultrasonography. The receiver operating characteristic (ROC) curves and DeLong method were used to compare the values for predicting neurologic outcomes.
Results
Out of the 36 patients enrolled, 18 had a good outcome. ONSD, ONSD, and ONSD were higher in the poor outcome group. The area under ROC curve of ONSD was 0.91 (95% confidence interval 0.77-0.98) in predicting poor neurologic outcomes. With a cut off value of 4.90 mm, ONSD had a sensitivity of 83.3% and a specificity of 94.4% in predicting poor neurologic outcomes.
Conclusion
Our findings demonstrate ONSD as a valuable tool to predict the neurologic outcome in post-cardiac arrest patients treated with TTM. Therefore, we recommend performing ONSD measurement using ultrasonography at 24 h after ROSC, rather than immediately after ROSC, to predict neurologic outcome in post-cardiac arrest patients treated with TTM.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:173-179
Park JS, Cho Y, You Y, Min JH, ... Lee J, Lee IH
Resuscitation: 29 Sep 2019; 143:173-179 | PMID: 31306717
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Impact:
Abstract

Modulating effects of immediate neuroprognosis on early coronary angiography and targeted temperature management following out-of-hospital cardiac arrest: A retrospective cohort study.

Wang CH, Tsai MS, Chang WT, Yu PH, ... Huang CH, Chen WJ
Aim
The simplified cardiac arrest hospital prognosis (sCAHP) score is a validated tool for predicting neurological outcomes after out-of-hospital cardiac arrest (OHCA). We used the sCAHP score to evaluate whether the effects of early coronary angiography (CAG) and targeted temperature management (TTM) for OHCA were modulated by immediate neuroprognosis.
Methods
This was a single-centre retrospective observational study. Consecutive OHCA patients were screened between 2011 and 2017. Multivariate logistic regression analysis and generalised additive models (GAMs) were used to examine the associations between independent variables and outcomes. Early CAG was defined as CAG performed within 24 h after return of spontaneous circulation (ROSC).
Results
A total of 412 patients were included in the study, and 94 (22.8%) patients had neurologically intact survival. The GAM plot identified a sCAHP score of 185 as the cut-off point to differentiate high-risk (sCAHP score ≧185) from low-risk (sCAHP score <185) patients. Regression models indicated that early CAG was significantly associated with favourable neurological [odds ratio (OR) 4.43, 95% confidence interval (CI) 2.28-8.60, p < 0.001] and survival outcomes (OR 3.47, 95% CI 1.93-6.25, p < 0.001), independent of the sCAHP score. Although TTM was associated with favourable neurological outcome only in low-risk patients (OR 2.13, 95% CI 1.10-4.13, p = 0.02), TTM was associated with improved survival for all patients (OR 2.66, 95% CI 1.54-4.59, p < 0.001), independent of the sCAHP score.
Conclusions
Early CAG and TTM should be considered for all OHCA patients as suggested by guidelines, irrespective of the immediately predicted neuroprognosis after ROSC.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:42-49
Wang CH, Tsai MS, Chang WT, Yu PH, ... Huang CH, Chen WJ
Resuscitation: 29 Sep 2019; 143:42-49 | PMID: 31422106
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Impact:
Abstract

Ethnic disparities in the incidence and outcome from out-of-hospital cardiac arrest: A New Zealand observational study.

Dicker B, Todd V, Tunnage B, Swain A, ... Laufale C, Howie G
Background
New Zealand (NZ) has an ethnically diverse population. International studies have demonstrated significant differences in health equity by ethnicity; however, there is limited evidence in the context of out-of-hospital cardiac arrest in NZ. We investigated whether heath disparities in incidence and outcome of out-of-hospital cardiac arrest exist between NZ ethnic groups.
Method
A retrospective observational study was conducted using NZ cardiac arrest registry data for a 2-year period. Ethnic cohorts investigated were the indigenous Māori population, Pacific Peoples and European/Others. Incidence rates, population characteristics and outcomes (Return of Spontaneous Circulation sustained to hospital handover and thirty-day survival) were compared.
Results
Age-adjusted incidence rates per 100,000 person-years were higher in Māori (144.4) and Pacific Peoples (113.5) compared to European/Others (93.8). Return of spontaneous circulation sustained to hospital handover was significantly lower in Māori (adjusted OR 0.74, 95% CI 0.64-0.87, p < 0.001). Survival to thirty-days was lower for both Māori (adjusted OR 0.61, 95%CI 0.48-0.78, p < 0.001) and Pacific Peoples (adjusted OR 0.52, 95% CI 0.37-0.72, p < 0.001). A higher proportion of events occurred in all age groups below 65 years old in Māori and Pacific Peoples (p < 0.001), and a higher proportion of events occurred among women in Māori and Pacific Peoples (p < 0.001).
Conclusions
There are significant differences in health equity by ethnicity. Both Māori and Pacific Peoples have higher incidence of out-of-hospital cardiac arrest and at a younger age. Māori and Pacific Peoples have lower rates of survival to thirty-days. Our results provide impetus for targeted health strategies for at-risk ethnic populations.

Copyright © 2019 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 30 Sep 2019; epub ahead of print
Dicker B, Todd V, Tunnage B, Swain A, ... Laufale C, Howie G
Resuscitation: 30 Sep 2019; epub ahead of print | PMID: 31585186
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Impact:
Abstract

The usefulness of neuron-specific enolase in cerebrospinal fluid to predict neurological prognosis in cardiac arrest survivors who underwent target temperature management: A prospective observational study.

You Y, Park JS, Min J, Yoo I, ... Lee D, Youn CS
Aim
Cerebrospinal fluid (CSF) neuron-specific enolase (NSE) levels increase ahead of serum NSE levels in patients with severe brain injury. We examined the prognostic performance between CSF NSE and serum NSE levels in out-of-cardiac arrest (OHCA) survivors who had undergone target temperature management (TTM).
Methods
This single-centre prospective observational study included OHCA patients who had undergone TTM. NSE levels were assessed in blood and CSF samples obtained immediately (Day 0), and at 24 h (Day 1), 48 h (Day 2), and 72 h (Day 3) after return of spontaneous circulation (ROSC). The primary outcome was the 6-month neurological outcome.
Results
We enrolled 34 patients (males, 24; 70.6%), and 16 (47.1%) had a poor neurologic outcome. CSF NSE and serum NSE values were significantly higher in the poor outcome group compared to the good outcome group at each time point, except for serum Day 0. CSF NSE and serum NSE had an area under curve (AUC) of 0.819-0.972 and 0.648-0.920, respectively. CSF NSE prognostic performances were significantly higher than serum NSE levels at Day 1 and showed excellent AUC values (0.969; 95% confidence interval [CI] 0.844-0.999) and high sensitivity (93.8%; 95% CI 69.8-99.8) at 100% specificity.
Conclusion
We found CSF NSE values were highly predictive and sensitive markers of 6-month poor neurological outcome in OHCA survivors treated with TTM at Day 1 after ROSC. Therefore, CSF NSE levels at day 1 after ROSC can be a useful early prognosticator in OHCA survivors.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Sep 2019; epub ahead of print
You Y, Park JS, Min J, Yoo I, ... Lee D, Youn CS
Resuscitation: 30 Sep 2019; epub ahead of print | PMID: 31585184
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Impact:
Abstract

Cost-effectiveness of extracorporeal cardiopulmonary resuscitation after in-hospital cardiac arrest: A Markov decision model.

Gravesteijn BY, Schluep M, Voormolen DC, van der Burgh AC, ... Hoeks SE, Endeman H
Background
This study aimed to estimate the cost-effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital cardiac arrest treatment.
Methods
A decision tree and Markov model were constructed based on current literature. The model was conditional on age, Charlson Comorbidity Index (CCI) and sex. Three treatment strategies were considered: ECPR for patients with an Age-Combined Charlson Comorbidity Index (ACCI) below different thresholds (2-4), ECPR for everyone (EALL), and ECPR for no one (NE). Cost-effectiveness was assessed with costs per quality-of-life adjusted life years (QALY).
Measurements and main results
Treating eligible patients with an ACCI below 2 points costs 8394 (95% CI: 4922-14,911) euro per extra QALY per IHCA patient; treating eligible patients with an ACCI below 3 costs 8825 (95% CI: 5192-15,777) euro per extra QALY per IHCA patient; treating eligible patients with an ACCI below 4 costs 9311 (95% CI: 5478-16,690) euro per extra QALY per IHCA patient; treating every eligible patient with ECPR costs 10,818 (95% CI: 6357-19,400) euro per extra QALY per IHCA patient. For WTP thresholds of 0-9500 euro, NE has the highest probability of being the most cost-effective strategy. For WTP thresholds between 9500 and 12,500, treating eligible patients with an ACCI below 4 has the highest probability of being the most cost-effective strategy. For WTP thresholds of 12,500 or higher, EALL was found to have the highest probability of being the most cost-effective strategy.
Conclusions
Given that conventional WTP thresholds in Europe and North-America lie between 50,000-100,000 euro or U.S. dollars, ECPR can be considered a cost-effective treatment after in-hospital cardiac arrest from a healthcare perspective. More research is necessary to validate the effectiveness of ECPR, with a focus on the long-term effects of complications of ECPR.

Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:150-157
Gravesteijn BY, Schluep M, Voormolen DC, van der Burgh AC, ... Hoeks SE, Endeman H
Resuscitation: 29 Sep 2019; 143:150-157 | PMID: 31473264
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Impact:
Abstract

Long-term survival in out-of-hospital cardiac arrest patients treated with targeted temperature control at 33 °C or 36 °C: A national registry study.

Abazi L, Awad A, Nordberg P, Jonsson M, ... Ringh M, Forsberg S
Aim
There are limited data on long-term outcome in out-of-hospital cardiac arrest patients following the treatment shift of target temperature management (TTM) from 33 °C to 36 °C outside the controlled settings of randomised trials. The aim of this study was to evaluate the adherence to TTM guidelines after the publication of the TTM trial and if the change in temperature level influence six-month survival.
Methods
OHCA patients admitted to intensive care units (ICU) and recorded in the Swedish Intensive Care Registry (January 2010-March 2016) were included. Each ICU in Sweden provided information on their TTM target (i.e. 33 °C [TTM33] or 36 °C [TTM36]) used and the date of shift to 36 °C. The primary outcome was six-months survival. Multivariate logistic regression and propensity score match was used to adjust for confounders.
Results
In total, 2899 OHCA patients from 69 ICUs were assessed; of those, 1038 patients were treated with TTM (TTM33, n = 755 and TTM36, n = 283). Patients receiving any TTM decreased during the study period from 70.5% to 54.5% (p for trend <0.001). There was no significant difference in six-month survival between the TTM33 (47.2%) and the TTM36 (47.3%) groups (adjusted OR 1.12 [0.80-1.56]. In the propensity score matched analysis the six-months survival was 52.7 vs 47.3 %, OR 1.29 [0.90-1.85]).
Conclusions
The proportion of patients receiving therapeutic hypothermia in Sweden has decreased significantly since the publication of the TTM-trial indicating lower adherence to guidelines. This was not associated with any significant difference in long term outcome.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:142-147
Abazi L, Awad A, Nordberg P, Jonsson M, ... Ringh M, Forsberg S
Resuscitation: 29 Sep 2019; 143:142-147 | PMID: 31470100
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Impact:
Abstract

Non-invasive continuous haemodynamic monitoring and response to intervention in haemodynamically unstable patients during rapid response team review.

Eyeington CT, Lloyd-Donald P, Chan MJ, Eastwood GM, ... Jones DA, Bellomo R
Introduction
During rapid response team (RRT) management of haemodynamic instability (HI), continuous non-invasive haemodynamic monitoring may provide supplemental physiological information.
Objectives
To continuously and non-invasively obtain the cardiac index (CI) and mean arterial pressure (MAP) in patients with HI at baseline and during RRT management using the ClearSightâ„¢ device.
Methods
We performed a prospective observational study in adult patients managed by the RRT for tachycardia or hypotension or both. We assessed changes from baseline in heart rate (HR), MAP, CI, stroke volume index (SVI) and systemic vascular resistance index (SVRI) (i) at 5-minutely intervals up to 20 min, and (ii) over the entire 20-min period. We analysed patients by RRT trigger (tachycardia/hypotension) and intervention (fluid bolus therapy [FBT]/ no FBT).
Results
We successfully recorded the CI in 47 of 50 (94%) patients. RRT reviews triggered by hypotension rather than tachycardia had a lower baseline HR (-45.4 bpm, p = <0.0001), MAP (-16.1 mmHg, p = 0.0007) and CI (1.0 L/min/m, p = 0.0025). Compared to baseline, in the tachycardia group, there was a small increase in MAP overall and at the 15-20 min time-block from 83.2 mmHg to 87.1 mmHg (+3.9 mmHg, p = 0.0066) and 85.5 mmHg (+2.3 mmHg, p = 0.0061), respectively. In those who received FBT, there was a statistically significant increase in MAP overall and at the 15-20 min time-block compared to baseline, from 70.1 mmHg to 73.5 mmHg (+3.4 mmHg, p = 0.0036) and 74.3 mmHg (+4.2 mmHg, p = 0.0037), respectively. However, there were no statistically significant changes in mean HR, CI, SVI, or SVRI when comparing baseline to the entire 20-min period or 5-min time-blocks within any group.
Conclusions
Continuous non-invasive measurement of haemodynamics during RRT management for HI was possible for 20 min. Patients with hypotension rather than tachycardia had lower baseline HR, MAP and CI values. There was a statistically significant but small increase in MAP at the 15-20 min time-block and overall, for both the tachycardia and FBT groups.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:124-133
Eyeington CT, Lloyd-Donald P, Chan MJ, Eastwood GM, ... Jones DA, Bellomo R
Resuscitation: 29 Sep 2019; 143:124-133 | PMID: 31446156
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Abstract

The frequency and nature of clinician identified medication-related rapid response system calls.

Levkovich BJ, Bingham G, Orosz J, Cooper DJJ, ... Dooley MJ, Jones DA
Aim
The contribution of adverse medication events to clinical deterioration is unknown. This study aimed to determine the frequency and nature of rapid response system (RRS) calls that clinicians perceived were medication-related using RRS quality arm data.
Methods
Analysis of routine data prospectively collected by clinicians responding to RRS calls in an Australian acute tertiary academic hospital.
Results
Between January 2013 and June 2017, 12,221 adult patients triggered the RRS for 25,906 medical emergency team (MET) and 512 code blue calls. Clinicians identified 433 medication-related RRS calls (1.6%) involving 406 patients (3.3%). These included 418 MET calls (1.3 medication-related MET calls per 1000 admissions) and 15 code blue calls (0.045 medication-related code blue calls per 1000 admissions). Medication-related calls occurred earlier in the admission (p = 0.002) and were more common for patients triggering multiple calls during the same admission (p < 0.001), compared to non-medication-related calls. Medication-related calls most commonly were triggered by low blood pressure (38.3%) and involved cardiovascular (43.0%) and nervous system medications (36.0%). Dose-related toxicity (n = 178) was the most frequent adverse medication event contributing to medication-related calls.
Conclusion
One in 30 patients triggering a RRS call experienced medication-related clinical deterioration, most often due to dose related toxicity of cardiovascular system medications. The perceived frequency and potential preventability of this medication-related harm suggest further research is required to increase recognition of medication-related RRS calls by responding clinicians and to reduce the incidence.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 10 Oct 2019; epub ahead of print
Levkovich BJ, Bingham G, Orosz J, Cooper DJJ, ... Dooley MJ, Jones DA
Resuscitation: 10 Oct 2019; epub ahead of print | PMID: 31610227
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Impact:
Abstract

Chest compression components (rate, depth, chest wall recoil and leaning): A scoping review.

Considine J, Gazmuri RJ, Perkins GD, Kudenchuk PJ, ... Escalante-Kanashiro R, Morley P
Aim
To understand whether the science to date has focused on single or multiple chest compression components and identify the evidence related to chest compression components to determine the need for a full systematic review.
Methods
This review was undertaken by members of the International Liaison Committee on Resuscitation and guided by a specific methodological framework and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). Studies were eligible for inclusion if they were peer-reviewed human studies that examined the effect of different chest compression depths or rates, or chest wall or leaning, on physiological or clinical outcomes. The databases searched were MEDLINE complete, Embase, and Cochrane.
Results
Twenty-two clinical studies were included in this review: five observational studies involving 879 patients examined both chest compression rate and depth; eight studies involving 14,285 patients examined chest compression rate only; seven studies involving 12001 patients examined chest compression depth only, and two studies involving 1848 patients examined chest wall recoil. No studies were identified that examined chest wall leaning. Three studies reported an inverse relationship between chest compression rate and depth.
Conclusion
This scoping review did not identify sufficient new evidence that would justify conducting new systematic reviews or reconsideration of current resuscitation guidelines. This scoping review does highlight significant gaps in the research evidence related to chest compression components, namely a lack of high-level evidence, paucity of studies of in-hospital cardiac arrest, and failure to account for the possibility of interactions between chest compression components.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 15 Sep 2019; epub ahead of print
Considine J, Gazmuri RJ, Perkins GD, Kudenchuk PJ, ... Escalante-Kanashiro R, Morley P
Resuscitation: 15 Sep 2019; epub ahead of print | PMID: 31536776
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Impact:
Abstract

Growth differentiation factor-15 predicts poor survival after cardiac arrest.

Richter B, Uray T, Krychtiuk KA, Schriefl C, ... Schwameis M, Speidl WS
Background
Early prognostication in post-cardiac arrest (CA) patients remains challenging and biomarkers have evolved as helpful tools in risk assessment. The stress-response cytokine growth differentiation factor-15 (GDF-15) is dramatically up-regulated during various kinds of tissue injury and predicts outcome in many pathological conditions. We aimed to assess the predictive value of circulating GDF-15 in post-CA patients.
Methods
This prospective observational study included 128 consecutive patients (median age 60.3 years, 75.8% male) with return of spontaneous circulation after in- or out-of-hospital CA who were treated at a tertiary university hospital. GDF-15 serum levels were determined at admission.
Results
A total of 52 patients (40.6%) died during the 6-month follow-up. Median GDF-15 levels were significantly lower in survivors (1601 ng/L (interquartile range: 1114-2983 ng/L) than in non-survivors (3172 ng/L (1927-8340 ng/L); p < 0.001). GDF-15 levels were also significantly lower in patients with favourable neurological 6-month outcome (cerebral performance category (CPC) 1-2) than in those with poor neurological outcome (CPC 3-5; p < 0.001). GDF-15 significantly predicted 6-month mortality in univariate Cox regression analysis (hazard ratio (HR) per 1-standard deviation increase 1.76 [95% confidence interval (CI) 1.35-2.31; p < 0.001] and remained significant after multivariable adjustment (HR 1.57 [95% CI 1.19-2.07; p = 0.001]). Subgroup analysis revealed that the association between GDF-15 and 6-month outcome was present both in patients with in- and out-of-hospital CA.
Conclusions
GDF-15 predicts poor survival and neurological outcome in post-CA patients. GDF-15 may reflect the extent of hypoxic injury to the brain and other organs and might help to improve early risk stratification after CA.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 29 Sep 2019; 143:22-28
Richter B, Uray T, Krychtiuk KA, Schriefl C, ... Schwameis M, Speidl WS
Resuscitation: 29 Sep 2019; 143:22-28 | PMID: 31394153
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Impact:
Abstract

Association between shockable rhythm conversion and outcomes in patients with out-of-hospital cardiac arrest and initial non-shockable rhythm, according to the cause of cardiac arrest.

Han KS, Lee SW, Lee EJ, Kwak MH, Kim SJ
Objective
Conversion to shockable rhythm from an initial non-shockable rhythm is associated with good neurologic prognoses in patients with out-of-hospital cardiac arrest (OHCA). We aimed to investigate whether conversion to shockable rhythm has an association with good neurologic outcomes, according to the etiology of cardiac arrest.
Methods
We conducted a nationwide, population-based, cohort study using the OHCA data from the Korea Centers for Disease Control and Prevention database in 2012-2016. We included patients with OHCA and an initial non-shockable rhythm. The primary outcome was good neurologic outcome at discharge, etiologies of arrest were categorized to medical, non-medical cause. We analyzed the effect of conversion to a shockable rhythm on outcome according to causes of cardiac arrest using multiple regression analysis.
Results
Of 114,628 patients with an initial non-shockable rhythm, 25,042 (21.8%) experienced conversion to a shockable rhythm; 83,437 (72.8%) had medical causes and 31,191(27.2%) had non-medical causes. In all patients with OHCA and initial non-shockable rhythm, adjusted odds ratio (OR) of conversion for good neurologic outcome was 2.051 (95% confidence interval [CI] 1.181-2.297). The medical cause group showed an adjusted OR 1.789 (95% CI 1.586-2.019) of conversion for good neurologic outcome. In non-medical cause group, the adjusted OR of conversion was 0.644 (95% CI 0.372-1.114).
Conclusion
Conversion to shockable rhythm had an association with good neurologic outcome in patients with OHCA with initial non-shockable rhythms, especially due to cardiac cause. However, rhythm conversion was not associated with better outcome in patients with non-medical causes.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Aug 2019; 142:144-152
Han KS, Lee SW, Lee EJ, Kwak MH, Kim SJ
Resuscitation: 30 Aug 2019; 142:144-152 | PMID: 31377392
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Impact:
Abstract

Frailty is associated with adverse outcome from in-hospital cardiopulmonary resuscitation.

Wharton C, King E, MacDuff A
Aim
To assess whether frailty was associated with cardio-pulmonary resuscitation (CPR) outcome in a UK setting.
Method
Retrospective review of prospectively collected data on in-hospital cardio-respiratory arrests between 1/1/17 and 31/12/17. Clinical Frailty Scale (CFS) scores were assigned from notes review, patients with CFS scores ≥6 signified moderate or greater frailty.
Results
There were 179 in-hospital cardiac arrest cases where the CFS could be calculated. The median age on admission was 74 (mean 71, range 27-102), 110 patients were male and 69 female. The initial rhythm was non-shockable in 64% of cases. In 49% of cases return of spontaneous circulation (ROSC) was achieved, 22% of the study population survived to hospital discharge. Moderate or greater frailty was present in 31.3% of patients. Return of spontaneous circulation (ROSC) was achieved in 56.1% of patients with a CFS score of 1-5 and 32.1% with scores 6-9 (p < 0.001). Survival to hospital discharge was also associated with frailty, being seen in 31.7% of CFS 1-5 patients but only in 1.8% of CFS 6-9 patients (p < 0.001). In multivariable analysis adjusting for age, presenting rhythm and admitting specialty the effect of frailty on survival to discharge remained significant (p = 0.044).
Conclusion
Patients with moderate or greater frailty as determined by CFS score are unlikely to survive to hospital discharge even if ROSC occurs following CPR. This should be considered when making resuscitation status and ceiling of care decisions in this patient group.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:208-211
Wharton C, King E, MacDuff A
Resuscitation: 29 Sep 2019; 143:208-211 | PMID: 31369792
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Impact:
Abstract

Prehospital advanced airway management for paediatric patients with out-of-hospital cardiac arrest: A nationwide cohort study.

Okubo M, Komukai S, Izawa J, Gibo K, ... Callaway CW, Kitamura T
Background
Although prehospital advanced airway management (AAM) (i.e., endotracheal intubation [ETI] and insertion of supraglottic airways [SGA]) has been performed for paediatric out-of-hospital cardiac arrest (OHCA), the effect of AAM has not been fully studied. We evaluated the association between prehospital AAM for paediatric OHCA and patient outcomes.
Methods
We conducted an observational cohort study, using the All-Japan Utstein Registry between 2014 and 2016. We included paediatric patients (age <18 years) with OHCA. We calculated time-dependent propensity score at each minute after initiation of cardiopulmonary resuscitation by EMS providers, using a Fine-Gray regression model. We sequentially matched patients who received AAM during cardiac arrest to patients at risk of receiving AAM within the same minute (risk-set matching). The primary outcome was 1-month survival. Secondary outcome was 1-month survival with favourable functional status, defined as Cerebral Performance Category score of 1 or 2.
Results
We analysed 3801 paediatric patients with OHCA. 481 patients (12.7%) received AAM and 3320 (87.3%) did not. Among the 3801 analysed patients, 912 patients underwent risk-set matching. In the matched cohort, AAM was not associated with 1-month survival (AAM: 52/456 [11.4%] vs. no AAM: 44/456 [9.6%]; risk ratio [RR], 1.15 [95% CI, 0.76-1.73]; risk difference [RD], 1.5% [-3.0 to 6.1%]) or favourable functional status (AAM: 9/456 [2.0%] vs. no AAM: 10/456 [2.2%]; RR, 0.69 [95% CI, 0.26-1.79]; RD, -0.8% [-2.9 to 1.3%]).
Conclusion
Among paediatric patients with OHCA, we found that prehospital AAM was not associated with 1-month survival or favourable functional status.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 16 Sep 2019; epub ahead of print
Okubo M, Komukai S, Izawa J, Gibo K, ... Callaway CW, Kitamura T
Resuscitation: 16 Sep 2019; epub ahead of print | PMID: 31539609
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Impact:
Abstract

Gender differences in utilization of coronary angiography and angiographic findings after out-of-hospital cardiac arrest: A registry study.

Lindgren E, Covaciu L, Smekal D, Lagedal R, ... James S, Rubertsson S
Introduction
We investigated the impact of gender in performance and findings of early coronary angiography (CAG) and percutaneous coronary intervention (PCI), comorbidity and outcome in a large population of out-of-hospital cardiac arrest (OHCA) patients with an initially shockable rhythm.
Methods
Retrospective cohort study. Data retrieved 2008-2013 from the Swedish Register for Cardio-Pulmonary Resuscitation, Swedeheart Registry and National Patient Register.
Results
We identified 1498 patients of whom 78% were men. Men and women had the same pathology on the first registered electrocardiogram (ECG): 30% vs. 29% had ST-elevation and 10% vs. 9% had left bundle branch block (LBBB) (P = 0.97). Proportions of performed CAG did not differ between genders. Among patients without ST-elevation/LBBB men more often had at least one significant stenosis, 78% vs. 54% (P = 0.001), more multi-vessel disease (P = 0.01), had normal coronary angiography less often, 22% vs. 46% and PCI more often, 59% vs. 42% (P = 0.03). Among patients without ST-elevation/LBBB on the initial ECG, more men had previously known ischaemic heart disease, 27% vs. 19% (P = 0.02) and a presumed cardiac origin of the cardiac arrest, 86% vs. 72% (P < 0.001). Multivariable analysis showed no association between gender and evaluation by early CAG. In men and women, 1-year survival was 56% vs. 50% (P = 0.22) in patients with ST-elevation/LBBB and 48% vs. 51% (P = 0.50) in patients without.
Conclusion
Despite no gender differences in ECG findings indicating an early CAG, men had more severe coronary artery disease while women more frequently had normal coronary angiography. However, this did not influence 1-year survival.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:189-195
Lindgren E, Covaciu L, Smekal D, Lagedal R, ... James S, Rubertsson S
Resuscitation: 29 Sep 2019; 143:189-195 | PMID: 31330199
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Impact:
Abstract

Association of antiepileptic drugs with resolution of epileptiform activity after cardiac arrest.

Solanki P, Coppler PJ, Kvaløy JT, Baldwin MA, ... Elmer J,
Introduction
We tested the impact of antiepileptic drug (AED) administration on post-cardiac arrest epileptiform electroencephalographic (EEG) activity.
Methods
We studied an observational cohort of comatose subjects treated at a single academic medical center after cardiac arrest from September 2010 to January 2018. We aggregated the observed EEG patterns into 5 categories: suppressed; discontinuous background with superimposed epileptiform activity; discontinuous background without epileptiform features; continuous background with epileptiform activity; and continuous background without epileptiform activity. We calculated overall probabilities of transitions between EEG states in a multistate model, then used Aalen\'s additive regression to test if AEDs or hypothermia are associated with a change in these probabilities.
Results
Overall, 828 subjects had EEG-monitoring for 42,840 h with a median of 40 [IQR 23-64] h per subject. Among patients with epileptiform findings on initial monitoring, 50% transitioned at least once to a non-epileptiform, non-suppressed state. By contrast, 19% with non-epileptiform initial activity transitioned to an epileptiform state at least once. Overall, 568 (78%) patients received at least one AED. Among patients with continuous EEG background activity, valproate, levetiracetam and lower body temperature were each associated with an increased probability of transition from epileptiform states to non-epileptiform states, where patients with discontinuous EEG background activity no agent linked to an increased probability of transitioning from epileptiform states.
Conclusion
After cardiac arrest, the impact of AEDs may depend on the presence of continuous cortical background activity. These data serve to inform experimental work to better define the opportunities to improve neurologic care post-cardiac arrest.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 30 Aug 2019; 142:82-90
Solanki P, Coppler PJ, Kvaløy JT, Baldwin MA, ... Elmer J,
Resuscitation: 30 Aug 2019; 142:82-90 | PMID: 31325554
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Impact:
Abstract

Cardiac arrest in the intensive care unit: An assessment of preventability.

Moskowitz A, Berg KM, Cocchi MN, Chase M, ... O\' Donoghue S, Donnino MW
Aim
Cardiac arrest in the intensive care unit (ICU-CA) is a common and highly morbid event. We investigated the preventability of ICU-CAs and identified targets for future intervention.
Methods
This was a prospective, observational study of ICU-CAs at a tertiary care center in the United States. For each arrest, the clinical team was surveyed regarding arrest preventability. An expert, multi-disciplinary team of physicians and nurses also reviewed each arrest. Arrests were scored 0 (not at all preventable) to 5 (completely preventable). Arrests were considered \'unlikely but potentially preventable\' or \'potentially preventable\' if at least 50% of reviewers assigned a score of ≥1 or ≥3 respectively. Themes of preventability were assessed for each arrest.
Results
43 patients experienced an ICU-CA and were included. A total of 14 (32.6%) and 13 (30.2%) arrests were identified as unlikely but potentially preventable by the expert panel and survey respondents respectively, and an additional 11 (25.6%) and 10 (23.3%) arrests were identified as potentially preventable. Timing of response to clinical deterioration, missed/incorrect diagnosis, timing of acidemia correction, timing of escalation to a more senior clinician, and timing of intubation were the most commonly cited contributors to potential preventability. Additional themes identified included the administration of anxiolytics/narcotics for agitation later identified to be due to clinical deterioration and misalignment between team and patient/family perceptions of prognosis and goals-of-care.
Conclusions
ICU-CAs may have preventable elements. Themes of preventability were identified and addressing these themes through data-driven quality improvement initiatives could potentially reduce CA incidence in critically-ill patients.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 11 Sep 2019; 145:15-20
Moskowitz A, Berg KM, Cocchi MN, Chase M, ... O' Donoghue S, Donnino MW
Resuscitation: 11 Sep 2019; 145:15-20 | PMID: 31521775
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Impact:
Abstract

Coronary angiographic findings after cardiac arrest in relation to ECG and comorbidity.

Lagedal R, Elfwén L, Jonsson M, Lindgren E, ... Nordberg P, Rubertsson S
Introduction
The relations between specific ECG patterns and coronary angiographic findings in cardiac arrest patients with different comorbidities are not properly assessed. More evidence is needed to identify patients with the highest risk for acute coronary artery disease as a cause of the cardiac arrest. This study aims to describe the coronary artery findings after cardiac arrest in relation to ECG and comorbidity.
Method
A retrospective study of out-of-hospital cardiac arrest patients, with coronary angiography performed within 28 days. ECG on admission, comorbidity, PCI attempts and angiographic findings are described. Data were retrieved from national registries in Sweden.
Results
Among 1133 patients with available ECG and angiography information the mean age was 64 years. The rate of shockable rhythm was 79%. The total incidence of any significant stenosis in cardiac arrest patients without ST-elevation who underwent coronary angiography within 28 days was 71%. The incidence of any stenosis in patients with normal ECG was 62.1% and in patients with LBBB, 59.3%. In patients with ST-depression or RBBB, PCI attempts were made in 47.1% and 42.4% respectively, compared with 33.3% in patients with normal ECG. Among patients without ST-elevation, those with diabetes mellitus and those with initial shockable rhythm respectively, 84.8% and 71.5 had at least one significant stenosis.
Conclusion
Our study suggests, that evaluation of ECG patterns and comorbidities in out-of-hospital cardiac arrest patients without ST-segment elevation may be important to identify those with a high risk of coronary artery lesions that could benefit from early revascularization.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 23 Sep 2019; epub ahead of print
Lagedal R, Elfwén L, Jonsson M, Lindgren E, ... Nordberg P, Rubertsson S
Resuscitation: 23 Sep 2019; epub ahead of print | PMID: 31560991
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Impact:
Abstract

Chest compression release velocity factors during out-of-hospital cardiac resuscitation.

Beger S, Sutter J, Vadeboncoeur T, Silver A, ... Spaite DW, Bobrow B
Background
Higher chest compression release velocity (CCRV) has been associated with better outcomes after out-of-hospital cardiac arrest (OHCA), and patient factors have been associated with variations in chest wall compliance and compressibility. We evaluated whether patient sex, age, weight, and time in resuscitation were associated with CCRV during pre-hospital resuscitation from OHCA.
Methods
Observational study of prospectively collected OHCA quality improvement data in two suburban EMS agencies in Arizona between 10/1/2008 and 12/31/2016. Subject-level mean CCRV during the first 10 min of compressions was correlated with categorical variables by the Wilcoxon rank-sum test and with continuous variables by the Spearman\'s rank correlation coefficient. Generalized estimating equation and linear mixed-effect models were used to study the trend of CCRV over time.
Results
During the study period, 2535 adult OHCA cases were treated. After exclusion criteria, 1140 cases remained for analysis. Median duration of recorded compressions was 8.70 min during the first 10 min of CPR. An overall decline in CCRV was observed even after adjusting for compression depth. The subject-level mean CCRV was higher for minutes 0-5 than for minutes 5-10 (mean 347.9 mm/s vs. 339.0 mm/s, 95% CI of the difference -12.4 to -5.4, p < 0.0001). Males exhibited a greater mean CCRV compared to females [344.4 mm/s (IQR 307.3-384.6) vs. 331.5 mm/s (IQR 285.3-385.5), p = 0.013]. Mean CCRV was negatively correlated with age and positively correlated with patient weight.
Conclusion
CCRV declines significantly over the course of resuscitation. Patient characteristics including male sex, younger age, and increased weight were associated with a higher CCRV.

Copyright © 2019. Published by Elsevier B.V.

Resuscitation: 23 Sep 2019; 145:37-42
Beger S, Sutter J, Vadeboncoeur T, Silver A, ... Spaite DW, Bobrow B
Resuscitation: 23 Sep 2019; 145:37-42 | PMID: 31560989
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Impact:
Abstract

Prearrest prediction of favourable neurological survival following in-hospital cardiac arrest: The Prediction of outcome for In-Hospital Cardiac Arrest (PIHCA) score.

Piscator E, Göransson K, Forsberg S, Bottai M, ... Herlitz J, Djärv T
Background
A prearrest prediction tool can aid clinicians in consolidating objective findings with clinical judgement and in balance with the values of the patient be a part of the decision process for do-not-attempt-resuscitation (DNAR) orders. A previous prearrest prediction tool for in-hospital cardiac arrest (IHCA) have not performed satisfactory in external validation in a Swedish cohort. Therefore our aim was to develop a prediction model for the Swedish setting.
Methods
Model development was based on previous external validation of The Good Outcome Following Attempted Resuscitation (GO-FAR) score, with 717 adult IHCAs. It included redefinition and reduction of predictors, and addition of chronic comorbidity, to create a full model of 9 predictors. Outcome was favourable neurological survival defined as Cerebral Performance Category score 1-2  at discharge. The likelihood of favourable neurological survival was categorised into very low (<1%), low (1-3%) and above low (>3%).
Results
We called the model the Prediction of outcome for In-Hospital Cardiac Arrest (PIHCA) score. The AUROC was 0.808 (95% CI 0.807-0.810) and calibration was satisfactory. With a cutoff of 3% likelihood of favourable neurological survival sensitivity was 99.4% and specificity 8.4%. Although specificity was limited, predictive value for classification into ≤3% likelihood of favorable neurological survival was high (97.4%) and false classification into ≤3% likelihood of favourable neurological survival was low (0.6%).
Conclusion
The PIHCA score has the potential to be used as an objective tool in prearrest prediction of outcome after IHCA, as part of the decision process for a DNAR order.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:92-99
Piscator E, Göransson K, Forsberg S, Bottai M, ... Herlitz J, Djärv T
Resuscitation: 29 Sep 2019; 143:92-99 | PMID: 31412292
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Impact:
Abstract

Regional trends in In-hospital Cardiac Arrest following sepsis-related admissions and subsequent mortality.

Desai R, Parekh T, Patel U, Hanna B, ... Sachdeva R, Kumar G
Background
Previous studies have reported regional variation in either the incidence or outcomes of sepsis or In-hospital Cardiac Arrest (IHCA) discretely; however, regional variations in the incidence and outcomes of sepsis-associated IHCA (SA-IHCA) have never been studied.
Methods
From the National Inpatient Sample (NIS), discharges with sepsis and sepsis-associated IHCA were identified in 4 geographic regions (Northeast, Midwest, South, West) from 2007 to 2014 using applicable ICD-9-CM codes. We assessed the regional incidence and trends in SA-IHCA and subsequent inpatient outcomes.
Results
Out of 8,058,091 sepsis-related admissions, 187,163 (2.3%) were associated with IHCA with a rising trend in the incidence from 2007- to 2014 (2.0% to 2.6%, p < 0.001). The overall incidence of SA-IHCA was highest in South (2.6%) with the highest mortality in West (74.4%) (p < 0.001). The incidence of SA-IHCA increased in the South (2.4%-3.0%) and Midwest (1.6%-2.4%) from 2007 to 2014. Mortality has not significantly increased or decreased across all regions. Compared with the West, survivors in the Northeast, Midwest, and the South were less likely to be discharged home and were more likely to be transferred to other facilities. In the SA-IHCA cohort, the mean length of stay for SA-IHCA was highest in Northeast (˜10.9 days) and lowest in Midwest (˜8.6 days) (p < 0.001). Hospital charges were highest in the West ($234,278) and lowest in the Midwest ($125,725) (p < 0.001).
Conclusion
This nationwide analysis demonstrates that the highest incidence of SA-IHCA is in the Southern region of the US whereas the associated in-hospital mortality was highest in the West. The incidence of SA-IHCA is rising in the Midwest and South from 2007 to 2014. Despite significant advances in the treatment of sepsis and IHCA, there has been no significant improvement in the incidence of SA-IHCA and subsequent survival in any US geographic region from 2007 to 2014.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:35-41
Desai R, Parekh T, Patel U, Hanna B, ... Sachdeva R, Kumar G
Resuscitation: 29 Sep 2019; 143:35-41 | PMID: 31408680
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Impact:
Abstract

Functional outcomes among survivors of pediatric in-hospital cardiac arrest are associated with baseline neurologic and functional status, but not with diastolic blood pressure during CPR.

Wolfe HA, Sutton RM, Reeder RW, Meert KL, ... ,
Aim
Diastolic blood pressure (DBP) during cardiopulmonary resuscitation (CPR) is associated with survival following pediatric in-hospital cardiac arrest. The relationship between intra-arrest haemodynamics and neurological status among survivors of pediatric cardiac arrest is unknown.
Methods
This study represents analysis of data from the prospective multicenter Pediatric Intensive Care Quality of cardiopulmonary resuscitation (PICqCPR) Study. Primary predictor variables were median DBP and median systolic blood pressure (SBP) over the first 10min of CPR. The primary outcome measure was \"new substantive morbidity\" determined by Functional Status Scale (FSS) and defined as an increase in the FSS of at least 3 points or increase of 2 in a single FSS domain. Univariable analyses were completed to investigate the relationship between new substantive morbidity and BPs during CPR.
Results
244 index CPR events occurred during the study period, 77 (32%) CPR events met all inclusion criteria as well as having both DBP and FSS data available. Among 77 survivors, 32 (42%) had new substantive morbidity as measured by the FSS score. No significant differences were identified in DBP (median 30.5mmHg vs. 30.9mmHg, p=0.5) or SBP (median 76.3mmHg vs. 63.0mmHg, p=0.2) between patients with and without new substantive morbidity. Children who developed new substantive morbidity were more likely to have lower pre-arrest FSS than those that did not (median [IQR]: 7.5 [6.0-9.0] versus 9.0 [7.0-13.0], p=0.01).
Conclusion
New substantive morbidity determined by FSS after a pediatric IHCA was associated with baseline functional status, but not DBP during CPR.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 29 Sep 2019; 143:57-65
Wolfe HA, Sutton RM, Reeder RW, Meert KL, ... ,
Resuscitation: 29 Sep 2019; 143:57-65 | PMID: 31404636
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Impact:
Abstract

Association of chest compression and recoil velocities with depth and rate in manual cardiopulmonary resuscitation.

González-Otero DM, Russell JK, Ruiz JM, Ruiz de Gauna S, ... Leturiondo LA, Daya MR
Aim
Maximum velocity during chest recoil has been proposed as a metric for chest compression quality during cardiopulmonary resuscitation (CPR). This study investigated the relationship of the maximum velocities during compression and recoil phases with compression depth and rate in manual CPR.
Methods
We measured compression instances in out-of-hospital cardiac arrest recordings using custom Matlab programs. Each compression cycle was characterized by depth and rate, maximum compression and recoil velocities (CV and RV), and compression and recoil durations (total and effective). Mean compression and recoil velocities were computed as depth divided by compression and recoil durations, respectively. We correlated CV and RV with their corresponding mean velocities (total and effective), characterized by Pearson\'s correlation coefficient.
Results
CV/RV were strongly correlated with their corresponding mean velocities, with a median r of 0.83 (0.77-0.88)/0.82 (0.76-0.87) in per patient analysis, 0.86/0.88 for all the population. Correlation with mean effective velocities had a median r of 0.91 (0.87-0.94)/0.92 (0.89-0.94) in per-patient, 0.92/0.94 globally (p < 0.001). Total and effective compression and recoil durations were inversely proportional to compression rate. We observed similar RV values among compressions regardless of whether they were compliant with recommended depth and rate. Conversely, we observed different RV values among compressions having the same depth and rate, but presenting very distinct compression waveforms.
Conclusion
CV and RV were highly correlated with compression depth and compression and recoil times, respectively. Better understanding of the relationship between novel and current quality metrics could help with the interpretation of CPR quality studies.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Aug 2019; 142:119-126
González-Otero DM, Russell JK, Ruiz JM, Ruiz de Gauna S, ... Leturiondo LA, Daya MR
Resuscitation: 30 Aug 2019; 142:119-126 | PMID: 31369793
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Impact:
Abstract

Prediction of good neurological recovery after out-of-hospital cardiac arrest: A machine learning analysis.

Park JH, Shin SD, Song KJ, Hong KJ, ... Choi JW, Choi SW
Background
This study aimed to train, validate and compare predictive models that use machine learning analysis for good neurological recovery in OHCA patients.
Methods
Adult OHCA patients who had a presumed cardiac etiology and a sustained return of spontaneous circulation between 2013 and 2016 were analyzed; 80% of the individuals were analyzed for training and 20% were analyzed for validation. We developed using six machine learning algorithms: logistic regression (LR), extreme gradient boosting (XGB), support vector machine, random forest, elastic net (EN), and neural network. Variables that could be obtained within 24 hours of the emergency department visit were used. The area under the receiver operation curve (AUROC) was calculated to assess the discrimination. Calibration was assessed by the Hosmer-Lemeshow test. Reclassification was assessed by using the continuous net reclassification index (NRI).
Results
A total of 19,860 OHCA patients were included in the analysis. Of the 15,888 patients in the training group, 2228 (14.0%) had a good neurological recovery; of the 3972 patients in the validation group, 577 (14.5%) had a good neurological recovery. The LR, XGB, and EN models showed the highest discrimination powers (AUROC (95% CI)) of 0.949 (0.941-0.957) for all), and all three models were well calibrated (Hosmer-Lemeshow test: p >0.05). The XGB model reclassified patients according to their true risk better than the LR model (NRI: 0.110), but the EN model reclassified patients worse than the LR model (NRI: -1.239).
Conclusion
The best performing machine learning algorithm was the XGB and LR algorithm.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Aug 2019; 142:127-135
Park JH, Shin SD, Song KJ, Hong KJ, ... Choi JW, Choi SW
Resuscitation: 30 Aug 2019; 142:127-135 | PMID: 31362082
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Impact:
Abstract

Cardiac output, heart rate and stroke volume during targeted temperature management after out-of-hospital cardiac arrest: Association with mortality and cause of death.

Grand J, Kjaergaard J, Bro-Jeppesen J, Wanscher M, ... Boesgaard S, Hassager C
Aim
Myocardial dysfunction and low cardiac index are common after out-of-hospital cardiac arrest (OHCA) as part of the post-cardiac arrest syndrome. This study investigates the association of cardiac index during targeted temperature management (TTM) with mortality.
Methods
In the TTM-trial, which randomly allocated patients to TTM of 33 °C or 36 °C for 24 h, we prospectively and consecutively monitored 151 patients with protocolized measurements from pulmonary artery catheters (PAC) as a single site substudy. Cardiac index, heart rate and stroke volume were measured at 3 time-points during the 24 h TTM period and averaged. Uni- and multivariate Cox regression was used to assess association with mortality.
Results
Of 151 patients, 50 (33%) were deceased after 180 days. Cardiac index during TTM was not significantly associated with mortality in univariate (HR: 0.84 [0.54-1.31], p = 0.59) or multivariate analyses (HR: 1.03 [0.57-1.83], p = 0.93). Cardiac index during TTM was also not significantly associated with non-neurological death (HR: 1.25 [0.43-3.59], p = 0.68). Higher heart rate (p = 0.03) and lower stroke volume (p = 0.04) were associated with increased mortality in univariate, but not multivariate analyses. No hemodynamic variables were associated with cerebral death, however, increasing lactate during TTM (HR: 2.15 [1.19-3.85], p = 0.01) and lower mean arterial pressure during TTM (HR: 0.89 [0.81-0.97], p = 0.008) were independently associated with non-neurological death.
Conclusion
Cardiac index during TTM after resuscitation from OHCA is not associated with mortality. Future studies should investigate whether certain subgroups of patients could benefit from targeting higher goals for cardiac index.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Aug 2019; 142:136-143
Grand J, Kjaergaard J, Bro-Jeppesen J, Wanscher M, ... Boesgaard S, Hassager C
Resuscitation: 30 Aug 2019; 142:136-143 | PMID: 31362081
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Impact:
Abstract

Circumstances, outcome and quality of cardiopulmonary resuscitation by lifeboat crews.

Seesink J, Nieuwenburg SAV, van der Linden T, Bierens JJLM
Background
Little is known regarding circumstances, outcomes and quality of cardiopulmonary resuscitation (CPR) and the use of automated external defibrillators (AEDs) performed by operational lifeboat crews. Our aim is to evaluate circumstances, outcomes and quality of CPR performed by the Royal Dutch Lifeboat Institution (KNRM) in out-of-hospital cardiac arrest (OHCA).
Methods
The internal KNRM database has been used to identify and analyse all OHCA cases between July 2011 and December 2017. A limited set of AED data was available to study the quality of CPR.
Results
In 37 patients the lifeboat crew members have performed CPR, of which 29 (78.4%) occurred under hostile conditions. The median response time to arrive at the location was 15min. In 11 (29.7%) patients return of spontaneous circulation was achieved at any moment during CPR and 3 (8.1%) patients were still alive after one month. The lifeboat AED was used in 12 patients. Their recordings show a high median compression frequency (120, IQR 111-131) and prolonged median interruption periods (pre-analysis pause 11s (IQR 10-13), post-analysis pause 4s (IQR 3-8), pre-shock pause 24s (IQR 19-26), post-shock pause 6s (IQR 6-11), ventilation pause 6s (IQR 4-8) and other pauses 9s (IQR 4-17)).
Conclusions
Compared to most out-of-hospital resuscitations, resuscitations by lifeboat crews have a low incidence, occur under difficult circumstances and in a younger population. AED\'s on lifeboats have not contributed to any of the survivals. Analysis of AED information can be used to study the quality of CPR and provide input for improving future training of lifeboat crews.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Aug 2019; 142:104-110
Seesink J, Nieuwenburg SAV, van der Linden T, Bierens JJLM
Resuscitation: 30 Aug 2019; 142:104-110 | PMID: 31351088
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Impact:
Abstract

Incorporating baseline functional status to improve validity of neurological outcome assessments following cardiac arrest.

Eng KJ, Yang JZ, Tyagi S, Odish MF, ... Sell RE, Beitler JR
Background
Neurological status at hospital discharge is routinely used to assess patient outcome after cardiac arrest. However, attribution of impairment to the arrest is valid only if baseline neurological status is known. This study evaluated whether incorporating baseline neurological status improves performance of a widely employed neurological outcome scale for quantifying arrest-attributable morbidity.
Methods
Retrospective cohort study of two U.S. hospitals. Neurological function was assessed via Cerebral performance category (CPC), an ordinal five-point scale with 1 indicating sufficient cognition to lead an independent life and 5 representing brain death. Hospitalized adult patients who suffered in-hospital cardiac arrest for which cardiopulmonary resuscitation was attempted between 2011-2015 were included. Patients were identified through a quality improvement registry that captures all inpatient arrests in the two hospitals.
Results
Of 486 patients who suffered in-hospital cardiac arrest, 124 (25.5%) had baseline abnormal neurological function (pre-hospitalization CPC>1). Although 54 patients had a normal discharge CPC of 1, 80 patients had no change in CPC from their prior baseline (11.1% vs. 16.5% met criterion for \"normal\" outcome defined as CPC of 1 vs. change-in-CPC of 0; McNemar p < .01; kappa for agreement: .78, 95% CI .69-.86). Across several formulations of criteria for \"good\" neurological outcome, similar discordance existed between conventional definitions considering only discharge CPC and modified definitions that included change-in-CPC from baseline.
Conclusions
Incorporating change-in-CPC into criteria for \"good\" neurological outcome post-arrest yields discordant results from traditional approaches that consider discharge CPC only and increases face validity of reporting arrest-related morbidity.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Aug 2019; 142:69-73
Eng KJ, Yang JZ, Tyagi S, Odish MF, ... Sell RE, Beitler JR
Resuscitation: 30 Aug 2019; 142:69-73 | PMID: 31310844
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Impact:
Abstract

Diagnostic value of lead aVR in electrocardiography for identifying acute coronary lesions in patients with out-of-hospital cardiac arrest.

Yamamoto M, Witsch T, Kubota S, Hara H, Hiroi Y
Aim
There is no simple clinical tool that reliably indicates the presence of acute coronary lesions in out-of-hospital cardiac arrest (OHCA) patients without typical ST-segment elevations. ST-segment elevation in electrocardiographic lead aVR suggests global subendocardial ischemia. This study aimed to evaluate the diagnostic value of lead aVR for identifying acute coronary lesions following resuscitation from OHCA.
Methods
A total of 74 patients without evidence of ST-segment elevations, who were resuscitated from OHCA, were examined. The degree of ST-segment elevation in lead aVR was measured directly after return of spontaneous circulation (ROSC) and at early follow-up. Coronary angiograms were retrospectively reviewed.
Results
Acute coronary lesions were detected in 20 patients (27%). No difference in ST-segment elevation in lead aVR directly after ROSC was observed between patients with or without acute coronary lesions. However, ST-segment elevation values significantly decreased at early follow-up (median, 137 min) in patients without acute coronary lesions. An ST-segment elevation ≥0.5 mm in lead aVR at early follow-up was associated with a higher prevalence of multivessel coronary artery disease and was an independent indicator of the presence of acute coronary lesions (odds ratio, 4.41; 95% confidence interval, 1.12-17.4; p = 0.034).
Conclusion
ST-segment elevation in lead aVR at early follow-up was associated with the presence of acute lesions accompanied by severe coronary artery disease in post-cardiac arrest patients without other ST-segment elevations. The analysis of ST-segment elevation in lead aVR may aid in the identification of patients who will benefit from further invasive coronary diagnostic procedures.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Aug 2019; 142:97-103
Yamamoto M, Witsch T, Kubota S, Hara H, Hiroi Y
Resuscitation: 30 Aug 2019; 142:97-103 | PMID: 31330201
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Impact:
Abstract

A centralized system for providing dispatcher assisted CPR instructions to 9-1-1 callers at multiple municipal public safety answering points.

Lerner EB, Farrell BM, Colella MR, Sternig KJ, ... Cady CE, Liu JM
Background
Dispatcher CPR instruction increases the odds of survival. However, many communities do not provide this lifesaving intervention, often citing the barriers of limited personnel, funding, and liability.
Objective
Describe the implementation of a novel centralized dispatcher CPR instruction program that serves seven public safety answering points (PSAPs).
Methods
Seven municipal PSAPs that did not previously provide dispatcher instructions implemented our program. Using a 30-min self-directed video, 84 PSAP dispatchers were trained to utilize a two-question protocol to identify and transfer suspected out-of-hospital cardiac arrest (OHCA) cases to a central communication center. At this central communication center, a trained communicator delivered CPR instructions to the caller. The 26 central communicators were trained with a 2-h in-person didactic session followed by a 2-h practice session. We collected and analyzed data from recordings of communicator-to-caller interactions.
Results
169 calls were transferred to the central communication center. Of those, 106 needed CPR instructions and 56 of those callers performed chest compressions (53%). The county-wide EMS documented bystander CPR rate was 20% the prior year. The 63 remaining transferred calls were non-OHCA calls. Of the calls where CPR was needed and performed, 11 victims survived to hospital discharge (20%); the countywide survival rate was 12%.
Conclusions
Using a central communication center for instructions allowed us to train and maintain a smaller group of communicators, leading to less cost and more experience for those communicators, while limiting the burden on PSAP dispatchers.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Aug 2019; 142:46-49
Lerner EB, Farrell BM, Colella MR, Sternig KJ, ... Cady CE, Liu JM
Resuscitation: 30 Aug 2019; 142:46-49 | PMID: 31323187
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Impact:
Abstract

Contemporary impacts of a cancer diagnosis on survival following in-hospital cardiac arrest.

Guha A, Buck B, Biersmith M, Arora S, ... Fradley MG, Addison D
Aim
The objective of this study was to determine whether survival and post-arrest procedural utilization following in-hospital cardiac arrest (IHCA) differ in patients with and without comorbid cancer.
Methods
We retrospectively reviewed all adult (age ≥18 years old) hospital admissions complicated by IHCA from 2003 to 2014 using the National Inpatient Sample (NIS) dataset. Utilizing propensity score matching using age, gender, race, insurance, all hospital level variables, HCUP mortality score, diabetes, hypertension and cardiopulmonary resuscitation use, rates of survival to hospital discharge and post-arrest procedural utilization were compared.
Results
From 2003 to 2014, there were a total of 1,893,768 hospitalizations complicated by IHCA, of which 112,926 occurred in patients with history of cancer. In a propensity matched cohort from 2012 to 2014, those with cancer were less likely to survive the hospitalization (31% vs. 46%, p < 0.0001). Following an IHCA, rates of procedural utilization in patients with cancer were significantly less when compared to those without a concurrent malignancy: coronary angiography (4.0% vs. 13.0%), percutaneous coronary intervention (2.2% and 8.0%), targeted temperature management (0.8% vs. 6.0%); p < 0.0001 for all comparisons. This patient population was less likely to have acute coronary syndrome (12.6% vs. 27.0%) or congestive heart failure (24.5% vs. 38.2%); p < 0.0001 for both comparisons. Survival improved in both groups over the study period (p < 0.0001).
Conclusions
Patients with a history of cancer who sustain IHCA are less likely to receive post-arrest procedures and survive to hospital discharge. Given the expected rise in the rates of cancer survivorship, these findings highlight the need for broader application of potentially life-saving interventions to lower risk cancer patients who have sustained a cardiac arrest.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Aug 2019; 142:30-37
Guha A, Buck B, Biersmith M, Arora S, ... Fradley MG, Addison D
Resuscitation: 30 Aug 2019; 142:30-37 | PMID: 31310845
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Impact:
Abstract

The impact of resuscitation guideline terminology on quality of dispatcher-assisted cardiopulmonary resuscitation: A randomised controlled manikin study.

Trethewey SP, Vyas H, Evans S, Hall M, ... Perkins GD, Couper K
Background
Cardiopulmonary resuscitation (CPR) guidelines vary in the terminology used to describe target chest compression depth, which may impact CPR quality. We investigated the impact of using different chest compression depth instruction terminologies on CPR quality.
Methods
We conducted a parallel group, three-arm, randomised controlled manikin trial in which individuals without recent CPR training were instructed to deliver compression-only CPR for 2-min based on a standardised dispatcher-assisted CPR script. Participants were randomised in a 1:1:1 ratio to receive CPR delivery instructions that instructed them to deliver chest compressions based on the following terminologies: \'press at least 5 cm\', \'press approximately 5 cm\' or \'press hard and fast.\' The primary outcome was compression depth, measured in millimetres.
Results
Between October 2017 and June 2018, 330 participants were randomised to \'at least 5 cm\' (n = 109), \'approximately 5 cm\' (n = 110) and \'hard and fast\' (n = 111), in which mean chest compression depth was 40.9 mm (SD 13.8), 35.4 mm (SD 14.1), and 46.8 mm (SD 15.0) respectively. Mean difference in chest compression depth between \'at least 5 cm\' and \'approximately 5 cm\' was 5.45 (95% confidence interval (95% CI) 0.78-10.12), between \'hard and fast\' and \'approximately 5 cm\' was 11.32 (95% CI 6.65-15.99), and between \'hard and fast\' and \'at least 5 cm\' was 5.87 (95% CI 1.21-10.53). Chest compression rate and count were both highest in the \'hard and fast\' group.
Conclusions
The use of \'hard and fast\' terminology was superior to both \'at least 5 cm\' and \'approximately 5 cm\' terminologies.
Trial registration
ISRCTN15128211.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Aug 2019; 142:91-96
Trethewey SP, Vyas H, Evans S, Hall M, ... Perkins GD, Couper K
Resuscitation: 30 Aug 2019; 142:91-96 | PMID: 31330198
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Impact:
Abstract

Neuron-specific enolase (NSE) improves clinical risk scores for prediction of neurological outcome and death in cardiac arrest patients: Results from a prospective trial.

Luescher T, Mueller J, Isenschmid C, Kalt J, ... Marsch S, Hunziker S
Aim
Neuron-specific enolase (NSE) increases in response to brain injury and is recommended for outcome prediction in cardiac arrest patients. Our aim was to investigate whether NSE measured at different days after a cardiac arrest and its kinetics would improve the prognostic ability of two cardiac arrest specific risk scores.
Methods
Within this prospective observational study, we included consecutive adult patients after cardiac arrest. We calculated the Out-of-hospital cardiac arrest (OHCA) score and the Cardiac Arrest Hospital Prognosis (CAHP) score upon ICU admission and measured serum NSE upon admission and days 1, 2, 3, 5 and 7. We calculated logistic regression models to study associations of scores and NSE levels with neurological outcome defined by Cerebral Performance Category (CPC) scale and in-hospital death.
Results
From 336 included patients, 180 (54%) survived until hospital discharge, of which 150 (45%) had a good neurological outcome. NSE at day 3 showed the highest prognostic accuracy (discrimination) for neurological outcome (area under the curve (AUC) 0.89) and in-hospital mortality (AUC 0.88). These results were robust in reclassification statistics and across different subgroups. NSE kinetics with admission levels serving as a baseline did not further improve prognostication. NSE on day 3 significantly improved discrimination of both clinical risk scores (CAHP from AUC 0.81 to 0.91; OHCA from AUC 0.79 to 0.89).
Conclusion
NSE measured at day 3 significantly improves clinical risk scores for outcome prediction in cardiac arrest patients and may thus add to clinical decision making about escalation or withdrawal of therapy in this vulnerable patient population.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Aug 2019; 142:50-60
Luescher T, Mueller J, Isenschmid C, Kalt J, ... Marsch S, Hunziker S
Resuscitation: 30 Aug 2019; 142:50-60 | PMID: 31306716
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Impact:
Abstract

Effect of estimated glomerular filtration rate (eGFR) on incidence of out-of-hospital cardiac arrests: A case-control study.

Lim HJ, Jeong J, Kim J, Ro YS, Shin SD
Objectives
Serum creatinine levels in the post-resuscitative state have been associated with poor prognosis for out-of-hospital cardiac arrest (OHCA). Several studies have focused on kidney dysfunction in the general population, and the results suggested that serum creatinine level elevation or reduction of the estimated glomerular filtration rate (eGFR) are associated with increased risk of death and cardiovascular events. However, it is uncertain whether the serum creatinine levels or eGFR of OHCA patients are related to the incidence of OHCA. The aim of this study was to determine the association between eGFR and the incidence of OHCA.
Methods
This study was a case-control study performed using the Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance (CAPTURES) project dataset and the Korea National Health and Nutrition Examination Survey (KNHANES) dataset. Cases were defined as emergency medical service-treated adult OHCA patients with presumed cardiac etiology collected from the CAPTURES dataset. Four controls from the KNHANES dataset were matched to one case based on age, gender, and county. Multivariable conditional logistic regression analysis was conducted to evaluate the effect of eGFR on the incidence of OHCA.
Results
A total of 1211 matched case-control pairs were included in the study analysis. We classified eGFR into 6 categories (≥90, 60-89, 45-59, 30-44, 15-29, and <15 mL/min/1.73 m) according to the chronic kidney disease stage. Subjects with an eGFR ≥90 mL/min/1.73 m were used as the reference group. In both the unadjusted and adjusted models, lower eGFR was significantly associated with OHCA incidence. The odds ratio (OR) for OHCA incidence increased sharply as the eGFR declined; the adjusted OR (95% CI) for OHCA incidence was 4.09 (2.81-5.95) with an eGFR of 60-89 mL/min/1.73 m, 36.59 (22.24-60.21) with an eGFR of 45-59 mL/min/1.73 m, 55.26(29.66-102.94) with an eGFR of 30-44 mL/min/1.73 m, 89.65 (37.25-215.79) with an eGFR of 15-29 mL/min/1.73 m, and 241.87 (73.49-796.01) with an eGFR of less than 15 mL/min/1.73 m.
Conclusion
In this study, we observed an association between reduced eGFR and the risk of OHCA incidence in a large, community-based population. Future prospective studies are needed to better understand how reduced renal function is associated with OHCA occurrence as well as the impact of intensive risk management and intervention of renal function on OHCA incidence.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Aug 2019; 142:38-45
Lim HJ, Jeong J, Kim J, Ro YS, Shin SD
Resuscitation: 30 Aug 2019; 142:38-45 | PMID: 31299221
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Abstract

Time of out-of-hospital cardiac arrest is not associated with outcome in a metropolitan area: A multicenter cohort study.

Schriefl C, Mayr FB, Poppe M, Zajicek A, ... Sterz F, Uray T
Aim
Whether time of day influences survival after out-of-hospital cardiac arrest (OHCA) remains controversial. We compared outcomes after OHCA between day and night and explored whether characteristics of pre-hospital advanced life support (ALS)-quality varied by time of day.
Methods
We conducted a prospective cohort study of individuals that suffered a non-traumatic OHCA in the city of Vienna between August 2013 and August 2015 and who received resuscitative efforts by EMS. We compared clinical outcomes between day and night, defined as 7:00 pm-7:00 am based on EMS shift time including rates of sustained return of spontaneous circulation (ROSC), 30-day survival and favourable neurologic outcome (cerebral performance category 1 or 2). ALS quality measures included time to first medical contact, time to first shock, total dose of epinephrine, and multiple ALS performance measures.
Results
We included 1811 patients (37% female) with a mean age of 67 ± 16 years in our analyses. Rates of ROSC and 30-day survival with favourable neurological outcome did not differ between day or night (30% vs 28%, p =  0.33; 12% vs. 11%, p =  0.51, respectively). These results remained unchanged after multivariate adjustment for ROSC (RR, 1.1; 95% CI, 1.0-1.3, p = 0.19) and 30-day survival with favourable neurological outcome (RR, 1.2; 95% CI, 1.0-1.5, p =  0.10). The quality of ALS did not differ between day and night.
Conclusions
In contrast to previous studies, there was no significant difference in sustained ROSC rates and 30-day survival with favourable neurological outcome after OHCA between day and night in the city of Vienna. This is likely due to nearly identical high bystander CPR rates and identical ALS performance provided by EMS personnel irrespective of time of the day.

Copyright © 2019 Elsevier B.V. All rights reserved.

Resuscitation: 30 Aug 2019; 142:61-68
Schriefl C, Mayr FB, Poppe M, Zajicek A, ... Sterz F, Uray T
Resuscitation: 30 Aug 2019; 142:61-68 | PMID: 31326405
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This program is still in alpha version.