<div><h4>Cardiovascular changes induced by targeted mild hypercapnia after out of hospital cardiac arrest. A sub-study of the TAME cardiac arrest trial.</h4><i>Baumann Melberg M, Flaa A, Øystein Andersen G, Sunde K, ... Mariero Olasveengen T, Qvigstad E</i><br /><b>Aim</b><br />Hypercapnia may elicit detrimental haemodynamic effects in critically ill patients. We aimed to investigate the consequences of targeted mild hypercapnia versus targeted normocapnia on pulmonary vascular resistance and right ventricular function in patients resuscitated from out-of-hospital cardiac arrest (OHCA).<br /><b>Methods</b><br />Pre-planned, single-centre, prospective, sub-study of the Targeted Therapeutic Mild Hypercapnia After Resuscitated Cardiac Arrest (TAME) trial. Patients were randomised to mild hypercapnia (PaCO<sub>2</sub> = 6.7-7.3 kPa) or normocapnia (PaCO<sub>2</sub> = 4.7-6.0 kPa) for 24 hours. Haemodynamic assessment was performed with right heart catheterisation and serial blood-gas analyses every4th hour for 48 hours.<br /><b>Results</b><br />We studied 84 patients. Mean pH was 7.24 (95 % CI 7.22-7.30) and 7.32 (95 % CI 7.31-7.34) with hypercapnia and normocapnia, respectively (P-group <0.001). Pulmonary vascular resistance index (PVRI), pulmonary artery pulsatility index, and right atrial pressure did not differ between groups (P-group >0.05). Mean cardiac index was higher with mild hypercapnia (P-group <0.001): 2.0 (95 % CI 1.85-2.1) vs 1.6 (95 % CI 1.52-1.76) L/min/m<sup>2</sup>. Systemic vascular resistance index was 2579 dyne-sec/cm-5/ m<sup>2</sup> (95 % CI 2356-2830) with hypercapnia, and 3249 dyne-sec/cm-5/ m<sup>2</sup> (95 % CI 2930 - 3368) with normocapnia (P-group <0.001). Stroke volumes (P-group =0.013) and mixed venous oxygen saturation (P-group <0.001) were higher in the hypercapnic group.<br /><b>Conclusion</b><br />In resuscitated OHCA patients, targeting mild hypercapnia did not increase PVRI or worsen right ventricular function compared to normocapnia. Mild hypercapnia comparatively improved cardiac performance and mixed venous oxygen saturation.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 14 Sep 2023:109970; epub ahead of print</small></div>

<div><h4>Effect of first epinephrine administration time on cerebral perfusion pressure and cortical cerebral blood flow in a porcine cardiac arrest model.</h4><i>Hyun Choi D, Jeong Hong K, Hong Kim K, Do Shin S, ... Sun Ro Y, Jeong Kang H</i><br /><b>Objective</b><br />The optimal time for epinephrine administration and its effects on cerebral blood flow (CBF) and microcirculation remain controversial. This study aimed to assess the effect of the first administration of epinephrine on cerebral perfusion pressure (CePP) and cortical CBF in porcine cardiac arrest model.<br /><b>Methods</b><br />After 4 min of untreated ventricular fibrillation, eight of 24 swine were randomly assigned to the early, intermediate, and late groups. In each group, epinephrine was administered intravenously at 5, 10, and 15 min after cardiac arrest induction. CePP was calculated as the difference between the mean arterial pressure and intracranial pressure. Cortical CBF was measured using a laser Doppler flow probe. The outcomes were CePP and cortical CBF measured continuously during cardiopulmonary resuscitation (CPR). Mean CePP and cortical CBF were compared using analysis of variance and a linear mixed model.<br /><b>Results</b><br />The mean CePP was significantly different between the groups at 6-11 min after cardiac arrest induction. The mean CePP in the early group was significantly higher than that in the intermediate group at 8-10 min and that in the late group at 6-9 min and 10-11 min. The mean cortical CBF was significantly different between the groups at 9-11 min. The mean cortical CBF was significantly higher in the early group than in the intermediate and late group at 9-10 min.<br /><b>Conclusion</b><br />Early administration of epinephrine was associated with improved CePP and cortical CBF compared to intermediate or late administration during the early period of CPR.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 14 Sep 2023:109969; epub ahead of print</small></div>

<div><h4>The Effects of Mechanical Versus Bag-Valve Ventilation on Gas Exchange During Cardiopulmonary Resuscitation in Emergency Department Patients: A Randomized Controlled Trial (CPR-VENT).</h4><i>Tangpaisarn T, Tosibphanom J, Sata R, Kotruchin P, Drumheller B, Phungoen P</i><br /><b>Introduction</b><br />Effective ventilation is crucial for successful cardiopulmonary resuscitation (CPR). Previous studies indicate that higher arterial oxygen levels (PaO<sub>2</sub>) during CPR increase the chances of successful resuscitation. However, the advantages of mechanical ventilators over bag-valve ventilation for achieving optimal PaO<sub>2</sub> during CPR remain uncertain.<br /><b>Method</b><br />We conducted a randomized trial involving non-traumatic adult cardiac arrest patients who received CPR in the ED. After intubation, patients were randomly assigned to ventilate with a mechanical ventilator (MV) or bag valve ventilation (BV). In MV group, ventilation settings were: breath rate 10/minute, tidal volume 6-7 ml/kg, inspiratory time 1 second, positive end-expiratory pressure 0 cm water, inspiratory oxygen fraction (FiO<sub>2</sub>) 100%. The primary outcome was to compare the difference in PaO<sub>2</sub> from arterial blood gases (ABG) obtained 4-10 minutes later during CPR between both groups.<br /><b>Results</b><br />Sixty patients were randomized (30 in each group). The study population consisted of: 57% male, median age 62 years, 37% received bystander CPR, and 20% had an initial shockable rhythm. Median time from arrest to intubation was 24 minutes. The median PaO<sub>2</sub> was not significantly different in the BV compared to MV [36.5 mmHg (14.0 - 70.0) vs. 29.0 mmHg (15.0-70.0), P = 0.879]. Other ABG parameters and rates of return of spontaneous circulation and survival were not different.<br /><b>Conclusions</b><br />In ED patients with refractory cardiac arrest, arterial oxygen levels during CPR were comparable between patients ventilated with MV and BV. Mechanical ventilation is at least feasible and safe during CPR in intubated cardiac arrest patients.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 12 Sep 2023:109966; epub ahead of print</small></div>

<div><h4>Ventilatory improvement with mechanical ventilator versus bag in non-traumatic out-of-hospital cardiac arrest: SYMEVECA study, phase 1.</h4><i>Hernández-Tejedor A, Gónzález Puebla V, Corral Torres E, Benito Sánchez A, Pinilla López R, Dolores Galán Calategui M</i><br /><b>Aim</b><br />To analyze differences in ventilatory parameters and outcome with different ventilatory methods during CPR.<br /><b>Methods</b><br />Pragmatic prospective quasi-experimental study in out-of-hospital urban environment. Patients over 18 years of age in non-traumatic cardiac arrest, attended by an emergency medical service between April 2021 and September 2022, were included. Two groups were compared according to the ventilatory method: mechanical ventilator (IPPV, tidal volume 7 ml/kg, frequency 10-12 bpm) or manual resuscitator bag. The main variables of interest are those of gasometry performed 15 minutes after intubation or when spontaneous circulation is recovered and final outcome. Patients were followed up to hospital discharge.<br /><b>Results</b><br />Of the 359 patients attended, 150 were included (71 in IPPV and 79 with a bag). In patients with arterial blood gases, pCO<sub>2</sub> was 67.8 ± 21.1 in the IPPV group vs 95.9 ± 39.0 mmHg in the bag group (p = 0.006) and pH was 7.00 ± 0.18 vs 6.92 ± 0.18 (p = 0.18). With a venous sample, the pCO<sub>2</sub> was 68.1 ± 18.9 vs 89.5 ± 26.5 mmHg (p < 0.001) and the pH was 7.03 ± 0.15 vs 6.94 ± 0.17 (p = 0.005), respectively. Survival with CPC 1-2 to hospital discharge was 15.6% with IPPV and 11.3% with bag (p = 0.44).<br /><b>Conclusion</b><br />The use of a mechanical ventilator in IPPV was associated with a better ventilatory status during CPR compared to the use of the bag, without conclusive data regarding its clinical repercussion with the sample collected.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 12 Sep 2023:109965; epub ahead of print</small></div>

<div><h4>A two-point strategy to clarify prognosis in >80 year olds experiencing out of hospital cardiac arrest.</h4><i>Paratz ED, Nehme E, Heriot N, Bissland K, ... La Gerche A, Nehme Z</i><br /><b>Background</b><br />The global population is aging, with the number of ≥80-year-olds projected to triple over the next 30 years. Rates of out-of-hospital cardiac arrest (OHCA) are also increasing within this age group.<br /><b>Methods</b><br />The Victorian Ambulance Cardiac Arrest Registry was utilised to identify OHCAs in patients aged ≥80 years between 2002-2021. Predictors of survival to discharge were defined and a prognostic score derived from this cohort.<br /><b>Results</b><br />77,628 patients experienced OHCA of whom 25,269 (32.6%) were ≥80 years (80-90 years=18,956; 90-100 years=6,148; >100 years=209). The number of patients ≥80 years increased over time both absolutely (p=0.002) and proportionally (p=0.028). 619 (2.4%) patients survived to discharge without change over time. Older ages had no difference in witnessed OHCA status but were less likely to have shockable rhythm (OR 0.50 (95% CI 0.44-0.57) for 90-100-year-olds, OR 0.28 (95% CI 0.12-0.63) for 90-100-year-olds). If OHCA was witnessed and there was a shockable rhythm then survival was 14%; if one factor was present survival was 5-6% and if neither factor was present, survival was 0.09%. These survival rates enabled derivation of a simplified prognostic assessment score - the \'15/5/0\' score - highly comparable to a previously-published American cohort.<br /><b>Conclusions</b><br />Elderly OHCA rates have increased to one-third of caseload. The most important factors predicting survival were whether the OHCA was witnessed and there was a shockable rhythm. We present a simple two-point \'15/5/0\' prognostic score defining which patients will gain most from advanced resuscitative measures.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 06 Sep 2023:109962; epub ahead of print</small></div>

<div><h4>Confounders for prognostic accuracy of neuron-specific enolase after cardiac arrest: A retrospective cohort study.</h4><i>Czimmeck C, Kenda M, Aalberts N, Endisch C, ... Streitberger KJ, Leithner C</i><br /><b>Aim</b><br />To evaluate neuron-specific enolase (NSE) thresholds for prediction of neurological outcome after cardiac arrest and to analyze the influence of hemolysis and confounders.<br /><b>Methods</b><br />Retrospective analysis from a cardiac arrest registry. Determination of NSE serum concentration and hemolysis-index (h-index) 48-96 hours after cardiac arrest. Evaluation of neurological outcome using the Cerebral Performance Category score (CPC) at hospital discharge. Separate analyses considering CPC 1-3 and CPC 1-2 as good neurological outcome. Analysis of specificity and sensitivity for poor and good neurological outcome prediction with and without exclusion of hemolytic samples (h-index larger than 50).<br /><b>Results</b><br />Among 356 survivors three days after cardiac arrest, hemolysis was detected in 28 samples (7.9%). At a threshold of 60 µg/L, NSE predicted poor neurological outcome (CPC 4-5) in all samples with a specificity of 92% (86%-95%) and sensitivity of 73% (66%-79%). In non-hemolytic samples, specificity was 94% (89%-97%) and sensitivity 70% (62%- 76%). At a threshold of 100 µg/L, specificity was 98% (95%-100%, all samples) and 99% (95%-100%, non-hemolytic samples), and sensitivity 58% (51%-65%) and 55% (47%-63%), respectively. Possible confounders for elevated NSE in patients with good neurological outcome were ECMO, malignancies, blood transfusions and acute brain diseases. Nine patients with NSE below 17 µg/L had CPC 5, all had plausible death causes other than hypoxic-ischemic encephalopathy.<br /><b>Conclusions</b><br />NSE concentrations higher than 100 µg/L predicted poor neurological outcome with high specificity. An NSE less than 17 µg/L indicated absence of severe hypoxic-ischemic encephalopathy. Hemolysis and other confounders need to be considered. Institutional protocol number: The local ethics committee (board name: Ethikkommission der Charite) approved this study by the number: EA2/066/23, approval date: 28th June 2023, study title \"\'ROSC\' - Resuscitation Outcome Study.\"<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 06 Sep 2023:109964; epub ahead of print</small></div>

<div><h4>Back vs. chest ECG electrode placement in neonatal resuscitation: a pilot randomized controlled trial.</h4><i>Gulati R, Sayegh L, McCurley C, Eyal F, Zayek M</i><br /><b>Background</b><br />The recent Neonatal Resuscitation Program advises the early utilization of an electrocardiogram (ECG) for non-vigorous newborns in the delivery room. However, placing ECG electrodes on the chest may delay obtaining a reliable heart rate (HR) and could interfere with chest compressions. Our previous study showed that preset ECG electrodes, attached to the back of the newborn, are quicker than a pulse oximeter (POX) for detecting HR.<br /><b>Aim</b><br />To compare time to detect a reliable HR using back-placed ECG electrodes versus standard front placement.<br /><b>Methods</b><br />Infants were randomly assigned to back (n=85) or chest (n=89) electrode placement. Time measurement began upon placing infants on a Panda warmer ResusView. Failure was defined as no HR detected within 5 minutes. Intention-to-treat analysis compared HR signal acquisition time between groups.<br /><b>Results</b><br />Both groups showed similar proportions of detectable HR within the first minute. Median (IQR) time to obtain HR was 26 (13,38) seconds for the chest group and 21 (12,54) seconds for the back group (p=0.91). A large number of vigorous infants were included. In the chest group, these vigorous infants had shorter HR acquisition times than non-vigorous infants (Mean ±SD of 34 ±48 seconds vs. 50 ±44 seconds respectively; p=0.049). Failure rates and time to acquire a HR for infants who were non-vigorous and required advanced resuscitation were similar between the back and chest groups (p=0.51).<br /><b>Conclusion</b><br />Preset back ECG electrodes have shown encouraging results in neonates requiring advanced resuscitation. Further studies are needed to enhance guidance during neonatal resuscitation.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 05 Sep 2023:109961; epub ahead of print</small></div>

<div><h4>Bicarbonate, Calcium, and Magnesium for In-Hospital Cardiac Arrest - An Instrumental Variable Analysis.</h4><i>Holmberg MJ, Granfeldt A, Andersen LW</i><br /><b>Introduction</b><br />Bicarbonate, calcium, and magnesium are commonly used during in-hospital cardiac arrest. Whether these drugs are associated with survival in cardiac arrest patients is uncertain.<br /><b>Methods</b><br />This was an observational study using data from the Get With The Guidelines registry. Adult patients with an in-hospital cardiac arrest between January 2008 and December 2021 were included. An instrumental variable approach was used based on hospital preferences for bicarbonate, calcium, and magnesium, respectively. The primary outcome was survival to hospital discharge.<br /><b>Results</b><br />A total of 319,230 patients were included. The median age was 66 years, 59% patients were male, and 85% patients presented with a non-shockable rhythm. Bicarbonate was administered in 58% patients, calcium in 33% patients, and magnesium in 10% patients. When considering drug use in the previous cardiac arrest patient at a given hospital as an instrument, the absolute difference in survival to hospital discharge was estimated at -14.2% (95% CI, -19.9 to -8.6) for bicarbonate, -3.0% (95% CI, -8.6 to 2.6) for calcium, and 10.7% (95% CI, -0.8 to 22.2) for magnesium as compared to no drug. When considering the proportion of drug use within the past year at a given hospital as an instrument, the confidence intervals were very wide, making the results difficult to interpret.<br /><b>Conclusions</b><br />In this analysis, the results for bicarbonate, calcium, and magnesium were inconclusive due to wide confidence intervals and inconsistencies in estimates across instrumental variables. Randomized trials are needed to investigate the effect of these drugs on patient outcomes.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 01 Sep 2023:109958; epub ahead of print</small></div>

<div><h4>Development and Validation of a Novel Score to Predict Brain Death After Out-of-Hospital Cardiac Arrest.</h4><i>Kitlen E, Kim N, Rubenstein A, Keenan C, ... Gilmore EJ, Beekman R</i><br /><b>Background:</b><br/>and objectives</b><br />Brain death (BD) occurs in 9-24% of successfully resuscitated out-of-hospital cardiac arrests (OHCA). To predict BD after OHCA, we developed a novel brain death risk (BDR) score.<br /><b>Methods</b><br />We identified independent predictors of BD after OHCA in a retrospective, single academic center cohort between 2011-2021. The BDR score ranges from 0-7 points and includes: non-shockable rhythm (1 point), drug overdose as etiology of arrest (1 point), evidence of grey-white differentiation loss or sulcal effacement on head computed tomography (CT) radiology report within 24 hours of arrest (2 points), Full-Outline-Of-UnResponsiveness (FOUR) score of 0 (2 points), FOUR score 1-5 (1 point), and age < 45 years (1 point). We internally validated the BDR score using k-fold cross validation (k = 8) and externally validated the score at an independent academic center. The main outcome was BD.<br /><b>Results</b><br />The development cohort included 362OHCA patients, of whom 18% (N=58) experienced BD. Internal validation provided an area under the receiving operator characteristic curve (AUC) (95% CI) of 0.931 (0.905 - 0.957). In the validation cohort, 19.8% (N=17) experienced BD. The AUC (95% CI) was 0.849 (0.765-0.933). In both cohorts, a BDR score > 4 was the optimal cut off (sensitivity 0.903 and 0.882, specificity 0.830 and 0.652, in the development and validation cohorts respectively).<br /><b>Discussion</b><br />The BDR score identifies those at highest risk for BD after OHCA. Our data suggest that a BDR score > 4 is the optimal cut off.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 01 Sep 2023:109955; epub ahead of print</small></div>

<div><h4>Early and late withdrawal of life-sustaining treatment after out-of-hospital cardiac arrest in the United Kingdom: institutional variation and association with hospital mortality.</h4><i>Vlachos S, Rubenfeld G, Menon D, Harrison D, Rowan K, Maharaj R</i><br /><b>Aim</b><br />Frequency and timing of Withdrawal of Life-Sustaining Treatment (WLST) after Out-of-Hospital Cardiac Arrest (OHCA) vary across Intensive Care Units (ICUs) in the United Kingdom (UK) and may be a marker of lower healthcare quality if instituted too frequently or too early. We aimed to describe WLST practice, quantify its variability across UK ICUs, and assess the effect of institutional deviation from average practice on patients\' risk-adjusted hospital mortality.<br /><b>Methods</b><br />We conducted a retrospective multi-centre cohort study including all adult patients admitted after OHCA to UK ICUs between 2010-2017. We identified patient and ICU characteristics associated with early (within 72h) and late (>72h) WLST and quantified the between-ICU variation. We used the ICU-level observed-to-expected (O/E) ratios of early and late-WLST frequency as separate metrics of institutional deviation from average practice and calculated their association with patients\' hospital mortality.<br /><b>Results</b><br />We included 28438 patients across 204 ICUs. 10775 (37.9%) had WLST and 6397 (59.4%) of them had early-WLST. Both WLST types were strongly associated with patient-level demographics and pre-existing conditions but weakly with ICU-level characteristics. After adjustment, we found unexplained between-ICU variation for both early-WLST (Median Odds Ratio 1.59, 95%CrI 1.49-1.71) and late-WLST (MOR 1.39, 95%CrI 1.31-1.50). Importantly, patients\' hospital mortality was higher in ICUs with higher O/E ratio of early-WLST (OR 1.29, 95%CI 1.21-1.38, p<0.001) or late-WLST (OR 1.39, 95%CI 1.31-1.48, p<0.001).<br /><b>Conclusions</b><br />Significant variability exists between UK ICUs in WLST frequency and timing. This matters because unexplained higher-than-expected WLST frequency is associated with higher hospital mortality independently of timing, potentially signalling prognostic pessimism and lower healthcare quality.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 01 Sep 2023:109956; epub ahead of print</small></div>

<div><h4>Agency Factors Associated with First Response Systems that Improve Out-of-Hospital Cardiac Arrest Outcomes.</h4><i>Huebinger R, Spring M, McNally B, Humphries A, ... Bobrow B, CARES Surveillance Group</i><br /><b>Background</b><br />Data are conflicting regarding the association between first responder (FR) intervention and improved outcomes after out-of-hospital cardiac arrest (OHCA). We evaluated characteristics of agencies that have positive associations between FR interventions and outcomes.<br /><b>Methods</b><br />We analyzed the 2016-2021 national Cardiac Arrest Registry to Enhance Survival (CARES). We defined the exposures as FR CPR and AED. The outcome was survival with favorable neurologic status. We used logistic regression models to evaluate the association between FR interventions with OHCA outcome for each agency, stratifying agencies into positive association (95% confidence interval above 1) and no/inverse association (95% confidence below or including 1). We compared characteristics between cohorts.<br /><b>Results</b><br />For the association between FR CPR and outcomes, 21 agencies caring for 42,856 OHCAs had a positive association; 371 agencies caring for 449,824 OHCAs had no association. For FR AED, 47 agencies caring for 103,120 OHCAs had a positive association; 262 agencies caring for 327,761 OHCAs had no association. Comparing agency characteristics for FR CPR, agencies with a positive association had more annual OHCAs (+300), lower FR CPR rate (-11.3%), and lower FR AED rate (-10.8%). Comparing FR AED, agencies with a positive association had more OHCAs per year (+150.5), lower FR CPR rate (-6.8%), lower FR AED rate (-13.3%), lower response time (-0.6 minutes), and more OHCAs from high-income neighborhoods (+3.7%).<br /><b>Conclusion</b><br />FR AED more commonly had a positive association with outcomes than FR CPR. Agencies with better outcomes from FR interventions treated more OHCAs and had lower rates of FR intervention.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 01 Sep 2023:109954; epub ahead of print</small></div>

<div><h4>Trends in use of intraosseous and intravenous access in out-of-hospital cardiac arrest across English Ambulance Services: A registry-based, cohort study.</h4><i>Vadeyar S, Buckle A, Hooper A, Booth S, ... Perkins GD, Couper K</i><br /><b>Introduction</b><br />The optimum route for drug administration in cardiac arrest is unclear. Recent data suggest that use of the intraosseous route may be increasing. This study aimed to explore changes over time in use of the intraosseous and intravenous drug routes in out-of-hospital cardiac arrest in England.<br /><b>Methods</b><br />We extracted data from the UK Out-of-Hospital Cardiac Arrest Outcomes registry. We included adult out-of-hospital cardiac arrest patients between 2015-2020 who were treated by an English Emergency Medical Service that submitted vascular access route data to the registry. The primary outcome was any use of the intraosseous route during cardiac arrest. We used logistic regression models to describe the association between time (calendar month) and intraosseous use.<br /><b>Results</b><br />We identified 75,343 adults in cardiac arrest treated by seven Emergency Medical Service systems between January 2015 and December 2020. The median age was 72 years, 64% were male and 23% presented in a shockable rhythm. Over the study period, the percentage of patients receiving intraosseous access increased from 22.8% in 2015 to 42.5% in 2020. For each study-month, the odds of receiving any intraosseous access increased by 1.019 (95% confidence interval 1.019 to 1.020, p<0.001). This observed effect was consistent across sensitivity analyses. We observed a corresponding decrease in use of intravenous access.<br /><b>Conclusion</b><br />In England, the use of intraosseous access in out-of-hospital cardiac arrest has progressively increased over time. There is an urgent need for randomised controlled trials to evaluate the clinical effectiveness of the different vascular access routes in cardiac arrest.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 28 Aug 2023:109951; epub ahead of print</small></div>

<div><h4>The Association of Arterial Blood Pressure Waveform-Derived Area Duty Cycle with Intra-arrest Hemodynamics and Cardiac Arrest Outcomes.</h4><i>Rappold TE, Morgan RW, Reeder RW, Cooper KK, ... the Eunice Kennedy Shriver National Institute of Child Health, Human Development Collaborative Pediatric Critical Care Research Network Investigator Groups</i><br /><b>Aim</b><br />Develop a novel, physiology-based measurement of duty cycle (Arterial BloodPressure - Area Duty Cycle [ABP-ADC]) and evaluate the association of ABP-ADCwith intra-arrest hemodynamics and patient outcomes.<br /><b>Methods</b><br />This was a secondary retrospective study of prospectively collected datafrom the ICU-RESUS trial (NCT02837497). Invasive arterial waveform data were usedto derive ABP-ADC. The primary exposure was ABP-ADC group (<30%; 30-35%;>35%). The primary outcome was systolic blood pressure (sBP). Secondary outcomesincluded intra-arrest physiologic goals, CPR quality targets, and patient outcomes. Inan exploratory analysis, adjusted splines and receiver operating characteristic (ROC)curves were used to determine an optimal ABP-ADC associated with improvedhemodynamics and outcomes using a multivariable model.<br /><b>Results</b><br />Of 1129 CPR events, 273 had evaluable arterial waveform data. Mean agewas 2.9 + 4.9 years. Mean ABP-ADC was 32.5% + 5.0%. In univariable analysis,higher ABP-ADC was associated with lower sBP (p<0.01) and failing to achieve sBPtargets (p<0.01). Other intra-arrest physiologic parameters, quality metrics, and patientoutcomes were similar across ABP-ADC groups. Using spline / ROC analysis andclinical judgement, the optimal ABP-ADC cut point was set at 33%. On multivariableanalysis, sBP was significantly higher (point estimate 13.18 mmHg, CI95 5.30 - 21.07,p<0.01) among patients with ABP-ADC <33%. Other intra-arrest physiologic andpatient outcomes were similar.<br /><b>Conclusions</b><br />In this multicenter cohort, a lower ABP-ADC was associated with highersBPs during CPR. Although ABP-ADC was not associated with outcomes, furtherstudies are needed to define the interactions between CPR mechanics and intra-arrestpatient physiology.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 25 Aug 2023:109950; epub ahead of print</small></div>

<div><h4>Mortality and Healthcare Resource Utilisation After Cardiac Arrest in the United States - A 10-Year Nationwide Analysis Prior to the COVID-19 Pandemic.</h4><i>Thevathasan T, Paul J, Gaul AL, Degbeon S, ... Landmesser U, Skurk C</i><br /><b>Aim</b><br />Understanding the public health burden of cardiac arrest (CA) is important to inform healthcare policies, particularly during health care crises such as the COVID-19 pandemic. This study aimed to analyse outcomes of in-hospital mortality and healthcare resource utilisation in adult patients with CA in the United States over the last decade prior to the COVID-19 pandemic.<br /><b>Methods</b><br />The United States (US) National Inpatient Sample was utilised to identify hospitalised adult patients with CA between 2010 and 2019. Logistic and Poisson regression models were used to analyse outcomes by adjusting for 47 confounders.<br /><b>Results</b><br />248,754 adult patients with CA (without \"Do Not Resuscitate\"-orders) were included in this study, out of which 57.5% were male. In-hospital mortality was high with 51.2% but improved significantly from 58.3% in 2010 to 46.4% in 2019 (P<0.001). Particularly, elderly patients, non-white patients and patients requiring complex therapy had a higher mortality rate. Although the average hospital LOS decreased by 11%, hospital expenses have increased by 13% between 2010 and 2019 (each P<0.001), presumably due to more frequent use of mechanical circulatory support (MCS, e.g. ECMO from 2.6% to 8.7% or Impella® micro-axial flow pump from 1.8% to 14.2%). Strong disparities existed among patient age groups and ethnicities across the US. Of note, the number of young adults with CA and opioid-induced CA has almost doubled within the study period.<br /><b>Conclusion</b><br />Over the last ten years prior to the COVID-19 pandemic, CA-related survival has incrementally improved with shorter hospitalisations and increased medical expenses, while strong disparities existed among different age groups and ethnicities. National standards for CA surveillance should be considered to identify trends and differences in CA treatment to allow for standardised medical care.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 25 Aug 2023:109946; epub ahead of print</small></div>

<div><h4>Comparison of four clinical risk scores in comatose patients after out-of-hospital cardiac arrest.</h4><i>Schmidbauer S, Rylander C, Cariou A, Wise MP, ... Friberg H, Dankiewicz J</i><br /><b>Background:</b><br/>and aims</b><br />Several different scoring systems for early risk stratification after out-of-hospital cardiac arrest have been developed, but few have been validated in large datasets. The aim of the present study was to compare the well-validated Out-of-hospital Cardiac Arrest (OHCA) and Cardiac Arrest Hospital Prognosis (CAHP)-scores to the less complex MIRACLE2- and Target Temperature Management (TTM)-scores.<br /><b>Methods</b><br />This was a post-hoc analysis of the Targeted Hypothermia versus Targeted Normothermia after Out-of-Hospital Cardiac Arrest (TTM2) trial. Missing data were handled by multiple imputation. The primary outcome was discriminatory performance assessed as the area under the receiver operating characteristics-curve (AUROC), with the outcome of interest being poor functional outcome or death (modified Rankin Scale 4-6) at 6 months after OHCA.<br /><b>Results</b><br />Data on functional outcome at 6 months were available for 1829 cases, which constituted the study population. The pooled AUROC for the MIRACLE2-score was 0.810 (95% CI 0.790 - 0.828), 0.835 (95% CI 0.816 - 0.852) for the TTM-score, 0.820 (95% CI 0.800 - 0.839) for the CAHP-score and 0.770 (95% CI 0.748 - 0.791) for the OHCA-score. At the cut-offs needed to achieve specificities >95%, sensitivities were <40 % for all four scoring systems.<br /><b>Conclusions</b><br />The TTM-, MIRACLE2- and CAHP-scores are all capable of providing objective risk estimates accurate enough to be used as part of a holistic patient assessment after OHCA of a suspected cardiac origin. Due to its simplicity, the MIRACLE2-score could be a practical solution for both clinical application and risk stratification within trials.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 25 Aug 2023:109949; epub ahead of print</small></div>

<div><h4>Extracorporeal Membrane Oxygenation for the Treatment of Massive Pulmonary Embolism. An Analysis of the ELSO Database.</h4><i>Rivers J, Pilcher D, Kim J, Bartos JA, Burrell A</i><br /><b>Aim</b><br />Extracorporeal membrane oxygenation (ECMO) may be beneficial in treatment of massive pulmonary embolus (PE), however the current evidence to guide its use is limited. We aimed to compare the incidence, characteristics, treatments, and outcomes of patients with massive PE by mode of ECMO from a large international registry.<br /><b>Methods</b><br />Retrospective observational study of the Extracorporeal Life Support Organization (ELSO) database.<br /><b>Results</b><br />A total of 821 patients underwent 833 ECMO episodes for PE. Mean age was 49 (±15) years, 408 (50.1%) were female, and 450 (54.7%) had a cardiac arrest prior to ECMO initiation. Venoarterial (VA) ECMO was the most common mode in 489 (58.7%), followed by extracorporeal cardiopulmonary resuscitation (ECPR) in 229 (27.4%) and venovenous (VV) ECMO in 85 (10.2%). The number of episodes per year increased over the study period, predominantly driven by an increase in ECPR. In-hospital mortality was the highest for ECPR 156/229 (68.1%), followed by VA ECMO 209/498 (42.7%) and VV ECMO 24/85 (28.2%) P<0.001. After controlling for univariate and clinically significant variables at the time of ECMO initiation, increasing age (OR 1.02 (1.00-1.03), lower pH (OR 0.18 (0.03-0.44), lower diastolic blood pressure (OR 0.99 (0.97-1.00) and ECPR mode (OR 3.67 (1.46-9.230) were independently associated with in-hospital mortality.<br /><b>Conclusion</b><br />ECMO use for massive PE is increasing globally, and overall mortality rates compare favorably with other indications of ECMO. The use of ECPR and worsening metabolic status at initiation were associated with higher in-hospital mortality, suggesting delays in initiating ECMO should be avoided.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 23 Aug 2023:109940; epub ahead of print</small></div>

<div><h4>Annual patterns in the outcomes and post-arrest care for pediatric out-of-hospital cardiac arrest: a nationwide multicenter prospective registry in Japan.</h4><i>Matsui S, Kurosawa H, Hayashi T, Takei H, ... Sobue T, Nitta M</i><br /><b>Aim</b><br />Out-of-hospital cardiac arrest (OHCA) has a poor prognosis in children; however, the annual patterns of prognosis and treatment have not been fully investigated.<br /><b>Methods</b><br />From the Japanese Association for Acute Medicine OHCA registry, a multicenter prospective observational registry in Japan, we identified pediatric patients (zero to 17 years old) between June 2014 and December 2019. The primary outcome was one-month survival. We investigated the annual patterns in patient characteristics, treatment, and one-month prognosis.<br /><b>Results</b><br />During the study period, 1,188 patients were eligible for analysis. For all years, the zero-year-old group accounted for a large percentage of the total population (between 30% and 40%). There were significant increases in the rates of bystander-initiated cardiopulmonary resuscitation (CPR; from 50.6% to 62.3%, p=0.003), dispatcher instructions (from 44.7% to 65.7%, p=0.001), and adrenaline administration (from 2.4% to 6.9%, p=0.014) over time, whereas the rate of advanced airway management decreased significantly (from 17.7% to 8.8%, p=0.003). The odds ratios for one-month survival adjusted for potential resuscitation factors also did not change significantly (from 7.1% to 10.3%, adjusted odds ratio for one-year increment=0.98, confidence interval: 0.86-1.11).<br /><b>Conclusion</b><br />Despite an increase in the rate of bystander-initiated CPR and pre-hospital adrenaline administration, there was no significant change in one-month survival.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 23 Aug 2023:109942; epub ahead of print</small></div>

<div><h4>Amplitude Spectrum Area Measured in Real-Time during Cardiopulmonary Resuscitation - How Does This Technology Work?</h4><i>Ruggeri L, Fumagalli F, Merigo G, Magliocca A, Ristagno G</i><br /><AbstractText>Amplitude spectrum area (AMSA) is one of the most accurate predictors of defibrillation outcome. Details on functioning and use of the available technology to measure AMSA during cardiopulmonary resuscitation (CPR) in the real clinical scenario are described. During chest compression (CC) pauses for ventilations, AMSA is promptly calculated and values displayed through a modified defibrillator. In addition, real-time AMSA analysis has the additional promise to monitor CPR quality, being AMSA threshold values contingent on CC depth. Future larger studies employing this new technology are now needed to demonstrate the impact of AMSA on survival of cardiac arrest.</AbstractText><br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 23 Aug 2023:109941; epub ahead of print</small></div>

<div><h4>Comparing strategies for prehospital transport to specialty care after cardiac arrest.</h4><i>Elmer J, Dougherty M, Guyette FX, Martin-Gill C, ... Callaway CW, Wallace DJ</i><br /><b>Unlabelled</b><br />Outcomes are better when patients resuscitated from out-of-hospital cardiac arrest (OHCA) are treated at specialty centers. The best strategy to transport patients from the scene of resuscitation to specialty care is unknown.<br /><b>Methods</b><br />We performed a retrospective cohort study. We identified patients treated at a single specialty center after OHCA from 2010 to 2021 and used OHCA geolocations to develop a catchment area using a convex hull. Within this area, we identified short term acute care hospitals, OHCA receiving centers, adult population by census block group, and helicopter landing zones. We determined population-level times to specialty care via: 1) direct ground transport; 2) transport to the nearest hospital followed by air interfacility transfer; and 3) ground transport to air ambulance. We used an instrumental variable (IV) adjusted probit regression to estimate the causal effect of transport strategy on functionally favorable survival to hospital discharge.<br /><b>Results</b><br />Direct transport to specialty care by ground to air ambulance had the shortest population-level times from OHCA to specialty care (median 56 [IQR 47 - 66] minutes). There were 1,861 patients included in IV regression of whom 395 (21%) had functionally favorable survival. Most (n=1,221, 66%) were transported to the nearest hospital by ground EMS then to specialty care by air. Patient outcomes did not differ across transport strategies in our IV analysis.<br /><b>Discussion</b><br />We did not find strong evidence in favor of a particular strategy for transport to specialty care after OHCA. Population level time to specialty care was shortest with ground ambulance transport to the nearest helicopter landing zone.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 23 Aug 2023:109943; epub ahead of print</small></div>

<div><h4>Association of CPR Simulation Program Characteristics with Simulated and Actual Performance during Paediatric In-Hospital Cardiac Arrest.</h4><i>Cashen K, Sutton RM, Reeder RW, Ahmed T, ... Zuppa AF, Meert KL</i><br /><b>Aim</b><br />To evaluate associations between characteristics of simulated point-of-care cardiopulmonary resuscitation (CPR) training with simulated and actual intensive care unit (ICU) CPR performance, and with outcomes of children after in-hospital cardiac arrest.<br /><b>Methods</b><br />This is a pre-specified secondary analysis of the ICU-RESUScitation Project; a prospective, multicentre cluster randomized interventional trial conducted in 18 ICUs from October 2016-March 2021. Point-of-care bedside simulations with real-time feedback to allow multidisciplinary ICU staff to practice CPR on a portable manikin were performed and quality metrics (rate, depth, release velocity, chest compression fraction) were recorded. Actual CPR performance was recorded for children 37 weeks post-conceptual age to 18 years who received chest compressions of any duration, and included intra-arrest haemodynamics and CPR mechanics. Outcomes included survival to hospital discharge with favourable neurologic status.<br /><b>Results</b><br />Overall, 18,912 point-of-care simulations were included. Simulation characteristics associated with both simulation and actual performance included site, participant discipline, and timing of simulation training. Simulation characteristics were not associated with survival with favourable neurologic outcome. However, participants in the top 3 sites for improvement in survival with favourable neurologic outcome were more likely to have participated in a simulation in the past month, on a weekday day, to be nurses, and to achieve targeted depth of compression and chest compression fraction goals during simulations than the bottom 3 sites.<br /><b>Conclusions</b><br />Point-of-care simulation characteristics were associated with both simulated and actual CPR performance. More recent simulation, increased nursing participation, and simulation training during daytime hours may improve CPR performance.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 23 Aug 2023:109939; epub ahead of print</small></div>

<div><h4>Maintaining normothermia immediately after birth in preterm infants < 34 weeks\' gestation: A Systematic review and meta-analysis.</h4><i>Ramaswamy VV, Dawson JA, de Almeida MF, Trevisanuto D, ... Liley HG, International Liaison Committee on Resuscitation Neonatal Life Support Task Force</i><br /><b>Aim</b><br />To evaluate delivery room (DR) interventions to prevent hypothermia and improve outcomes in preterm newborn infants < 34 weeks\' gestation.<br /><b>Methods</b><br />Medline, Embase, CINAHL and CENTRAL were searched till 22<sup>nd</sup> July 2022. Randomized controlled trials (RCTs), non-RCTs and quality improvement studies were considered. A random effects meta-analysis was performed, and the certainty of evidence was evaluated using GRADE guidelines.<br /><b>Results</b><br />DR temperature of ≥ 23°C compared to standard care improved temperature outcomes without an increased risk of hyperthermia (low certainty), whereas radiant warmer in servo mode compared to manual mode decreased mean body temperature (MBT) (moderate certainty). Use of a plastic bag or wrap (PBW) improved normothermia (low certainty), but with an increased risk of hyperthermia (moderate certainty). Plastic cap improved normothermia (moderate certainty) and when combined with PBW improved MBT (low certainty). Use of a cloth cap decreased moderate hypothermia (low certainty). Though thermal mattress (TM) improved MBT, it increased risk of hyperthermia (low certainty). Heated-humidified gases (HHG) for resuscitation decreased the risk of moderate hypothermia and severe intraventricular hemorrhage (very low to low certainty). None of the interventions was shown to improve survival, but sample sizes were insufficient.<br /><b>Conclusions</b><br />DR temperature of ≥ 23°C, radiant warmer in manual mode, use of a PBW and a head covering is suggested for preterm newborn infants < 34 weeks\' gestation. HHG and TM could be considered in addition to PBW provided resources allow, in settings where hypothermia incidence is high. Careful monitoring to avoid hyperthermia is needed.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 17 Aug 2023:109934; epub ahead of print</small></div>

<div><h4>Association Between the Presence of an Advanced Airway and Ventilation Rate during Pediatric CPR: A Report From the Videography in Pediatric Resuscitation (VIPER) Collaborative.</h4><i>O\'Connell KJ, Dutta A, Myers S, Neubrand T, ... Kerrey B, Donoghue A</i><br /><b>Objective</b><br />To determine the association between presence of an advanced airway during pediatric cardiopulmonary resuscitation (CPR) and ventilation rates.<br /><b>Methods</b><br />Prospective observational study, January 2017 to June 2020. Patients ≤ 18 years receiving CC for ≥ 2 minutes were enrolled. Ventilation rate and type of airway (advanced airway (AA), either endotracheal tube (ETT) or supraglottic airway (SGA); or natural airway (NA)) were collected from video review and analyzed in \'CPR segments\' (periods of CPR by individual providers). Ventilation rate (breaths per minute, bpm) was calculated for each segment; hyperventilation was defined as > 12 bpm according to 2015 American Heart Association guidelines. Univariate analysis between airway type was done by X2 testing. Multivariate regression was used to determine the association between the presence of AA with hyperventilation while controlling for within-patient covariance.<br /><b>Results</b><br />779 CPR segments from 94 CPR event were analyzed. The mean ventilation rate per CPR segment across all events was 22 bpm (± 16 bpm)). Mean ventilation rates were higher with AA, either ETT (24 ± 17 bpm) or SGA (34 ± 19 bpm), than with NA (17 ± 14, p<0.001). Hyperventilation occurred more often with AA in place (ETT: 68%; SGA: 96%; NA: 43%; p<0.001). The presence of AA was independently associated with hyperventilation (AOR 9.3, 95% CI 4.3 - 20.1).<br /><b>Conclusions</b><br />During pediatric CPR, hyperventilation occurs more often with an AA in place than during CPR with NA. Future research should focus on respiratory physiology during pediatric CPR to determine optimal ventilation rate(s) during pediatric cardiac arrest.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 17 Aug 2023:109923; epub ahead of print</small></div>

<div><h4>Brain-derived extracellular vesicles as serologic markers of brain injury following cardiac arrest: a pilot feasibility study.</h4><i>Shen H, Zaitseva D, Yang Z, Forsythe L, ... Issadore D, Abella BS</i><br /><b>Aim</b><br />Assessment of neurologic injury within the immediate hours following out-of-hospital cardiac arrest (OHCA) resuscitation remains a major clinical challenge. Extracellular vesicles (EVs), small bodies derived from cytosolic contents during injury, may provide the opportunity for \"liquid biopsy\" within hours following resuscitation, as they contain proteins and RNA linked to cell type of origin. We evaluated whether micro-RNA (miRNA) from serologic EVs were associated with post-arrest neurologic outcome.<br /><b>Methods</b><br />We obtained serial blood samples in an OHCA cohort. Using novel microfluidic techniques to isolate EVs based on EV surface marker GluR2 (present on excitatory neuronal dendrites enriched in hippocampal tissue), we employed reverse transcription quantitative polymerase chain reaction (RT-qPCR) methods to measure a panel of miRNAs and tested association with dichotomized modified Rankin Score (mRS) at discharge.<br /><b>Results</b><br />EVs were assessed in 27 post-arrest patients between 7/3/2019-7/21/2022; 9 patients experienced good outcomes. Several miRNA species including miR-124 were statistically associated with mRS at discharge when measured within 6 hours of resuscitation (AUC=0.84 for miR-124, p<0.05). In a Kendall ranked correlation analysis, miRNA associations with outcome were not strongly correlated with standard serologic marker measurements, or amongst themselves, suggesting that miRNA provide distinct information from common protein biomarkers.<br /><b>Conclusions</b><br />This study explores the associations between miRNAs from neuron-derived EVs (NDEs) and circulating protein biomarkers within 6 hours with neurologic outcome, suggesting a panel of very early biomarker may be useful during clinical care. Future work will be required to test larger cohorts with a broader panel of miRNA species.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 15 Aug 2023:109937; epub ahead of print</small></div>

<div><h4>Serum Lactate in Refractory Out-of-Hospital Cardiac Arrest: Post-hoc Analysis of the Prague OHCA Study.</h4><i>Dusik M, Rob D, Smalcova J, Havranek S, ... Bakker J, Belohlavek J</i><br /><b>Background</b><br />The severity of tissue hypoxia is routinely assessed by serum lactate. We aimed to determine whether early lactate levels predict outcomes in refractory out-of-hospital cardiac arrest (OHCA) treated by conventional and extracorporeal cardiopulmonary resuscitation (ECPR).<br /><b>Methods</b><br />This study is a post-hoc analysis of a randomized Prague OHCA study (NCT01511666) assessing serum lactate levels in refractory OHCA treated by ECPR (the ECPR group) or conventional resuscitation with prehospital achieved return of spontaneous circulation (the ROSC group). Lactate concentrations measured on admission and every 4 hours (h) during the first 24 h were used to determine their relationship with the neurological outcome (the best Cerebral Performance Category score within 180 days post-cardiac arrest).<br /><b>Results</b><br />In the ECPR group (92 patients, median age 58.5 years, 83% male) 26% attained a favorable neurological outcome. In the ROSC group (82 patients, median age 55 years, 83% male) 59% achieved a favorable neurological outcome. In ECPR patients lactate concentrations could discriminate favorable outcome patients, but not consistently in the ROSC group. On admission, serum lactate >14.0 mmol/L for ECPR (specificity 87.5%, sensitivity 54.4%) and >10.8 mmol/L for the ROSC group (specificity 83%, sensitivity 41.2%) predicted an unfavorable outcome.<br /><b>Conclusion</b><br />In refractory OHCA serum lactate concentrations measured anytime during the first 24 h after admission to the hospital were found to correlate with the outcome in patients treated by ECPR but not in patients with prehospital ROSC. A single lactate measurement is not enough for a reliable outcome prediction and cannot be used alone to guide treatment.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 11 Aug 2023:109935; epub ahead of print</small></div>

<div><h4>Impaired Echocardiographic Left Ventricular Global Longitudinal Strain after Pediatric Cardiac Arrest Children is Associated with Mortality.</h4><i>Gardner MM, Wang Y, Himebauch AS, Conlon TW, ... Mercer-Rosa L, Topjian AA</i><br /><b>Background</b><br />Global longitudinal strain (GLS) is an echocardiographic method to identify left ventricular (LV) dysfunction after cardiac arrest that is less sensitive to loading conditions. We aimed to identify the frequency of impaired GLS following pediatric cardiac arrest, and its association with hospital mortality.<br /><b>Methods</b><br />This is a retrospective single-center cohort study of children <18 years of age treated in the pediatric intensive care unit (PICU) after in- or out-of-hospital cardiac arrest (IHCA and OHCA), with echocardiogram performed within 24 hours of initiation of post-arrest PICU care between 2013-2020. Patients with congenital heart disease, post-arrest extracorporeal support, or inability to measure GLS were excluded. Echocardiographic LV ejection fraction (EF) and shortening fraction (SF) were abstracted from the chart. GLS was measured post hoc; impaired strain was defined as LV GLS ≥ 2 SD worse than age-dependent normative values. Demographics and pre-arrest, arrest, and post-arrest characteristics were compared between subjects with normal versus impaired GLS. Correlation between GLS, SF and EF were calculated with Pearson comparison. Logistic regression tested the association of GLS with mortality. Area under the receiver operator curve (AUROC) was calculated for discriminative utility of GLS, EF, and SF with mortality.<br /><b>Results</b><br />GLS was measured in 124 subjects; impaired GLS was present in 46 (37.1%). Subjects with impaired GLS were older (median 7.9 vs. 1.9 years, p<0.001), more likely to have ventricular tachycardia/fibrillation as initial rhythm (19.6% versus 3.8%, p=0.017) and had higher peak troponin levels in the first 24 hours post-arrest (median 2.5 vs. 0.5, p=0.002). There were no differences between arrest location or CPR duration by GLS groups. Subjects with impaired GLS compared to normal GLS had lower median EF (42.6% versus 62.3%) and median SF (23.3% versus 36.6%), all p<0.001, with strong inverse correlation between GLS and EF (rho -0.76, p<0.001) and SF (rho -0.71, p<0.001). Patients with impaired GLS had higher rates of mortality (60% vs. 32%, p=0.009). GLS was associated with mortality when controlling for age and initial rhythm [aOR 1.17 per 1% increase in GLS (95% CI 1.09-1.26), p<0.001]. GLS, EF and SF had similar discrimination for mortality: GLS AUROC 0.69 (95% CI 0.60-0.79); EF AUROC 0.71 (95% CI 0.58-0.88); SF AUROC 0.71 (95% CI 0.61-0.82), p=0.101.<br /><b>Conclusions</b><br />Impaired LV function as measured by GLS after pediatric cardiac arrest is associated with hospital mortality. GLS is a novel complementary metric to traditional post-arrest echocardiography that correlates strongly with EF and SF and is associated with mortality. Future large prospective studies of post-cardiac arrest care should investigate the prognostic utilities of GLS, alongside SF and EF.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 11 Aug 2023:109936; epub ahead of print</small></div>

<div><h4>Efficacy of Emergency Department Calcium Administration in Cardiac Arrest: A 9-year Retrospective Evaluation.</h4><i>Dillon DG, Wang RC, Shetty P, Douchee J, Rodriguez RM, Carlos C Montoy J</i><br /><b>Background</b><br />The efficacy of empiric calcium for patients with undifferentiated cardiac arrest has come under increased scrutiny, including a randomized controlled trial that was stopped early due to a trend towards harm with calcium administration. However, small sample sizes and non-significant findings have hindered precise effect estimates. In this analysis we evaluate the association of calcium administration with survival in a large retrospective cohort of patients with cardiac arrest treated in the emergency department (ED).<br /><b>Methods</b><br />We conducted a retrospective review of medical records from two academic hospitals (one quaternary care center, one county trauma center) in San Francisco between 2011-2019. Inclusion criteria were patients aged greater than or equal to 18 years old who received treatment for cardiac arrest during their ED course. Our primary exposure was the administration of calcium while in the ED and the main outcome was survival to hospital admission. The association between calcium and survival to admission was estimated using a multivariable log-binomial regression, and also with two propensity score models.<br /><b>Results</b><br />We examined 781 patients with cardiac arrest treated in San Francisco EDs between 2011-2019 and found that calcium administration was associated with decreased survival to hospital admission (RR 0.74; 95% CI 0.66 - 0.82). These findings remained significant after adjustment for patient age, sex, whether the cardiac arrest was witnessed, and including an interaction term for shockable cardiac rhythms (RR 0.60; 95% CI 0.50 - 0.72) and non-shockable cardiac rhythms (RR 0.87; 95% CI 0.76 - 0.99). Risk ratios for the association between calcium and survival to hospital admission were also similar between two propensity score-based models: nearest neighbor propensity matching model (RR 0.79; 95% CI 0.68 - 0.89) and inverse propensity weighted regression adjustment model (RR 0.75; 95% CI 0.67 - 0.84).<br /><b>Conclusions</b><br />Calcium administration as part of ED-directed treatment for cardiac arrest was associated with lower survival to hospital admission. Given the lack of statistically significant outcomes from smaller, more methodologically robust evaluations on this topic, we believe these findings have an important role to serve in confirming previous results and allowing for more precise effect estimates. Our data adds to the growing body evidence against the empiric use of calcium in cardiac arrest.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 08 Aug 2023:109933; epub ahead of print</small></div>

<div><h4>Sociodemographic Factors Associated with Paediatric Out-of-Hospital Cardiac Arrest: A Systematic Review.</h4><i>Idrees S, Abdullah R, Anderson KK, Tijssen JA</i><br /><b>Background</b><br />Paediatric out-of-hospital cardiac arrest (POHCA) is associated with poor survival and severe neurological sequelae. We conducted a systematic review on the impact of sociodemographic factors across different stages of POHCA.<br /><b>Methods</b><br />We searched MEDLINE, EMBASE, and Web of Science from database inception to October 2022. We included studies examining the association between sociodemographic factors (i.e., race, ethnicity, migrant status and socioeconomic status, SES) and POHCA risk, bystander cardiopulmonary resuscitation (CPR) provision, bystander automated external defibrillator (AED) application, survival, or neurological outcome (at or 30-days post-discharge). We synthesized the data qualitatively.<br /><b>Results</b><br />We screened 11,097 citations and included 19 articles (arising from 16 studies). There were 4 articles reporting on POHCA risk, 5 on bystander CPR provision, 3 on bystander AED application, 14 on survival, and 6 on neurological outcome. In all studies on POHCA risk, significant differences were found across racial groups, with minority populations being disproportionately impacted. There were no articles reporting on the association between SES and POHCA risk. Bystander CPR provision was consistently associated with race and ethnicity, with disparities impacting Black and Hispanic children. The association between bystander CPR provision and SES was variable. There was little evidence of socioeconomic or racial disparities in studies on bystander AED application, survival, and neurological outcome, particularly across adjusted analyses.<br /><b>Conclusions</b><br />Race and ethnicity are likely associated with POHCA risk and bystander CPR provision. These findings highlight the importance of prioritizing at-risk groups in POHCA prevention and intervention efforts. Further research is needed to better understand underlying mechanisms.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 08 Aug 2023:109931; epub ahead of print</small></div>

<div><h4>Effect of a national awareness campaign on ambulance attendances for chest pain and out-of-hospital cardiac arrest.</h4><i>Nehme Z, Cameron P, Nehme E, Finn J, ... Doan TN, Bray JE</i><br /><b>Aim</b><br />Awareness of heart attack symptoms may enhance health-seeking behaviour and prevent premature deaths from out-of-hospital cardiac arrest (OHCA). We sought to investigate the impact of a national awareness campaign on emergency medical service (EMS) attendances for chest pain and OHCA.<br /><b>Methods</b><br />Between January 2005 and December 2017, we included registry data for 97,860 EMS-attended OHCA cases from 3 Australian regions and dispatch data for 1,631,217 EMS attendances for chest pain across 5 Australian regions. Regions were exposed to between 11 and 28 months of television, radio, and print media activity. Multivariable negative binomial models were used to explore the effect of campaign activity on the monthly incidence of EMS attendances for chest pain and OHCA.<br /><b>Results</b><br />Months with campaign activity were associated with an 8.8% (IRR 1.09, 95% CI: 1.07, 1.11) increase in the incidence of EMS attendances for chest pain and a 5.6% (IRR 0.94, 95% CI: 0.92, 0.97) reduction in OHCA attendances. Larger intervention effects were associated with increasing months of campaign activity, increasing monthly media spending and media exposure in 2013. In stratified analyses of OHCA cases, the largest reduction in incidence during campaign months was observed for unwitnessed arrests (IRR 0.93, 95% CI: 0.90, 0.96), initial non-shockable arrests (IRR 0.93, 95% CI: 0.90, 0.97) and arrests occurring in private residences (IRR 0.95, 95% CI: 0.91, 0.98).<br /><b>Conclusion</b><br />A national awareness campaign targeting knowledge of heart attack symptoms was associated with an increase in EMS use for chest pain and a reduction in OHCA incidence and may serve as an effective primary prevention strategy for OHCA.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 08 Aug 2023:109932; epub ahead of print</small></div>

<div><h4>Temperature Control After Adult Cardiac Arrest: An Updated Systematic Review and Meta-Analysis.</h4><i>Granfeldt A, Holmberg MJ, Nolan JP, Soar J, Andersen LW, International Liaison Committee on Resuscitation ILCOR Advanced Life Support Task Force</i><br /><b>Aim</b><br />To perform an updated systematic review and meta-analysis on temperature control in adult patients with cardiac arrest.<br /><b>Methods</b><br />The review is an update of a previous systematic review published in 2021. An updated search including PubMed, Embase, and the Cochrane Central Register of Controlled Trials was performed on May 31, 2023. Controlled trials in humans were included. The population included adult patients with cardiac arrest. The review included all aspects of temperature control including timing, temperature, duration, method of induction and maintenance, and rewarming. Two investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Data were pooled using random-effects models. Certainty of evidence was evaluated using GRADE.<br /><b>Results</b><br />The updated systematic search identified six new trials. Risk of bias in the trials was assessed as intermediate for most of the outcomes. For temperature control with a target of 32-34°C vs. normothermia or 36°C, two new trials were identified, with seven trials included in an updated meta-analysis. Temperature control with a target of 32-34°C did not result in an improvement in survival (risk ratio: 1.06 [95%CI: 0.91, 1.23]) or favorable neurological outcome (risk ratio: 1.27 [95%CI: 0.89, 1.81]) at 90 to 180 days after the cardiac arrest (low certainty evidence). Subgroup analysis according to location of cardiac arrest (in-hospital vs. out-of-hospital) found similar results. A sensitivity analysis of nine trials comparing temperature control at 32-34°C to normothermia or 36°C for favorable neurological outcome at any time point also did not show an improvement in outcomes (risk ratio: 1.14 [95%CI 0.98, 1.34]). New individual trials comparing a target of 31°C to 34°C, temperature control for 12-24 hours to 36 hours, a rewarming rate of 0.25 °C/hour to 0.5 °C/hour, and the effect of temperature control with fever prevention found no differences in outcomes.<br /><b>Conclusions</b><br />This updated systematic review showed no benefit of temperature control at 32-34°C compared to normothermia or 36°C, although the 95% confidence intervals cannot rule out a potential beneficial effect. Important knowledge gaps exist for topics such as hypothermic temperature targets, rewarming rate, and fever control.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 07 Aug 2023:109928; epub ahead of print</small></div>

<div><h4>Neurological outcomes and reperfusion strategies in out-of-hospital cardiac arrest patients due to pulmonary embolism who underwent venoarterial extracorporeal membrane oxygenation: a post-hoc analysis of a multicenter retrospective cohort study.</h4><i>Sakuraya M, Hifumi T, Inoue A, Sakamoto T, Kuroda Y, SAVE-J Ⅱ Study Group</i><br /><b>Introduction</b><br />This study aimed to evaluate the effect of different reperfusion strategies on neurological outcomes in patients with pulmonary embolism who received venoarterial extracorporeal membrane oxygenation (VA-ECMO) for out-of-hospital cardiac arrest (OHCA).<br /><b>Methods</b><br />This was a post-hoc analysis of a multicenter retrospective cohort study conducted in 36 institutions in Japan over six years. We included patients who underwent VA-ECMO and were diagnosed with pulmonary embolism caused by OHCA. Neurological outcomes were evaluated on the basis of the cerebral performance category at hospital discharge. We also assessed the association between reperfusion strategies and successful separation from ECMO.<br /><b>Results</b><br />Among the 78 included patients, approximately half were successfully weaned from ECMO. Hospital mortality and favorable neurological outcomes at hospital discharge were 60.3% and 17.9%, respectively. Thirty-one patients (39.7%) underwent reperfusion strategies after ECMO, including 13 who received systemic thrombolytic therapy and 18 who underwent mechanical reperfusion strategy. After adjusting for prespecified covariates using the competing risk model, reperfusion strategies increased ECMO separation rate (systemic thrombolytic therapy: subdistribution hazard ratio [sHR] 2.24, 95% confidence interval [CI] 1.21-4.17, P = 0.011; mechanical reperfusion strategy: sHR 1.70, 95% CI 0.86-3.41, P = 0.129) compared with anticoagulation therapy alone, whereas higher cardiac Sequential Organ Failure Assessment score decreased ECMO separation rate (sHR 0.81, 95% CI 0.67-0.97, P = 0.020).<br /><b>Conclusions</b><br />Favorable neurological outcomes were observed in less than 20% of patients with OHCA due to pulmonary embolism undergoing ECMO. Reperfusion strategies may be associated with shorter ECMO durations in these patients.<br /><b>Clinical trial registration</b><br />https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041577 (unique identifier: UMIN000036490).<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 04 Aug 2023:109926; epub ahead of print</small></div>

<div><h4>Time-saving effect of real-time ultrasound-guided cannulation for extracorporeal cardiopulmonary resuscitation: A multicenter retrospective cohort study.</h4><i>Nakatsutsumi K, Endo A, Todd W C, Takayama W, ... Kuroda Y, Save-J Ⅱ study group</i><br /><b>Background</b><br />Extracorporeal cardiopulmonary resuscitation (ECPR), a bridge to treatments for cardiac arrest patients, can be technically challenging and requires expertise. While ultrasound guidance is frequently used for vascular access, its effects on cannulation time in patients treated with ECPR are poorly defined. We hypothesized that real-time ultrasound guidance would contribute to faster and safer cannulation for ECPR.<br /><b>Methods</b><br />This nationwide, multicenter, retrospective study analyzed data from 36 Japanese institutions. Patients who were over age 18 years and underwent ECPR between January 1, 2013, and December 31, 2018, were included. Patients who underwent open surgical vascular access were excluded. Cannulation time and outcomes of patients who underwent real-time ultrasound-guided cannulation (i.e., ultrasound-guided group) were compared to those cannulated without the use of real-time ultrasound guidance (control group) using propensity score matching analysis.<br /><b>Results</b><br />The ultrasound-guided group comprised 510 cases, whereas the control group comprised 941 cases. Of those, 443 propensity score-matched pairs were evaluated. Cannulation time in the ultrasound-guided group was 2.5 minutes shorter than in the control group (difference, -2.5 minutes; 95% CI, -3.7 - -1.3, p<0.001). The incidence of catheter-related complications and the incidence of the poor neurological outcomes (Cerebral Performance Category ≥3) did not differ between groups (OR, 1.51; 95% CI, 0.75 - 2.74; OR, 1.51; 95% CI, 0.64 - 3.74; OR, 1.08; 95% CI, 0.83 - 1.59).<br /><b>Conclusion</b><br />Real-time ultrasound-guided cannulation was associated with shorter cannulation time of ECPR.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 04 Aug 2023:109927; epub ahead of print</small></div>

<div><h4>Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation.</h4><i>Morrison LJ, Sandroni C, Grunau B, Parr M, ... Brooks SC, International Liaison Committee on Resuscitation</i><br /><b>Aim of the review</b><br />Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries.<br /><b>Methods</b><br />The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section.<br /><b>Results</b><br />There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness.<br /><b>Conclusions</b><br />All health systems should develop, implement, and evaluate protocols designed to optimise organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.<br /><br />Copyright © 2023 European Resuscitation Council, merican Heart Association, Inc., International Liaison Committee on Resuscitation. Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 03 Aug 2023:109864; epub ahead of print</small></div>

<div><h4>Effects of a volunteer responder system for out-of-hospital cardiac arrest in areas of different population density- a retrospective cohort study.</h4><i>Lapidus O, Jonsson M, Svensson L, Hollenberg J, ... Nord A, Ringh M</i><br /><b>Background</b><br />Volunteer responder dispatch to nearby out-of-hospital cardiac arrests using a smartphone application can increase the proportion of patients receiving cardiopulmonary resuscitation. It is unknown how population density is related to the efficacy of a volunteer responder system. This study aimed to compare the response time of volunteer responders and EMS dispatched to suspected OHCAs in areas of different population density.<br /><b>Methods</b><br />A total of 2630 suspected OHCAs in Stockholm County during 2018-2020 where at least one dispatched volunteer responder reached the patient were identified through the HeartRunner™ application database. Study outcome was the proportion of cases where volunteer responders arrived at the scene before EMS, as well as the difference in time between the arrival of volunteer responders and EMS. ResultsVolunteer responders arrived before EMS in 68% of examined cases (n=1613). Higher population density was associated with a lower proportion of cases where volunteer responders arrived at the scene before EMS. Time on scene before arrival of EMS was highest in areas of low population density and averaged 4:07 (mm:ss). Response time was significantly shorter for volunteer responders compared to EMS across all population density groups at 4:47 vs 8:11 (mm:ss) (p<0.001); the largest difference in response time was found in low population density areas.<br /><b>Conclusion</b><br />Volunteer responders have significantly shorter response time than EMS regardless of population density, with the greatest difference in low population density areas. Although their impact on clinical outcome remains unknown, the benefits of dispatching volunteer responders to OHCAs may be greatest in rural areas.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 03 Aug 2023:109921; epub ahead of print</small></div>

<div><h4>Vasopressin and Methylprednisolone and Hemodynamics after In-Hospital Cardiac Arrest - A Post Hoc Analysis of the VAM-IHCA Trial.</h4><i>Andersen LW, Holmberg MJ, Høybye M, Isbye D, ... Fink Valentin M, Granfeldt A</i><br /><b>Introduction</b><br />The Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest (VAM-IHCA) trial demonstrated a significant improvement in return of spontaneous circulation (ROSC) with no clear effect on long-term outcomes. The objective of the current manuscript was to evaluate the hemodynamic effects of intra-cardiac arrest vasopressin and methylprednisolone during the first 24 hours after ROSC.<br /><b>Methods</b><br />The VAM-IHCA trial randomized patients with in-hospital cardiac arrest to a combination of vasopressin and methylprednisolone or placebo during the cardiac arrest. This study is a post hoc analysis focused on the hemodynamic effects of the intervention after ROSC. Post-ROSC data on the administration of glucocorticoids, mean arterial blood pressure, heart rate, blood gases, vasopressor and inotropic therapy, and sedation were collected. Total vasopressor dose between the two groups was calculated based on noradrenaline-equivalent doses for adrenaline, phenylephrine, terlipressin, and vasopressin.<br /><b>Results</b><br />The present study included all 186 patients who achieved ROSC in the VAM IHCA-trial of which 100 patients received vasopressin and methylprednisolone and 86 received placebo. The number of patients receiving glucocorticoids during the first 24 hours was 22/86 (26%) in the placebo group and 14/100 (14%) in the methylprednisolone group with no difference in the cumulative hydrocortisone-equivalent dose. There was no significant difference between the groups in the mean cumulative noradrenaline-equivalent dose (vasopressin and methylprednisolone: 603 ug/kg [95CI% 227; 979] vs. placebo: 651 ug/kg [95CI% 296; 1007], mean difference -48 ug/kg [95CI% -140; 42.9], p = 0.30), mean arterial blood pressure, or lactate levels. There was no difference between groups in arterial blood gas values and vital signs.<br /><b>Conclusion</b><br />Treatment with vasopressin and methylprednisolone during cardiac arrestcaused no difference in mean arterial blood pressure, vasopressor use, or arterial blood gases within the first 24 hours after ROSC when compared to placebo.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 03 Aug 2023:109922; epub ahead of print</small></div>

<div><h4>Head-to-Pelvis CT Imaging after Sudden Cardiac Arrest: Current Status and Future Directions.</h4><i>Branch KR, Nguyen ML, Kudenchuk PJ, Johnson NJ</i><br /><AbstractText>Causes for sudden circulatory arrest (SCA) can vary widely making early treatment and triage decisions challenging. Additionally, cardiopulmonary resuscitation (CPR), while a life-saving link in the chain of survival, can be associated with traumatic injuries. Computed tomography (CT) can identify many causes of SCA as well as its sequelae. However, the diagnostic and therapeutic impact of CT in survivors of SCA has not been reviewed to date. This general review outlines the rationale and potential applications of focused head, chest, and abdomen/pelvis CT as well as comprehensive head-to-pelvis CT imaging after SCA. CT has a diagnostic yield approaching 30% to identify causes of SCA while the addition of ECG-gated chest CT provides further information about coronary anatomy and cardiac function. Risks of CT include radiation exposure, contrast-induced kidney injury, and incidental findings. This review\'s findings suggest that routine head-to-pelvis CT can yield clinically actional findings with the potential to improve clinical outcome after SCA that merits further investigation.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 26 Jul 2023:109916; epub ahead of print</small></div>

<div><h4>Impact of Time-to-Compression on Out-of-Hospital Cardiac Arrest Survival Outcomes: a National Registry Study.</h4><i>Ling Goh J, Pin Pek P, Man Chung Fook-Chong S, Fw Ho A, ... Eng Hock Ong M, PAROS Clinical Research Network</i><br /><b>Objective</b><br />We aimed to quantify the association of no-flow interval in out-of-hospital cardiac arrests (OHCA) with the odds of neurologically favorable survival and survival to hospital discharge/ 30<sup>th</sup> day. Our secondary aim was to explore futility thresholds to guide clinical decisions, such as prehospital termination of resuscitation.<br /><b>Methods</b><br />All OHCAs from 2012-2017 in Singapore were extracted. We examined the association between no-flow interval (continuous variable) and survival outcomes using univariate and multivariable logistic regressions. The primary outcome was survival with favorable cerebral performance (Glasgow-Pittsburgh Cerebral Performance Categories 1/2), the secondary outcome was survival to hospital discharge/ 30<sup>th</sup> day if not discharged. To determine futility thresholds, we plotted the adjusted probability of good neurological outcomes to no-flow interval.<br /><b>Results</b><br />12,771 OHCAs were analyzed. The per-minute adjusted OR when no-flow interval was incorporated as a continuous variable in the multivariable model was: good neurological function- aOR 0.98 (95%CI: 0.97 - 0.98); survival to discharge- aOR 0.98 (95%CI: 0.98 - 0.99). Taking the 1% futility of survival line gave a no-flow interval cutoff of 12 mins (NPV 99%, sensitivity 85% and specificity 42%) overall and 7.5 mins for witnessed arrests.<br /><b>Conclusion</b><br />We demonstrated that prolonged no-flow interval had a significant effect on lower odds of favorable neurological outcomes, with medical futility occurring when no-flow interval was >12 mins (> 7.5 mins for witnessed arrest). Our study adds to the literature of the importance of early CPR and EMS response and provided a threshold beyond traditional \'down-times\', which could aid clinical decisions in TOR or OHCA management.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 26 Jul 2023:109917; epub ahead of print</small></div>

<div><h4>Out-of-Hospital Cardiac Arrest Survival When CPR is Initiated by First Responders.</h4><i>El-Zein RS, Kennedy KF, Chan PS</i><br /><b>Background</b><br />In most patients with out-of-hospital cardiac arrest (OHCA), cardiopulmonary resuscitation (CPR) is initiated by first responders (non-transporting firefighters or police) or emergency medical service (EMS) personnel. Whether survival outcomes differ when CPR is initiated by first responders vs. EMS is unclear.<br /><b>Methods</b><br />Within the CARES registry, we identified 162,896 adult patients with a non-traumatic OHCA in whom CPR was initiated by first responders or EMS during 2013-2021. Using multivariable hierarchical logistic regression to adjust for demographics, cardiac arrest characteristics and time to first CPR, we compared rates of survival to hospital admission and to discharge in patients with CPR initiated by first responders and EMS.<br /><b>Results</b><br />CPR was initiated by first responders in 70,889 (43.5%) and by EMS in 92,007 (56.5%) patients. Time to first CPR was shorter when first responders initiated CPR (median: 8.0 [5.0-13.0] vs. 10.0 minutes [IQR: 6.0-14.0]; standardized difference 16.1%). The likelihood of survival to hospital admission was similar when CPR was initiated by first responders (27.1% [first responders] vs. 26.8% [EMS]; adjusted OR: 0.98 [0.96, 1.01], P=0.15) whereas survival rates to discharge were higher with CPR initiated by first responders (9.4% [first responders] vs. 7.7% [EMS]; adjusted OR: 1.17 [1.02, 1.21], P<0.001). After adjustment for time to first CPR, rates of survival to discharge were similar between the first responder and EMS groups (adjusted OR: 1.04 [1.00-1.08]; P=0.07).<br /><b>Conclusions</b><br />CPR initiated by first responders for OHCA is associated with higher overall survival rates and higher survival was largely mediated by earlier response times.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 26 Jul 2023:109914; epub ahead of print</small></div>

<div><h4>Kidney-Specific Biomarkers for Predicting Acute Kidney Injury Following Cardiac Arrest.</h4><i>Berlin N, Pawar RD, Liu X, Balaji L, ... Moskowitz A, V Grossestreuer A</i><br /><b>Aim</b><br />To evaluate the performance of kidney-specific biomarkers (neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and cystatin-C) in early detection of acute kidney injury (AKI) following cardiac arrest (CA) when compared to serum creatinine.<br /><b>Methods</b><br />Adult CA patients who had kidney-specific biomarkers of AKI collected within 12 hours of return of spontaneous circulation (ROSC) were included. The association between renal biomarker levels post-ROSC and the development of KDIGO stage III AKI within 7 days of enrollment were assessed as well as their predictive value of future AKI development, neurological outcomes, and survival to discharge.<br /><b>Results</b><br />Of 153 patients, 54 (35%) developed stage III AKI within 7 days, and 98 (64%) died prior to hospital discharge. Patients who developed stage III AKI, compared to those who did not, had higher median levels of creatinine, NGAL, and cystatin-C (p<0.001 for all). There was no statistically significant difference in KIM-1 between groups. No biomarker outperformed creatinine in the ability to predict stage III AKI, neurological outcomes, or survival outcomes (p>0.05 for all). However, NGAL, cystatin-C, and creatinine all performed better than KIM-1 in their ability to predict AKI development (p<0.01 for all).<br /><b>Conclusion</b><br />In post-CA patients, creatinine, NGAL, and cystatin-C (but not KIM-1) measured shortly after ROSC were higher in patients who subsequently developed AKI. No biomarker was statistically superior to creatinine on its own for predicting the development of post-arrest AKI.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 25 Jul 2023:109911; epub ahead of print</small></div>

<div><h4>The Effect of Recognition on Survival after Out-of-Hospital Cardiac Arrest and Implications for Biosensor Technologies.</h4><i>Hutton J, Grunau B, Asamoah-Boaheng M, Christenson J, ... Shadgan B, Sobolev B</i><br /><b>Background</b><br />Biosensor technologies have been proposed as a solution to provide recognition and facilitate earlier responses to unwitnessed out-of-hospital cardiac arrest (OHCA) cases. We sought to estimate the effect of recognition on survival and modelled the potential incremental impact of increased recognition of unwitnessed cases on survival to hospital discharge, to demonstrate the potential benefit of biosensor technologies.<br /><b>Methods</b><br />We included cases from the British Columbia Cardiac Arrest Registry (2019-2020), which includes Emergency Medical Services (EMS)-assessed OHCAs. We excluded cases that would not have benefitted from early recognition (EMS-witnessed, terminal illness, or do-not-resuscitate). Using a mediation analysis, we estimated the relative benefits on survival of a witness recognizing vs. intervening in an OHCA; and estimated the expected additional number of survivors resulting from increasing recognition alone using a bootstrap logistic regression framework.<br /><b>Results</b><br />Of 13,655 EMS-assessed cases, 11,412 were included (6314 EMS-treated, 5098 EMS-untreated). Survival to hospital discharge was 191/8879 (2.2%) in unwitnessed cases and 429/2533 (17%) in bystander-witnessed cases. Of the total effect attributable to a bystander witness, recognition accounted for 84% (95% CI: 72, 86) of the benefit. If all previously unwitnessed cases had been bystander witnessed, we would expect 1198 additional survivors. If these cases had been recognized, but no interventions performed, we would expect 912 additional survivors.<br /><b>Conclusion</b><br />Unwitnessed OHCA account for the majority of OHCAs, yet survival is dismal. Methods to improve recognition, such as with biosensor technologies, may lead to substantial improvements in overall survival.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 13 Jul 2023:109906; epub ahead of print</small></div>

<div><h4>Racial and Ethnic Disparities in the Provision of Bystander CPR after Witnessed Out-of-Hospital Cardiac Arrest in the United States.</h4><i>Toy J, Bosson N, Schlesinger S, Gausche-Hill M</i><br /><b>Objective</b><br />To evaluate the association between race/ethnicity and the odds of receiving bystander cardiopulmonary resuscitation (bCPR) after witnessed out-of-hospital cardiac arrest (OHCA).<br /><b>Methods</b><br />For this cross-sectional retrospective study, data were obtained from the National Emergency Medical Services Information System database for adults (≥18 years) with a witnessed non-traumatic OHCA in the year 2021. Patients were separated into two groups including Black/Hispanic and White. The primary outcome was the odds of receiving bCPR. We excluded traumatic etiology, do-not-resuscitate order, and arrest in a healthcare facility or wilderness location. Multiple logistic regression controlling for known covariates was utilized and analyses were stratified public versus non-public location, median household income, and rural, suburban, or urban setting.<br /><b>Results</b><br />A total of 64,007 witnessed OHCAs were included. When compared to White, the Black/Hispanic group were younger (62 vs 67 years) and more often female (40% vs 33%), in neighborhoods with the lowest median household income (31% vs 13%) and in an urban setting (92% vs 80%). Overall, bystander CPR rates were 60% and 67% for the Black/Hispanic and White groups, respectively. Multiple logistic regression stratified by OHCA location found that the Black/Hispanic group had a decreased odds of receiving bCPR compared to the White group both in the home (adjusted OR [aOR] 0.77; 95% CI 0.74-0.81) and in public (aOR 0.69; 95% CI 0.64-0.76). These inequities persisted throughout neighborhoods of different socioeconomic status and across the rural-urban spectrum.<br /><b>Conclusions</b><br />Racial/ethnic disparities exist for Black and Hispanic persons in the odds of receiving bCPR after a witnessed non-traumatic OHCA regardless of public or private setting, neighborhood income level, or population density.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 11 Jul 2023:109901; epub ahead of print</small></div>

<div><h4>Racial and Ethnic Disparities amongst Patients with Lay Rescuer Automated External Defibrillator Placement After Out-of-Hospital Cardiac Arrest.</h4><i>Toy J</i><br /><b>Objective</b><br />This study evaluated the association between patient race/ethnicity and the odds of AED provision by a lay rescuer in out-of-hospital cardiac arrest (OHCA) in the United States.<br /><b>Methods</b><br />This was a cross-sectional retrospective study of OHCA patients in the National Emergency Medical Services Information System database from the year 2021. Patients were excluded for age <18 years, EMS-witnessed arrest, traumatic arrest, arrest in a healthcare setting, do-not-resuscitate order, and arrest in a wilderness location. The primary outcome was the association between race/ethnicity and the odds of lay-rescuer AED placement for OHCA. Multiple logistic regression adjusting for known covariates was performed and odds ratios were reported.<br /><b>Results</b><br />A total of 207,134 patients were included. Patients with lay rescuer AED use had statistically significant differences with regard to arrest location and arrest witnessed status, and had longer EMS response times (8.5 minutes vs 7 minutes). The odds of AED use was lowest for American Indian/Alaskan Native persons (OR 0.62; 95% CI 0.54, 0.72) followed by Asian (OR 0.66; 95% CI 0.60, 0.72), Hispanic (OR 0.66; 95% CI 0.63, 0.69) and Native Hawaiian/Pacific Islander patients (OR 0.69; 95% CI 0.57, 0.83) when compared to White patients. Black patients had the highest odds of AED use (OR 1.10; 95% CI 1.07, 1.12).<br /><b>Conclusion</b><br />When compared to White persons, the odds of lay rescuer AED use in OHCA was between 31-38% lower for American Indian/Alaskan Native, Asian, Hispanic, and Native Hawaiian/Pacific Islander persons, and 10% higher for Black persons.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 07 Jul 2023:109902; epub ahead of print</small></div>

<div><h4>AWAreness during REsuscitation - II: A Multi-Center Study of Consciousness and Awareness in Cardiac Arrest.</h4><i>Parnia S, Keshavarz Shirazi T, Patel J, Tran L, ... Pradhan D, Deakin CD</i><br /><b>Introduction</b><br />Cognitive activity and awareness during cardiac arrest (CA) are reported but ill understood. This first of a kind study examined consciousness and its underlying electrocortical biomarkers during cardiopulmonary resuscitation (CPR).<br /><b>Methods</b><br />In a prospective 25-site in-hospital study, we incorporated a) independent audiovisual testing of awareness, including explicit and implicit learning using a computer and headphones, with b) continuous real-time electroencephalography(EEG) and cerebral oxygenation(rSO<sub>2</sub>) monitoring into CPR during in-hospital CA (IHCA). Survivors underwent interviews to examine for recall of awareness and cognitive experiences. A complementary cross-sectional community CA study provided added insights regarding survivors\' experiences.<br /><b>Results</b><br />Of 567 IHCA, 53(9.3%) survived, 28 of these (52.8%) completed interviews, and 11(39.3%) reported CA memories/perceptions suggestive of consciousness. Four categories of experiences emerged: 1) emergence from coma during CPR (CPR-induced consciousness [CPRIC]) 2/28(7.1%), or 2) in the post-resuscitation period 2/28(7.1%), 3) dream-like experiences 3/28(10.7%), 4) transcendent recalled experience of death (RED) 6/28(21.4%). In the cross-sectional arm, 126 community CA survivors\' experiences reinforced these categories and identified another: delusions (misattribution of medical events). Low survival limited the ability to examine for implicit learning. Nobody identified the visual image, 1/28(3.5%) identified the auditory stimulus. Despite marked cerebral ischemia (Mean rSO<sub>2</sub>=43%) normal EEG activity (delta, theta and alpha) consistent with consciousness emerged as long as 35-60 minutes into CPR.<br /><b>Conclusions</b><br />Consciousness. awareness and cognitive processes may occur during CA. The emergence of normal EEG may reflect a resumption of a network-level of cognitive activity, and a biomarker of consciousness, lucidity and RED (authentic \"near-death\" experiences).<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 07 Jul 2023:109903; epub ahead of print</small></div>

<div><h4>Diagnostic Yield of Computed Tomography After Non-Traumatic Out-of-Hospital Cardiac Arrest.</h4><i>Tam J, Soufleris C, Ratay C, Frisch A, ... Coppler PJ, University of Pittsburgh Post-Cardiac Arrest Service</i><br /><b>Aim</b><br />Determine the frequency with which computed tomography (CT) after out-of-hospital cardiac arrest (OHCA) identifies clinically important findings.<br /><b>Methods</b><br />We included non-traumatic OHCA patients treated at a single center from February 2019 to February 2021. Clinical practice was to obtain CT head in comatose patients. Additionally, CT of the cervical spine, chest, abdomen, and pelvis were obtained if clinically indicated. We identified CT imaging obtained within 24 hours of emergency department (ED) arrival, and summarized radiology findings. We used descriptive statistics to summarize population characteristics and imaging results, report their frequencies and, post hoc, compared time from ED arrival to catheterization between patients who did and did not undergo CT.<br /><b>Results</b><br />We included 597 subjects, of which 491 (82.2%) had a CT obtained. Time to CT was 4.1 hours [2.8-5.7]. Most (n=480, 80.4%) underwent CT head, of which 36 (7.5%) had intracranial hemorrhage and 161 (33.5%) had cerebral edema. Fewer subjects (230, 38.5%) underwent a cervical spine CT, and 4 (1.7%) had acute vertebral fractures. Most subjects (410, 68.7%) underwent a chest CT, and abdomen and pelvis CT (363, 60.8%). Chest CT abnormalities included rib or sternal fractures (227, 55.4%), pneumothorax (27, 6.6%), aspiration or pneumonia (309, 75.4%), mediastinal hematoma (18, 4.4%) and pulmonary embolism (6, 3.7%). Significant abdomen and pelvis findings were bowel ischemia (24, 6.6%) and solid organ laceration (7, 1.9%). Most subjects that had CT imaging deferred were awake and had shorter time to catheterization.<br /><b>Conclusions</b><br />CT identifies clinically important pathology after OHCA.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 06 Jul 2023:109898; epub ahead of print</small></div>

<div><h4>Oxygen targets after cardiac arrest: a narrative review.</h4><i>Bray J, Skrifvars M, Bernard S</i><br /><AbstractText>A significant focus of post-resuscitation research over the last decade has included optimising oxygenation. This has primarily occurred due to an improved understanding of the possible harmful biological effects of high oxygenation, particularly the neurotoxicity of oxygen free radicals. Animal studies and some observational research in humans suggest harm with the occurrence of severe hyperoxaemia (PaO2 >300mmHg) in the post-resuscitation phase. This early data informed in a change in treatment recommendations, with the International Liaison Committee on Resuscitation (ILCOR) recommending the avoidance of hyperoxaemia. However, the optimal oxygenation level for maximal survival has not yet been determined. Recent Phase 3 randomised control trials (RCTs) provide further insight into when oxygen titration should occur. The EXACT RCT suggested that decreasing oxygen fraction post-resuscitation in the prehospital setting, with limited ability to titrate and measure oxygenation, is too soon. The BOX RCT, suggests delaying titration to a normal level in intensive care may be too late. While further RCTs are currently underway in ICU cohorts, titration of oxygen early after arrival at hospital should be considered.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 05 Jul 2023:109899; epub ahead of print</small></div>

<div><h4>Value of EEG in outcome prediction of hypoxic-ischemic brain injury in the ICU: a narrative review.</h4><i>Hoedemaekers C, Hofmeijer J, Horn J</i><br /><AbstractText>Prognostication of comatose patients after cardiac arrest aims to identify patients with a large probability of favourable or unfavouble outcome, usually within the first week after the event. Electroencephalography (EEG) is a technique that is increasingly used for this purpose and has many advantages, such as its non-invasive nature and the possibility to monitor the evolution ofbrain function over time. At the same time, use of EEG in a critical care environment faces a number of challenges. This narrative review describes the current role and future applications of EEG for outcome prediction of comatose patients with postanoxic encephalopathy.</AbstractText><br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 05 Jul 2023:109900; epub ahead of print</small></div>

<div><h4>Swedish emergency medical dispatch centres\' ability to answer emergency medical calls and dispatch an ambulance in response to out-of-hospital cardiac arrest calls in accordance with the American Heart Association performance goals: an observational study.</h4><i>Byrsell F, Jonsson M, Claesson A, Ringh M, ... Hollenberg J, Nord A</i><br /><b>Aim</b><br />To investigate the ability of Swedish Emergency Medical Dispatch Centres (EMDCs) to answer medical emergency calls and dispatch an ambulance for out-of-hospital cardiac arrest (OHCA) in accordance with the American Heart Association (AHA) performance goals in a 1-step (call connected directly to the EMDC) and a 2-step (call transferred to regional EMDC) procedure over 10 years, and to assess whether delays may be associated with 30-day survival.<br /><b>Method</b><br />Observational data from the Swedish Registry for Cardiopulmonary Resuscitation and EMDC.<br /><b>Results</b><br />A total of 9,174,940 medical calls were answered (1-step). The median answer delay was 7.3 s (interquartile range [IQR], 3.6-14.5 s). Furthermore, 594,008 calls (6.1%) were transferred in a 2-step procedure, with a median answer delay of 39 s (IQR, 30-53 s). A total of 45,367 cases (0.5%, 1-step) were registered as OHCA, with a median answer delay of 7.2 s (IQR, 3.6-14.1 s) (AHA high-performance goal, 10 s). For 1-step procedure, no difference in 30-day survival was found regarding answer delay. For OHCA (1-step), an ambulance was dispatched after a median of 111.9 s (IQR, 81.7-159.9s). Thirty-day survival was 10.8% (n=664) when an ambulance was dispatched within 70 s (AHA high-performance) versus 9.3% (n=2174) >100 s (AHA acceptable) (p=0.0013). Outcome data in the 2-step procedure was unobtainable.<br /><b>Conclusion</b><br />The majority of calls were answered within the AHA performance goals. When an ambulance was dispatched within the AHA high-performance standard in response to OHCA calls, survival was higher compared with calls when dispatch was delayed.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 04 Jul 2023:109896; epub ahead of print</small></div>

<div><h4>Interpretable machine learning model for imaging-based outcome prediction after cardiac arrest.</h4><i>Liu C, Elmer J, Arefan D, Pease M, Wu S</i><br /><b>Introduction</b><br />Early identification of brain injury patterns in computerized tomography (CT) imaging is crucial for post-cardiac arrest prognostication. Lack of interpretability of machine learning prediction reduces trustworthiness by clinicians and prevents translation to clinical practice. We aimed to identify CT imaging patterns associated with prognosis with interpretable machine learning.<br /><b>Methods</b><br />In this IRB-approved retrospective study, we included consecutive comatose adult patients hospitalized at a single academic medical center after resuscitation from in- and out-of-hospital cardiac arrest between August 2011 and August 2019 who underwent unenhanced CT imaging of the brain within 24 hours of their arrest. We decomposed the CT images into subspaces to identify interpretable and informative patterns of injury, and developed machine learning models to predict patient outcomes (i.e., survival and awakening status) using the identified imaging patterns. Practicing physicians visually examined the imaging patterns to assess clinical relevance. We evaluated machine learning models using 80%-20% random data split and reported AUC values to measure the model performance.<br /><b>Results</b><br />We included 1284 subjects of whom 35% awakened from coma and 34% survived hospital discharge. Our expert physicians were able to visualize decomposed image patterns and identify those believed to be clinically relevant on multiple brain locations. For machine learning models, the AUC was 0.710±0.012 for predicting survival and 0.702±0.053 for predicting awakening, respectively.<br /><b>Discussion</b><br />We developed an interpretable method to identify patterns of early post-cardiac arrest brain injury on CT imaging and showed these imaging patterns are predictive of patient outcomes (i.e., survival and awakening status).<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 04 Jul 2023:109894; epub ahead of print</small></div>

<div><h4>Outcomes and Characteristics of Cardiac Arrest in Children with Pulmonary Hypertension: A Secondary Analysis of the ICU-RESUS Clinical Trial.</h4><i>Morgan RW, Reeder RW, Ahmed T, Bell MJ, ... Berg RA, Sutton RM</i><br /><b>Background</b><br />Previous studies have identified pulmonary hypertension (PH) as a relatively common diagnosis in children with in-hospital cardiac arrest (IHCA), and preclinical laboratory studies have found poor outcomes and low systemic blood pressures during CPR for PH-associated cardiac arrest. The objective of this study was to determine the prevalence of PH among children with IHCA and the association between PH diagnosis and intra-arrest physiology and survival outcomes.<br /><b>Methods</b><br />This was a prospectively designed secondary analysis of patients enrolled in the ICU-RESUS clinical trial (NCT02837497). The primary exposure was a pre-arrest diagnosis of PH. The primary survival outcome was survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category score 1-3 or unchanged from baseline). The primary physiologic outcome was event-level average diastolic blood pressure (DBP) during CPR.<br /><b>Results</b><br />Of 1276 patients with IHCAs during the study period, 1129 index IHCAs were enrolled; 184 (16.3%) had PH and 101/184 (54.9%) were receiving inhaled nitric oxide at the time of IHCA. Survival with favorable neurologic outcome was similar between patients with and without PH on univariate (48.9% vs. 54.4%; p=0.17) and multivariate analyses (aOR 0.82 [95%CI: 0.56, 1.20]; p=0.32). There were no significant differences in CPR event outcome or survival to hospital discharge. Average DBP, systolic BP, and end-tidal carbon dioxide during CPR were similar between groups.<br /><b>Conclusions</b><br />In this prospective study of pediatric IHCA, pre-existing PH was present in 16% of children. Pre-arrest PH diagnosis was not associated with statistically significant differences in survival outcomes or intra-arrest physiologic measures.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 03 Jul 2023:109897; epub ahead of print</small></div>

<div><h4>Non-shockable Rhythms: A parametric model for the Immediate Probability of Return of Spontaneous Circulation.</h4><i>Unneland E, Norvik A, Bergum D, Buckler DG, ... Terje Kvaløy J, Skogvoll E</i><br /><b>Background</b><br />Cardiac arrest can present with asystole, Pulseless Electrical Activity (PEA), or Ventricular Fibrillation/Tachycardia (VF/VT). We investigated the transition intensity of return of spontaneous circulation (ROSC) from PEA and asystole during in-hospital resuscitation.<br /><b>Materials and methods</b><br />We included 770 episodes of cardiac arrest. PEA was defined as ECG with > 12 QRS complexes per min, asystole by an isoelectric signal > 5 seconds. The observed times of PEA to ROSC transitions were fitted to five different parametric time-to-event models. At values ≤ 0.1, transition intensities roughly represent next-minute probabilities allowing for direct interpretation. Different entities of PEA and asystole, dependent on whether it was the primary or a secondary rhythm, were included as covariates.<br /><b>Results</b><br />The transition intensities to ROSC from primary PEA and PEA after asystole were unimodal with peaks of 0.12 at 3 min and 0.09 at 6 min, respectively. Transition intensities to ROSC from PEA after VF/VT, or following transient ROSC, exhibited high initial values of 0.32 and 0.26 at 3 minutes, respectively, but decreased. The transition intensity to ROSC from initial asystole and asystole after PEA were both about 0.01 and 0.02; while asystole after VF/VT had an intensity to ROSC of 0.15 initially which decreaed. The transition intensity from asystole after temporary ROSC was constant at 0.08.<br /><b>Conclusion</b><br />The immediate probability of ROSC develops differently in PEA and asystole depending on the preceding rhythm and the duration of the resuscitation attempt. This knowledge may aid simple bedside prognostication and electronic resuscitation algorithms for monitors/defibrillators.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 03 Jul 2023:109895; epub ahead of print</small></div>

<div><h4>ChatGPT can pass the AHA exams: Open-ended questions outperform multiple-choice format.</h4><i>Zhu L, Mou W, Yang T, Chen R</i><br /><AbstractText>The study by Fijačko et al. tested ChatGPT\'s ability to pass the BLS and ACLS exams of AHA, but found that ChatGPT failed both exams. A limitation of their study was using ChatGPT to generate only one response, which may have introduced bias. When generating three responses per question, ChatGPT can pass BLS exam with an overall accuracy of 84%. When incorrectly answered questions were rewritten as open-ended questions, ChatGPT\'s accuracy rate increased to 96% and 92.1% for the BLS and ACLS exams, respectively, allowing ChatGPT to pass both exams with outstanding results.</AbstractText><br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 01 Jul 2023; 188:109783</small></div>

<div><h4>Outcomes after cardiac arrest in Medical Intensive Care Unit: A propensity score matching analysis of COVID-19 MICU vs non COVID-19 MICU cardiac arrest.</h4><i>Bhardwaj A, Alwakeel M, Kirincich J, Shaheen H, ... Abi Fadel F, Krishnan S</i><br /><b>Aim</b><br />To assess whether there were differences in resuscitation efforts and outcomes for medical intensive care unit (MICU) in-hospital cardiac arrest (IHCA) during the COVID-19 pandemic when compared to pre-pandemic.<br /><b>Methods</b><br />Comparing COVID-19 MICU-IHCA patients (03/2020 to 10/2020) to non-COVID-19 MICU IHCA (01/2014 to 12/2018) at Clevleand Clinic Health System (CCHS) of NE Ohio. Propensity score matching analysis (PSMA) was used to create comparable groups.<br /><b>Results</b><br />There werea total of 516 patients, 51 in COVID-19 MICU IHCA cohort and 465 in the non-COVID-19 MICU IHCA cohort. The mean (SD) age of the study population was 60.9 (16) years and 56% were males. In 92.1% (n=475) patients, initial arrest rhythm was non-shockable. At the time of ICU admission, compared to the non-COVID-19 MICU-IHCA cohort, the COVID-19 MICU IHCA cohort had a lower mean APACHE III score (70 [32.9] vs 101.3 [39.6], P=<0.01). The COVID-19 cohort had a higher rate of survival to hospital discharge (12 [23.5%] vs 59 [12.7%], P=0.03). Upon PSMA, the algorithm selected 40 COVID-19 patients and 200 non-COVID-19 patients. Imbalances in baseline characteristics, comorbidities, and APACHE III were well-balanced after matching. Survival rate after matching became non-significant; (10 [25%) vs 42 [21%], P=0.67). Further, there were no significant differences in ICU or hospital length-of-stay or neurological outcomes at discharge for survivors in the two matched cohorts.<br /><b>Conclusion</b><br />It is imperative that COVID-19 patients receive unbiased and unrestricted resuscitation measures, without any discouragement.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 28 Jun 2023:109890; epub ahead of print</small></div>

<div><h4>Title: Age, sex, and survival following ventricular fibrillation cardiac arrest: a mechanistic evaluation of the ECG waveform: Short title: Age, sex, and survival via VF waveform in OHCA.</h4><i>Yang BY, Coult J, Blackwood J, Kwok H, ... Kudenchuk PJ, Rea TD</i><br /><b>Background</b><br />Studies of outcome differences by sex in out-of-hospital cardiac arrest (OHCA) have produced mixed results that may depend on age, a potential surrogate for menopausal status.<br /><b>Objective</b><br />We used quantitative measures of ventricular fibrillation (VF) waveforms - indicators of the myocardium\'s physiology - to assess whether survival differences according to sex and age group may be mediated via a biologic mechanism.<br /><b>Methods</b><br />We conducted a cohort study of VF-OHCA in a metropolitan EMS system. We used multivariable logistic regression to assess the association of survival to hospital discharge with sex and age group (<55, ≥55 years). We determined the proportion of outcome difference mediated by VF waveform measures: VitalityScore and amplitude spectrum area (AMSA).<br /><b>Results</b><br />Among 1526 VF-OHCA patients, the average age was 62 years, and 29% were female. Overall, younger women were more likely to survive than younger men (survival 67% vs 54%, p=0.02), while survival among older women and older men did not differ (40% vs 44%, p=0.3). Adjusting for Utstein characteristics, women <55 compared to men <55 had greater odds of survival to hospital discharge (OR=1.93, 95% CI 1.23-3.09), an association not observed between the ≥55 groups. Waveform measures were more favorable among women and mediated some of the beneficial association between female sex and survival among those <55 years: 47% for VitalityScore and 25% for AMSA.<br /><b>Conclusions</b><br />Women <55 years were more likely to survive than men <55 years following VF-OHCA. The biologic mechanism represented by VF waveform mediated some, though not all, of the outcome difference.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 28 Jun 2023:109891; epub ahead of print</small></div>

<div><h4>Haemodynamic impact of aortic balloon occlusion combined with percutaneous left ventricular assist device during cardiopulmonary resuscitation in a swine model of cardiac arrest.</h4><i>Hakam Tiba M, Nakashima T, McCracken BM, Hsu CH, ... Ward KR, Neumar RW</i><br /><b>Aim</b><br />To investigate the effect of tandem use of transient balloon occlusion of the descending aorta (AO) and percutaneous left ventricular assist device (pl-VAD) during cardiopulmonary resuscitation in a large animal model of prolonged cardiac arrest.<br /><b>Methods</b><br />Ventricular fibrillation was induced and left untreated for 8 minutes followed by 16 minutes of mechanical CPR (mCPR) in 24 swine, under general anesthesia. Animals were randomized to 3 treatment groups (n = 8 per group): A) pL-VAD (Impella CP®) B) pL-VAD+ AO, and C) AO. Impella CP® and the aortic balloon catheter were inserted via the femoral arteries. mCPR was continued during treatment. Defibrillation was attempted 3 times starting at minute 28 and then every 4 minutes. Haemodynamic, cardiac function and blood gas measurements were recorded for up to 4 hours.<br /><b>Results</b><br />Coronary perfusion pressure (CoPP) in the pL-VAD+AO Group increased by a mean (SD) of 29.2(13.94) mmHg compared to an increase of 7.1(12.08) and 7.1(5.95) mmHg for groups pL-VAD and AO respectively (p=0.02). Similarly, cerebral perfusion pressure (CePP) in pL-VAD+AO increased by a mean (SD) of 23.6 (6.11), mmHg compared with 0.97 (9.07) and 6.9 (7.98) mmHg for the other two groups (p<0.001). The rate of return of spontaneous heartbeat (ROSHB) was 87.5%, 75%, and 100% for pL-VAD+AO, pL-VAD, and AO.<br /><b>Conclusion</b><br />Combined AO and pL-VAD improved CPR hemodynamics compared to either intervention alone in this swine model of prolonged cardiac arrest.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 27 Jun 2023:109885; epub ahead of print</small></div>

<div><h4>Out-of-hospital cardiac arrests occurring at school in France: a nation-wide retrospective cohort study from the RéAC registry.</h4><i>Lafrance M, Canon V, Hubert H, Grunau B, ... GR-RéAC, members of the SFMU cardiac arrest board</i><br /><b>Aim</b><br />We sought to describe the characteristics of at-school out-of-hospital cardiac arrests cases, subsequent basic life support, as well as ultimate patient outcomes.<br /><b>Methods</b><br />This was a nation-wide, multicentre, retrospective cohort study from the French national population-based RéAC out-of-hospital cardiac arrest registry (July 2011 - March 2023). We compared the characteristics and outcomes of cases occurring at schools vs. in other public places.<br /><b>Results</b><br />Of the 149,088 national out-of-hospital cardiac arrests, 25,071 were public: 86 (0.3%) and 24,985 (99.7%) in schools and other public places, respectively. At-school out-of-hospital cardiac arrests, in comparison to other public places, were: significantly younger (median: 42.5 vs. 58 years, p<0.001); more commonly of a medical cause (90.7% vs. 63.8%, p<0.001), more commonly bystander-witnessed (93.0% vs. 73.4%, p<0.001) and recipients of bystander cardiopulmonary resuscitation (78.8% vs. 60.6%, p=0.001) with shorter median no-flow durations (2 min. vs. 7 min.); with greater bystander automated external defibrillator application (38.9% vs. 18.4%) and defibrillation (23.6%, vs. 7.9%; all p<0.001). At-school patients had greater rates of return of spontaneous circulation than out-of-school ones (47.7%, vs. 31.8%; p=0.002), higher rates of survival at arrival at hospital (60.5% vs. 30.7%; p<0.001) and at 30-days (34.9% vs. 11.6%; p<0.001), and survival with favourable neurological outcomes at 30 days (25.9% vs. 9.2%; p<0.001).<br /><b>Conclusion</b><br />At-school out-of-hospital cardiac arrests were rare in France, however demonstrated favourable prognostic features and outcomes. The use of automated external defibrillators in at-school cases, while more common than cases occurring elsewhere, should be improved.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 26 Jun 2023:109888; epub ahead of print</small></div>

<div><h4>Blood pressure targets and management during post-cardiac arrest care.</h4><i>Skrifvars MB, Ameloot K, Åneman A</i><br /><AbstractText>Blood pressure is one modifiable physiological target in patients treated in the intensive care unit after cardiac arrest. Current Guidelines recommend targeting a mean arterial pressure (MAP) of higher than 65-70 mmHg using fluid resuscitation and the use of vasopressors. Management strategies will vary based in the setting, i.e. the pre-hospital compared to the in-hospital phase. Epidemiological data suggest that some degree of hypotension requiring vasopressors occur in almost 50% of patients. A higher MAP could theoretically increase coronary blood flow but on the other hand the use of vasopressor may result in an increase in cardiac oxygen demand and arrhythmia. An adequate MAP is paramount for maintaining cerebral blood flow. In some cardiac arrest patients the cerebral autoregulation may be disturbed resulting in the need for higher MAP in order to avoid decreasing cerebral blood flow. Thus far, four studies including little more than 1000 patients have compared a lower and higher MAP target in cardiac arrest patients. The achieved mean difference of MAP between groups has varied from 10-15 mmHg. Based on these studies a Bayesian meta-analysis suggests that the posterior probability that a future study would find treatment effects higher than a 5% difference between groups to be less than 50%. On the other hand, this analysis also suggests, that the likelihood of harm with a higher MAP target is also low. Noteworthy is that all studies to date have focused mainly on patients with a cardiac cause of the arrest with the majority of patients being resuscitated from a shockable initial rhythm. Future studies should aim to include also non-cardiac causes and aim to target a wider separation in MAP between groups.</AbstractText><br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 26 Jun 2023:109886; epub ahead of print</small></div>