Journal: Resuscitation

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Abstract

Sodium bicarbonate administration during in-hospital pediatric cardiac arrest: a systematic review and meta-analysis.

Chang CY, Wu PH, Hsiao CT, Chang CP, Chen YC, Wu KH
Background
Current American Heart Association Pediatric Life Support (PLS) guidelines do not recommend the routine use of sodium bicarbonate (SB) during cardiac arrest in pediatric patients. However, SB administration during pediatric resuscitation is still common in clinical practice. The objective of this study was to assess the impact of SB on mortality and neurological outcomes in pediatric patients with in-hospital cardiac arrest.
Methods
We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to January 2021. We included studies of pediatric patients that had two treatment arms (treated with SB or not treated with SB) during in-hospital cardiac arrest (IHCA). Risk of bias was assessed using the Newcastle-Ottawa Scale and the certainty of evidence was assessed using GRADE system.
Results
We included 7 observational studies with a total of 4,877 pediatric in-hospital cardiac arrest patients. Meta-analysis showed that SB administration during pediatric cardiac resuscitation was associated with a significantly decreased rate of survival to hospital discharge (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.25-0.63, p value = 0.0003). There were insufficient studies for 24 -h survival and neurologic outcomes analysis. The subgroup analysis showed a significantly decreased rate of survival to hospital discharge in both the \"before 2010\" subgroup (OR 0.47; 95% CI 0.30-0.73; p value = 0.006) and the \"after 2010\" subgroup (OR 0.46; 95% CI 0.25-0.87; p value = 0.02). The certainty of evidence ranged from very low to low.
Conclusions
This meta-analysis of non-randomized studies supported current PLS guideline that routine administration of SB is not recommended in pediatric cardiac arrest except in special resuscitation situations.
Trial registration
The protocol was registered with PROSPERO on 8 August 2020 (registration number: CRD42020197837).

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 28 Feb 2021; epub ahead of print
Chang CY, Wu PH, Hsiao CT, Chang CP, Chen YC, Wu KH
Resuscitation: 28 Feb 2021; epub ahead of print | PMID: 33662526
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Abstract

Recovery among post-arrest patients with mild-to-moderate cerebral edema.

Fuller ZL, Faro JW, Callaway CW, Coppler PJ, Elmer J, University of Pittsburgh Post-Cardiac Arrest Service
Background
Cerebral edema after cardiac arrest may be a modifiable cause of secondary brain injury. We aimed to identify processes of care associated with recovery in a cohort of patients with mild to moderate edema.
Methods
We conducted a retrospective cohort study of adults resuscitated from out-of-hospital arrest (OHCA) at a single center from 2010-2018. We included those with cerebral edema ranging from mild to moderate (gray to white matter attenuation ratio (GWR) 1.2 to 1.3 on initial brain computerized tomography (CT). We used Pittsburgh Cardiac Arrest Category (PCAC) to adjust for illness severity and considered the following values in the first 24 hours of admission as additional predictors: GWR, lab values affecting serum osmolality (sodium, glucose, blood urea nitrogen (BUN)), total osmolality, change in osmolality from 0 to 24 hours, cardiac etiology of arrest, targeted temperature to 33 °C (vs 36 °C), time-weighted mean arterial pressure (MAP), partial pressures of arterial oxygen and carbon dioxide and select medications. Our primary outcome was discharge with Cerebral Performance Category 1 to 3. We used unadjusted and adjusted logistic regression for analysis.
Results
We included 214 patients for whom CT was performed median 3.8 [IQR 2.4 - 5.2] hours after collapse. Median age was 57 [IQR 48-67] years, 82 (38%) were female, and 68 (32%) arrested from ventricular tachycardia or fibrillation. In adjusted models, modifiable processes of care were not associated with outcome.
Conclusions
Illness severity, but not modifiable processes of care, were associated with recovery among post-arrest patients with mild-to-moderate cerebral edema.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 28 Feb 2021; epub ahead of print
Fuller ZL, Faro JW, Callaway CW, Coppler PJ, Elmer J, University of Pittsburgh Post-Cardiac Arrest Service
Resuscitation: 28 Feb 2021; epub ahead of print | PMID: 33662524
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Abstract

Public health impact of daily life triggers of sudden cardiac death: a systematic review and comparative risk assessment.

Čulić V, AlTurki A, Proietti R
Background
Sudden cardiac death (SCD) may be triggered by daily circumstances and activities such as stressful psycho-emotional events, physical exertion or substance misuse. We calculated population attributable fractions (PAFs) to estimate the public health relevance of daily life triggers of SCD and to compare their population impacts.
Methods
We searched PubMed, Scopus and the Web of Science citation databases to retrieve studies of triggers of SCD and cardiac arrest that would enable a computation of PAFs. When more studies investigated the same trigger, a meta-analytical pooled risk random-effect estimate was used.
Results
Of the retrieved studies, eight provided data enabling computation of PAFs. The prevalence of exposure within population for SCD triggers in the control periods ranged from 1.06% for influenza infection to 8.73% for recent use of cannabis. Triggers ordered from the highest to the lowest risk increase were: physical exertion, recent cocaine use, episodic alcohol consumption, recent amphetamine use, episodic coffee consumption, psycho-emotional stress within the previous month, influenza infection, and recent cannabis use. The relative risk increase ranged from 1.10 to 4.98. By accounting for both the magnitude of the risk increase and the prevalence in the population, the present estimates of PAF assign 14.5% (95% confidence interval [CI] 4.9-28.5) of all SCDs to episodic alcohol consumption, 9.4% (95%CI 1.2-29.3) to physical exertion, 6.9% (95%CI 0.3-25.0) to cocaine, 6% (95%CI 1.2-14.6) to episodic coffee consumption, 3% (95%CI 0.4-6.8) to psycho-emotional stress in the previous month, 1.7% (95%CI -0.9-12.9) to amphetamines, 0.9% (95%CI -4.9-12.5) to cannabis, and 0.3% (95%CI 0.2-0.4) to influenza infections.
Conclusions
In addition to episodic alcohol consumption, a trigger with the greatest public health importance for SCD, episodic physical exertion, cocaine use and coffee consumption also show a considerable population impact.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 28 Feb 2021; epub ahead of print
Čulić V, AlTurki A, Proietti R
Resuscitation: 28 Feb 2021; epub ahead of print | PMID: 33662523
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Abstract

Prognosis of myocardial infarction-related cardiogenic shock according to preadmission out-of-hospital cardiac arrest.

Lauridsen MD, Josiassen J, Schmidt M, Butt JH, ... Køber L, Fosbøl EL
Aims
Out-of-hospital cardiac arrest (OHCA) is highly prevalent among patients with myocardial infarction and cardiogenic shock (MI-CS). We aimed to examine the prognostic importance of OHCA in patients with MI-CS.
Methods
Using Danish nationwide registries, we identified first-time hospitalized MI-CS patients (2010-2015) by OHCA status. Cumulative incidence curves and adjusted Cox regression models were used to compare in-hospital mortality, and among hospital survivors we compared 5-year rates of heart failure hospitalization and mortality.
Results
We identified 3,107 MI-CS patients of whom 979 presented with OHCA (32%). OHCA patients were younger (median age: 65 vs. 74 years) and had less comorbidity. In-hospital mortality was 57% in those with OHCA compared with 67% in those without, but after adjustment the hazard ratio (HR) was 0.99 [95% CI: 0.87-1.11]. Hospital survivors consisted of 1,375 MI-CS patients including 531 OHCA patients (39%). Five-year mortality was 22% for OHCA patients and 42% for patients without OHCA (adjusted HR: 0.90 [95% CI: 0.70-0.1.17]). The HR for five-year cardiovascular mortality was 0.80 [95% CI: 0.62-0.98]. Lastly, 5-year rate of heart failure hospitalization was 17% for patients with OHCA compared with 34% in those without (HR: 0.44 [95% CI: 0.34-0.57]).
Conclusion
Among patients hospitalized with MI-CS, OHCA did not influence all-cause in-hospital or long-term mortality but was a marker for reduced long-term rates of heart failure hospitalization and cardiovascular mortality. Future randomized studies are needed to improve prognosis of MI-CS, however, the importance of OHCA must be considered.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 28 Feb 2021; epub ahead of print
Lauridsen MD, Josiassen J, Schmidt M, Butt JH, ... Køber L, Fosbøl EL
Resuscitation: 28 Feb 2021; epub ahead of print | PMID: 33662522
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Abstract

End-tidal carbon dioxide (ETCO) and ventricular fibrillation amplitude spectral area (AMSA) for shock outcome prediction in out-of-hospital cardiac arrest. Are they two sides of the same coin?

Frigerio L, Baldi E, Aramendi E, Chicote B, ... Savastano S, Lombardia CARe Researchers
Aim
Ventricular fibrillation amplitude spectral area (AMSA) and end-tidal carbon dioxide (ETCO2) are predictors of shock success, understood as restoration of an organized rhythm, and return of spontaneous circulation (ROSC). However, little is known about their combined use. We aimed to assess the prediction accuracy when combined, and to clarify if they are correlated in out of hospital cardiac arrest\' victims.
Materials and methods
Records acquired by external defibrillators in out-of-hospital cardiac arrest patients of the Lombardia Cardiac Arrest registry were processed. The 1-min pre-shock ETCO2 median value (METCO2) was computed from the capnogram and AMSA (2-48 mV.Hz range) computed applying the Fast Fourier Transform to a 2-second pre-shock filtered ECG interval (0.5-30 Hz). Support Vector Machine (SVM) predictive models based on METCO2, AMSA and their combination were fit; results were given as the area under the curve (AUC) of the receiver operating characteristic (ROC) curves.
Results
We considered 112 patients with 391 shocks delivered. METCO2 and AMSA were predictors of shock success [AUC (IQR) of the ROC curve: 0.59 (0.56-0.62); 0.68 (0.65-0.72), respectively] and of ROSC [0.56 (0.53-0.59); 0.74 (0.71-0.78),]. Their combination in a SVM model increased the accuracy for predicting shock success [AUC (IQR) of the ROC curve: 0.71 (0.68-0.75)] and ROSC [0.77 (0.73-0.8)]. AMSA and METCO2 were significantly correlated only in patients who achieved ROSC (rho = 0.33 p = 0.03).
Conclusions
AMSA and ETCO2 predict shock success and ROSC after every shock, and their predictive power increases if combined. Notably, they were correlated only in patients who achieved ROSC.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 27 Feb 2021; 160:142-149
Frigerio L, Baldi E, Aramendi E, Chicote B, ... Savastano S, Lombardia CARe Researchers
Resuscitation: 27 Feb 2021; 160:142-149 | PMID: 33181229
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Abstract

Emergency veno-arterial extracorporeal membrane oxygenation (VA ECMO)-supported percutaneous interventions in refractory cardiac arrest and profound cardiogenic shock.

Radsel P, Goslar T, Bunc M, Ksela J, Gorjup V, Noc M
Aims
We investigated the spectrum of emergency veno-arterial extracorporeal membrane oxygenation (VA ECMO)-supported interventions including percutaneous coronary intervention (PCI), transcatheter aortic valve implantation (TAVI) and invasive electrophysiology (EP).
Methods and results
Between June 2010 and February 2020, 52 consecutive patients underwent VA ECMO implantation for refractory cardiac arrest (E-CPR) and 78 for profound cardiogenic shock. Percutaneous interventions on VA ECMO included PCI (n = 29), TAVI (n = 4) and EP (n = 1). Surgical interventions were cardiac (n = 36) or non-cardiac (n = 5). During PCI, ECMO flow was maintained at 2.7 ± 1.0 L/min. Of the 40 treated lesions, 48% were located on left anterior descending and 20% on the left main artery. An average 2.0 ± 1.8 DES/patient with diameter 3.2 ± 0.5 mm and stented length 41 ± 35 mm were implanted. PCI success was 83%. TAVI was performed in 4 patients with left ventricular ejection fraction 21 ± 10% and mean aortic valve gradient 41 ± 5 mmHg. After successful valve implantation supported by 1.4 ± 0.1 L/min ECMO flow, mean gradient decreased to 11 ± 5 mmHg without significant aortic regurgitation. In one patient radiofrequency ablation of His bundle followed by permanent pacemaker implantation was performed under ECMO flow of 2.8 L/min. Overall survival to hospital discharge with good neurological recovery was 29% in E-CPR and 44% in profound cardiogenic shock.
Conclusions
Our study showed feasibility and effectiveness of VA ECMO-supported percutaneous interventions in patients with profound hemodynamic collapse.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 27 Feb 2021; 160:150-157
Radsel P, Goslar T, Bunc M, Ksela J, Gorjup V, Noc M
Resuscitation: 27 Feb 2021; 160:150-157 | PMID: 33309699
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Abstract

Does a combination of ≥2 abnormal tests vs. the ERC-ESICM stepwise algorithm improve prediction of poor neurological outcome after cardiac arrest? A post-hoc analysis of the ProNeCA multicentre study.

Scarpino M, Lolli F, Lanzo G, Carrai R, ... Grippo A, Sandroni C
Background
Bilaterally absent pupillary light reflexes (PLR) or N20 waves of short-latency evoked potentials (SSEPs) are recommended by the 2015 ERC-ESICM guidelines as robust, first-line predictors of poor neurological outcome after cardiac arrest. However, recent evidence shows that the false positive rates (FPRs) of these tests may be higher than previously reported. We investigated if testing accuracy is improved when combining PLR/SSEPs with malignant electroencephalogram (EEG), oedema on brain computed tomography (CT), or early status myoclonus (SM).
Methods
Post-hoc analysis of ProNeCA multicentre prognostication study. We compared the prognostic accuracy of the ERC-ESICM prognostication strategy vs. that of a new strategy combining ≥2 abnormal results from any of PLR, SSEPs, EEG, CT and SM. We also investigated if using alternative classifications for abnormal SSEPs (absent-pathological vs. bilaterally-absent N20) or malignant EEG (ACNS-defined suppression or burst-suppression vs. unreactive burst-suppression or status epilepticus) improved test sensitivity.
Results
We assessed 210 adult comatose resuscitated patients of whom 164 (78%) had poor neurological outcome (CPC 3-5) at six months. FPRs and sensitivities of the ≥2 abnormal test strategy vs. the ERC-ESICM algorithm were 0[0-8]% vs. 7 [1-18]% and 49[41-57]% vs. 63[56-71]%, respectively (p < .0001). Using alternative SSEP/EEG definitions increased the number of patients with ≥2 concordant test results and the sensitivity of both strategies (67[59-74]% and 54[46-61]% respectively), with no loss of specificity.
Conclusions
In comatose resuscitated patients, a prognostication strategy combining ≥2 among PLR, SSEPs, EEG, CT and SM was more specific than the 2015 ERC-ESICM prognostication algorithm for predicting 6-month poor neurological outcome.

Copyright © 2020 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 27 Feb 2021; 160:158-167
Scarpino M, Lolli F, Lanzo G, Carrai R, ... Grippo A, Sandroni C
Resuscitation: 27 Feb 2021; 160:158-167 | PMID: 33338571
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Abstract

Software annotation of defibrillator files: Ready for prime time?

Gupta V, Schmicker RH, Owens P, Pierce AE, Idris AH
Background
High-quality chest compressions are associated with improved outcomes after cardiac arrest. Defibrillators record important information about chest compressions during cardiopulmonary resuscitation (CPR) and can be used in quality-improvement programs. Defibrillator review software can automatically annotate files and measure chest compression metrics. However, evidence is limited regarding the accuracy of such measurements.
Objective
To compare chest compression fraction (CCF) and rate measurements made with software annotation vs. manual annotation vs. limited manual annotation of defibrillator files recorded during out-of-hospital cardiac arrest (OHCA) CPR.
Methods
This was a retrospective, observational study of 100 patients who had CPR for OHCA. We assessed chest compression bioimpedance waveforms from the time of initial CPR until defibrillator removal. A reviewer revised software annotations in two ways: completely manual annotations and limited manual annotations, which marked the beginning and end of CPR and ROSC, but not chest compressions. Measurements were compared for CCF and rate using intraclass correlation coefficient (ICC) analysis.
Results
Case mean rate showed no significant difference between the methods (108.1-108.6 compressions per minute) and ICC was excellent (>0.90). The case mean (±SD) CCF for software, manual, and limited manual annotation was 0.64 ± 0.19, 0.86 ± 0.07, and 0.81 ± 0.10, respectively. The ICC for manual vs. limited manual annotation of CCF was 0.69 while for individual minute epochs it was 0.83.
Conclusion
Software annotation performed very well for chest compression rate. For CCF, the difference between manual and software annotation measurements was clinically important, while manual vs. limited manual annotation were similar with an ICC that was good-to-excellent.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 27 Feb 2021; 160:7-13
Gupta V, Schmicker RH, Owens P, Pierce AE, Idris AH
Resuscitation: 27 Feb 2021; 160:7-13 | PMID: 33388365
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Abstract

Diagnostic test accuracy of the initial electrocardiogram after resuscitation from cardiac arrest to indicate invasive coronary angiographic findings and attempted revascularization: A systematic review and meta-analysis.

McFadden P, Reynolds JC, Madder RD, Brown M
Aim
Conduct a diagnostic test accuracy systematic review and meta-analysis of the post-return of spontaneous circulation (ROSC) electrocardiogram (ECG) to indicate an acute-appearing coronary lesion and revascularization.
Methods
We searched PubMed, EMBASE, CINAHL, Cochrane Library, and Web of Science through February 18, 2020. Two investigators screened titles and abstracts, extracted data, and assessed risks of bias using QUADAS-2. We estimated sensitivity (Sn), specificity (Sp), and likelihood ratios (LR) for all reported ECG features to indicate all reported reference standards. Random-effects meta-analysis pooled comparable studies without critical risk of bias. GRADE methodology evaluated the certainty of evidence.
Results
Overall, 48 studies reported 94 combinations of ECG features and reference standards with wide variation in their definitions. Most studies had risks of bias from selection for coronary angiography and blinding to the ECG and/or reference standard. Meta-analysis combined 6 studies for STE and acute coronary lesion (Sn 0.70 [95% CI 0.54-0.82]; Sp 0.85 [95% CI 0.78-0.90]; LR + 4.7 [95% CI 3.3-6.7]; LR- 0.4 [95% CI 0.2-0.6]) and 4 studies for STE and revascularization (Sn 0.53 [95% CI 0.47-0.58]; Sp 0.86 [95% CI 0.80-0.91]; LR + 3.9 [95% CI 2.8-5.5]; LR- 0.5 [95% CI 0.5-0.6]). Overall certainty of evidence was low with substantial heterogeneity.
Conclusions
Based on low certainty evidence, STE had good classification for acute coronary lesion and fair classification for revascularization. STE was more specific than sensitive for these outcomes and no single ECG feature excluded them. Uniform definitions and terminology would greatly facilitate the interpretation of subsequent studies.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 27 Feb 2021; 160:20-36
McFadden P, Reynolds JC, Madder RD, Brown M
Resuscitation: 27 Feb 2021; 160:20-36 | PMID: 33444708
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Impact:
Abstract

\'I think he\'s dead\': A cohort study of the impact of caller declarations of death during the emergency call on bystander CPR.

Riou M, Ball S, Morgan A, Gallant S, ... Bailey P, Finn J
Background
In emergency calls for out-of-hospital cardiac arrest (OHCA), dispatchers are instrumental in the provision of bystander cardiopulmonary resuscitation (CPR) through the recruitment of the caller. We explored the impact of caller perception of patient viability on initial recognition of OHCA by the dispatcher, rates of bystander CPR and early patient survival outcomes.
Methods
We conducted a retrospective cohort study of 422 emergency calls where OHCA was recognised by the dispatcher and resuscitation was attempted by paramedics. We used the call recordings, dispatch data, and electronic patient care records to identify caller statements that the patient was dead, initial versus delayed recognition of OHCA by the dispatcher, caller acceptance to perform CPR, provision of bystander-CPR, prehospital return of spontaneous circulation (ROSC), and ROSC on arrival at the Emergency Department.
Results
Initial recognition of OHCA by the dispatcher was more frequent in cases with a declaration of death by the caller than in cases without (92%, 73/79 vs. 66%, 227/343, p < 0.001). Callers who expressed such a view (19% of cases) were more likely to decline CPR (38% vs. 10%, adjusted odds ratio 4.59, 95% confidence interval 2.49-8.52, p < 0.001). Yet, 15% (12/79) of patients described as non-viable by callers achieved ROSC.
Conclusion
Caller statements that the patient is dead are helpful for dispatchers to recognise OHCA early, but potentially detrimental when recruiting the caller to perform CPR. There is an opportunity to improve the rate of bystander-CPR and patient outcomes if dispatchers are attentive to caller statements about viability.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 27 Feb 2021; 160:1-6
Riou M, Ball S, Morgan A, Gallant S, ... Bailey P, Finn J
Resuscitation: 27 Feb 2021; 160:1-6 | PMID: 33444705
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Abstract

Acute kidney injury after in-hospital cardiac arrest.

Mah KE, Alten JA, Cornell TT, Selewski DT, ... Dean JM, Moler FW
Aim
Determine 1) frequency and risk factors for acute kidney injury (AKI) after in-hospital cardiac arrest (IHCA) in the Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital (THAPCA-IH) trial and associated outcomes; 2) impact of temperature management on post-IHCA AKI.
Methods
Secondary analysis of THAPCA-IH; a randomized controlled multi-national trial at 37 children\'s hospitals.
Eligibility
Serum creatinine (Cr) within 24 h of randomization.
Outcomes
Prevalence of severe AKI defined by Stage 2 or 3 Kidney Disease Improving Global Outcomes Cr criteria. 12-month survival with favorable neurobehavioral outcome. Analyses stratified by entire cohort and cardiac subgroup. Risk factors and outcomes compared among cohorts with and without severe AKI.
Results
Subject randomization: 159 to hypothermia, 154 to normothermia. Overall, 80% (249) developed AKI (any stage), and 66% (207) developed severe AKI. Cardiac patients (204, 65%) were more likely to develop severe AKI (72% vs 56%,p = 0.006). Preexisting cardiac or renal conditions, baseline lactate, vasoactive support, and systolic blood pressure were associated with severe AKI. Comparing hypothermia versus normothermia, there were no differences in severe AKI rate (63% vs 70%,p = 0.23), peak Cr, time to peak Cr, or freedom from mortality or severe AKI (p = 0.14). Severe AKI was associated with decreased hospital survival (48% vs 65%,p = 0.006) and decreased 12-month survival with favorable neurobehavioral outcome (30% vs 53%,p < 0.001).
Conclusion
Severe post-IHCA AKI occurred frequently especially in those with preexisting cardiac or renal conditions and peri-arrest hemodynamic instability. Severe AKI was associated with decreased survival with favorable neurobehavioral outcome. Hypothermia did not decrease incidence of severe AKI post-IHCA.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 27 Feb 2021; 160:49-58
Mah KE, Alten JA, Cornell TT, Selewski DT, ... Dean JM, Moler FW
Resuscitation: 27 Feb 2021; 160:49-58 | PMID: 33450335
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Impact:
Abstract

Duration of exposure to a prehospital advanced airway and neurological outcome for out-of-hospital cardiac arrest: A retrospective cohort study.

Benoit JL, Stolz U, McMullan JT, Wang HE
Background
Out-of-hospital cardiac arrest (OHCA) studies have focused on the benefits and harms of placing an intra-arrest advanced airway, but few studies have evaluated the benefits and harms after successful placement. We hypothesize that increased time in the tumultuous prehospital environment after intra-arrest advanced airway placement results in reduced patient survival.
Methods
This was a secondary analysis of adult, non-traumatic, OHCA patients with an advanced airway placed in the PRIMED trial. The exposure variable was the time interval between successful advanced airway placement and Emergency Department (ED) arrival. The outcome was cerebral performance category (CPC) 1 or 2 at hospital discharge. Multivariable logistic regression, adjusted for Utstein variables and resuscitation-associated time intervals, was used to estimate adjusted odds ratios (aOR).
Results
The cohort of complete cases included 4779 patients. The median time exposed to a prehospital advanced airway was 27 min (IQR 20-35). The total prehospital time was 39.4 min (IQR 32.3-48.1). An advanced airway was placed intra-arrest in 3830 cases (80.1%) and post-return of spontaneous circulation (post-ROSC) in 949 cases (19.9%). Overall, 486 (10.2%) of the cohort achieved the CPC outcome, but this was higher in the post-ROSC (21.7%) versus intra-arrest (7.5%) cohort. CPC was not associated with the time interval from advanced airway placement to ED arrival in the intra-arrest airway cohort (aOR 0.98, 95%CI 0.94-1.01).
Conclusions
In OHCA patients who receive an intra-arrest advanced airway, longer time intervals exposed to a prehospital advanced airway are not associated with reduced patient survival.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 27 Feb 2021; 160:59-65
Benoit JL, Stolz U, McMullan JT, Wang HE
Resuscitation: 27 Feb 2021; 160:59-65 | PMID: 33482266
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Impact:
Abstract

Randomized blinded trial of automated REBOA during CPR in a porcine model of cardiac arrest.

Olsen MH, Olesen ND, Karlsson M, Holmlöv T, ... Mathiesen T, Møller K
Background
Resuscitative endovascular balloon occlusion of the aorta (REBOA) reportedly elevates arterial blood pressure (ABP) during non-traumatic cardiac arrest.
Objectives
This randomized, blinded trial of cardiac arrest in pigs evaluated the effect of automated REBOA two minutes after balloon inflation on ABP (primary endpoint) as well as arterial blood gas values and markers of cerebral haemodynamics and metabolism.
Methods
Twenty anesthetized pigs were randomized to REBOA inflation or sham-inflation (n = 10 in each group) followed by insertion of invasive monitoring and a novel, automated REBOA catheter (NEURESCUE® Catheter & NEURESCUE® Assistant). Cardiac arrest was induced by ventricular pacing. Cardiopulmonary resuscitation was initiated three min after cardiac arrest, and the automated REBOA was inflated or sham-inflated (blinded to the investigators) five min after cardiac arrest.
Results
In the inflation compared to the sham group, mean ABP above the REBOA balloon after inflation was higher (inflation: 54 (95%CI: 43-65) mmHg; sham: 44 (33-55) mmHg; P = 0.06), and diastolic ABP was higher (inflation: 38 (29-47) mmHg; sham: 26 (20-33) mmHg; P = 0.02), and the arterial to jugular oxygen content difference was lower (P = 0.04). After return of spontaneous circulation, mean ABP (inflation: 111 (95%CI: 94-128) mmHg; sham: 94 (95%CI: 65-123) mmHg; P = 0.04), diastolic ABP (inflation: 95 (95%CI: 78-113) mmHg; sham: 78 (95%CI: 50-105) mmHg; P = 0.02), CPP (P = 0.01), and brain tissue oxygen tension (inflation: 315 (95%CI: 139-491)% of baseline; sham: 204 (95%CI: 75-333)%; P = 0.04) were higher in the inflation compared to the sham group.
Conclusion
Inflation of REBOA in a porcine model of non-traumatic cardiac arrest improves central diastolic arterial pressure as a surrogate marker of coronary artery pressure, and cerebral perfusion.
Institutional protocol number
2017-15-0201-01371.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 27 Feb 2021; 160:39-48
Olsen MH, Olesen ND, Karlsson M, Holmlöv T, ... Mathiesen T, Møller K
Resuscitation: 27 Feb 2021; 160:39-48 | PMID: 33482264
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Impact:
Abstract

Analyze Whilst Compressing algorithm for detection of ventricular fibrillation during CPR: A comparative performance evaluation for automated external defibrillators.

Didon JP, Ménétré S, Jekova I, Stoyanov T, Krasteva V
Objective
The aim of this study was to present new combination of algorithms for rhythm analysis during cardiopulmonary resuscitation (CPR) in automated external defibrillators (AED), called Analyze Whilst Compressing (AWC), designed for decreasing pre-shock pause and early stopping of chest compressions (CC) for treating refibrillation.
Methods
Two stages for AED rhythm analysis were presented, namely, \"Standard Analysis Stage\" (conventional shock-advisory analysis run over 5 s after CC interruption every two minutes) and \"AWC Stage\" (two-step sequential analysis process during CPR). AWC steps were run in presence of CC (Step1), and if shockable rhythm was detected then a reconfirmation step was run in absence of CC (Step2, analysis duration 5 s).
Results
In total 16,057 ECG strips from 2916 out-of-hospital cardiac arrest (OHCA) patients treated with AEDs (DEFIGARD TOUCH7, Schiller Médical, France) were subjected patient-wise to AWC training (8559 strips, 1604 patients) and validation (7498 strips, 1312 patients). Considering validation results, \"Standard Analysis Stage\" presented ventricular fibrillation (VF) sensitivity Se = 98.3% and non-shockable rhythm specificity Sp>99%; \"AWC Stage\" decision after Step2 reconfirmation achieved Se = 92.1%, Sp>99%.
Conclusion
AWC presented similar performances to other AED algorithms during CPR, fulfilling performance goals recommended by standards. AWC provided advances in the challenge for improving CPR quality by: (i) not interrupting chest compressions for prevalent part of non-shockable rhythms (66-83%); (ii) minimizing pre-shock pause for 92.1% of VF patients. AWC required hands-off reconfirmation in 34.4% of cases. Reconfirmation was also common limitation of other reported algorithms (25.7-100%) although following different protocols for triggering chest compression resumption and shock delivery.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 27 Feb 2021; 160:94-102
Didon JP, Ménétré S, Jekova I, Stoyanov T, Krasteva V
Resuscitation: 27 Feb 2021; 160:94-102 | PMID: 33524490
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Impact:
Abstract

Long term outcomes of participants in the PARAMEDIC2 randomised trial of adrenaline in out-of-hospital cardiac arrest.

Haywood KL, Ji C, Quinn T, Nolan JP, ... O\'Shea L, Perkins GD
Aims
We recently reported early outcomes in patients enrolled in a randomised trial of adrenaline in out-of-hospital cardiac arrest: the PARAMEDIC2 (Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration in Cardiac Arrest) trial. The purpose of the present paper is to report long-term survival, quality of life, functional and cognitive outcomes at 3, 6 and 12-months.
Methods
PARAMEDIC2 was a pragmatic, individually randomised, double blind, controlled trial with an economic evaluation. Patients were randomised to either adrenaline or placebo. This paper reports results on the modified Rankin Scale scores at 6-months, survival at 6 and 12-months, as well as other cognitive, functional and quality of life outcomes collected at 3 and 6 months (Two Simple Questions, the Mini Mental State Examination, the Informant Questionnaire on Cognitive Decline Evaluation for Cardiac Arrest, Hospital Anxiety and Depression Scale, the Post Traumatic Stress Disorder Checklist - Civilian Version, Short-Form 12-item Health Survey and the EuroQoL EQ-5D-5L).
Results
8014 patients were randomised with confirmed trial drug administration. At 6-months, 78 (2.0%) of the patients in the adrenaline group and 58 (1.5%) of patients in the placebo group had a favourable neurological outcome (adjusted odds ratio 1.35 [95% confidence interval: 0.93, 1.97]). 117 (2.9%) patients were alive at 6-months in the adrenaline group compared with 86 (2.2%) in the placebo group (1.43 [1.05, 1.96], reducing to 107 (2.7%) and 80 (2.0%) respectively at 12-months (1.38 [1.00, 1.92]). Measures of 3 and 6-month cognitive, functional and quality of life outcomes were reduced, but there was no strong evidence of differences between groups.
Conclusion
Adrenaline improved survival through to 12-months follow-up. The study did not find evidence of improvements in favourable neurological outcomes. (ISCRTN 73485024).

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 27 Feb 2021; 160:84-93
Haywood KL, Ji C, Quinn T, Nolan JP, ... O'Shea L, Perkins GD
Resuscitation: 27 Feb 2021; 160:84-93 | PMID: 33524488
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Impact:
Abstract

Pediatric timing of epinephrine doses: A systematic review.

Ohshimo S, Wang CH, Couto TB, Bingham R, ... Morrison L, International Liaison Committee on Resuscitation (ILCOR) Pediatric Task Force
Aim
To evaluate the optimal timing and doses of epinephrine for Infants and children suffering in-hospital or out-of-hospital cardiac arrest.
Methods
We searched Medline, EMBASE, and Cochrane Controlled Register of Trials (CENTRAL) for human randomized clinical trials and observational studies including comparative cohorts. Two investigators reviewed relevance of studies, extracted the data, conducted meta-analyses and assessed the risk of bias using the GRADE and CLARITY frameworks. Authors of the eligible studies were contacted to obtain additional data. Critically important outcomes included return of spontaneous circulation, survival to hospital discharge and survival with good neurological outcome.
Results
We identified 7 observational studies suitable for meta-analysis and no randomized clinical trials. The overall certainty of evidence was very low. For the critically important outcomes, the earlier administration of epinephrine was favorable for both in-hospital and out-of-hospital cardiac arrest. Because of a limited number of eligible studies and the presence of severe confounding factors, we could not determine the optimal interval of epinephrine administration.
Conclusions
Earlier administration of the first epinephrine dose could be more favorable in non-shockable pediatric cardiac arrest. The optimal interval for epinephrine administration remains unclear.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 27 Feb 2021; 160:106-117
Ohshimo S, Wang CH, Couto TB, Bingham R, ... Morrison L, International Liaison Committee on Resuscitation (ILCOR) Pediatric Task Force
Resuscitation: 27 Feb 2021; 160:106-117 | PMID: 33529645
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Impact:
Abstract

Association between admission to a cardiac arrest centre and survival to hospital discharge for adults following out-of-hospital cardiac arrest: A multi-centre observational study.

von Vopelius-Feldt J, Perkins GD, Benger J
Aim
This study examined the association between admission to a cardiac arrest centre and survival to hospital discharge for adults following out-of-hospital cardiac arrest (OHCA).
Methods
We undertook a multicentre retrospective observational study of patients transferred to hospital after OHCA of presumed cardiac aetiology in three ambulance services in England. We used propensity score matching to compare rates of survival to hospital discharge in patients admitted to OHCA centres (defined as either 24/7 PPCI availability or >100 OHCA admissions per year) to rates of survival of patients admitted to non-centres.
Results
Between January 2017 and December 2018, 10,650 patients with OHCA were included in the analysis. After propensity score matching, admission to a hospital with 24/7 PPCI availability or a high volume centre was associated with an absolute improvement in survival to hospital discharge of 2.5% and 2.8%, respectively. The corresponding odds ratios and 95% confidence intervals were 1.69 (1.28-2.23) and 1.41 (1.14-1.75), respectively. The results were similar when missing values were imputed. In subgroup analyses, the association between admission to an OHCA centre and improved rates of survival was mainly seen in patients with OHCA due to shockable rhythms, with no or minimal potential benefit for patients with OHCA and asystole as first presenting rhythm.
Conclusion
Following OHCA, admission to a cardiac arrest centre is associated with a moderate improvement in survival to hospital discharge. A corresponding bypass policy would need to consider the resulting increased workload for OHCA centres.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 27 Feb 2021; 160:118-125
von Vopelius-Feldt J, Perkins GD, Benger J
Resuscitation: 27 Feb 2021; 160:118-125 | PMID: 33548360
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Impact:
Abstract

The effect of team and leadership training of advanced life support providers on patient outcomes: A systematic review.

Kuzovlev A, Monsieurs KG, Gilfoyle E, Finn J, Greif R, Education Implementation and Teams Task Force of the International Liaison Committee on Resuscitation
Aim
To conduct a systematic review evaluating improvement in team and leadership performance and resuscitation outcomes after such a training of healthcare providers during advanced life support (ALS) courses.
Methods
This systematic review asked the question of whether students taking structured and standardised ALS courses in an educational setting which include specific leadership or team training, compared to no such specific training in these courses, improves patient survival, skill performance in actual resuscitations, skill performance at 3-15 months (patient tasks, teamwork, leadership), skill performance at course conclusion (patient tasks, teamwork, leadership), or cognitive knowledge PubMed, Embase and the Cochrane database were searched until April 2020. Screening of articles, analysis of risk of bias, outcomes and quality assessment were performed according to the Grading of Recommendations Assessment, Development and Evaluation methodology. Only studies with abstracts in English were included.
Results
14 non-randomised studies and 17 randomised controlled trials, both in adults and children, and seven studies involving patients were included in this systematic review. No randomised controlled trials but three observational studies of team and leadership training showed improvement in the critical outcome of \"patient survival\". However, they suffered from risk of bias (indirectness and imprecision). The included studies reported many different methods to teach leadership skills and team behaviour.
Conclusion
This systematic review found very low certainty evidence that team and leadership training as part of ALS courses improved patient outcome. This supports the inclusion of team and leadership training in ALS courses for healthcare providers.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 27 Feb 2021; 160:126-139
Kuzovlev A, Monsieurs KG, Gilfoyle E, Finn J, Greif R, Education Implementation and Teams Task Force of the International Liaison Committee on Resuscitation
Resuscitation: 27 Feb 2021; 160:126-139 | PMID: 33556422
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Impact:
Abstract

QT interval dynamics and triggers for QT prolongation immediately following cardiac arrest.

Cohen RB, Dai M, Aizer A, Barbhaiya C, ... Chinitz L, Jankelson L
Background
The prolongation in QT interval typically observed following cardiac arrest is considered to be multifactorial and induced by external triggers such as hypothermia therapy and exposure to antiarrhythmic medications.
Objective
To evaluate the corrected QT interval (QTc) dynamics in the first 10 days following cardiac arrest with respect to the etiology of arrest, hypothermia and QT prolonging medications.
Methods
We enrolled 104 adult survivors of cardiac arrest, where daily ECG was available for at least 3 days. We followed their QT and QRS intervals for the first 10 days of hospitalization. We used both Bazett and Fridericia formulas to correct for heart rate. For patients with QRS < 120 we analyzed the QTc interval (n = 90) and for patients with QRS > 120 ms we analyzed the JTc (n = 104) vs. including only the narrow QRS samples (n = 89). We stratified patients by 3 groups: (1) presence of ischemic heart disease (IHD) (2) treatment with hypothermia protocol, and (3) treatment with QTc prolonging medications. Additionally, genetic information obtained during hospitalization was analyzed.
Results
QTc and JTc intervals were significantly prolonged in the first 6 days. Maximal QTc/JTc prolongation was observed in day 2 (QTcB = 497 ± 55). There were no differences in daily QTc/JTc and QRS intervals in the first 2 days post arrest between patients with or without hypothermia induction but such difference. All subgroups demonstrated significantly prolonged QTc/JTc interval regardless of the presence of IHD, hypothermia protocol or QTc prolonging medication exposure. Our results were consistent for both Bazetts\' and Frediricia correction and for any QRS duration. Prolongation of the JTcB beyond 382 ms after day 3 predicted sustained QTc/JTc prolongation beyond day 6 with an ROC of 0.78.
Conclusions
QTc/JTc interval is significantly and independently prolonged post SCA, regardless of known QT prolonging triggers. Normalization of the QTc post cardiac arrest should be expected only after day 6 of hospitalization. Assessment of the QTc for adjudication of the etiology of arrest or for monitoring the effect of QT prolonging medications may be unreliable.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 26 Feb 2021; epub ahead of print
Cohen RB, Dai M, Aizer A, Barbhaiya C, ... Chinitz L, Jankelson L
Resuscitation: 26 Feb 2021; epub ahead of print | PMID: 33652119
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Impact:
Abstract

Video laryngoscopy for out of hospital cardiac arrest.

Huebinger RM, Stilgenbauer H, Jarvis JL, Ostermayer D, Schulz K, Wang HE
Introduction
Endotracheal intubation is an import component of out-of-hospital cardiac arrest (OHCA) resuscitation. In this analysis, we evaluate the association of video laryngoscopy (VL) with first pass success and return of spontaneous circulation (ROSC) using a national OHCA cohort.
Methods
We analyzed 2018 data from ESO Inc. (Austin, TX), a national prehospital electronic health record. We included all adult, non-traumatic cardiac arrests undergoing endotracheal intubation. We defined VL and direct laryngoscopy (DL) based on paramedic recorded intubation device. The primary outcomes were first pass success, ROSC, and sustained ROSC. Using multivariable, mixed models, we determined the association between VL and first pass success rate, ROSC, and sustained ROSC (survival to ED or ROSC in the field for greater than 20 minutes), fitting agency as a random intercept and adjusting for confounders.
Results
We included 22,132 patients cared for by 914 EMS agencies, including 5,702 (25.7%) VL and 16,430 (74.2%) DL. Compared to DL, VL had a lower rate of bystander CPR, but other characteristics were similar between the groups. VL exhibited higher first pass success than DL (75.1% v 69.5%, p < .001). On mixed model analysis, VL was associated with a higher first pass success (OR 1.5, CI 1.3-1.6) but not ROSC (OR 1.1, CI 0.97-1.2) or sustained ROSC (OR 1.1, CI 0.9-1.2).
Conclusion
While associated with higher FPS, VL was not associated with increased rate of ROSC. The role of VL in OHCA remains unclear.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 24 Feb 2021; epub ahead of print
Huebinger RM, Stilgenbauer H, Jarvis JL, Ostermayer D, Schulz K, Wang HE
Resuscitation: 24 Feb 2021; epub ahead of print | PMID: 33640431
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Impact:
Abstract

Long-term survival among OHCA patients who survive to 30 days: Does initial arrest rhythm remain a prognostic determinant?

Majewski D, Ball S, Bailey P, Bray J, Finn J
Objective
To determine whether initial cardiac arrest rhythm remains a prognostic determinant in longer term OHCA survival.
Methods
The St John Western Australian OHCA database was used to identify adults who survived for at least 30 days after an OHCA of presumed medical aetiology, in the Perth metropolitan area between 1998 and 2017. Associations between 8-year OHCA survival and variables of interest were analysed using a Multi-Resolution Hazard (MRH) estimator model with 1-year intervals.
Results
Of the 871 OHCA patients who survived 30 days, 718 (82%) presented with a shockable initial arrest rhythm and 153 (18%) presented with a non-shockable rhythm. Compared to patients with initial shockable arrests, patients with non-shockable arrests experienced increased mortality in the first (HR 3.33, 95% CI 2.12-5.32), second (HR 2.58, 95% CI 1.22-5.15), third (HR 2.21, 95% CI 1.02-4.42) and fourth (HR 2.21, 95% CI 1.02-4.42) year post arrest; however, in subsequent years the initial arrest rhythm ceased to be significantly associated with survival. The overall 8-year survival estimates after adjustment for peri-arrest factors (as potential confounders) were 87% (95% CI 77-93%) for shockable arrests and 73% (95% CI 55-86%) for non-shockable arrests.
Conclusions
Patients with non-shockable (as opposed to shockable) initial arrest rhythms experienced higher mortality in the first 4-years following their OHCA; however, after four years the initial arrest rhythm ceased to be associated with survival.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 24 Feb 2021; epub ahead of print
Majewski D, Ball S, Bailey P, Bray J, Finn J
Resuscitation: 24 Feb 2021; epub ahead of print | PMID: 33640430
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Impact:
Abstract

Machine learning-based dispatch of drone-delivered defibrillators for out-of-hospital cardiac arrest.

Chu J, Leung KHB, Snobelen P, Nevils G, ... Cheskes S, Chan TCY
Background
Drone-delivered defibrillators have the potential to significantly reduce response time for out-of-hospital cardiac arrest (OHCA). However, optimal policies for the dispatch of such drones are not yet known. We sought to develop dispatch rules for a network of defibrillator-carrying drones.
Methods
We identified all suspected OHCAs in Peel Region, Ontario, Canada from Jan. 2015 to Dec. 2019. We developed drone dispatch rules based on the difference between a predicted ambulance response time to a calculated drone response time for each OHCA. Ambulance response times were predicted using linear regression and neural network models, while drone response times were calculated using drone specifications from recent pilot studies and the literature. We evaluated the dispatch rules based on response time performance and dispatch decisions, comparing them to two baseline policies of never dispatching and always dispatching drones.
Results
A total of 3,573 suspected OHCAs were included in the study with median and mean historical ambulance response times of 5.8 and 6.2 minutes. All machine learning-based dispatch rules significantly reduced the median response time to 3.9 minutes and mean response time to 4.1-4.2 minutes (all P < 0.001) and were non-inferior to universally dispatching drones (all P < 0.001) while reducing the number of drone flights by up to 30%. Dispatch rules with more drone flights achieved higher sensitivity but lower specificity and accuracy.
Conclusion
Machine learning-based dispatch rules for drone-delivered defibrillators can achieve similar response time reductions as universal drone dispatch while substantially reducing the number of trips.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 21 Feb 2021; epub ahead of print
Chu J, Leung KHB, Snobelen P, Nevils G, ... Cheskes S, Chan TCY
Resuscitation: 21 Feb 2021; epub ahead of print | PMID: 33631293
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Impact:
Abstract

Impact of a trauma-focused resuscitation protocol on survival outcomes after traumatic out-of-hospital cardiac arrest: an interrupted time series analysis.

Alqudah Z, Nehme Z, Williams B, Oteir A, Bernard S, Smith K
Aim
In this study, we examine the impact of a trauma-focused resuscitation protocol on survival outcomes following adult traumatic out-of-hospital cardiac arrest (OHCA).
Methods
We included adult traumatic OHCA patients aged >16 years occurring between 2008 and 2019. In December 2016, a new resuscitation protocol for traumatic OHCA was introduced prioritising the treatment of potentially reversible causes before conventional cardiopulmonary resuscitation (CPR). The effect of the new protocol on survival outcomes was assessed using adjusted interrupted time series regression.
Results
Over the study period, paramedics attempted resuscitation on 996 patients out of 3,958 attended cases. Of the treated cases, 672 (67.5%) and 324 (32.5%) occurred during pre-intervention and intervention periods, respectively. The frequency of almost all trauma interventions was significantly higher in the intervention period, including external haemorrhage control (15.7% vs 7.6; p-value <0.001), blood administration (3.8% vs 0.2%; p-value <0.001), and needle thoracostomy (75.9% vs 42.0%; p-value <0.001). There was also a significant reduction in the median time from initial patient contact to the delivery of needle thoracostomy (4.4 minutes vs 8.7 minutes; p-value <0.001) and splinting (8.7 minutes vs 17.5 minutes; p-value = 0.009). After adjustment, the trauma-focused resuscitation protocol was not associated with a change in the level of survival to hospital discharge (adjusted odds ratio [AOR] 0.98; 95% confidence interval [CI]: 0.11-8.59), event survival (AOR 0.82; 95% CI: 0.33-2.03), or prehospital return of spontaneous circulation (AOR 1.30; 95% CI: 0.61-2.76).
Conclusion
Despite an increase in trauma-based interventions and a reduction in the time to their administration, our study did not find a survival benefit from a trauma-focused resuscitation protocol over initial conventional CPR. However, survival was low with both approaches.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 21 Feb 2021; epub ahead of print
Alqudah Z, Nehme Z, Williams B, Oteir A, Bernard S, Smith K
Resuscitation: 21 Feb 2021; epub ahead of print | PMID: 33631292
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Impact:
Abstract

Biomarker prognostication of cognitive impairment may be feasible even in out-of hospital cardical arrest survivors with good neurological outcome.

Brønnick K, Evald L, Valdemar Duez CH, Grejs AM, ... Nielsen JF, Søreide E
Background
Patients surviving out-of hospital cardicac arrest, with good neurological outcome according to Cerebral Performance Category, frequently have neuropsychological impairment. We studied whether biomarker data (S-100b and neuron-specific enolase) obtained during the ICU stay predicted cognitive impairment 6 months after resuscitation.
Methods
Patients (N = 79) with a CPC-score ≤2 were recruited from two trial sites taking part in the TTH48 trial comparing targeted temperature management (TTM) for 48 hours vs. 24 hours at 33 ± 1 °C. We assessed patients 6 months after the OHCA. We measured biomarkers S-100b and NSE at arrival and at 24, 48 and 72 hours after reaching the target temperature of 33 ± 1 °C. Four cognitive domain z-scores were calculated, and global cognitive impairment was defined as z<-1.67 on at least 3 out of 13 cognitive tests. Non-parametric correlations were used to assess the relationship between cognitive domain and biomarkers. ROC curves were used to assess prediction of cognitive impairment from the biomarkers. Logistic regression was used to investigate whether TTM duration moderated biomarker prediction of cognitive impairment.
Results
Cognitive impairment was present in 22% of the patients with memory impairment being the most common. The biomarkers correlated significantly with several cognitive domain scores and NSE at 48 hours predicted cognitive impairment with 100% sensitivity and 56% specificity. The predictive properties of NSE at 48 hours was unaffected by duration of TTM.
Conclusions
Early biomarker prognostication of cognitive impairment is feasible even in OHCA survivors with good neurological outcome as defined by CPC. NSE at 48 hours predicted cognitive impairment.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 21 Feb 2021; epub ahead of print
Brønnick K, Evald L, Valdemar Duez CH, Grejs AM, ... Nielsen JF, Søreide E
Resuscitation: 21 Feb 2021; epub ahead of print | PMID: 33631291
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Impact:
Abstract

Prognostic value of signs of life throughout cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest.

Debaty G, Lamhaut L, Aubert R, Nicol M, ... Chouihed T, Labarère J
Purpose
Prognostication of refractory out-of-hospital cardiac arrest (OHCA) is essential for selecting the population that may benefit from extracorporeal cardiopulmonary resuscitation (ECPR). We aimed to examine the prognostic value of signs of life before or throughout conventional CPR for individuals undergoing ECPR for refractory OHCA.
Methods
Pooling the original data from three cohort studies, we estimated the prevalence of signs of life, for individuals with refractory OHCA resuscitated with ECPR. We performed multivariable logistic regression to examine the independent associations between the occurrence of signs of life and 30-day survival with a CPC score ≤ 2.
Results
The analytical sample consisted of 434 ECPR recipients. The prevalence of any sign of life was 61%, including pupillary light reaction (48%), gasping (32%), or increased level of consciousness (13%). Thirty-day survival with favorable neurological outcome was 15% (63/434). In multivariable analysis, the adjusted odds ratios of 30-day survival with favorable neurological outcome were 7.35 (95% confidence interval [CI], 2.71-19.97), 5.86 (95% CI, 2.28-15.06), 4.79 (95% CI, 2.16-10.63), and 1.75 (95% CI, 0.95-3.21) for any sign of life, pupillary light reaction, increased level of consciousness, and gasping, respectively.
Conclusion
The assessment of signs of life before or throughout CPR substantially improves the accuracy of a multivariable prognostic model in predicting 30-day survival with favorable neurological outcome. The lack of any sign of life might obviate the provision of ECPR for patients without shockable cardiac rhythm.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 16 Feb 2021; epub ahead of print
Debaty G, Lamhaut L, Aubert R, Nicol M, ... Chouihed T, Labarère J
Resuscitation: 16 Feb 2021; epub ahead of print | PMID: 33609608
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Impact:
Abstract

Targeted temperature management after cardiac arrest. A systematic review and meta-analysis of animal studies.

Arrich J, Herkner H, Müllner D, Behringer W
Aim
Animal studies are an important knowledge base when information from clinical trials is missing or conflicting. The goal of this systematic review and meta-analysis was to investigate the effect of conventional targeted temperature management (TTM) between 32-36 °C in animal cardiac arrest models, and to estimate the influence of effect modifiers on the pooled effect of TTM.
Data sources
We searched Medline and Scopus from inception to May 2020 for randomised controlled animal trials assessing the effect of conventional TTM versus normothermia on neurologic outcome after cardiac arrest. We extracted data on study characteristics, study quality data, neurologic outcome, mortality, and potential effect modifiers.
Results
We retrieved 1635 studies, 45 studies comprising data of 981 animals met the inclusion criteria. Risk of bias was high in 17 studies and moderate in 28 studies. We undertook random-effects meta-analyses and meta-regression analyses to calculate the pooled effect and the influence of effect modifiers. There was a strong beneficial effect of TTM as compared to normothermia on neurologic outcome (standardised mean difference of 1.4 [95% CI -1.7 to -1.1; I2 = 75%]). Faster cooling rates, lower target temperature of TTM within the range of 32-36 °C, and shorter duration of cooling were independently associated with an increasing effect size of TTM.
Conclusions
This systematic review of animal cardiac arrest studies showed a consistent favourable effect of postresuscitation TTM as compared to normothermia on neurologic outcome that increased with lower target temperatures.

Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.

Resuscitation: 11 Feb 2021; 162:47-55
Arrich J, Herkner H, Müllner D, Behringer W
Resuscitation: 11 Feb 2021; 162:47-55 | PMID: 33582259
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Impact:
Abstract

Thermoregulation in post-cardiac arrest patients treated with targeted temperature management.

Hoeyer-Nielsen AK, Holmberg MJ, Christensen EF, Cocchi MN, Donnino MW, Grossestreuer AV
Objective
Evaluate the relationship between heat generation during rewarming in post-cardiac arrest patients receiving targeted temperature management (TTM) as a surrogate of thermoregulatory ability and clinical outcomes.
Methods
This is a prospective observational single-centre study conducted at an urban tertiary-care hospital. We included post-cardiac arrest adults who received TTM via surface cooling device between April 2018 and June 2019.
Results
Patient heat generation was calculated by multiplying the inverse of the average machine water temperature with time to rewarm to 37 °C and standardized in two ways to account for target temperature variation: (1) divided by number of degrees between target temperature and 37 °C, and (2) limited to when patient was rewarmed from 36 °C to 37 °C. The primary outcome was poor neurologic status, defined as Cerebral Performance Category (CPC) score 3-5, and the secondary outcome was 30-day survival. Sixty-six patients were included: 45 (68%) had a CPC-score of 3-5 and 23 (35%) were alive at 30 days. Besides initial rhythm and arrest downtime, baseline characteristics were similar between outcomes. Heat generation was not associated with poor neurological outcome (CPC 3-5: 6.6 [IQR: 6.1, 7.4] versus CPC 1-2: 6.6 [IQR: 5.7, 7.6], p = 0.89) or survival at 30 days (non-survivors: 6.6 [IQR: 6.6, 7.4] vs. survivors: 6.6 [IQR: 5.7, 8.0, p = 0.78]).
Conclusion
Heat generation during rewarming was not associated with neurologic outcomes. However, there was a relationship between poor neurological outcome and higher median water temperatures. Time to rewarm was prolonged in patients with poor neurological outcome.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 11 Feb 2021; 162:63-69
Hoeyer-Nielsen AK, Holmberg MJ, Christensen EF, Cocchi MN, Donnino MW, Grossestreuer AV
Resuscitation: 11 Feb 2021; 162:63-69 | PMID: 33582256
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Impact:
Abstract

Airway strategy and chest compression quality in the Pragmatic Airway Resuscitation Trial.

Wang HE, Jaureguibeitia X, Aramendi E, Jarvis JL, ... Suchting R, Idris AH
Background
Chest compression (CC) quality is associated with improved out-of-hospital cardiopulmonary arrest (OHCA) outcomes. Airway management efforts may adversely influence CC quality. We sought to compare the effects of initial laryngeal tube (LT) and initial endotracheal intubation (ETI) airway management strategies upon chest compression fraction (CCF), rate and interruptions in the Pragmatic Airway Resuscitation Trial (PART).
Methods
We analyzed CPR process files collected from adult OHCA enrolled in PART. We used automated signal processing techniques and a graphical user interface to calculate CC quality measures and defined interruptions as pauses in chest compressions longer than 3 s. We determined CC fraction, rate and interruptions (number and total duration) for the entire resuscitation and compared differences between LT and ETI using t-tests. We repeated the analysis stratified by time before, during and after airway insertion as well as by successive 3-min time segments. We also compared CC quality between single vs. multiple airway insertion attempts, as well as between bag-valve-mask (BVM-only) vs. ETI or LT.
Results
Of 3004 patients enrolled in PART, CPR process data were available for 1996 (1001 LT, 995 ETI). Mean CPR analysis duration were: LT 22.6 ± 10.8 min vs. ETI 25.3 ± 11.3 min (p < 0.001). Mean CC fraction (LT 88% vs. ETI 87%, p = 0.05) and rate (LT 114 vs. ETI 114 compressions per minute (cpm), p = 0.59) were similar between LT and ETI. Median number of CC interruptions were: LT 11 vs. ETI 12 (p = 0.001). Total CC interruption duration was lower for LT than ETI (LT 160 vs. ETI 181 s, p = 0.002); this difference was larger before airway insertion (LT 56 vs. ETI 78 s, p < 0.001). There were no differences in CC quality when stratified by 3-min time epochs.
Conclusion
In the PART trial, compared with ETI, LT was associated with shorter total CC interruption duration but not other CC quality measures. CC quality may be associated with OHCA airway management.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 10 Feb 2021; 162:93-98
Wang HE, Jaureguibeitia X, Aramendi E, Jarvis JL, ... Suchting R, Idris AH
Resuscitation: 10 Feb 2021; 162:93-98 | PMID: 33582258
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Impact:
Abstract

The effect of alternative methods of cardiopulmonary resuscitation - Cough CPR, percussion pacing or precordial thump - on outcomes following cardiac arrest. A systematic review.

Dee R, Smith M, Rajendran K, Perkins GD, ... Vaillancourt C, International Liaison Committee on Resuscitation Basic Life Support Task Force Collaborators
Background
Cardiopulmonary resuscitation (CPR) improves cardiac arrest survival. Cough CPR, percussion pacing and precordial thump have been reported as alternative CPR techniques. We aimed to summarise in a systematic review the effectiveness of these alternative CPR techniques.
Methods
We searched Ovid MEDLINE, EMBASE and the Cochrane Library on 24/08/2020. We included randomised controlled trials, observational studies and case series with five or more patients. Two reviewers independently reviewed title and abstracts to identify studies for full-text review, and reviewed bibliographies and \'related articles\' (using PubMed) of full-texts for further eligible studies. We extracted data and performed risk-of-bias assessments on studies included in the systematic review. We summarised data in a narrative synthesis, and used GRADE to assess evidence certainty.
Results
We included 23 studies (cough CPR n = 4, percussion pacing n = 4, precordial thump n = 16; one study studied two interventions). Only two (both precordial thump) had a comparator group (\'standard\' CPR). For all techniques evidence certainty was very low. Available evidence suggests that precordial thump does not improve survival to hospital discharge in out-of-hospital cardiac arrest. The review did not find evidence that cough CPR or percussion pacing improve clinical outcomes following cardiac arrest.
Conclusion
Cough CPR, percussion pacing and precordial thump should not be routinely used in established cardiac arrest. In specific inpatient, monitored settings cough CPR (in conscious patients) or percussion pacing may be attempted at the onset of a potential lethal arrhythmia. These must not delay standard CPR efforts in those who lose cardiac output.
Prospero registration number
CRD42019152925.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 10 Feb 2021; 162:73-81
Dee R, Smith M, Rajendran K, Perkins GD, ... Vaillancourt C, International Liaison Committee on Resuscitation Basic Life Support Task Force Collaborators
Resuscitation: 10 Feb 2021; 162:73-81 | PMID: 33582257
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Impact:
Abstract

Comparison of femoral and carotid arteries in terms of pulse check in cardiopulmonary resuscitation: A prospective observational study.

Yılmaz G, Bol O
Background
There is no gold standard pulse localisation for pulse check in cardiopulmonary resuscitation.
Aim
To compare the femoral and carotid arteries in terms of pulse check in cardiopulmonary resuscitation and recommend the most appropriate pulse localisation in advanced life support guidelines and cardiopulmonary resuscitation training programmes.
Materials and methods
We prospectively conducted the study with patients who developed non-traumatic cardiopulmonary arrest between September 2018 and March 2019. The pulse check team was established and divided into two groups, A and B. Both carotid and femoral arteries were checked simultaneously for pulse by members of groups A and B, with the groups alternating between sites to avoid bias. We used some criteria to make pulse detection more effective. These were ETCO2, rhythm and cardiac ultrasonography.
Results
We evaluated 1289 pulse checks in 102 patients. As a result of the statistical analysis with manual palpations and pulses criteria, which we used to detected the presence of a pulse in CPR, we found that the sensitivity of the carotid artery was significantly higher than that of the femoral artery (p = 0.017), with almost identical specificities.
Conclusion
The carotid artery should be recommended as the gold standard localisation for pulse checks in cardiopulmonary resuscitation in CPR training programmes and ACLS guidelines.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 10 Feb 2021; 162:56-62
Yılmaz G, Bol O
Resuscitation: 10 Feb 2021; 162:56-62 | PMID: 33582255
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Impact:
Abstract

Age-Related Cognitive Bias in In-Hospital Cardiac Arrest.

Holmberg MJ, Granfeldt A, Moskowitz A, Andersen LW, American Heart Association\'s Get With The Guidelines-Resuscitation Investigators
Aims
Cognitive bias has been recognized as a potential source of medical error as it may affect clinical decision making. In this study, we explored how cognitive bias, specifically left-digit bias, may affect patient outcomes in in-hospital cardiac arrest.
Methods
Using the Get With The Guidelines® - Resuscitation registry, we included adult patients with an in-hospital cardiac arrest from 2011 to 2019. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation, favorable neurological outcome, and duration of resuscitation. Using a regression discontinuity design, we explored whether there was a sudden change in survival at the age threshold of 80 years which would indicate left-digit bias. Additional analyses were performed at age thresholds of 60, 70, and 90 years.
Results
A total of 26,784 patients were included for the primary analysis. The overall survival was 22% in this cohort. There was no discontinuity of survival below and above the age of 80 years (risk difference, 0.47%; 95%CI, -1.61% to 2.56%). Similar results were estimated for the secondary outcomes and for the age thresholds of 60, 70, and 90 years. The results were consistent in sensitivity analyses.
Conclusions
There was no indication that cognitive bias based on age affected outcomes in in-hospital cardiac arrest in these data.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 10 Feb 2021; epub ahead of print
Holmberg MJ, Granfeldt A, Moskowitz A, Andersen LW, American Heart Association's Get With The Guidelines-Resuscitation Investigators
Resuscitation: 10 Feb 2021; epub ahead of print | PMID: 33582254
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Impact:
Abstract

Use and Coverage of Automated External Defibrillators According to Location in Out-of-Hospital Cardiac Arrest.

Sarkisian L, Mickley H, Schakow H, Gerke O, ... Jørgensen G, Henriksen FL
Aims
To evaluate 1) the relative use of automated external defibrillators (AEDs) at different types of AED locations 2) the percentage of AEDs crossing location types during OHCA before use 3) the AED coverage distance at different types of AED locations, and 4) the 30-day-survival in different subgroups.
Methods
From 2014-2018, AEDs used by bystanders during out-of-hospital cardiac arrest (OHCA) in the Region of Southern Denmark were collected. Data regarding registered AEDs was retrieved from the national AED-network. The OHCA site and AED placement was categorized into; 1) Residential; 2) Public; 3) Nursing home, 4) Company/workplace; 5) Institution; 6) Health clinic and 7) Sports facility/recreational. To evaluate 30-day-survival, groups 4-7 were pooled into one Mixed group.
Results
In total 509 OHCAs were included. There was high relative usage of AEDs from public places, nursing homes, health clinics and sports facilities, and low relative usage from companies/workplaces, residential areas and institutions. Of AEDs used during residential OHCAs 39% were collected from public places. AEDs placed in residential areas and public places had a coverage of 575 meters (IQR 130-1300) and 270 meters (IQR5-550), respectively. Thirty-day- survival in public, residential and mixed groups were 49%, 14% and 67%, respectively.
Conclusion
The relative use of AEDs from public places, nursing homes, sports facilities and health clinics was high, and AEDs used during OHCA in residential areas were most frequently collected from public places. AEDs placed in both residential areas and public places may have a wider coverage area than proposed in current literature.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 09 Feb 2021; epub ahead of print
Sarkisian L, Mickley H, Schakow H, Gerke O, ... Jørgensen G, Henriksen FL
Resuscitation: 09 Feb 2021; epub ahead of print | PMID: 33581227
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Impact:
Abstract

Outcome in refractory out-of-hospital cardiac arrest before and after implementation of an ECPR protocol.

Alm-Kruse K, Sørensen G, Osbakk SA, Sunde K, ... Hagen OA, Kramer-Johansen J
Aim
To compare the outcomes in patients with refractory out-of-hospital cardiac arrest (OHCA) fulfilling the criteria for extracorporeal cardiopulmonary resuscitation (ECPR) before and after implementation of an ECPR protocol, whether the patient received ECPR or not.
Methods
We compared cardiac arrest registry data before (2014-2015) and after (2016-2019) implementation of the ECPR protocol. The ECPR criteria were presumed cardiac origin, witnessed arrest with ventricular fibrillation, bystander CPR, age 18-65, advanced life support (ALS) within 15 min and ALS > 10 min without return of spontaneous circulation (ROSC). The primary outcome was 30-day survival; the secondary outcomes were sustained ROSC, neurological outcome and the proportion of patients transported with ongoing ALS.
Results
There were 1086 and 3135 patients in the pre- and post-implementation sample; 48 (4%) and 100 (3%) met the ECPR criteria, respectively. Of these, 21 (44%) vs. 37 (37%) were alive after 30 days, p = 0.4, and 30 (63%) vs. 50 (50%) achieved sustained ROSC, p = 0.2. All survivors in the pre-implementation sample had cerebral performance category 1-2 vs. 30 (81%) in the post-implementation sample, p = 0.03. Of the patients fulfilling the ECPR criteria, 7 (15%) and 26 (26%), p = 0.1, were transported with ongoing ALS in the pre- and post-implementation sample, respectively.
Conclusions
There were no differences in 30-day survival or prehospital ROSC in patients with refractory OHCA before and after initiation of an ECPR protocol.

Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.

Resuscitation: 09 Feb 2021; 162:35-42
Alm-Kruse K, Sørensen G, Osbakk SA, Sunde K, ... Hagen OA, Kramer-Johansen J
Resuscitation: 09 Feb 2021; 162:35-42 | PMID: 33581226
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Impact:
Abstract

Family presence during resuscitation in paediatric and neonatal cardiac arrest: A systematic review.

Dainty KN, Atkins DL, Breckwoldt J, Maconochie I, ... Furuta M, International Liaison Committee on Resuscitation’s (ILCOR) Pediatric and Neonatal Life Support Task Forces
Context
Parent/family presence at pediatric resuscitations has been slow to become consistent practice in hospital settings and has not been universally implemented. A systematic review of the literature on family presence during pediatric and neonatal resuscitation has not been previously conducted.
Objective
To conduct a systematic review of the published evidence related to family presence during pediatric and neonatal resuscitation.
Data sources
Six major bibliographic databases was undertaken with defined search terms and including literature up to June 14, 2020.
Study selection
3200 titles were retrieved in the initial search; 36 ultimately included for review.
Data extraction
Data was double extracted independently by two reviewers and confirmed with the review team. All eligible studies were either survey or interview-based and as such we turned to narrative systematic review methodology.
Results
The authors identified two key sets of findings: first, parents/family members want to be offered the option to be present for their child\'s resuscitation. Secondly, health care provider attitudes varied widely (ranging from 15% to >85%), however, support for family presence increased with previous experience and level of seniority.
Limitations
English language only; lack of randomized control trials; quality of the publications.
Conclusions
Parents wish to be offered the opportunity to be present but opinions and perspectives on the family presence vary greatly among health care providers. This topic urgently needs high quality, comparative research to measure the actual impact of family presence on patient, family and staff outcomes.
Prospero registration number
CRD42020140363.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 08 Feb 2021; 162:20-34
Dainty KN, Atkins DL, Breckwoldt J, Maconochie I, ... Furuta M, International Liaison Committee on Resuscitation’s (ILCOR) Pediatric and Neonatal Life Support Task Forces
Resuscitation: 08 Feb 2021; 162:20-34 | PMID: 33577966
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Impact:
Abstract

Bystander interventions and survival following out-of-hospital cardiac arrest at Copenhagen International Airport.

Gantzel Nielsen C, Andelius LC, Hansen CM, Blomberg SNF, ... Ringgren KB, Folke F
Aim
To examine incidence and outcome following out-of-hospital cardiac (OHCA) arrest in a high-risk area characterised by high density of potential bystanders and easy access to nearby automated external defibrillators (AEDs).
Methods
This retrospective observational study investigated pre-hospital and in-hospital treatment, as well as survival amongst persons with OHCA at Copenhagen International Airport between May 25, 2015 and May 25, 2019. OHCA data from pre- and in-hospital medical records were obtained and compared with public bystander witnessed OHCAs in Denmark.
Results
Of the 23 identified non-traumatic OHCAs, 91.3% were witnessed by bystanders, 73.9% received bystander cardiopulmonary resuscitation (CPR), and 43.5% were defibrillated by a bystander. Survival to hospital discharge was 56.5%, with 100% survival among persons with an initial shockable heart rhythm. Compared with nationwide bystander witnessed OHCAs, persons with OHCA at the airport were less likely to receive bystander CPR (73.9% vs. 89.4%, OR 0.33; 95% CI, 0.13-0.86), more likely to receive bystander defibrillation (43.5% vs. 24.8%, OR 2.32; 95% CI, 1.01-5.31), to achieve return of spontaneous circulation (78.2% vs. 50.6%, OR 3.51; 95% CI, 1.30-9.49), and survive to hospital discharge (56.5% vs. 45.2%, OR 1.58; 95% CI, 0.69-3.62).
Conclusion
We found a high proportion of bystander defibrillation indicating that bystanders will quickly apply an AED, when accessible. Importantly, 56% of all persons, and all persons with a shockable heart rhythm survived. These findings suggest increased potential for survival following OHCA and support current guidelines to strategically deploy accessible AEDs in high-risk OHCA areas.

Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.

Resuscitation: 08 Feb 2021; epub ahead of print
Gantzel Nielsen C, Andelius LC, Hansen CM, Blomberg SNF, ... Ringgren KB, Folke F
Resuscitation: 08 Feb 2021; epub ahead of print | PMID: 33577965
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Impact:
Abstract

Ubiquinol (reduced coenzyme Q10) as a metabolic resuscitator in post-cardiac arrest: A randomized, double-blind, placebo-controlled trial.

Holmberg MJ, Andersen LW, Moskowitz A, Berg KM, ... Kirkegaard H, Donnino MW
Introduction
Ubiquinol (reduced coenzyme Q10) is essential for adequate aerobic metabolism. The objective of this trial was to determine whether ubiquinol administration in patients resuscitated from cardiac arrest could increase physiological coenzyme Q10 levels, improve oxygen consumption, and reduce neurological biomarkers of injury.
Materials and methods
This was a randomized, double-blind, placebo-controlled trial in patients successfully resuscitated from cardiac arrest. Patients were randomized to receive enteral ubiquinol (300 mg) or placebo every 12 h for up to 7 days. The primary endpoint was total coenzyme Q10 plasma levels at 24 h after enrollment. Secondary endpoints included neuron specific enolase, S100B, lactate, cellular and global oxygen consumption, neurological status, and in-hospital mortality.
Results
Forty-three patients were included in the modified intention-to-treat analysis. Median coenzyme Q10 levels were significantly higher in the ubiquinol group as compared to the placebo group at 24 h (441 [IQR, 215-510] ηg/mL vs. 113 [IQR, 94-208] ηg/mL, P < 0.001). Similar results were observed at 48 and 72 h. There were no differences between the two groups in any of the secondary endpoints. Median neuron specific enolase levels were not different between the two groups at 24 h (16.8 [IQR, 9.5-19.8] ηg/mL vs. 8.2 [IQR, 4.3-19.1] ηg/mL, P = 0.61).
Conclusions
Administration of enteral ubiquinol increased plasma coenzyme Q10 levels in post-cardiac arrest patients as compared to placebo. There were no differences in neurological biomarkers and oxygen consumption between the two groups.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 08 Feb 2021; epub ahead of print
Holmberg MJ, Andersen LW, Moskowitz A, Berg KM, ... Kirkegaard H, Donnino MW
Resuscitation: 08 Feb 2021; epub ahead of print | PMID: 33577964
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Impact:
Abstract

Resuscitation highlights in 2020.

Nolan JP, Ornato JP, Parr MJA, Perkins GD, Soar J
Background
This review is the latest in a series of regular annual reviews undertaken by the editors and aims to highlight some of the key papers published in Resuscitation during 2020. The number of papers submitted to the Journal in 2020 increased by 25% on the previous year.MethodsHand-searching by the editors of all papers published in Resuscitation during 2020. Papers were selected based on then general interest and novelty and were categorised into general themes.ResultsA total of 103 papers were selected for brief mention in this review.ConclusionsResuscitation science continues to evolve rapidly and incorporate all links in the chain of survival.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 08 Feb 2021; 162:1-10
Nolan JP, Ornato JP, Parr MJA, Perkins GD, Soar J
Resuscitation: 08 Feb 2021; 162:1-10 | PMID: 33577963
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Impact:
Abstract

Health-related quality of life after out-of-hospital cardiac arrest - a five-year follow-up study.

Wimmer H, Lundqvist C, Šaltytė Benth J, Stavem K, ... Sunde K, Nakstad ER
Background
Health-related quality of life (HRQoL) is affected after out-of-hospital cardiac arrest (OHCA), but data several years after the arrest are lacking. We assessed long-term HRQoL in OHCA survivors and how known outcome predictors impact HRQoL.
Methods
In adult OHCA survivors, HRQoL was assessed five years post arrest using Short-form 36 (SF-36), EQ-5D-3 L (EQ-5D) and Hospital Anxiety and Depression Scale (HADS) among others. Results were compared to the next of kins\' estimates and to a Norwegian reference population.
Results
Altogether 96 survivors were included mean 5.3 (range 3.6-7.2) years after OHCA. HRQoL compared well to the reference population, except for lower score for general health with 67.2 (95%CI (62.1; 72.3) vs. 72.9 (71.9; 74.0)), p = 0.03. Younger (≤58 years) vs. older survivors scored lower for general health with mean (SD) of 62.1 (27.5) vs. 73.0 (19.5), p = 0.03, vitality (55.2 (20.5) vs. 64.6 (17.3), p = 0.02, social functioning (75.3 (28.7) vs. 94.1 (13.5), p < 0.001 and mental component summary (49.0 (9.9) vs. 55.8 (6.7), p < 0.001. They scored higher for HADS-anxiety (4.8 (3.6 vs. 2.7 (2.5), p = 0.001, and had lower EQ-5D index (0.72 (0.34) vs. 0.84 (0.19), p = 0.04. Early vs. late awakeners had higher EQ-5D index (0.82 (0.23) vs. 0.71 (0.35), p = 0.04 and lower HADS-depression scores (2.5 (2.9) vs. 3.8 (2.3), p = 0.04. Next of kin estimated HRQoL similar to the survivors\' own estimates.
Conclusions
HRQoL five years after OHCA was good and mainly comparable to a matched reference population. Stratified analyses revealed impaired HRQoL among younger survivors and those awakening late, mainly for mental domains.

Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.

Resuscitation: 07 Feb 2021; epub ahead of print
Wimmer H, Lundqvist C, Šaltytė Benth J, Stavem K, ... Sunde K, Nakstad ER
Resuscitation: 07 Feb 2021; epub ahead of print | PMID: 33571604
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Impact:
Abstract

Arterial carbon dioxide tension has a non-linear association with survival after out-of-hospital cardiac arrest: A multicentre observational study.

Mckenzie N, Finn J, Dobb G, Bailey P, ... Bray J, Ho KM
Purpose
International guidelines recommend targeting normocapnia in mechanically ventilated out-of-hospital cardiac arrest (OHCA) survivors, but the optimal arterial carbon dioxide (PaCO2) target remains controversial. We hypothesised that the relationship between PaCO2 and survival is non-linear, and targeting an intermediate level of PaCO2 compared to a low or high PaCO2 in the first 24-h of ICU admission is associated with an improved survival to hospital discharge (STHD) and at 12-months.
Methods
We conducted a retrospective multi-centre cohort study of adults with non-traumatic OHCA requiring admission to one of four tertiary hospital intensive care units for mechanical ventilation. A four-knot restricted cubic spline function was used to allow non-linearity between the mean PaCO2 within the first 24 h of ICU admission after OHCA and survival, and optimal PaCO2 cut-points were identified from the spline curve to generate corresponding odds ratios.
Results
We analysed 3769 PaCO2 results within the first 24-h of ICU admission, from 493 patients. PaCO2 and survival had an inverted U-shape association; normocapnia was associated with significantly improved STHD compared to either hypocapnia (<35 mmHg) (adjusted odds ratio [aOR] 0.45, 95% confidence interval [CI] 0.24-0.83) or hypercapnia (>45 mmHg) (aOR 0.45, 95% CI 0.24-0.84). Of the twelve predictors assessed, PaCO2 was the third most important predictor, and explained >11% of the variability in survival. The survival benefits of normocapnia extended to 12-months.
Conclusions
Normocapnia within the first 24-h of intensive care admission after OHCA was associated with an improved survival compared to patients with hypocapnia or hypercapnia.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 07 Feb 2021; 162:82-90
Mckenzie N, Finn J, Dobb G, Bailey P, ... Bray J, Ho KM
Resuscitation: 07 Feb 2021; 162:82-90 | PMID: 33571603
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Impact:
Abstract

Resuscitation and emergency care in drowning: A scoping review.

Bierens J, Abelairas-Gomez C, Barcala Furelos R, Beerman S, ... Morley PT, Perkins GD
Background
The ILCOR Basic Life Support Task Force and the international drowning research community considered it timely to undertake a scoping review of the literature to identify evidence relating to the initial resuscitation, hospital-based interventions and criteria for safe discharge related to drowning.
Methods
Medline, PreMedline, Embase, Cochrane Reviews and Cochrane CENTRAL were searched from 2000 to June 2020 to identify relevant literature. Titles and abstracts and if necessary full text were reviewed in duplicate. Studies were eligible for inclusion if they reported on the population (adults and children who are submerged in water), interventions (resuscitation in water / boats, airway management, oxygen administration, AED use, bystander CPR, ventilation strategies, ECMO, protocols for hospital discharge (I), comparator (standard care) and outcomes (O) survival, survival with a favourable neurological outcome, CPR quality, physiological end-points).
Results
The database search yielded 3242 references (Medline 1104, Pre-Medline 202, Embase 1722, Cochrane reviews 12, Cochrane CENTRAL 202). After removal of duplicates 2377 papers were left for screening titles and abstracts. In total 65 unique papers were included. The evidence identified was from predominantly high-income countries and lacked consistency in the populations, interventions and outcomes reported. Clinical studies were exclusively observational in nature.
Conclusion
This scoping review found that there is very limited evidence from observational studies to inform evidence based clinical practice guidelines for drowning. The review highlights an urgent need for high quality research in drowning.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 03 Feb 2021; epub ahead of print
Bierens J, Abelairas-Gomez C, Barcala Furelos R, Beerman S, ... Morley PT, Perkins GD
Resuscitation: 03 Feb 2021; epub ahead of print | PMID: 33549689
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Impact:
Abstract

Incidence and characteristics of drowning in Sweden during a 15-year period.

Claesson A, Krig A, Jonsson M, Ringh M, ... Nilsson L, Hollenberg J
Aim
Drowning is a global health problem and deeper knowledge about the extent and causes is of utmost importance for implementing preventative actions. The aim of this study was to describe the incidence and characteristics of drowning in Sweden over time, including both non-fatal and fatal cases.
Methods
All cases identified as drowning (ICD-10 coding) at a national level in Sweden between 2003-2017 were collected. Three sources of data from the Swedish National Board of Health and Welfare were extracted via the Cause of Death Register and the National Patient Register.
Results
Over 15 years, a total of 6609 cases occurred, resulting in an annual incidence of 4.66 per 100 000. The median age was 49 years (IQR 23-67) and 67% were males. Non-fatal drownings represented 51% (n = 3363), with an overall non-fatal to fatal ratio of 1:1, this being 8:1 for children (0-17 years of age). Non-fatal cases were more often female (36% vs. 30%; p < 0.001), younger 30 (IQR 10-56) vs. 60 (IQR: 45-72) (p < 0.001) and of unintentional nature (81% vs. 55%; p < 0.001). The overall incidence decreased over time from 5.6 to 4.1 per 100 000 (p < 0.001). The highest rate of 30-day survival was found in females 0-17 years (94%, 95% CI 91.1-95.5) and the lowest in males >66 years (28.7%, 95% CI 26.2-31.2). Although the incidence in children 0-4 years increased from 7.4 to 8.1 per 100 000 (p < 0.001), they demonstrated the highest non-fatal to fatal ratio (13:1).
Conclusion
Drowning is declining but remains a consistent and underestimated public-health problem. Non-fatal drowning cases represent about half of the burden and characteristics differ from fatal drowning cases, being younger, more often female and of unintentional nature.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 03 Feb 2021; 162:11-19
Claesson A, Krig A, Jonsson M, Ringh M, ... Nilsson L, Hollenberg J
Resuscitation: 03 Feb 2021; 162:11-19 | PMID: 33549688
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Impact:
Abstract

Lung ultrasound during newborn resuscitation predicts the need for surfactant therapy in very- and extremely preterm infants.

Badurdeen S, Kamlin COF, Rogerson SR, Kane SC, ... Davis PG, Blank DA
Introduction
Early identification of infants requiring surfactant therapy improves outcomes. We evaluated the accuracy of delivery room lung ultrasound (LUS) to predict surfactant therapy in very- and extremely preterm infants.
Methods
Infants born at <320/7 weeks were prospectively enrolled at 2 centres. LUS videos of both sides of the chest were obtained 5-10 minutes, 11-20 minutes, and 1-3 hours after birth. Clinicians were masked to the results of the LUS assessment and surfactant therapy was provided according to local guidelines. LUS videos were graded blinded to clinical data. Presence of unilateral type 1 (\'whiteout\') LUS or worse was considered test positive. Receiver Operating Characteristic (ROC) analysis compared the accuracy of LUS and an FiO2 threshold of 0.3 to predict subsequent surfactant therapy.
Results
Fifty-two infants with a median age of 276/7 weeks (IQR 260/7 to 286/7) were studied. Thirty infants (58%) received surfactant. Area under the ROC curve (AUC) for LUS at 5-10 minutes, 11-20 minutes and 1-3 hours was 0.78 (95% CI, 0.66-0.90), 0.76 (95% CI, 0.65-0.88) and 0.86 (95% CI, 0.75-0.97) respectively, outperforming FiO2 at the 5-10 minute timepoint (AUC 0.45, 95% CI 0.29-0.62, p = 0.001). At 11-20 minutes, LUS had a specificity of 95% (95% CI 77-100%) and sensitivity of 59% (95% CI, 39-77%) to predict surfactant therapy. All infants born at 23-276/7 weeks with LUS test positive received surfactant. Twenty-six infants (50%) had worsening of LUS grades on serial assessment.
Conclusions
LUS in the delivery room and accurately predicts surfactant therapy in infants <320/7 weeks.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 02 Feb 2021; epub ahead of print
Badurdeen S, Kamlin COF, Rogerson SR, Kane SC, ... Davis PG, Blank DA
Resuscitation: 02 Feb 2021; epub ahead of print | PMID: 33548362
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Impact:
Abstract

Impact of therapeutic hypothermia during cardiopulmonary resuscitation on neurologic outcome: A systematic review and meta-analysis.

Annoni F, Peluso L, Fiore M, Nordberg P, ... Creteur J, Taccone FS
Background
Therapeutic cooling initiated during cardiopulmonary resuscitation (intra arrest therapeutic hypothermia, IATH) provided diverging effect on neurological outcome of out-of-hospital cardiac arrest (OHCA) patients depending on the initial cardiac rhythm and the cooling methods used.
Methods
We performed a systematic search of PubMed, EMBASE and the CENTRAL databases using established Medical Subject Headings (MeSH) terms for IATH and OHCA. Only studies comparing IATH to standard in-hospital targeted temperature management (TTM) were selected. We used the revised Cochrane RoB-2 and the Newcastle-Ottawa scale tool to assess risk of bias of each study. Primary outcome was favorable neurological outcome (FO); secondary outcomes included return of spontaneous circulation (ROSC) rate and survival to hospital discharge.
Results
Out of 20,950 studies, 8 studies (n = 3493 patients, including 4 randomized trials, RCTs) were included in the final analysis. Compared to controls, the use of IATH was not associated with improved FO (OR 0.96 [95% CIs 0.68-1.37]; p = 0.84), increased ROSC rate (OR 1.11 [95% CIs 0.83-1.49]; p = 0.46) or survival (OR 0.91 [95% CIs 0.73-1.14]; p = 0.43). Significant heterogeneity among studies was observed for the analysis of ROSC rate (I2 = 69%). Trans-nasal evaporative cooling and cold fluids were explored in two RCTs each and no differences were observed on FO, event when only patients with an initial shockable rhythm were analyzed (OR 1.62 [95% CI 1.00-2.64]; p = 0.05].
Conclusions
In this meta-analysis, IATH was not associated with improved neurological outcome when compared to standard in-hospital TTM, based on very low certainty of evidence.
Clinical trial registration
PROSPERO (CRD42019130322).

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 01 Feb 2021; epub ahead of print
Annoni F, Peluso L, Fiore M, Nordberg P, ... Creteur J, Taccone FS
Resuscitation: 01 Feb 2021; epub ahead of print | PMID: 33545107
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Impact:
Abstract

A rapid review of advanced life support guidelines for cardiac arrest associated with anaphylaxis.

McLure M, Eastwood K, Parr M, Bray J
Background
We conducted a rapid review of current international and Australian advanced life support (ALS) guidelines for cardiac arrest associated with anaphylaxis to (1) assess the variation and (2) determine if a systematic review update of ALS guideline recommendations is warranted.
Method
A search and comparison of key recommendations was conducted for major international and Australian clinical guidelines, including member societies and councils of the World Allergy Organisation and the International Liaison Committee on Resuscitation (ILCOR). Systematic database searches (Medline, Cochrane Database of Systematic Reviews, PROSPERO international register of systematic reviews and ClinicalTrials.gov databases) was conducted to identify existing and in-progress research published on the topic of anaphylaxis and cardiac arrest.
Results
Eight international guidelines were identified from Australia/New Zealand, Europe, United States and Canada, and 5 national guidelines were identified for Australia. There was general consensus across all guidelines for the use of adrenaline, oxygen, patient positioning and glucagon. There was variation across international and Australian guidelines for adrenaline dosing and frequency, antihistamines and corticosteroid recommendations. Most recommendations were based on low-level evidence, and the review of published systematic reviews and clinical trials identified new evidence in the last decade.
Conclusions
We found significant variation between current ALS guideline recommendations for treating anaphylaxis. While there is no new evidence to suggest a systematic review of guideline recommendations is needed, there may be an opportunity to produce more consistent international guideline recommendations and educational materials.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Jan 2021; 159:137-149
McLure M, Eastwood K, Parr M, Bray J
Resuscitation: 30 Jan 2021; 159:137-149 | PMID: 33068641
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Impact:
Abstract

A multimodal sevoflurane-based sedation regimen in combination with targeted temperature management in post-cardiac arrest patients reduces the incidence of delirium: An observational propensity score-matched study.

Foudraine NA, Algargoush A, van Osch FH, Bos AT
Background
Recent studies suggest that volatile anaesthetics are safe, efficient, and reliable alternatives to the use of intravenous anaesthetics for out-of-hospital cardiac arrest (OHCA) patients admitted to the intensive care unit (ICU). We hypothesised that volatile anaesthetics may reduce the incidence of delirium rather than intravenous sedatives. This retrospective study aimed to investigate whether sevoflurane combined with higher targeted temperature management could decrease the incidence of delirium when compared with intravenous anaesthetics with lower targeted temperature management.
Methods
Using a propensity score-matched analysis, we retrospectively compared a target temperature management (32-34 °C) method along with intravenous sedation (TTM-33/IV) and a modified target temperature management (34-36 °C) method along with sevoflurane sedation (mTTM-36/sevo). We used the confusion assessment method for the ICU to measure the incidence of delirium. We calculated the time-dependent risk on delirium using the multivariate Cox regression model.
Results
The incidence of delirium was significantly lower (p = 0.001) in OHCA patients of the mTTM-36/sevo group (9/56, 16.1%) than in those of the TTM-33/IV group (25/67, 37.3%). Mechanical ventilation and lengths of stay in the ICU (p < 0.001) and hospital stay (p = 0.04) were shorter in the mTTM-36/sevo group. Patients in the TTM-33/IV group required more midazolam, propofol, and fentanyl. We observed no significant difference in mortality.
Conclusion
A multimodal sevoflurane-based sedation regimen together with targeted temperature management resulted in a lower incidence of delirium and a shorter duration for mechanical ventilation and ICU length of stay than did the treatment with intravenous sedation combined with the classical cooling protocol.

Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.

Resuscitation: 30 Jan 2021; 159:158-164
Foudraine NA, Algargoush A, van Osch FH, Bos AT
Resuscitation: 30 Jan 2021; 159:158-164 | PMID: 33189803
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Impact:
Abstract

Substantial variation exists in post-cardiac arrest outcomes across Michigan hospitals.

Berger DA, Chen NW, Miller JB, Welch RD, ... Swor DO RA, CARES Surveillance Group
Aim
Resuscitation from out of hospital cardiac arrest (OHCA) requires success across the entire chain of survival. Using a large state-wide registry, we characterized variation in clinical outcomes at hospital discharge in Michigan hospitals.
Methods
We utilized the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) and included adult OHCA subjects with return of spontaneous circulation (ROSC) from 2014 - 2017 that survived to hospital admission. 39 Michigan hospitals were included which managed >30 cases during the study period. Multilevel logistic regression, controlling for both subject characteristics and clustering of subjects within hospitals, assessed variation across hospitals in survival to hospital discharge and survival with cerebral performance category (CPC 1-2).
Results
There were 5,486 CARES subjects that survived to hospital admission, and 4,690 met inclusion for analysis. Of 39 included hospitals, median survival to discharge was 31.3% (range 12.5%-46.7%) and median survival to discharge with CPC 1-2 was 25.0% (range 5.2%-42.2%). We identified 12-fold variation in the utilization of TTM by hospital (median 47.9%, range 6.7%-80.0%) for all admitted subjects. Similarly, there was nearly an eight-fold variation in LHC for all post-arrest subjects (median 22.1%, range 5.4%-42.2%). In multivariable analyses, median adjusted survival to discharge was 26.9% (range 18.1%-42.1%) and median adjusted survival to discharge with CPC 1-2 was 21.3% (range 9.6%-32.1%).
Conclusion
We observed substantial variation in clinical outcomes at discharge between Michigan hospitals, including a four-fold range of survival and eight-fold range of survival with CPC 1-2. This variation was ameliorated but still persisted in adjusted modeling. Variation in post arrest survival by hospital was not fully explained by available covariates, which suggests the possibility of improving post-arrest clinical outcomes at some hospitals via quality improvement activities.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Jan 2021; 159:97-104
Berger DA, Chen NW, Miller JB, Welch RD, ... Swor DO RA, CARES Surveillance Group
Resuscitation: 30 Jan 2021; 159:97-104 | PMID: 33221364
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Impact:
Abstract

Clinical evaluation of intravenous alone versus intravenous or intraosseous access for treatment of out-of-hospital cardiac arrest.

Tan BKK, Chin YX, Koh ZX, Md Said NAZB, ... Ng YY, Ong MEH
Objective
Obtaining vascular access during out-of-hospital cardiac arrest (OHCA) is challenging. The aim of this study was to determine if using intraosseous (IO) access when intravenous (IV) access fails improves outcomes.
Methods
This was a prospective, parallel-group, cluster-randomised study that compared \'IV only\' against \'IV + IO\' in OHCA patients, where if 2 IV attempts failed or took more than 90 s, paramedics had 2 further attempts of IO. Primary outcome was any return of spontaneous circulation (ROSC). Secondary outcomes were insertion success rate, adrenaline administration, time to adrenaline and survival outcome.
Results
A total of 1007 patients were included in the analysis. An Intention To Treat analysis showed a significant difference in success rates of obtaining vascular access in the IV + IO arm compared to the IV arm (76.6% vs 61.1% p = 0.001). There were significantly more patients in the IV + IO arm than the IV arm being administered prehospital adrenaline (71.3% vs 55.4% p = 0.001). The IV + IO arm also received adrenaline faster compared to the IV arm in terms of median time from emergency call to adrenaline (23 min vs 25 min p = 0.001). There was no significant difference in ROSC (adjusted OR 0.99 95%CI: 0.75-1.29), survival to discharge or survival with CPC 2 or better in both groups. A Per Protocol analysis also showed there was higher success in obtaining vascular access in the IV + IO arm, but ROSC and survival outcomes were not statistically different.
Conclusion
Using IO when IV failed led to a higher rate of vascular access, prehospital adrenaline administration and faster adrenaline administration. However, it was not associated with higher ROSC, survival to discharge, or good neurological outcome.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Jan 2021; 159:129-136
Tan BKK, Chin YX, Koh ZX, Md Said NAZB, ... Ng YY, Ong MEH
Resuscitation: 30 Jan 2021; 159:129-136 | PMID: 33221362
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Impact:
Abstract

Diagnosis of out-of-hospital cardiac arrest by emergency medical dispatch: A diagnostic systematic review.

Drennan IR, Geri G, Brooks S, Couper K, ... Pediatric Task Force, EIT Task Force
Introduction
Cardiac arrest is a time-sensitive condition requiring urgent intervention. Prompt and accurate recognition of cardiac arrest by emergency medical dispatchers at the time of the emergency call is a critical early step in cardiac arrest management allowing for initiation of dispatcher-assisted bystander CPR and appropriate and timely emergency response. The overall accuracy of dispatchers in recognizing cardiac arrest is not known. It is also not known if there are specific call characteristics that impact the ability to recognize cardiac arrest.
Methods
We performed a systematic review to examine dispatcher recognition of cardiac arrest as well as to identify call characteristics that may affect their ability to recognize cardiac arrest at the time of emergency call. We searched electronic databases for terms related to \"emergency medical dispatcher\", \"cardiac arrest\", and \"diagnosis\", among others, with a focus on studies that allowed for calculating diagnostic test characteristics (e.g. sensitivity and specificity). The review was consistent with Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method for evidence evaluation.
Results
We screened 2520 article titles, resulting in 47 studies included in this review. There was significant heterogeneity between studies with a high risk of bias in 18 of the 47 which precluded performing meta-analyses. The reported sensitivities for cardiac arrest recognition ranged from 0.46 to 0.98 whereas specificities ranged from 0.32 to 1.00. There were no obvious differences in diagnostic accuracy between different dispatching criteria/algorithms or with the level of education of dispatchers.
Conclusion
The sensitivity and specificity of cardiac arrest recognition at the time of emergency call varied across dispatch centres and did not appear to differ by dispatch algorithm/criteria used or education of the dispatcher, although comparisons were hampered by heterogeneity across studies. Future efforts should focus on ways to improve sensitivity of cardiac arrest recognition to optimize patient care and ensure appropriate and timely resource utilization.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 30 Jan 2021; 159:85-96
Drennan IR, Geri G, Brooks S, Couper K, ... Pediatric Task Force, EIT Task Force
Resuscitation: 30 Jan 2021; 159:85-96 | PMID: 33253767
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Impact:
Abstract

Coding and classification of heroin overdose calls by MPDS dispatch software: Implications for bystander response with naloxone.

Dietze P, Crossin R, Scott D, Smith K, ... Lubman DI, Cantwell K
Background:
and aims
Take-home naloxone, a key response to heroin overdose, may be compromised by the way in which overdose cases are coded in EMS dispatch systems as call-takers direct callers at cardiac arrest events against using any medication. We examined the ways in which confirmed heroin overdose cases attended by ambulances are coded at dispatch to determine whether incorrect coding of overdoses as cardiac arrests may limit the use of take-home naloxone.
Methods
We conducted a retrospective analysis of coded ambulance clinical records collected in Victoria, Australia from 2012-2017. Counts of heroin overdose cases were examined by dispatch coding (heroin overdose, cardiac/respiratory arrest and \'other\'), along with age, sex, GCS and respiratory rate. Data were analysed using chi-square and Poisson regression for quarterly counts, adjusting for age, sex and patient GCS.
Results
A total of 5637 heroin overdose cases were attended over the period 2012-2017 (71.4% male, 36.4% aged under 35 years). Almost half (n = 2674, 47.4%) were coded as cardiac/respiratory arrest at dispatch, with 36.8% (n = 2075) coded as heroin overdose and 15.7% (n = 886) coded as other/unknown.
Discussion and conclusions
Almost half of the heroin overdoses were dispatched according to a protocol that would preclude the use of take-home naloxone prior to ambulance arrival and this changed little over the period in which take-home naloxone programs were operating in Victoria, Australia. EMS should move as quickly as possible to newer versions of dispatch systems that enable the use of naloxone in cases of obvious opioid overdose that may be classified as cardiac/respiratory arrest.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Jan 2021; 159:13-18
Dietze P, Crossin R, Scott D, Smith K, ... Lubman DI, Cantwell K
Resuscitation: 30 Jan 2021; 159:13-18 | PMID: 33301886
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Impact:
Abstract

Cerebral regional oxygen saturation during cardiopulmonary resuscitation and return of spontaneous circulation: A systematic review and meta-analysis.

Sanfilippo F, Murabito P, Messina A, Dezio V, ... Cecconi M, Astuto M
Aim
Predicting the return of spontaneous circulation (ROSC) during cardiopulmonary resuscitation in victims of cardiac arrest (CA) remains challenging. Cerebral regional oxygen saturation (rSO2) measured during resuscitation is feasible, and higher initial and overall values seem associated with ROSC. However, these observations were limited to the analysis of few small single-centre studies. There is a growing number of studies evaluating the role of cerebral rSO2 in the prediction of ROSC.
Methods
We conducted an updated meta-analysis aimed at investigating the association of initial and overall values of cerebral rSO2 with ROSC after CA. We performed subgroups analyses according to the location of CA and conducted a secondary analysis according to the country where the study was conducted (resuscitation practice varies greatly for out-of-hospital CA).
Results
We included 17 studies. Higher initial rSO2 values (11 studies, n = 2870, 16.6% achieved ROSC) were associated with ROSC: Mean Difference (MD) -11.54 [95%Confidence Interval (CI)-20.96, -2.12]; p = 0.02 (I2 = 97%). The secondary analysis confirmed this finding when pooling together European and USA studies, but did not for Japanese studies (p = 0.06). One multi-centre Japanese study was an outlier with large influence on 95%CI. Higher overall rSO2 values during resuscitation (9 studies, n = 894, 33.7% achieving ROSC) were associated with ROSC: MD-10.38; [-13.73, -7.03]; p < 0.00001 (I2 = 77%). All studies were conducted in Europe/USA.
Conclusions
This updated meta-analysis confirmed the association between higher initial and overall values of cerebral rSO2 and ROSC after CA. However, we found geographical differences, since this association was not present when Japanese studies were analysed separately.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Jan 2021; 159:19-27
Sanfilippo F, Murabito P, Messina A, Dezio V, ... Cecconi M, Astuto M
Resuscitation: 30 Jan 2021; 159:19-27 | PMID: 33333181
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Impact:
Abstract

The epidemiology of Medical Emergency Team calls for orthopedic patients in a teaching hospital: A retrospective cohort study.

Zhang R, Maher B, Ramos JGR, Hardidge A, ... Peyton P, Jones D
Background
Patients undergoing orthopedic surgery are at risk of post-operative complications and needing Medical Emergency Team (MET) review. We assessed the frequency of, and associations with MET calls in orthopedic patients, and whether this was associated with increased in-hospital morbidity and mortality.
Methods
Retrospective cohort study of patients admitted over four years to a University teaching hospital using hospital administrative and MET call databases.
Results
Amongst 6344 orthopedic patients, 55.8% were female, the median (IQR) age and Charlson comorbidity index were 66 years (47-79) and 3 (1-5), respectively. Overall, 54.5% of admissions were emergency admissions, 1130 (17.8%) were non-operative, and 605 (9.5%) patients received a MET call. The strongest independent associations with receiving a MET call was the operative procedure, especially hip and knee arthroplasty. Common MET triggers were hypotension (37.5%), tachycardia (25.0%) and tachypnoea (9.1%). Patients receiving a MET call were at increased risk of anemia, delirium, pressure injury, renal failure and wound infection. The mortality of patients who received a MET call was 9.8% compared with 0.8% for those who did not. After adjusting for pre-defined co-variates, requirement for a MET call was associated with an adjusted odd-ratio of 9.57 (95%CI 3.1-29.7) for risk of in-hospital death.
Conclusions
Approximately 10% of orthopedic patients received a MET call, which was most strongly associated with major hip and knee arthroplasty. Such patients are at increased risk of morbidity and in-hospital mortality. Further strategies are needed to more pro-actively manage at-risk orthopedic patients.

Crown Copyright © 2020. Published by Elsevier B.V. All rights reserved.

Resuscitation: 30 Jan 2021; 159:1-6
Zhang R, Maher B, Ramos JGR, Hardidge A, ... Peyton P, Jones D
Resuscitation: 30 Jan 2021; 159:1-6 | PMID: 33347940
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Impact:
Abstract

NAloxone CARdiac Arrest Decision Instruments (NACARDI) for targeted antidotal therapy in occult opioid overdose precipitated cardiac arrest.

Rodriguez RM, Tseng ZH, Montoy JCC, Repplinger D, ... Addo N, Wang RC
Background
We have recently demonstrated that a significant proportion of fatal out-of-hospital cardiac arrests (OHCAs) are precipitated by occult overdose, which could benefit from antidote therapy administered adjunctively with other cardiac resuscitation measures. We sought to develop simple decision instruments that EMS providers and other first responders can use to rapidly identify occult opioid overdose-associated OHCAs.
Methods
We examined data from February 2011 through December 2017 in the Postmortem Systematic Investigation of Sudden Cardiac Death study, in which San Francisco (California) County EMS-attended OHCA deaths received autopsy and expert panel adjudication of cause of death. Using classification tree analyses, we derived highly sensitive and specific decision instruments that predicted our primary outcome of occult opioid OD-associated OHCA. We then calculated screening performance characteristics of these instruments.
Results
Of 767 OHCA deaths, 80 (10.4%) were associated with occult opioid overdose. Of the eight models with 100% sensitivity for opioid overdose-associated cardiac arrest, the highest specificity model (23.4%, 95% confidence interval [CI] 20.3-26.7%) was age < 60 years OR race = black or non-Latinx white OR arrest in public place. The highest specificity instrument (96.3%, 95% CI 94.6-97.5%) consisting of age < 60 years AND race = black or non-Latinx white AND unwitnessed arrest AND female sex had 25% (95% CI 16-35.9%) sensitivity.
Conclusions
We have derived simple decision instruments that can identify patients whose OHCA precipitant was occult opioid overdose. These instruments may be used to guide selective administration of the antidote naloxone in OHCA resuscitations.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Jan 2021; 159:69-76
Rodriguez RM, Tseng ZH, Montoy JCC, Repplinger D, ... Addo N, Wang RC
Resuscitation: 30 Jan 2021; 159:69-76 | PMID: 33359417
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Impact:
Abstract

Cardiopulmonary resuscitation in quaternary neonatal intensive care units: a multicenter study.

Ali N, Lam T, Gray MM, Clausen D, ... Grover TR, Sawyer T
Background
The reported incidence of cardiopulmonary resuscitation (CPR) in quaternary NICU is approximately 10-times higher than in the delivery room. However, the etiologies and outcomes of CPR in quaternary NICUs are poorly understood. We hypothesized that demographic characteristics, diagnoses, interventions, and arrest etiologies would be associated with survival to discharge after CPR.
Methods
Multicenter retrospective cohort study of four quaternary NICUs over six years (2011-2016). Demographics, resuscitation event data, and post-arrest outcomes were analyzed. The primary outcome was survival to discharge.
Results
Of 17,358 patients admitted to four NICUs, 200 (1.1%) experienced a CPR event, and 45.5% of those survived to discharge. Acute respiratory compromise leading to cardiopulmonary arrest occurred in 182 (91%) of the CPR events. Most neonates requiring CPR were on mechanical ventilation (79%) and had central venous access (90%) at the time of arrest. Treatments at the time of the arrest associated with decreased survival to discharge included mechanical ventilation, antibiotics, or vasopressor therapy (p < 0.01). Etiologies of arrest associated with decreased survival to discharge included multisystem organ failure, septic shock, and pneumothorax (p < 0.05). Longer duration of CPR was associated with decreased survival to discharge. The odds of surviving to discharge decreased for infants who had a primarily cardiac arrest and for infants who received epinephrine during the arrest.
Conclusion
Approximately 1% of neonates admitted to quaternary NICUs require CPR. The most common etiology of arrest is acute respiratory compromise on a ventilator. CPR events with respiratory etiology have a favorable outcome as compared to non-respiratory causes.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Jan 2021; 159:77-84
Ali N, Lam T, Gray MM, Clausen D, ... Grover TR, Sawyer T
Resuscitation: 30 Jan 2021; 159:77-84 | PMID: 33359416
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Impact:
Abstract

Assessing neurological prognosis in post-cardiac arrest patients from short vs plain text EEG reports: A survey among intensive care clinicians.

Lilja L, Joelsson S, Nilsson J, Thuccani M, ... Lindgren S, Rylander C
Background
Electroencephalography (EEG) patterns are predictive of neurological prognosis in comatose survivors from cardiac arrest but intensive care clinicians are dependent of neurophysiologist reports to identify specific patterns. We hypothesized that the proportion of correct assessment of neurological prognosis would be higher from short statements confirming specific EEG patterns compared with descriptive plain text reports.
Methods
Volunteering intensive care clinicians at two university hospitals were asked to assess the neurological prognosis of a fictional patient with high neuron specific enolase. They were presented with 17 authentic plain text reports and three short statements, confirming whether a \"highly malignant\", \"malignant\" or \"benign\" EEG pattern was present. Primary outcome was the proportion of clinicians who correctly identified poor neurological prognosis from reports consistent with highly malignant EEG patterns. Secondary outcomes were how the prognosis was assessed from reports consistent with malignant and benign patterns.
Results
Out of 57 participants, poor prognosis was correctly identified by 61% from plain text reports and by 93% from the short statement \"highly malignant\" EEG patterns. Unaffected prognosis was correctly identified by 28% from plain text reports and by 40% from the short statement \"malignant\" patterns. Good prognosis was correctly identified by 64% from plain text reports and by 93% from the short statement \"benign\" pattern.
Conclusion
Standardized short statement, \"highly malignant EEG pattern present\", as compared to plain text EEG descriptions in neurophysiologist reports, is associated with more accurate identification of poor neurological prognosis in comatose survivors of cardiac arrest.

Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.

Resuscitation: 30 Jan 2021; 159:7-12
Lilja L, Joelsson S, Nilsson J, Thuccani M, ... Lindgren S, Rylander C
Resuscitation: 30 Jan 2021; 159:7-12 | PMID: 33359178
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Impact:
Abstract

The association of pH values during the first 24 h with neurological status at hospital discharge and futility among patients with out-of-hospital cardiac arrest.

Al Assil R, Singer J, Heidet M, Fordyce CB, ... Christenson J, Grunau B
Study objective
Post-resuscitation prognostic biomarkers for out-of-hospital cardiac arrest (OHCA) outcomes have not been fully elucidated. We examined the association of acid-base blood values (pH) with patient outcomes and calculated the pH test performance to predict prognosis.
Methods
This was a post-hoc analysis of data from the continuous chest compression trial, which enrolled non-traumatic adult emergency medical system-treated OHCA in Canada and the United States. We examined cases who survived a minimum of 24 h post hospital arrival. The independent variables of interest were initial pH, final pH, and the change in pH (δpH). The primary outcome was neurological status at hospital discharge, with favorable status defined as modified Rankin Scale (mRS) ≤ 3. We reported adjusted odds ratios for favorable neurological outcome using multivariable logistic regression models. We calculated the test performance of increasing pH thresholds in 0.1 increments to predict unfavorable neurological status (defined as mRS >3) at hospital discharge.
Results
We included 4189 patients. 32% survived to hospital discharge with favorable neurological status. In the adjusted analysis, higher initial pH (OR 6.82; 95% CI 3.71-12.52) and higher final pH (OR 7.99; 95% CI 3.26-19.62) were associated with higher odds of favorable neurological status. pH thresholds with highest positive predictive values were initial pH < 6.8 (92.5%; 95% CI 86.2 %-98.8%) and final pH < 7.0 (100%; 95% CI 95.2 %-100%).
Conclusion
In patients with OHCA, pH values were associated with patients\' subsequent neurological status at hospital discharge. Final pH may be clinically useful to predict unfavorable neurological status at hospital discharge.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 30 Jan 2021; 159:105-114
Al Assil R, Singer J, Heidet M, Fordyce CB, ... Christenson J, Grunau B
Resuscitation: 30 Jan 2021; 159:105-114 | PMID: 33385471
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Impact:
Abstract

Improving post-cardiac arrest cerebral perfusion pressure by elevating the head and thorax.

Duhem H, Moore JC, Rojas-Salvador C, Salverda B, ... Debaty G, Lurie KG
Aim
The optimal head and thorax position after return of spontaneous circulation (ROSC) following cardiac arrest (CA) is unknown. This study examined whether head and thorax elevation post-ROSC is beneficial, in a porcine model.
Methods
Protocol A: 40 kg anesthetized pigs were positioned flat, after 7.75 min of untreated CA the heart and head were elevated 8 and 12 cm, respectively, above the horizontal plane, automated active compression decompression (ACD) plus impedance threshold device (ITD) CPR was started, and 2 min later the heart and head were elevated 10 and 22 cm, respectively, over 2 min to the highest head up position (HUP). After 30 min of CPR pigs were defibrillated and randomized 10 min later to four 5-min epochs of HUP or flat position. Multiple physiological parameters were measured. In Protocol B, after 6 min of untreated VF, pigs received 6 min of conventional CPR flat, and after ROSC were randomized HUP versus Flat as in Protocol A. The primary endpoint was cerebral perfusion pressure (CerPP). Multivariate analysis-of-variance (MANOVA) for repeated measures was used. Data were reported as mean ± SD.
Results
In Protocol A, intracranial pressure (ICP) (mmHg) was significantly lower post-ROSC with HUP (9.1 ± 5.5) versus Flat (18.5 ± 5.1) (p < 0.001). Conversely, CerPP was higher with HUP (62.5 ± 19.9) versus Flat (53.2 ± 19.1) (p = 0.004), respectively. Protocol A and B results comparing HUP versus Flat were similar.
Conclusion
Post-ROSC head and thorax elevation in a porcine model of cardiac arrest resulted in higher CerPP and lower ICP values, regardless of VF duration or CPR method.
Iacuc protocol number
19-09.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Jan 2021; 159:45-53
Duhem H, Moore JC, Rojas-Salvador C, Salverda B, ... Debaty G, Lurie KG
Resuscitation: 30 Jan 2021; 159:45-53 | PMID: 33385469
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Impact:
Abstract

Association of post-resuscitation inflammatory response with favorable neurologic outcomes in adults with in-hospital cardiac arrest.

Patel JK, Sinha N, Hou W, Shah R, ... Parikh PB, Parnia S
Background
Early prediction of mortality in adults after in-hospital cardiac arrest (IHCA) remains vital to optimizing treatment strategies. Inflammatory cytokines specific to early prognostication in this population have not been well studied. We evaluated whether novel inflammatory cytokines obtained from adults with IHCA helped predict favorable neurologic outcome.
Methods
The study population included adults with IHCA who underwent ACLS-guided resuscitation between March 2014 and May 2019 at an academic tertiary medical center. Peripheral blood samples were obtained within 6, 24, 48, 72, and 96 h of IHCA and analysis of 15 cytokines were performed. The primary outcome of interest was presence of favorable neurologic outcome at hospital discharge, defined as a Glasgow Outcome Score of 4 or 5.
Results
Of the 105 adults with IHCA studied, 27 (25.7%) were noted to have survival with a favorable neurologic outcome while 78 (74.3%) did not. Patients who survived with favorable neurologic outcome were more often men (88.9% vs 61.5%, p = 0.008) and had higher rates of ventricular tachyarrhythmias as their initial rhythm (34.6% vs 11.7%, p = 0.018). Levels of interleukin (IL)-6, IL-8, IL-10, and Tumor Necrosis Factor (TNF)-R1 within 6 or 24 h were significantly lower in patients with favorable neurologic outcome compared with those who had unfavorable neurologic outcome. In multivariable analysis, IL-10 levels within 6 h was the only independent predictor of favorable neurologic outcomes [odds ratio (OR) 0.895, 95% confidence interval 0.805-0.996, p = 0.041].
Conclusion
In this contemporary observational study of adults with IHCA receiving ACLS-guided resuscitative and post-resuscitative care, inflammatory cytokines specific to early prognostication in adults with IHCA exist. Further larger scale studies examining the association of these inflammatory cytokines with prognosis are warranted.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Jan 2021; 159:54-59
Patel JK, Sinha N, Hou W, Shah R, ... Parikh PB, Parnia S
Resuscitation: 30 Jan 2021; 159:54-59 | PMID: 33385467
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Impact:
Abstract

PROLOGUE (PROgnostication using LOGistic regression model for Unselected adult cardiac arrest patients in the Early stages): Development and validation of a scoring system for early prognostication in unselected adult cardiac arrest patients.

Bae DH, Lee HY, Jung YH, Jeung KW, ... Heo T, Min YI
Background
Early prognostication after cardiac arrest would be useful. We aimed to develop a scoring model for early prognostication in unselected adult cardiac arrest patients.
Methods
We retrospectively analysed data of adult non-traumatic cardiac arrest patients treated at a tertiary hospital between 2014 and 2018. The primary outcome was poor outcome at hospital discharge (cerebral performance category, 3-5). Using multivariable logistic regression analysis, independent predictors were identified among known outcome predictors, that were available at intensive care unit admission, in patients admitted in the first 3 years (derivation set, N = 671), and a scoring system was developed with the variables that were retained in the final model. The scoring model was validated in patients admitted in the last 2 years (validation set, N = 311).
Results
The poor outcome rates at hospital discharge were similar between the derivation (66.0%) and validation sets (64.3%). Age <59 years, witnessed collapse, shockable rhythm, adrenaline dose <2 mg, low-flow duration <18 min, reactive pupillary light reflex, Glasgow Coma Scale motor score ≥2, and levels of creatinine <1.21 mg dl-1, potassium <4.4 mEq l-1, phosphate <5.8 mg dl-1, haemoglobin ≥13.2 g dl-1, and lactate <8 mmol l-1 were retained in the final multivariable model and used to develop the scoring system. Our model demonstrated excellent discrimination in the validation set (area under the curve of 0.942, 95% confidence interval 0.917-0.968).
Conclusions
We developed a scoring model for early prognostication in unselected adult cardiac arrest patients. Further validations in various cohorts are needed.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Jan 2021; 159:60-68
Bae DH, Lee HY, Jung YH, Jeung KW, ... Heo T, Min YI
Resuscitation: 30 Jan 2021; 159:60-68 | PMID: 33388366
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Impact:
Abstract

Racial disparities in survival outcomes following pediatric in-hospital cardiac arrest.

Haskell SE, Girotra S, Zhou Y, Zimmerman MB, ... Merchant RM, Atkins DL
Background
Among adults with in-hospital cardiac arrest (IHCA), overall survival is lower in black patients compared to white patients. Data regarding racial differences in survival for pediatric IHCA are unknown.
Methods
Using 2000-2017 data from the American Heart Association Get With the Guidelines-Resuscitation® registry, we identified children >24 h and <18 years of age with IHCA due to an initial pulseless rhythm. We used generalized estimation equation to examine the association of black race with survival to hospital discharge, return of spontaneous circulation (ROSC), and favorable neurologic outcome at discharge.
Results
Overall, 2940 pediatric patients (898 black, 2042 white) at 224 hospitals with IHCA were included. The mean age was 3.0 years, 57% were male and 16% had an initial shockable rhythm. Age, sex, interventions in place at the time of arrest and cardiac arrest characteristics did not differ significantly by race. The overall survival to discharge was 36.9%, return of spontaneous circulation (ROSC) was 73%, and favorable neurologic survival was 20.8%. Although black race was associated with lower rates of ROSC compared to white patients (69.5% in blacks vs. 74.6% in whites; risk-adjusted OR 0.79, 95% CI 0.67-0.94, P = 0.016), black race was not associated with survival to discharge (34.7% in blacks vs. 37.8% in whites; risk-adjusted OR 0.96, 95% CI 0.80-1.15, P = 0.68) or favorable neurologic outcome (18.7% in blacks vs. 21.8% in whites, risk-adjusted OR 0.98, 95% CI 0.80-1.20, p = 0.85).
Conclusions
In contrast to adults, we did not find evidence for racial differences in survival outcomes following IHCA among children.

Copyright © 2020 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 30 Jan 2021; 159:117-125
Haskell SE, Girotra S, Zhou Y, Zimmerman MB, ... Merchant RM, Atkins DL
Resuscitation: 30 Jan 2021; 159:117-125 | PMID: 33400929
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Impact:
Abstract

P-COSCA (Pediatric Core Outcome Set for Cardiac Arrest) in Children: An Advisory Statement From the International Liaison Committee on Resuscitation.

Topjian AA, Scholefield BR, Pinto NP, Fink EL, ... Hazinski MF, Slomine BS
Studies of pediatric cardiac arrest use inconsistent outcomes, including return of spontaneous circulation and short-term survival, and basic assessments of functional and neurological status. In 2018, the International Liaison Committee on Resuscitation sponsored the COSCA initiative (Core Outcome Set After Cardiac Arrest) to improve consistency in reported outcomes of clinical trials of adult cardiac arrest survivors and supported this P-COSCA initiative (Pediatric COSCA). The P-COSCA Steering Committee generated a list of potential survival, life impact, and economic impact outcomes and assessment time points that were prioritized by a multidisciplinary group of healthcare providers, researchers, and parents/caregivers of children who survived cardiac arrest. Then expert panel discussions achieved consensus on the core outcomes, the methods to measure those core outcomes, and the timing of the measurements. The P-COSCA includes assessment of survival, brain function, cognitive function, physical function, and basic daily life skills. Survival and brain function are assessed at discharge or 30 days (or both if possible) and between 6 and 12 months after arrest. Cognitive function, physical function, and basic daily life skills are assessed between 6 and 12 months after cardiac arrest. Because many children have prearrest comorbidities, the P-COSCA also includes documentation of baseline (ie, prearrest) brain function and calculation of changes after cardiac arrest. Supplementary outcomes of survival, brain function, cognitive function, physical function, and basic daily life skills are assessed at 3 months and beyond 1 year after cardiac arrest if resources are available.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 26 Jan 2021; epub ahead of print
Topjian AA, Scholefield BR, Pinto NP, Fink EL, ... Hazinski MF, Slomine BS
Resuscitation: 26 Jan 2021; epub ahead of print | PMID: 33515637
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Impact:
Abstract

Neurological and clinical status from early time point to long-term follow-up after in-hospital cardiac arrest.

Jeon SB, Lee H, Park B, Choi SH, ... Hong SB, Kim YH
Aim
We aimed to evaluate neurological profiles of patients with in-hospital cardiac arrest (IHCA) from early time points to long-term follow-up periods.
Methods
For this prospective cohort study, we established a neurological rapid response team, and serially evaluated the neurological status of patients with IHCA from the initial resuscitation to 12 months after the onset of IHCA. The primary outcome was good neurological status defined as a Clinical Performance Category score of 1-2 at 12 months after IHCA. The secondary outcomes included the awakening and neurological recovery during the first week, the survival and neurological status at hospital discharge, and the survival at 12 months.
Results
A total of 291 adult patients with IHCA were included. On the first day and during the first week after IHCA, the awakening was achieved in 61 (21.0 %) and 119 patients (40.9 %), respectively; and neurological recovery in 12 (4.1 %) and 46 patients (15.8 %), respectively. Epileptic seizures developed in 9.7 % following restoration of spontaneous circulation. At hospital discharge, 106 patients (36.4 %) had survived; among them, 63.2 % showed good neurological status. At 12 months, 63 (21.6 %) patients survived; among them, 81.7 % showed good neurological status (17.0 % among all patients with IHCA). Of patients without awakening during the first 3 and 7 days, 2.7 % and 1.2 % showed good neurological status at 12 months, respectively.
Conclusions
Among patients with IHCA, awakening and neurological recovery were remarkable throughout the first week. Survival and good neurological status were substantial at 12 months after IHCA.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 20 Jan 2021; epub ahead of print
Jeon SB, Lee H, Park B, Choi SH, ... Hong SB, Kim YH
Resuscitation: 20 Jan 2021; epub ahead of print | PMID: 33485879
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Impact:
Abstract

Why, when and how do secondary-care clinicians have emergency care and treatment planning conversations? Qualitative findings from the ReSPECT Evaluation study.

Eli K, Hawkes CA, Ochieng C, Huxley CJ, ... Slowther AM, Griffiths F
Background
The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is an emergency care and treatment planning (ECTP) process, developed to offer a patient-centred approach to deciding about and recording treatment recommendations. Conversations between clinicians and patients or their representatives are central to the ReSPECT process. This study aims to understand why, when, and how ReSPECT conversations unfold in practice.
Methods
ReSPECT conversations were observed in hospitals within six acute National Health Service (NHS) trusts in England; the clinicians who conducted these conversations were interviewed. Following observation-based thematic analysis, five ReSPECT conversation types were identified: resuscitation and escalation; confirmation of decision; bad news; palliative care; and clinical decision. Interview-based thematic analysis examined the reasons and prompts for each conversation type, and the level of detail and patient engagement in these different conversations.
Results
Whereas resuscitation and escalation conversations concerned possible futures, palliative care and bad news conversations responded to present-tense changes. Conversations were timed to respond to organisational, clinical, and patient/relative prompts. While bad news and palliative care conversations included detailed discussions of treatment options beyond CPR, this varied in other conversation types. ReSPECT conversations varied in doctors\' engagement with patient/relative preferences, with only palliative care conversations consistently including an open-ended approach.
Conclusions
While ReSPECT supports holistic, person-centred, anticipatory decision-making in some situations, a gap remains between the ReSPECT\'s aims and their implementation in practice. Promoting an understanding and valuing of the aims of ReSPECT among clinicians, supported by appropriate training and structural support, will enhance ReSPECT conversations.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 18 Jan 2021; epub ahead of print
Eli K, Hawkes CA, Ochieng C, Huxley CJ, ... Slowther AM, Griffiths F
Resuscitation: 18 Jan 2021; epub ahead of print | PMID: 33482270
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Impact:
Abstract

Public defibrillator accessibility and mobility trends during the COVID-19 pandemic in Canada.

Leung KHB, Alam R, Brooks SC, Chan TCY
Introduction
The COVID-19 pandemic has led to closures of non-essential businesses and buildings. The impact of such closures on automated external defibrillator (AED) accessibility compared to changes in foot traffic levels is unknown.
Methods
We identified all publicly available online AED registries in Canada last updated May 1, 2019 or later. We mapped AED locations to location types and classified each location type as completely inaccessible, partially inaccessible, or unaffected based on government-issued closure orders as of May 1, 2020. Using location and mobility data from Google\'s COVID-19 Community Mobility Reports, we identified the change in foot traffic levels between February 15-May 1, 2020 (excluding April 10-12) compared to the baseline of January 3-February 1, 2020, and determined the discrepancy between foot traffic levels and AED accessibility.
Results
We identified four provincial and two municipal AED registries containing a total of 5848 AEDs. Of those, we estimated that 69.9% were completely inaccessible, 18.8% were partially inaccessible, and 11.3% were unaffected. Parks, retail and recreation locations, and workplaces experienced the greatest reduction in AED accessibility. The greatest discrepancies between foot traffic levels and AED accessibility occurred in parks, retail and recreation locations, and transit stations.
Conclusion
A majority of AEDs became inaccessible during the COVID-19 pandemic due to government-mandated closures. In a substantial number of locations across Canada, the reduction in AED accessibility was far greater than the reduction in foot traffic.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 18 Jan 2021; epub ahead of print
Leung KHB, Alam R, Brooks SC, Chan TCY
Resuscitation: 18 Jan 2021; epub ahead of print | PMID: 33482269
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Impact:
Abstract

Impact of prehospital airway interventions on outcome in cardiac arrest following drowning: A study from the CARES Surveillance Group.

Ryan KM, Bui MD, Dugas JN, Zvonar I, Tobin JM
Introduction
Drowning results in more than 360,000 deaths annually, making it the 3rd leading cause of unintentional injury death worldwide. Prior studies have examined airway interventions affecting patient outcomes in cardiac arrest, but less is known about drowning patients in arrest. This study evaluated the outcomes of drowning patients in the Cardiac Arrest Registry to Enhance Survival (CARES) who received advanced airway management.
Methods
A retrospective analysis of the CARES database identified cases of drowning etiology between 2013 and 2018. Patients were stratified by airway intervention performed by EMS personnel. Demographics, sustained return of spontaneous circulation [ROSC], survival to hospital admission, survival to hospital discharge, and neurological outcomes were compared between airway groups using chi-squared tests and logistic regression.
Results
Among 2388 drowning patients, 70.4% were male, 41.8% white, and 13.1% survived to hospital discharge. Patients that received supraglottic airways [SGA] had statistically significantly lower odds of survival to hospital admission compared to endotracheal tube [ETT] use (adjusted odds ratio [aOR] = 0.56, 95% confidence interval [CI] 0.42-0.76) as well as lower odds of survival to discharge compared to bag valve mask [BVM] use (aOR = 0.40, 95% CI 0.19-0.86) when accounting for relative ROSC timing.
Conclusion
In this national cohort of drowning patients in cardiac arrest, SGA use was associated with significantly lower odds of survival to hospital admission and discharge. However, survival to discharge with favorable neurological outcome did not differ significantly between airway management techniques. Further studies will need to examine if airway intervention order or time to intervention affects outcomes.

Copyright © 2021 Elsevier B.V. All rights reserved.

Resuscitation: 18 Jan 2021; epub ahead of print
Ryan KM, Bui MD, Dugas JN, Zvonar I, Tobin JM
Resuscitation: 18 Jan 2021; epub ahead of print | PMID: 33482267
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Impact:
Abstract

Analyzing the heart rhythm during chest compressions: Performance and clinical value of a new AED algorithm.

de Graaf C, Beesems SG, Oud S, Stickney RE, ... Chapman FW, Koster RW
Purpose
Automated external defibrillators (AED) prompt the rescuer to stop chest compressions (CC) for ECG analysis during out-of-hospital cardiac arrest (OHCA). We assessed the diagnostic accuracy and clinical benefit of a new AED algorithm (cprINSIGHT), which analyzes ECG and impedance signals during CC, allowing rhythm analysis with ongoing chest compressions.
Methods
Amsterdam Police and Fire Fighters used a conventional AED in 2016-2017 (control) and an AED with cprINSIGHT in 2018-2019 (intervention). In the intervention AED, cprINSIGHT was activated after the first (conventional) analysis. This algorithm classified the rhythm as \"shockable\" (S) and \"non-shockable\" (NS), or \"pause needed\". Sensitivity for S, specificity for NS with 90% lower confidence limit (LCL), chest compression fractions (CCF) and pre-shock pause were compared between control and intervention cases accounting for multiple observations per patient.
Results
Data from 465 control and 425 intervention cases were analyzed. cprINSIGHT reached a decision during CC in 70% of analyses. Sensitivity of the intervention AED was 96%, (LCL 93%) and specificity was 98% (LCL 97%), both not significantly different from control. Intervention cases had a shorter median pre-shock pause compared to control cases (8 s vs 22 s, p < 0.001) and higher median CCF (86% vs 80%, P < 0.001).
Conclusion
AEDs with cprINSIGHT analyzed the ECG during chest compressions in 70% of analyses with 96% sensitivity and 98% specificity when it made a S or a NS decision. Compared to conventional AEDs, cprINSIGHT leads to a significantly shorter pre-shock pause and a significant increase in CCF.

Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.

Resuscitation: 15 Jan 2021; epub ahead of print
de Graaf C, Beesems SG, Oud S, Stickney RE, ... Chapman FW, Koster RW
Resuscitation: 15 Jan 2021; epub ahead of print | PMID: 33460749
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Impact:
Abstract

Mechanical versus manual chest compressions in the treatment of in-hospital cardiac arrest patients in a non-shockable rhythm: A multi-centre feasibility randomised controlled trial (COMPRESS-RCT).

Couper K, Quinn T, Booth K, Lall R, ... Yeung J, Perkins GD
Background
Mechanical chest compression devices deliver high-quality chest compressions. Early data suggests that mechanical devices may be superior to manual chest compressions in adults following an in-hospital cardiac arrest patients. To determine the feasibility of undertaking an effectiveness trial in this population, we undertook a feasibility randomised controlled trial.
Methods
We undertook a multi-centre parallel group feasibility randomised controlled trial (COMPRESS-RCT). Adult in-hospital cardiac arrest patients that were in a non-shockable rhythm were randomised in a 3:1 ratio to receive mechanical CPR (Jolfe AB/Stryker, Lund, Sweden) or ongoing manual CPR. Recruitment was led by the clinical cardiac arrest team. The primary study outcome was the proportion of eligible participants randomised in the study during site operational recruitment hours. Patients were enrolled under a model of deferred consent. We report data using descriptive statistics, point estimates and 95% confidence intervals.
Results
Over a two-year period, we recruited 127 patients across five UK hospitals. We recruited 55.2% (95% CI 48.5%-61.8%) of eligible study participants in site operational recruitment hours. Most participants were male (n = 76, 59.8%) with a mean age of 72 (95% CI: 69.9-74.9) years. Median arrest duration was 18 (IQR 13-29) minutes. In patients randomised to mech-CPR, median time from CPR start to device deployment was 11 (IQR 7-15) minutes. ROSC was achieved in 27.6% (n = 35) participants and 4.7% (n = 6) were alive at 30-days.
Conclusion
COMPRESS-RCT identified important factors that preclude progression to an effectiveness trial of mechanical CPR in the hospital setting in the UK. Findings will inform the design of future in-hospital intra-arrest intervention trials. ISRCTN38139840, date of registration 9th January 2017.

Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:228-235
Couper K, Quinn T, Booth K, Lall R, ... Yeung J, Perkins GD
Resuscitation: 30 Dec 2020; 158:228-235 | PMID: 33038438
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Impact:
Abstract

Controlled sequential elevation of the head and thorax combined with active compression decompression cardiopulmonary resuscitation and an impedance threshold device improves neurological survival in a porcine model of cardiac arrest.

Moore JC, Salverda B, Rojas-Salvador C, Lick M, Debaty G, G Lurie K
Aim of the study
Controlled sequential elevation of the head and thorax (CSE) during active compression decompression (ACD) cardiopulmonary resuscitation (CPR) with an impedance threshold device (ITD) has been shown to increase cerebral perfusion pressure and cerebral blood flow in previous animal studies as compared to the traditional supine position. The potential for this novel bundled treatment strategy to improve survival with intact neurological function is unknown.
Methods
Female farm pigs were sedated, intubated, and anesthetized. Central arterial and venous access were continuously monitored. Regional brain tissue perfusion (CerO2) was also measured transcutaneous. Ventricular fibrillation (VF) was induced and untreated for 10 min. Pigs were randomized to (1) Conventional CPR (C-CPR) flat or (2) ACD + ITD CSE CPR that included 2 min of ACD + ITD with the head and heart first elevated 10 and 8 cm, and then gradual elevation over 2 min to 22 and 9 cm, respectively. After 19 min of CPR, pigs were defibrillated and recovered. A veterinarian blinded to the intervention assessed cerebral performance category (CPC) at 24 h. A neurologically intact outcome was defined as a CPC score of 1 or 2. Categorical outcomes were analyzed by Fisher\'s exact test and continuous outcomes with an unpaired student\'s t-test.
Results
In 16 animals, return of spontaneous circulation rate was 8/8 (100%) with ACD + ITD CSE and 3/8 (25%) for C-CPR (p = 0.026). For the primary outcome of neurologically intact survival, 6/8 (75%) pigs had a CPC score 1 or 2 with ACD + ITD CSE versus 1/8 (12.5%) with C-CPR (p = 0.04). Coronary perfusion pressure (mmHg, mean ± SD) was higher with CSE at 18 min (41 ± 24 versus 10 ± 5, p = 0.004). rSO2 (%, mean ± SD) and ETCO2 (mmHg, mean ± SD) values were higher at 18 min with CSE (32 ± 9 versus 17 ± 2, p = 0.01, and 55 mmHg ± 10 versus 21 mmHg ± 4, p < 0.001), respectively.
Conclusions
The novel bundled resuscitation approach of CSE with ACD + ITD CPR increased favorable neurological survival versus C-CPR in a swine model of cardiac arrest.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:220-227
Moore JC, Salverda B, Rojas-Salvador C, Lick M, Debaty G, G Lurie K
Resuscitation: 30 Dec 2020; 158:220-227 | PMID: 33027619
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Impact:
Abstract

Neonatal delivery room CPR: An analysis of the Get with the Guidelines®-Resuscitation Registry.

Halling C, Raymond T, Brown LS, Ades A, ... Wyckoff MH, American Heart Association’s Get With The Guidelines–Resuscitation Investigators
Background
Cardiopulmonary resuscitation (CPR) in the delivery room (DR) after birth is rare. We hypothesized that factors related to maternal, delivery, infant and resuscitation event characteristics associated with outcomes could be identified. We also hypothesized there would be substantial variation from the Neonatal Resuscitation Program (NRP) algorithm.
Methods
Retrospective review of all neonates receiving chest compressions in the DR from the AHA Get With The Guidelines-Resuscitation registry from 2001 to 2014. The primary outcome was return of spontaneous circulation (ROSC) in the DR. Secondary outcome was survival to hospital discharge. Descriptive statistics were used to characterize data. Odds ratios with confidence intervals were calculated as appropriate to compare survivors and non-survivors.
Results
There were 1153 neonates who received chest compressions in the DR. ROSC was achieved in 968 (84%) newborns and 761 (66%) survived to hospital discharge. Fifty-one percent of the cohort received chest compressions without medications. Cardiac compressions were initiated within the first minute of life in 76% of the events, and prior to endotracheal intubation in 79% of the events. In univariate analysis, factors such as prematurity, number of endotracheal intubation attempts, increased time to first adrenaline dose, and CPR duration were associated with decreased odds of ROSC in the DR. Longer CPR duration was associated with decreased odds of ROSC in multivariate analysis.
Conclusion
In this cohort of infants receiving chest compressions following delivery, recognizable pre-birth risk factors as well as resuscitation interventions associated with increased and decreased odds of achieving ROSC were identified. Chest compressions were frequently initiated in the first minute of the event and often prior to endotracheal intubation. Further investigations should focus on methods to decrease time to critical resuscitation interventions, such as successful endotracheal intubation and administration of the first dose of adrenaline, in order to improve DR-CPR outcomes.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:236-242
Halling C, Raymond T, Brown LS, Ades A, ... Wyckoff MH, American Heart Association’s Get With The Guidelines–Resuscitation Investigators
Resuscitation: 30 Dec 2020; 158:236-242 | PMID: 33080368
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Impact:
Abstract

Postanoxic electrographic status epilepticus and serum biomarkers of brain injury.

Lybeck A, Friberg H, Nielsen N, Rundgren M, ... Cronberg T, Westhall E
Aim
To explore if electrographic status epilepticus (ESE) after cardiac arrest causes additional secondary brain injury reflected by serum levels of two novel biomarkers of brain injury: neurofilament light chain (NfL) originating from neurons and glial fibrillary acidic protein (GFAP) from glial cells.
Methods
Simplified continuous EEG (cEEG) and serum levels of NfL and GFAP, sampled at 24, 48 and 72 h after cardiac arrest, were collected during the Target Temperature Management (TTM)-trial. Two statistical methods were used: multivariable regresssion analysis; and a matched control group of patients without ESE matched for early predictors of poor neurological outcome.
Results
128 patients had available biomarkers and cEEG. Twenty-six (20%) patients developed ESE, the majority (69%) within 24 h. ESE was an independent predictor of elevated serum NfL (p < 0.001) but not of serum GFAP (p = 0.16) at 72 h after cardiac arrest. Compared to a control group matched for early predictors of poor neurological outcome, patients who developed ESE had higher levels of serum NfL (p = 0.03) and GFAP (p = 0.04) at 72 h after cardiac arrest.
Conclusion
ESE after cardiac arrest is associated with higher levels of serum NfL which may suggest increased secondary neuronal injury compared to matched patients without ESE but similar initial brain injury. Associations with GFAP reflecting glial injury are less clear. The study design cannot exclude imperfect matching or other mechanisms of secondary brain injury contributing to the higher levels of biomarkers of brain injury seen in the patients with ESE.

Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:253-257
Lybeck A, Friberg H, Nielsen N, Rundgren M, ... Cronberg T, Westhall E
Resuscitation: 30 Dec 2020; 158:253-257 | PMID: 33127439
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Impact:
Abstract

Translation from animal studies of novel pharmacological therapies to clinical trials in cardiac arrest: A systematic review.

Lind PC, Johannsen CM, Vammen L, Magnussen A, Andersen LW, Granfeldt A
Background
There is a lack of new promising therapies to improve the dismal outcomes from cardiac arrest. The objectives of this study were: (1) To identify novel pharmacological therapies investigated in experimental animal studies and (2) to identify pharmacological therapies translated from experimental animal studies to clinical trials.
Methods
PubMed was searched to first identify relevant experimental cardiac arrest animal models published within the last 20 years. Based on this, a list of interventions was created and a second search was performed to identify clinical trials testing one of these interventions. Data extraction was performed using standardised data extraction forms.
Results
We identified 415 animal studies testing 190 different pharmacological interventions. The most commonly tested interventions were classified as vasopressors, anaesthetics/gases, or interventions aimed at molecular targets. We found 43 clinical trials testing 26 different interventions identified in the animal studies. Of these, 13 trials reported positive findings and 30 trials reported neutral findings with regards to the primary endpoint. No study showed harm of the intervention. Some interventions tested in human clinical trials, had previously been tested in animal studies without a positive effect on outcomes. A large number of animal studies was performed after publication of a clinical trial.
Conclusion
Numerous different pharmacological interventions have been tested in experimental animal models. Despite this only a limited number of these interventions have advanced to clinical trials, however several of the clinical trials tested interventions that were first tested in experimental animal models.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:258-269
Lind PC, Johannsen CM, Vammen L, Magnussen A, Andersen LW, Granfeldt A
Resuscitation: 30 Dec 2020; 158:258-269 | PMID: 33147523
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Impact:
Abstract

Trends over time in drug administration during pediatric in-hospital cardiac arrest in the United States.

Ross CE, Moskowitz A, Grossestreuer AV, Holmberg MJ, ... Donnino MW, American Heart Association’s Get With The Guidelines – Resuscitation Investigators
Aims
To describe trends in pediatric in-hospital cardiac arrest drug administration and to assess temporal associations of the Pediatric Advanced Life Support (PALS) guideline changes with drug usage.
Methods
Pediatric patients <18 years old with in-hospital cardiac arrest recorded in the American Heart Association Get With The Guidelines-Resuscitation database between 2002 and 2018 were included. The annual adjusted odds of receiving each intra-arrest medication was determined. The association between changes in the PALS Guidelines and medication use over time was assessed interrupted time series analyses.
Results
A total of 6107 patients were analyzed. The adjusted odds of receiving lidocaine (0.33; 95% CI, 0.18, 0.61; p < 0.001), atropine (0.19; 95% CI 0.12, 0.30; p < 0.001) and bicarbonate (0.54; 95% CI 0.35, 0.86; p = 0.009) were lower in 2018 compared to 2002. For lidocaine, there were no significant changes in the step (-2.1%; 95% CI, -5.9%, 1.6%; p = 0.27) after the 2010 or 2015 (Step: -1.5%; 95% CI, -8.0%, 5.0; p = 0.65) guideline releases. There were no significant changes in the step for bicarbonate (-2.3%; 95% CI, -7.6%, 3.0%; p = 0.39) after the 2010 updates. For atropine, there was a downward step change after the 2010 guideline release (-5.9%; 95% CI, -10.5%, -1.3%; p = 0.01).
Conclusions
Changes to the PALS guidelines for lidocaine and bicarbonate were not temporally associated with acute changes in the use of these medications; however, better alignment with these updates was observed over time. A minor update to the language surrounding atropine in the PALS text was associated with a modest acute change in the observed use of atropine. Future studies exploring other factors that influence prescribers in pediatric IHCA are needed.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:243-252
Ross CE, Moskowitz A, Grossestreuer AV, Holmberg MJ, ... Donnino MW, American Heart Association’s Get With The Guidelines – Resuscitation Investigators
Resuscitation: 30 Dec 2020; 158:243-252 | PMID: 33147522
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Impact:
Abstract

The performance of the National Early Warning Score and National Early Warning Score 2 in hospitalised patients infected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Kostakis I, Smith GB, Prytherch D, Meredith P, ... Chauhan A, Portsmouth Academic ConsortIum For Investigating COVID-19 (PACIFIC-19)
Introduction
Since the introduction of the UK\'s National Early Warning Score (NEWS) and its modification, NEWS2, coronavirus disease 2019 (COVID-19), has caused a worldwide pandemic. NEWS and NEWS2 have good predictive abilities in patients with other infections and sepsis, however there is little evidence of their performance in COVID-19.
Methods
Using receiver-operating characteristics analyses, we used the area under the receiver operating characteristic (AUROC) curve to evaluate the performance of NEWS or NEWS2 to discriminate the combined outcome of either death or intensive care unit (ICU) admission within 24 h of a vital sign set in five cohorts (COVID-19 POSITIVE, n = 405; COVID-19 NOT DETECTED, n = 1716; COVID-19 NOT TESTED, n = 2686; CONTROL 2018, n = 6273; CONTROL 2019, n = 6523).
Results
The AUROC values for NEWS or NEWS2 for the combined outcome were: COVID-19 POSITIVE, 0.882 (0.868-0.895); COVID-19 NOT DETECTED, 0.875 (0.861-0.89); COVID-19 NOT TESTED, 0.876 (0.85-0.902); CONTROL 2018, 0.894 (0.884-0.904); CONTROL 2019, 0.842 (0.829-0.855).
Conclusions
The finding that NEWS or NEWS2 performance was good and similar in all five cohorts (range = 0.842-0.894) suggests that amendments to NEWS or NEWS2, such as the addition of new covariates or the need to change the weighting of existing parameters, are unnecessary when evaluating patients with COVID-19. Our results support the national and international recommendations for the use of NEWS or NEWS2 for the assessment of acute-illness severity in patients with COVID-19.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 159:150-157
Kostakis I, Smith GB, Prytherch D, Meredith P, ... Chauhan A, Portsmouth Academic ConsortIum For Investigating COVID-19 (PACIFIC-19)
Resuscitation: 30 Dec 2020; 159:150-157 | PMID: 33176170
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Impact:
Abstract

Bougie-assisted endotracheal intubation in the pragmatic airway resuscitation trial.

Bonnette AJ, Aufderheide TP, Jarvis JL, Lesnick JA, ... Colella MR, Wang HE
Objective
Paramedics may perform endotracheal intubation (ETI) while treating patients with out-of-hospital cardiac arrest (OHCA). The gum elastic Bougie (Bougie) is an intubation adjunct that may optimize intubation success. There are few reports of Bougie-assisted intubation in OHCA nor its association with outcomes. We compared intubation success rates and OHCA outcomes between Bougie-assisted and non-Bougie ETI in the out-of-hospital Pragmatic Airway Resuscitation Trial (PART).
Methods
This was a secondary analysis of patients receiving ETI enrolled in the Pragmatic Airway Resuscitation Trial (PART), a multicenter clinical trial comparing intubation-first vs. laryngeal tube-first strategies of airway management in adult OHCA. The primary exposure was use of Bougie for ETI-assistance. The primary endpoint was first-pass ETI success. Secondary endpoints included overall ETI success, time to successful ETI, return of spontaneous circulation, 72-h survival, hospital survival and hospital survival with favorable neurologic status (Modified Rankin Score ≤3). We analyzed the data using Generalized Estimating Equations and Cox Regression, adjusting for known confounders.
Results
Of the 3004 patients enrolled in PART, 1227 received ETI, including 440 (35.9%) Bougie-assisted and 787 (64.1%) non-Bougie ETIs. First-pass ETI success did not differ between Bougie-assisted and non-Bougie ETI (53.1% vs. 42.8%; adjusted OR 1.12, 95% CI: 0.97-1.39). ETI overall success was slightly higher in the Bougie-assisted group (56.2% vs. 49.1%; adjusted OR 1.19, 95% CI: 1.01-1.32). Time to endotracheal tube placement or abandonment was longer for Bougie-assisted than non-Bougie ETI (median 13 vs. 11 min; adjusted HR 0.63, 95% CI: 0.45-0.90). While survival to hospital discharge was lower for Bougie-assisted than non-Bougie ETI (3.6% vs. 7.5%; adjusted OR 0.94, 95% CI: 0.92-0.96), there were no differences in ROSC, 72-h survival or hospital survival or hospital survival with favorable neurologic status.
Conclusion
While exhibiting slightly higher ETI overall success rates, Bougie-assisted ETI entailed longer airway placement times and potentially lower survival. The role of the Bougie assistance in ETI of OHCA remains unclear.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:215-219
Bonnette AJ, Aufderheide TP, Jarvis JL, Lesnick JA, ... Colella MR, Wang HE
Resuscitation: 30 Dec 2020; 158:215-219 | PMID: 33181232
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Impact:
Abstract

Sex differences in patients with out-of-hospital cardiac arrest without ST-segment elevation: A COACT trial substudy.

Spoormans EM, Lemkes JS, Janssens GN, van der Hoeven NW, ... Appelman Y, van Royen N
Background
Whether sex is associated with outcomes of out-of-hospital cardiac arrest (OHCA) is unclear.
Objectives
This study examined sex differences in survival in patients with OHCA without ST-segment elevation myocardial infarction (STEMI).
Methods
Using data from the randomized controlled Coronary Angiography after Cardiac Arrest (COACT) trial, the primary point of interest was sex differences in OHCA-related one-year survival. Secondary points of interest included the benefit of immediate coronary angiography compared to delayed angiography until after neurologic recovery, angiographic and clinical outcomes.
Results
In total, 522 patients (79.1% men) were included. Overall one-year survival was 59.6% in women and 63.4% in men (HR 1.18; 95% CI: 0.76-1.81;p = 0.47). No cardiovascular risk factors were found that modified survival. Women less often had significant coronary artery disease (CAD) (37.0% vs. 71.3%;p < 0.001), but when present, they had a worse prognosis than women without CAD (HR 3.06; 95% CI 1.31-7.19;p = 0.01). This was not the case for men (HR 1.05; 95% CI 0.67-1.65;p = 0.83). In both sexes, immediate coronary angiography did not improve one-year survival compared to delayed angiography (women, odds ratio (OR) 0.87; 95% CI 0.58-1.30;p = 0.49; vs. men, OR 0.97; 95% CI 0.45-2.09;p = 0.93).
Conclusion
In OHCA patients without STEMI, we found no sex differences in overall one-year survival. Women less often had significant CAD, but when CAD was present they had worse survival than women without CAD. This was not the case for men. Both sexes did not benefit from a strategy of immediate coronary angiography as compared to delayed strategy with respect to one-year survival.
Clinical trial registration number
Netherlands trial register (NTR) 4973.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 30 Dec 2020; 158:14-22
Spoormans EM, Lemkes JS, Janssens GN, van der Hoeven NW, ... Appelman Y, van Royen N
Resuscitation: 30 Dec 2020; 158:14-22 | PMID: 33189807
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Impact:
Abstract

Association between chronic liver disease and clinical outcomes in out-of-hospital cardiac arrest.

Pak JE, Kim KH, Shin SD, Song KJ, ... Ro YS, Park JH
Objectives
Out-of-hospital cardiac arrest (OHCA) and chronic liver disease (CLD) are global health issues. The purpose of this study is to evaluate the association between chronic liver disease and clinical outcomes in OHCA.
Methods
A retrospective observation study, using a nationwide population-based OHCA registry, was conducted. Adult patients with cardiac OHCAs who were treated by emergency medical service (EMS) providers between January 2013 and December 2015 were screened. The main exposure was the status of chronic liver disease that had been diagnosed before OHCA, categorized into three groups: no CLD, CLD without cirrhosis, and CLD with cirrhosis. Multivariable logistic regression analysis for survival and neurologic recovery were conducted to calculate the adjusted odds ratio (AOR) and confidence intervals (CIs). Interaction analysis for age, gender were performed and sensitivity analysis by imputation for main exposure missing was also.
Result
A total of 8844 eligible OHCA patients were enrolled. There were 361 (4.1%) patients in the CLD without cirrhosis group and 1323 (15%) patients in the CLD with cirrhosis group. Compared to no CLD group, CLD with cirrhosis group was less likely to have favorable outcomes for good neurological recovery and survival to discharge. Patients with CLD but without cirrhosis showed similar associations in neurologic recovery and survival with those without CLD. In multivariable logistic regression analysis, the AOR and 95% CIs for good neurological outcome and survival to discharge were as below; good neurological outcome - 1.07 (0.70-1.64) for CLD without cirrhosis, 0.08 (0.04-0.16) for CLD with cirrhosis, survival to discharge - 1.01 (0.70-1.45) for CLD without cirrhosis, 0.13 (0.08-0.20) for CLD with cirrhosis. Same trends of association were demonstrated in interaction and imputation analysis.
Conclusion
OHCA patients with liver cirrhosis showed poor clinical outcomes and CLD had no negative association unless they progressed to cirrhotic status.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:1-7
Pak JE, Kim KH, Shin SD, Song KJ, ... Ro YS, Park JH
Resuscitation: 30 Dec 2020; 158:1-7 | PMID: 33189806
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Impact:
Abstract

The effect of airway management on CPR quality in the PARAMEDIC2 randomised controlled trial.

Deakin CD, Nolan JP, Ji C, Fothergill RT, ... Lall R, Perkins GD
Introduction
Good quality basic life support (BLS) is associated with improved outcome from cardiac arrest. Chest compression fraction (CCF) is a BLS quality indicator, which may be influenced by the type of airway used. We aimed to assess CCF according to the airway strategy in the PARAMEDIC2 study: no advanced airway, supraglottic airway (SGA), tracheal intubation, or a combination of the two. Our hypothesis was that tracheal intubation was associated with a decrease in the CCF compared with alternative airway management strategies.
Methods
PARAMEDIC2 was a multicentre double-blinded placebo-controlled trial of adrenaline vs placebo in out-of-hospital cardiac arrest. Data showing compression rate and ratio from patients recruited by London Ambulance Service (LAS) as part of this study was collated and analysed according to the advanced airway used during the resuscitation attempt.
Results
CPR process data were available from 286/ 2058 (13.9%) of the total patients recruited by LAS. The mean compression rate for the first 5 min of data recording was the same in all groups (P = 0.272) and ranged from 104.2 (95% CI of mean: 100.5, 107.8) min-1 to 108.0 (95% CI of mean: 105.1, 108.3) min-1. The mean compression fraction was also similar across all groups (P = 0.159) and ranged between 74.7% and 78.4%. There was no difference in the compression rates and fractions across the airway management groups, regardless of the duration of CPR.
Conclusion
There was no significant difference in the compression fraction associated with the airway management strategy.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 30 Dec 2020; 158:8-13
Deakin CD, Nolan JP, Ji C, Fothergill RT, ... Lall R, Perkins GD
Resuscitation: 30 Dec 2020; 158:8-13 | PMID: 33189805
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Impact:
Abstract

Gender and location disparities in prehospital bystander AED usage.

Jadhav S, Gaddam S
Background
With bystander AED usage being critical for prehospital cardiac arrest patient outcomes, it is important to analyze if the gender and location disparities found in bystander CPR rates also exist for bystander AED usage.
Methods
Using the National Emergency Medical Services Information System (NEMSIS) database, 1,144,969 bystander AED cases were analyzed on the basis of gender and location. Chi-squared testing checked for statistical significance and effect size was measured using relative risk (RR).
Results
Using female patients as a baseline, the RR for bystander AED usage for male patients was 1.34 (95% CI [1.3310, 1.3557], p < 0.001) indicating male patients are 34% more likely to receive bystander AED usage compared to female patients. Analyzing bystander AED usage per urbanity region using urban patients as a baseline, resulted in a RR of 0.87 for suburban patients (95% CI [0.8572, 0.8833], p < 0.001), 0.39 for rural patients (95% CI [0.3849, 0.3971], p < 0.001), and 0.36 for frontier patients (95% CI [0.3515, 0.3726], p < 0.001) showing a sharp decline in the chance of bystander AED usage in rural and frontier areas.
Conclusions
Female patients are less likely to receive bystander AED usage compared to male patients. To resolve these disparities increased public awareness is necessary that supports AED usage on females as socially acceptable and necessary for patient outcomes. Furthermore, given bystander AED usage among males and females declined as cardiac arrest locations became more remote, improvements in rural and frontier AED availability and training are necessary to increase bystander AED usage rates in those regions.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:139-142
Jadhav S, Gaddam S
Resuscitation: 30 Dec 2020; 158:139-142 | PMID: 33189804
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Impact:
Abstract

Crowdsourcing to save lives: A scoping review of bystander alert technologies for out-of-hospital cardiac arrest.

Valeriano A, Van Heer S, de Champlain F, C Brooks S
Aim
Out-of-hospital cardiac arrest (OHCA) constitutes a significant global health burden, with a survival rate of only 10-12%. Mobile phone technologies have been developed that crowdsource citizen volunteers to nearby OHCAs in order to initiate resuscitation prior to ambulance arrival. We performed a scoping review to map the available literature on these crowdsourcing technologies and compared their technical specifications.
Methods
A search strategy was developed for five online databases. Two reviewers independently assessed all articles for inclusion and extracted relevant study information. Subsequently, we performed a supplementary internet search and consulted experts to identify all available bystander alert technologies and their specifications.
Results
We included 65 articles examining bystander alerting technologies from more than 15 countries. We also identified 25 unique technologies, of which 18 were described in the included literature. Technologies were text message-based systems (n = 3) or mobile phone applications (n = 22). Most (21/25) used global positioning systems to direct bystanders to victims and nearby AEDs. Response radii for alerts varied widely from 200 m to 10 km. Some technologies incorporated advanced features such as video-conferencing with ambulance dispatch and detailed alert settings. Not all systems required volunteers to have training in cardiopulmonary resuscitation. Only ten studies assessed impact on clinical outcomes. Key barriers discussed included false positive alerts, legal liability, and potential psychological impact on volunteers.
Conclusion
Our review provides a comprehensive overview of crowdsourcing technologies for bystander intervention in out-of-hospital cardiac arrest. Future work should focus on clinical outcomes and methods of addressing barriers to implementation.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:94-121
Valeriano A, Van Heer S, de Champlain F, C Brooks S
Resuscitation: 30 Dec 2020; 158:94-121 | PMID: 33188832
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Impact:
Abstract

Non-linear association between arterial oxygen tension and survival after out-of-hospital cardiac arrest: A multicentre observational study.

Mckenzie N, Finn J, Dobb G, Bailey P, ... Bray J, Ho KM
Background
Studies to identify safe oxygenation targets after out-of-hospital cardiac arrest (OHCA) have often assumed a linear relationship between arterial oxygen tension (PaO2) and survival, or have dichotomised PaO2 at a supra-physiological level. We hypothesised that abnormalities in mean PaO2 (both high and low) would be associated with decreased survival after OHCA.
Methods
We conducted a retrospective multicentre cohort study of adult OHCA patients who received mechanical ventilation on admission to the intensive care unit (ICU). The potential non-linear relationship between the mean PaO2 within the first 24 -hs of ICU admission and survival to hospital discharge (STHD) was assessed by a four-knot restricted cubic spline function with adjustment for potential confounders.
Results
3764 arterial blood gas results were available for 491 patients in the first 24-hs of ICU admission. The relationship between mean PaO2 over the first 24-hs and STHD was an inverted U-shape, with highest survival for those with a mean PaO2 between 100 and 180 mmHg (reference category) compared to a mean PaO2 of <100 mmHg (adjusted odds ratio [aOR] 0.50 95% confidence interval [CI] 0.30, 0.84), or >180 mmHg (aOR 0.41, 95% CI 0.18, 0.92). Mean PaO2 within 24 -hs was the third most important predictor and explained 9.1% of the variability in STHD.
Conclusion
The mean PaO2 within the first 24-hs after admission for OHCA has a non-linear association with the highest STHD seen between 100 and 180 mmHg. Randomised controlled trials are now needed to validate the optimal oxygenation targets in mechanically ventilated OHCA patients.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:130-138
Mckenzie N, Finn J, Dobb G, Bailey P, ... Bray J, Ho KM
Resuscitation: 30 Dec 2020; 158:130-138 | PMID: 33232752
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Impact:
Abstract

Clinical decision rules for termination of resuscitation during in-hospital cardiac arrest: A systematic review of diagnostic test accuracy studies.

Lauridsen KG, Baldi E, Smyth M, Perkins GD, Greif R, Education Implementation and Team Task Force of the International Liaison Committee on Resuscitation (ILCOR)
Aim
To assess whether any clinical decision rule for patients sustaining an in-hospital cardiac arrest (IHCA) can predict mortality or survival with poor neurological outcome.
Methods
We searched online databases from inception through July 2020 for randomized controlled trials and non-randomized studies. Two reviewers assessed studies for inclusion. We followed PRISMA guidelines for Diagnostic Test Accuracy Studies, used the Quality Assessment of Diagnostic Accuracy Studies framework to evaluate risk of bias, and Grading of Recommendations Assessment, Development and Evaluation methodology to evaluate certainty of evidence. We assessed predictive values for no return of spontaneous circulation (ROSC), death before hospital discharge, and survival with unfavorable neurological outcome.
Results
Out of 6436 studies, 92 studies were selected for full-text screening. We included 3 observational studies describing the derivation and external validation for the UN10 rule (Unwitnessed arrest; Nonshockable rhythm; 10 min of resuscitation without ROSC) amongst patients suffering from IHCA. No studies were identified for clinical implementation. Positive Predicted Values (PPV) for death before hospital discharge for the three studies were 100% (95% CI: 97.1%-100%), 98.9% (95% CI: 96.5%-99.7%), and 93.7% (95% CI: 93.3%-94.0%). One study reported a PPV for prediction of survival with unfavorable neurological outcome, 95.2% (95% CI: 94.9%-95.6%). The level of evidence was rated as very low certainty.
Conclusions
We identified very low certainty evidence for one clinical decision rule (the UN-10 rule) that was unable to reliably predict mortality or survival with unfavorable neurological outcome for adults suffering from IHCA. We identified no evidence for children. PROSPERO CRD42020164091.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:23-29
Lauridsen KG, Baldi E, Smyth M, Perkins GD, Greif R, Education Implementation and Team Task Force of the International Liaison Committee on Resuscitation (ILCOR)
Resuscitation: 30 Dec 2020; 158:23-29 | PMID: 33197522
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Impact:
Abstract

Can a Shockable Initial Rhythm Identify Out-of-Hospital Cardiac Arrest Patients with a Short No-flow Time?

Cournoyer A, de Montigny L, Potter BJ, Segal E, ... Marquis M, Daoust R
Aims
Initial shockable rhythms may be a marker of shorter duration between collapse and initiation of cardiopulmonary resuscitation, known as no-flow time (NFT), for patients suffering an out-of-hospital cardiac arrest (OHCA). Eligibility for extracorporeal resuscitation is conditional on a short NFT. Patients with an unwitnessed OHCA could be candidate for extracorporeal resuscitation despite uncertain NFT if an initial shockable rhythm is a reliable stand-in. Herein, we sought to describe the sensitivity and specificity of an initial shockable rhythm for predicting a NFT of five minutes or less.
Methods
Using a registry of OHCA in Montreal, Canada, adult patients who experienced a witnessed non-traumatic OHCA, but who did not receive bystander cardiopulmonary resuscitation, were included. The sensitivity and specificity of an initial shockable rhythm for predicting a NFT of five minute or less were calculated. The association between the NFT and the presence of a shockable rhythm was evaluated using a multivariable logistic regression.
Results
A total of 2450 patients were included, of whom 863 (35%) had an initial shockable rhythm and 1085 (44%) a NFT of five minutes or less. The sensitivity of an initial shockable rhythm to predict a NFT of five minutes or less was 36% (95% confidence interval [95%CI] 33-39), specificity was 66% (95%CI 63-68), the positive likelihood ratio was 1.05 (95%CI 0.94-1.17) and the negative likelihood ratio of 0.97 (95%CI 0.92-1.03). The probabilities of observing a shockable rhythm stayed stable up to 15 minutes, while the probabilities of observing a PEA lowered rapidly initially. Longer NFT were associated with lower odds of observing an initial shockable rhythm (adjusted odds ratio = 0.97 [95%CI 0.94-0.99], p = 0.012).
Conclusions
An initial shockable rhythm is a poor predictor of a short NFT, despite there being an association between the NFT and the presence of a shockable rhythm.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:57-63
Cournoyer A, de Montigny L, Potter BJ, Segal E, ... Marquis M, Daoust R
Resuscitation: 30 Dec 2020; 158:57-63 | PMID: 33220352
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Impact:
Abstract

Merits of expanding the Utstein case definition for out of hospital cardiac arrest.

Shin J, Chocron R, Rea T, Kudenchuk P, McNally B, Eisenberg M
Background
The Utstein population is defined by non-traumatic, bystander-witnessed out-of-hospital cardiac arrest (OHCA) presenting with ventricular fibrillation (VF). It is used to compare resuscitation performance across emergency medical services (EMS) systems. We hypothesized a system-specific survival correlation between the current Utstein population and other VF populations defined by unwitnessed VF OHCA and VF OHCA after EMS arrival (EMS-witnessed). Expanding performance metrics to this more comprehensive population would make the Utstein definition more representative of the actual community burden and response to VF OHCA.
Methods
We performed a cohort investigation of all non-traumatic, VF OHCA in the Cardiac Arrest Registry to Enhance Survival from 1/1/2013-12/31/2018 among EMS agencies that treated > = 100 VF OHCA. We evaluated sample size and survival with the addition of the new VF populations. We used Pearson coefficient to assess whether there was a correlation of agency-specific survival outcomes between the current Utstein population and unwitnessed and EMS-witnessed VF OHCA.
Results
A total of 107 EMS agencies treated 38,836 VF arrests: 22,918 current Utstein, 11,297 unwitnessed VF, and 4621 EMS-witnessed VF OHCA. Overall, survival was 29.8% (11,567/38,836): 33.9% (7774/22,918) among current Utstein, 17.2% (1942/11,297) among unwitnessed VF, and 40.1% (1851/4621) among EMS-witnessed VF. For agency-specific survival outcome, the Pearson correlation was 0.52 between the current Utstein population versus combined unwitnessed and EMS-witnessed groups. For survival with Cerebral Performance Category 1-2, the Pearson correlation was 0.61.
Conclusion
Expanding the Utstein population to include unwitnessed and EMS-witnessed VF OHCA achieves a simpler, more inclusive case definition that minimizes variability in case determination and increases the number of survivors and eligible population by ∼50%, while still achieving a distinguishing metric of system-specific performance.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:88-93
Shin J, Chocron R, Rea T, Kudenchuk P, McNally B, Eisenberg M
Resuscitation: 30 Dec 2020; 158:88-93 | PMID: 33220350
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Impact:
Abstract

Emergency Medical Services and Do Not Attempt Resuscitation directives among patients with out-of-hospital cardiac arrest.

Counts CR, Blackwood J, Winchell R, Drucker C, ... Kudenchuk PJ, Rea T
Background
Emergency Medical Services (EMS) are often involved in end-of-life circumstances, yet little is known about how EMS interfaces with advance directives to forego unwanted resuscitation (Do Not Attempt Resuscitation (DNAR)). We evaluated the frequency of these directives involved in out-of-hospital cardiac arrest (OHCA) and how they impact care.
Methods
We conducted a cohort investigation of adult, EMS-attended OHCA from January 1 to December 31, 2018 in King County, WA. DNAR status was ascertained from dispatch, EMS, and hospital records. Resuscitation was classified according to DNAR status: not initiated, initiated but ceased due to the DNAR, or full efforts.
Results
Of 3152 EMS-attended OHCA, 314 (9.9%) had a DNAR directive. DNAR was present more often among those for whom EMS did not attempt resuscitation compared to when EMS provided some resuscitation (13.2% [212/1611] vs 6.6% [101/1541], (p < 0.05). Of those receiving resuscitation with a DNAR directive (n = 101), the DNAR was presented on average 6 min following EMS arrival. A total of 82% (n = 83) had EMS efforts ceased as a consequence of the DNAR while 18% (n = 18) received full efforts. Full-efforts compared to ceased-efforts were more likely to have a witnessed arrest (67% vs 36%), present with shockable rhythm (22% vs 6%), achieve spontaneous circulation by time of DNAR presentation (50% vs 4%), and have family contradict the DNAR (33% vs 0%) (p < 0.05 for each comparison).
Conclusions
Approximately 10% of EMS-attended OHCA involved DNAR. EMS typically fulfilled this end-of-life preference, though wishes were challenged by delayed directive presentation or contradictory family wishes.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:73-78
Counts CR, Blackwood J, Winchell R, Drucker C, ... Kudenchuk PJ, Rea T
Resuscitation: 30 Dec 2020; 158:73-78 | PMID: 33221365
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Impact:
Abstract

The Design of an Adaptive Clinical Trial to Evaluate the Efficacy of Extra-Corporeal Membrane Oxygenation for Out-of-Hospital Cardiac Arrest.

Tolles J, Kidwell KM, Broglio K, Graves T, ... Lewis RJ, Neumar RW
Background
Extracorporeal cardiopulmonary resuscitation (ECPR) is a promising therapy for out-of-hospital cardiac arrest (OHCA) that is refractory to standard therapy, but no multicenter randomized clinical trials have been conducted to establish its efficacy. We report the design and operating characteristics of a proposed randomized Bayesian adaptive \"enrichment\" clinical trial designed to determine whether ECPR is effective for refractory OHCA and, if effective, to define the interval after arrest during which patients derive benefit.
Methods
Through iterative trial simulation and trial design modification, we developed a Bayesian adaptive trial of ECPR for adults who experience non-traumatic out-of-hospital cardiac arrest. Our proposed trial design addresses the threats to trial success identified during the design process, which were (1) the uncertainty surrounding the cardiac arrest (CA)-to-ECPR interval within which clinical benefit might be preserved (2) the difference in prognosis between patients with an initial rhythm that is non-shockable vs. shockable. Trial subjects will be randomized 1:1 to receive either standard care or expedited transport to a hospital for potential ECPR. The CA-to-ECPR interval will be estimated in real time based on the sum of the estimated paramedic response time (911 call to scene arrival), paramedic scene time, and transport time to hospital. A Bayesian decreasing step function will be used to estimate the efficacy of the treatment with an outcome of the 90-day utility-weighted Modified Rankin Scale (uwmRS) for each rhythm subgroup and estimated CA-to-ECPR interval at pre-specified interims. The trial will adaptively lengthen the estimated CA-to-ECPR eligibility window if the treatment appears effective at the upper limit of initial eligibility window. If ECPR appears ineffective at longer estimated CA-to-ECPR intervals, the upper limit of the window for enrollment eligibility will be shortened. The analysis will be stratified by rhythm subgroup.
Results
With a maximum total sample size of 400, and a cap on the maximum sample size of 300 for the non-shockable rhythm subgroup, the trial design has power ranging from 91-100% to detect a benefit from ECPR for non-shockable rhythms under the various efficacy scenarios simulated and power ranging from 69-98% for shockable rhythms under the same scenarios. The trial design also has a high probability of correctly identifying the maximum CA-to-ECPR interval within which ECPR produces a clinically significant benefit of 0.2 on the uwMRS. If ECPR is equivalent to standard CA care, the type I error is 2.5% with a 99% probability of stopping enrollment early for futility in the non-shockable subgroup and a 97% probability of stopping enrollment early for futility in the shockable subgroup.
Conclusion
This proposed adaptive trial design helps to ensure the population of patients who are most likely to benefit from treatment-as defined both by rhythm subgroup and estimated CA-to-ECPR interval-is enrolled. The design promotes early termination of the trial if continuation is likely to be futile.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:185-192
Tolles J, Kidwell KM, Broglio K, Graves T, ... Lewis RJ, Neumar RW
Resuscitation: 30 Dec 2020; 158:185-192 | PMID: 33221363
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Impact:
Abstract

In-Hospital vs. Out-of-Hospital Cardiac Arrest: Patient Characteristics and Survival.

Høybye M, Stankovic N, Holmberg M, Christensen HC, Granfeldt A, Andersen LW
Background
Cardiac arrests are often categorized into two separate groups depending on the location of the arrest: in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA). Despite this distinction, few studies have compared the two groups directly. The aim of this study was to compare patient characteristics, cardiac arrest characteristics, and outcomes for IHCA and OHCA patients.
Methods
Data on IHCA and OHCA in Denmark were obtained from two nationwide, prospective registries. All adult (≥18 years old) patients with index IHCA or OHCA from January 1, 2017 to December 31, 2018 were included. Supplementary information on outcomes, hospitalizations, and chronic diseases came from additional national registries. The primary outcome was 30-day survival and secondary outcomes were return of spontaneous circulation (ROSC) and 1-year survival.
Results
The study included 3501 patients with IHCA and 8846 patients with OHCA. The two groups were similar in demographics, most comorbidities, and initial cardiac arrest rhythm. In the unadjusted analysis, IHCA was associated with increased survival to 30 days compared to OHCA (risk ratio [RR] = 1.41; 95% CI, 1.30; 1.54) and 1 year (RR = 1.46; 95% CI, 1.33; 1.61). Adjusting for age, sex, and comorbidities did not change the RR substantially. When cardiac arrest characteristics were added to the model, the RR decreased from 1.51 (95% CI, 1.39; 1.65) to 1.06 (95% CI, 0.93; 1.20) for survival to 30 days and from 1.66 (95% CI, 1.50; 1.84) to 1.09 (95% CI, 0.94; 1.26) for survival to 1 year. In all subgroup analyses based on cardiac arrest characteristics (e.g. witnessed status), the association between location and outcome was substantially mitigated compared to the primary analyses.
Conclusions
In this large, national study, we found that IHCA and OHCA patients were remarkably similar in demographics and most comorbidities. IHCA patients had better outcomes compared to OHCA patients, although these differences disappeared when comparing patients with similar cardiac arrest characteristics.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 30 Dec 2020; 158:157-165
Høybye M, Stankovic N, Holmberg M, Christensen HC, Granfeldt A, Andersen LW
Resuscitation: 30 Dec 2020; 158:157-165 | PMID: 33221361
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Impact:
Abstract

Comparison between dispatcher-assisted bystander CPR and self-led bystander CPR in out-of-hospital cardiac arrest (OHCA).

Kim MW, Kim TH, Song KJ, Shin SD, ... Lee EJ, Kim K
Introduction
Bystander cardiopulmonary resuscitation (CPR) is an important prognostic factor for outcome in out-of-hospital cardiac arrest (OHCA). The dispatcher-assisted (DA) bystander CPR program has increased the rate of bystander CPR by targeting bystanders with a lower level of CPR training. We evaluated the effects of dispatcher-assisted bystander CPR and self-led bystander CPR.
Methods
A retrospective analysis was performed using a nationwide OHCA database from 2014 to 2018. Adult EMS-treated OHCA patients with presumed cardiac origin were enrolled. OHCAs were classified into 3 groups according to the type of bystander CPR (DA bystander CPR vs. self-led bystander CPR vs. no bystander CPR) provided. The primary outcome was good neurologic recovery at hospital discharge. A multivariable logistic regression model was used to estimate the association between the type of bystander CPR and outcomes.
Results
A total of 91,557 eligible OHCA patients was enrolled in the final analysis. The proportion of patients with favorable neurologic outcomes was highest with self-led bystander CPR (9.0% for self-led bystander CPR, 5.2% for DA bystander CPR and 3.2% for no bystander CPR, p < 0.01). Self-led bystander CPR was associated with better neurological recovery than DA bystander CPR (aOR with 95% CI (DA-CPR as reference): 0.63 (0.58-0.69) for no bystander CPR, 1.28 (1.17-1.40) for self-led bystander CPR).
Conclusion
Although DA CPR was associated with better neurologic outcomes than no bystander CPR, good neurologic outcomes were most strongly associated with self-led bystander CPR.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 30 Dec 2020; 158:64-70
Kim MW, Kim TH, Song KJ, Shin SD, ... Lee EJ, Kim K
Resuscitation: 30 Dec 2020; 158:64-70 | PMID: 33221356
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Impact:
Abstract

Impact of the coronavirus pandemic on the patterns of vital signs recording and staff compliance with expected monitoring schedules on general wards.

Kostakis I, Smith GB, Prytherch D, Meredith P, ... Chauhan A, Portsmouth Academic ConsortIum For Investigating COVID-19 (PACIFIC-19)
Introduction
Coronavirus disease 2019 (COVID-19) placed increased burdens on National Health Service hospitals and necessitated significant adjustments to their structures and processes. This research investigated if and how these changes affected the patterns of vital sign recording and staff compliance with expected monitoring schedules on general wards.
Methods
We compared the pattern of vital signs and early warning score (EWS) data collected from admissions to a single hospital during the initial phase of the COVID-19 pandemic with those in three control periods from 2018, 2019 and 2020. Main outcome measures were weekly and monthly hospital admissions; daily and hourly patterns of recorded vital signs and EWS values; time to next observation and; proportions of \'on time\', \'late\' and \'missed\' vital signs observations sets.
Results
There were large falls in admissions at the beginning of the COVID-19 era. Admissions were older, more unwell on admission and throughout their stay, more often required supplementary oxygen, spent longer in hospital and had a higher in-hospital mortality compared to one or more of the control periods. More daily observation sets were performed during the COVID-19 era than in the control periods. However, there was no clear evidence that COVID-19 affected the pattern of vital signs collection across the 24-h period or the week.
Conclusions
The increased burdens of the COVID-19 pandemic, and the alterations in healthcare structures and processes necessary to respond to it, did not adversely affect the hospitals\' ability to monitor patients under its care and to comply with expected monitoring schedules.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:30-38
Kostakis I, Smith GB, Prytherch D, Meredith P, ... Chauhan A, Portsmouth Academic ConsortIum For Investigating COVID-19 (PACIFIC-19)
Resuscitation: 30 Dec 2020; 158:30-38 | PMID: 33221355
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Impact:
Abstract

Early outcome prediction for out-of-hospital cardiac arrest with initial shockable rhythm using machine learning models.

Hirano Y, Kondo Y, Sueyoshi K, Okamoto K, Tanaka H
Aim
Early outcome prediction for out-of-hospital cardiac arrest with initial shockable rhythm is useful in selecting the choice of resuscitative treatment by clinicians. This study aimed to develop and validate a machine learning-based outcome prediction model for out-of-hospital cardiac arrest with initial shockable rhythm, which can be used on patient\'s arrival at the hospital.
Methods
Data were obtained from a nationwide out-of-hospital cardiac arrest registry in Japan. Of 43,350 out-of-hospital cardiac arrest patients with initial shockable rhythm registered between 2013 and 2017, patients aged <18 years and those with cardiac arrest caused by external factors were excluded. Subjects were classified into training (n = 23,668, 2013-2016 data) and test (n = 6381, data from 2017) sets for validation. Only 19 prehospital variables were used for the outcome prediction. The primary outcome was death at 1 month or survival with poor neurological function (cerebral performance category 3-5; \"poor\" outcome). Several machine learning models, including those based on logistic regression, support vector machine, random forest, and multilayer perceptron classifiers were compared.
Results
In validation analyses, all machine learning models performed satisfactorily with area under the receiver operating characteristic curve values of 0.882 [95% confidence interval [CI]: 0.869-0.894] for logistic regression, 0.866 [95% CI: 0.853-0.879] for support vector machine, 0.877 [95% CI: 0.865-0.890] for random forest, and 0.888 [95% CI: 0.876-0.900] for multilayer perceptron classifiers.
Conclusions
A favourable machine learning-based prognostic model available to use on patient arrival at the hospital was developed for out-of-hospital cardiac arrest with initial shockable rhythm.

Copyright © 2020 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:49-56
Hirano Y, Kondo Y, Sueyoshi K, Okamoto K, Tanaka H
Resuscitation: 30 Dec 2020; 158:49-56 | PMID: 33227398
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Abstract

Impact of perceived inappropiate cardiopulmonary resuscitation on emergency clinicians\' intention to leave the job: Results from a cross-sectional survey in 288 centres across 24 countries.

Druwé P, Monsieurs KG, Gagg J, Nakahara S, ... Benoit DD, REAPPROPRIATE study group
Introduction
Cardiopulmonary resuscitation (CPR) in patients with a poor prognosis increases the risk of perception of inappropriate care leading to moral distress in clinicians. We evaluated whether perception of inappropriate CPR is associated with intention to leave the job among emergency clinicians.
Methods
A cross-sectional multi-centre survey was conducted in 24 countries. Factors associated with intention to leave the job were analysed by conditional logistic regression models. Results are expressed as odds ratios with 95% confidence intervals.
Results
Of 5099 surveyed emergency clinicians, 1836 (36.0%) were physicians, 1313 (25.7%) nurses, 1950 (38.2%) emergency medical technicians. Intention to leave the job was expressed by 1721 (33.8%) clinicians, 3403 (66.7%) often wondered about the appropriateness of a resuscitation attempt, 2955 (58.0%) reported moral distress caused by inappropriate CPR. After adjustment for other covariates, the risk of intention to leave the job was higher in clinicians often wondering about the appropriateness of a resuscitation attempt (1.43 [1.23-1.67]), experiencing associated moral distress (1.44 [1.24-1.66]) and who were between 30-44 years old (1.53 [1.21-1.92] compared to <30 years). The risk was lower when the clinician felt valued by the team (0.53 [0.42-0.66]), when the team leader acknowledged the efforts delivered by the team (0.61 [0.49-0.75]) and in teams that took time for debriefing (0.70 [0.60-0.80]).
Conclusion
Resuscitation attempts perceived as inappropriate by clinicians, and the accompanying moral distress, were associated with an increased likelihood of intention to leave the job. Interprofessional collaboration, teamwork, and regular interdisciplinary debriefing were associated with a lower risk of intention to leave the job. ClinicalTrials.gov; No.: NCT02356029.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:41-48
Druwé P, Monsieurs KG, Gagg J, Nakahara S, ... Benoit DD, REAPPROPRIATE study group
Resuscitation: 30 Dec 2020; 158:41-48 | PMID: 33227397
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Abstract

Factors associated with shockable versus non-shockable rhythms in patients with in-hospital cardiac arrest.

Stankovic N, Høybye M, Holmberg MJ, Lauridsen KG, Andersen LW, Granfeldt A
Aim
To identify factors associated with the initial rhythm in patients with in-hospital cardiac arrest and to assess whether potential differences in outcomes based on the initial rhythm can be explained by patient and event characteristics.
Methods
Adult patients (≥18 years old) with in-hospital cardiac arrest in 2017 and 2018 were included from the Danish In-Hospital Cardiac Arrest Registry (DANARREST). We used population-based registries to obtain data on comorbidities, cardiac procedures, and medications. Unadjusted and adjusted risk ratios (RRs) for initial rhythm, return of spontaneous circulation (ROSC), and survival were estimated in separate models including an incremental number of prespecified variables.
Results
A total of 3422 patients with in-hospital cardiac arrest were included, of which 639 (19%) had an initial shockable rhythm. Monitored cardiac arrest, witnessed cardiac arrest, and specific cardiac diseases (i.e. ischemic heart disease, dysrhythmias, and valvular heart disease) were associated with initial shockable rhythm. Conversely, higher age, female sex, and specific non-cardiovascular comorbidities (e.g. overweight and obesity, renal disease, and pulmonary cancer) were associated with an initial non-shockable rhythm. Initial shockable rhythm remained strongly associated with increased ROSC (RR = 1.63, 95%CI 1.51-1.76), 30-day survival (RR = 2.31, 95%CI 2.02-2.64), and 1-year survival (RR = 2.36, 95%CI 2.02-2.76) compared to initial non-shockable rhythm in the adjusted analyses.
Conclusion
In this study, specific patient and cardiac arrest characteristics were associated with initial rhythm in patients with in-hospital cardiac arrest. However, differences in patient and cardiac arrest characteristics did not fully explain the association with survival for initial shockable rhythm compared to a non-shockable rhythm.

Copyright © 2020 Elsevier B.V. All rights reserved.

Resuscitation: 30 Dec 2020; 158:166-174
Stankovic N, Høybye M, Holmberg MJ, Lauridsen KG, Andersen LW, Granfeldt A
Resuscitation: 30 Dec 2020; 158:166-174 | PMID: 33248155
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