Journal: Resuscitation

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Abstract

A systematic review of the impact of emergency medical service practitioner experience and exposure to out of hospital cardiac arrest on patient outcomes.

Bray J, Nehme Z, Nguyen A, Lockey A, Finn J
Aim
To conduct a systematic review to evaluate the impact of emergency medical service (EMS) practitioner\'s years of career experience and exposure to out-of-hospital cardiac arrest (OHCA) on patient outcomes.
Methods
We searched electronic databases (Ovid MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Web of Science Core Collection) from inception until 10 April 2020. Studies were included that examined the exposures of interest on OHCA patient outcomes: good neurological outcome at discharge/30 days, survival to hospital discharge/30 days, survival to hospital and return of spontaneous circulation (ROSC). Prospero Registration: CRD42019153599.
Results
We included 7 of 22 observational studies shortlisted. Four of these studies examined the years of career experience of EMS practitioners, and four studies examined their exposure to attempted resuscitation. The evidence for both exposures of interest was assessed as very-low certainty. Overall, we found no association between patient outcomes and years of career experience. However, the best evidence found, from two large studies, suggests greater recent exposure to cases of attempted resuscitation is associated with better outcomes (ROSC/survival to hospital discharge). One of these studies also reports lower survival to hospital discharge when the team attempting resuscitation had no exposure in the previous six-months.
Conclusion
Very low certainty evidence suggests higher exposure to attempted resuscitation cases, but not years of clinical EMS experience, is associated with improved OHCA patient outcomes. This review highlights the need for EMS to monitor OHCA exposure, and the need for further research exploring the relationship between EMS exposure and patient outcomes.

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

Resuscitation: 29 Sep 2020; 155:134-142
Bray J, Nehme Z, Nguyen A, Lockey A, Finn J
Resuscitation: 29 Sep 2020; 155:134-142 | PMID: 32768497
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Abstract

The association of scene-access delay and survival with favourable neurological status in patients with out-of-hospital cardiac arrest.

Sinden S, Heidet M, Scheuermeyer F, Kawano T, ... Christenson J, Grunau B
Background
Rapid emergency medical service (EMS) response after out-of-hospital cardiac arrest (OHCA) is a major determinant of survival, however this is typically measured until EMS vehicle arrival. We sought to investigate whether the interval from EMS vehicle arrival to patient attendance (curb-to-care interval [CTC]) was associated with patient outcomes.
Methods
We performed a secondary analysis of the \"CCC Trial\" dataset, which includes EMS-treated adult non-traumatic OHCA. We fit an adjusted logistic regression model to estimate the association between CTC interval (divided into quartiles) and the primary outcome (survival with favourable neurologic status at hospital discharge; mRS ≤ 3). We described the CTC interval distribution among enrolling clusters.
Results
We included 24,685 patients: median age was 68 (IQR 56-81), 23% had initial shockable rhythms, and 7.6% survived with favourable neurological status. Compared to the first quartile (≤62 s), longer CTC quartiles (63-115, 116-180, and ≥181 s) demonstrated the following associations with survival with favourable neurological status: adjusted odds ratios 0.95, 95% CI 0.83-1.09; 0.77, 95% CI 0.66-0.89; 0.66, 95% CI 0.56-0.77, respectively. Of the 49 study clusters, median CTC intervals ranged from 86 (IQR 58-130) to 179 s (IQR 112-256).
Conclusion
A lower CTC interval was associated with improved patient outcomes. These results demonstrate a wide range of access metrics within North America, and provide a rationale to create protocols to mitigate access obstacles. A 2-min CTC threshold may represent an appropriate target for quality improvement.

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

Resuscitation: 29 Sep 2020; 155:211-218
Sinden S, Heidet M, Scheuermeyer F, Kawano T, ... Christenson J, Grunau B
Resuscitation: 29 Sep 2020; 155:211-218 | PMID: 32522699
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Abstract

Epinephrine treatment but not time to ROSC is associated with intestinal injury in patients with cardiac arrest.

Krychtiuk KA, Richter B, Lenz M, Hohensinner PJ, ... Heinz G, Speidl WS
Aim
Current guidelines suggest the use of epinephrine in patients with cardiac arrest (CA). However, evidence for increased survival in good neurological condition is lacking. In experimental settings, epinephrine-induced impairment of microvascular flow was shown. The aim of our study was to analyze the association between epinephrine treatment and intestinal injury in patients after CA.
Methods
We have included 52 patients with return of spontaneous circulation (ROSC) after CA admitted to our medical intensive care unit (ICU). Blood was taken on admission and levels of circulating intestinal fatty acid binding protein (iFABP) were analyzed.
Results
Patients were 64 (49.8-73.8) years old and predominantly male (76.9%). After six months, 50% of patients died and 38.5% of patients had a cerebral performance category (CPC)-score of 1-2. iFABP levels were lower in survivors (234 IQR 90-399 pg/mL) as compared to non-survivors (283, IQR 86-11500 pg/mL; p < 0.05). Plasma levels of iFABP were not associated with time to ROSC but correlated with epinephrine-dose (R = 0.32; p < 0.05). 40% of patients receiving ≥3 mg of epinephrine as compared to 10.5% of patients treated with <3 mg (p < 0.05) developed iFABP plasma levels >1500 pg/mL, which was associated with dramatically increased mortality (HR4.87, 95%CI 1.95-12.1; p < 0.001). iFABP levels predicted mortality independent from time to ROSC and the disease severity score SAPS II. In contrast to mortality, iFABP plasma levels were not associated with neurological outcome.
Conclusions
In this small, single centre study, cumulative dose of epinephrine used in cardiac arrest patients was associated with an increase in biomarker indicative of intestinal injury and 6-month mortality.

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

Resuscitation: 29 Sep 2020; 155:32-38
Krychtiuk KA, Richter B, Lenz M, Hohensinner PJ, ... Heinz G, Speidl WS
Resuscitation: 29 Sep 2020; 155:32-38 | PMID: 32522698
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Abstract

Continuous amplitude-integrated electroencephalography for prognostication of cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation with targeted temperature management.

Kobata H, Tucker A, Sarapuddin G, Negoro T, Kawakami M
Background
Extracorporeal cardiopulmonary resuscitation (ECPR) has been increasingly used for adult cardiac arrest (CA) patients refractory to conventional CPR. However, data on early prognosticators of neurological outcome are lacking.
Methods
CA patients undergoing ECPR were prospectively monitored via amplitude-integrated EEG (aEEG). Targeted temperature management (TTM) was induced using an extracorporeal membrane oxygenation system. aEEG background patterns were classified into continuous normal voltage (CNV), discontinuous normal voltage (DNV), low voltage (LV), flat trace (FT), burst suppression (BS), and status epilepticus (SE). The Cerebral Performance Category (CPC) scale scores at hospital discharge and at 6 months after discharge were assessed, as was wakefulness after TTM. Good neurological outcome was defined as a CPC score of 1 or 2.
Results
Twenty-two patients were studied. Six patients who showed CNV within 24 hours after arrival, including one with initial FT and two with initial LV, regained consciousness and had good neurological outcome except for one who died of haemorrhagic complication. Patients with persistent FT or BS at any time did not regain consciousness. Regarding 19 patients in whom aEEG data were obtained within 24 hours, CNV background predicted good outcome at 6 months with 100% sensitivity, 93% specificity, 83% positive predictive values, and 100% negative predictive values. All these indices were 100% concerning wakefulness after TTM.
Conclusion
aEEG monitoring was feasible and practical in adult CA patients undergoing ECPR and TTM. Evolution of aEEG background within 24 hours provides early accurate information for neurological prognostication.

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

Resuscitation: 30 Oct 2020; 156:107-113
Kobata H, Tucker A, Sarapuddin G, Negoro T, Kawakami M
Resuscitation: 30 Oct 2020; 156:107-113 | PMID: 32918986
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Abstract

The relationship between no-flow interval and survival with favourable neurological outcome in out-of-hospital cardiac arrest: Implications for outcomes and ECPR eligibility.

Guy A, Kawano T, Besserer F, Scheuermeyer F, ... Christenson J, Grunau B
Background
The \"no flow\" interval is the time from out-of-hospital cardiac arrest (OHCA) to cardiopulmonary resuscitation (CPR). Its prognostic value is important to define for prehospital resuscitation decisions, post-resuscitation care and prognostication, and extracorporeal cardiopulmonary resuscitation (ECPR) candidacy assessment.
Methods
We examined bystander-witnessed OHCAs without bystander CPR from two Resuscitation Outcomes Consortium datasets. We used modified Poisson regression to model the relationship between the no-flow interval (9-1-1 call to professional resuscitation) and favourable neurological outcome (Modified Rankin Score ≤ 3) at hospital discharge. Furthermore, we identified the no-flow interval beyond which no patients had a favourable outcome. We analysed a subgroup to simulate ECPR-treated patients (witnessed arrest, age < 65, non-asystole initial rhythm, and >30 min until return of circulation).
Results
Of 43,593 cases, we included 7299; 616 (8.4%) had favourable neurological outcomes. Increasing no-flow interval was inversely associated with favourable neurological outcomes (adjusted relative risk 0.87, 95% CI 0.85-0.90); the adjusted probability of a favourable neurological outcome decreased by 13% (95% CI 10-15%) per minute. No patients (0/7299, 0%; 1-sided 97.5% CI 0-0.051%) had both a no-flow interval >20 min and a favourable neurological outcome. In the hypothetical ECPR group, 0/152 (0%; 1-sided 97.5% CI 0-2.4%) had both a no-flow interval >10 min and a favourable neurological outcome.
Conclusions
The probability of a favourable neurological outcome in OHCA decreases by 13% for every additional minute of no-flow time until high-quality CPR, with the possibility of favourable outcomes up to 20 min.

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

Resuscitation: 29 Sep 2020; 155:219-225
Guy A, Kawano T, Besserer F, Scheuermeyer F, ... Christenson J, Grunau B
Resuscitation: 29 Sep 2020; 155:219-225 | PMID: 32553923
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Abstract

Double (dual) sequential defibrillation for refractory ventricular fibrillation cardiac arrest: A systematic review.

Deakin CD, Morley P, Soar J, Drennan IR
Introduction
Cardiac arrests associated with shockable rhythms such as ventricular fibrillation or pulseless VT (VF/pVT) are associated with improved outcomes from cardiac arrest. The more defibrillation attempts required to terminate VF/pVT, the lower the survival. Double sequential defibrillation (DSD) has been used for refractory VF/pVT cardiac arrest despite limited evidence examining this practice. We performed a systematic review to summarize the evidence related to the use of DSD during cardiac arrest.
Methods
This review was performed according to PRISMA and registered on PROSPERO (ID: CRD42020152575). We searched Embase, Pubmed, and the Cochrane library from inception to 28 February 2020. We included adult patients with VF/pVT in any setting. We excluded case studies, case series with less than five patients, conference abstracts, simulation studies, and protocols for clinical trials. We predefined our outcomes of interest as neurological outcome, survival to hospital discharge, survival to hospital admission, return of spontaneous circulation (ROSC), and termination of VF/pVT. Risk of bias was examined using ROBINS-I or ROB-2 and certainty of studies were reported according to GRADE methodology.
Results
Overall, 314 studies were identified during the initial search. One hundred and thirty studies were screened during title and abstract stage and 10 studies underwent full manuscript screening, nine included in the final analysis. Included studies were cohort studies (n = 4), case series (n = 3), case-control study (n = 1) and a prospective pilot clinical trial (n-1). All studies were considered to have serious or critical risk of bias and no meta-analysis was performed. Overall, we did not find any differences in terms of neurological outcome, survival to hospital discharge, survival to hospital admission, ROSC, or termination of VF/pVT between DSD and a standard defibrillation strategy.
Conclusion
The use of double sequential defibrillation was not associated with improved outcomes from out-of-hospital cardiac arrest, however the current literature has a number of limitations to interpretation. Further high-quality evidence is needed to answer this important question.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 29 Sep 2020; 155:24-31
Deakin CD, Morley P, Soar J, Drennan IR
Resuscitation: 29 Sep 2020; 155:24-31 | PMID: 32561473
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Abstract

The impact of ventilation rate on end-tidal carbon dioxide level during manual cardiopulmonary resuscitation.

Ruiz de Gauna S, Gutiérrez JJ, Ruiz J, Leturiondo M, ... Russell JK, Daya MR
Aim
Ventilation rate is a confounding factor for interpretation of end-tidal carbon dioxide (ETCO) during cardiopulmonary resuscitation (CPR). The aim of our study was to model the effect of ventilation rate on ETCO during manual CPR in adult out-of-hospital cardiac arrest (OHCA).
Methods
We conducted a retrospective analysis of OHCA monitor-defibrillator files with concurrent capnogram, compression depth, transthoracic impedance and ECG. We annotated pairs of capnogram segments presenting differences in average ventilation rate and average ETCO value but with other influencing factors (e.g. compression rate and depth) presenting similar values within the pair. ETCO variation as a function of ventilation rate was adjusted through curve fitting using non-linear least squares as a measure of goodness of fit.
Results
A total of 141 pairs of segments from 102 patients were annotated. Each pair provided a single data point for curve fitting. The best goodness of fit yielded a coefficient of determination R of 0.93. Our model described that ETCO decays exponentially with increasing ventilation rate. The model showed no differences attributable to the airway type (endotracheal tube or supraglottic King-LT-D).
Conclusion
Capnogram interpretation during CPR is challenging since many factors influence ETCO. For adequate interpretation, we need to know the effect of each factor on ETCO. Our model allows quantifying the effect of ventilation rate on ETCO variation. Our findings could contribute to better interpretation of ETCO during CPR.

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

Resuscitation: 30 Oct 2020; 156:215-222
Ruiz de Gauna S, Gutiérrez JJ, Ruiz J, Leturiondo M, ... Russell JK, Daya MR
Resuscitation: 30 Oct 2020; 156:215-222 | PMID: 32622015
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Abstract

Immediate coronary angiogram in out-of-hospital cardiac arrest patients with non-shockable initial rhythm and without ST-segment elevation - Is there a clinical benefit?

Voicu S, Bajoras V, Gall E, Deye N, ... Megarbane B, Sideris G
Aim
Coronary angiogram (CA) may be useful after resuscitated out-of-hospital cardiac arrest (OHCA), but data regarding its benefit in patients with non-shockable initial rhythm without ST-segment elevation is scarce. We aimed to evaluate the prevalence of acute coronary syndrome (ACS) and survival in OHCA patients with non-shockable initial rhythm without ST-segment elevation and compare them to patients with shockable initial rhythm without ST-segment elevation.
Methods
Retrospective single-centre study approved by the ethics committee of our institution, including adults successfully resuscitated from OHCA of presumed cardiac cause, undergoing routine CA on admission. Baseline characteristics, angiographic data including presence of ACS and survival were compared between patients with non-shockable and shockable initial rhythm focusing on patients without ST-segment elevation.
Results
Among 517 patients included between 2002 and 2018, 311 had no ST-elevation, of whom 179 had non-shockable and 132 shockable initial rhythm. Compared with shockable initial rhythm patients without ST-elevation, non-shockable initial rhythm patients without ST-elevation had longer no-flow duration, 5 (1-10) versus 2 (0-8) min, p = 0.024, more frequent shock requiring vasopressors, 72% versus 47% p < 0.0001, a lower prevalence of ACS, 2 (1%), versus 29 (22%), p < 0.001 and higher mortality, 85% versus 39% (p < 0.0001). Among ACS patients, none survived in the non-shockable without ST-elevation group, while 20 (69%) survived in the shockable rhythm without ST-elevation group.
Conclusions
Prevalence of ACS in patients without ST-segment elevation and non-shockable initial rhythm is extremely low, and survival extremely poor, therefore routine emergency CA does not seem beneficial in these patients.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 29 Sep 2020; 155:226-233
Voicu S, Bajoras V, Gall E, Deye N, ... Megarbane B, Sideris G
Resuscitation: 29 Sep 2020; 155:226-233 | PMID: 32629093
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Abstract

Effects of different adrenaline doses on cerebral oxygenation and cerebral metabolism during cardiopulmonary resuscitation in pigs.

Putzer G, Martini J, Spraider P, Hornung R, ... Helbok R, Mair P
Background
The influence of adrenaline during cardiopulmonary resuscitation (CPR) on the neurological outcome of cardiac arrest survivors is unclear. As little is known about the pathophysiological effects of adrenaline on cerebral oxygen delivery and cerebral metabolism we investigated its effects on parameters of cerebral oxygenation and cerebral metabolism in a pig model of CPR.
Methods
Fourteen pigs were anesthetized, intubated and instrumented. After 5 min of cardiac arrest CPR was started and continued for 15 min. Animals were randomized to receive bolus injections of either 15 or 30 μg/kg adrenaline every 5 min after commencement of CPR.
Results
Measurements included mean arterial pressure (MAP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), cerebral regional oxygen saturation (rSO), brain tissue oxygen tension (PO), arterial and cerebral venous blood gases and cerebral microdialysis parameters, e.g. lactate/pyruvate ratio. Adrenaline induced a significant increase in MAP and CPP in all pigs. However, increases in MAP and CPP were short-lasting and tended to decrease with repetitive bolus administration. There was no statistical difference in any parameter of cerebral oxygenation or metabolism between study groups.
Conclusions
Both adrenaline doses resulted in short-lasting CPP peaks which did not translate into improved cerebral tissue oxygen tension and metabolism. Further studies are needed to determine whether other dosing regimens targeting a sustained increase in CPP, may lead to improved brain oxygenation and metabolism, thereby improving neurological outcome of cardiac arrest patients.

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

Resuscitation: 30 Oct 2020; 156:223-229
Putzer G, Martini J, Spraider P, Hornung R, ... Helbok R, Mair P
Resuscitation: 30 Oct 2020; 156:223-229 | PMID: 32652117
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Abstract

Characteristics and outcomes of cardiac arrest survivors with acute pulmonary embolism.

Dutta A, Tayal B, Kragholm KH, Masmoudi Y, ... Sogaard P, Qureshi WT
Introduction
The characteristics and outcomes of patients that suffer cardiac arrest due to acute pulmonary embolism (PE) are not well studied. We compared the characteristics and outcomes of cardiac arrest survivors that suffered PE with other forms of cardiac arrest.
Methods
Consecutive cardiac arrest survivors were enrolled that were able to survive for 24 h post cardiopulmonary resuscitation. Diagnosis of PE was confirmed by CT angiogram or high-probability of PE on ventilation perfusion scan after the successful resuscitation from cardiac arrest. Survival curves were examined and predictors of mortality in PE patients were examined in an adjusted Cox proportional hazard model.
Results
Among the 996 cardiac arrest patients (mean age 62.6 ± 14.8 years, females 39.4%), 87 (8.7%) patients were found to have acute PE. The mortality rate of cardiac arrest survivors with and without acute PE was not significant different (68.3% vs. 64%). There were no significant differences in mortality among PE patients that received thrombolytics versus those who did not. Out of 87 patients, 33 (37.9%) required transfusion and had a bleeding complication. The risk of mortality in PE patients was predicted by older age, female sex, history of diabetes mellitus, end-stage renal disease and use of targeted temperature management.
Conclusion
Cardiac arrest survivors with PE did not have significantly better survival than patients with non-PE related cardiac arrest. In addition, use of thrombolytics did not improve survival but these patients ended up requiring transfusion that could have off set the benefit of thrombolytics.

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

Resuscitation: 29 Sep 2020; 155:6-12
Dutta A, Tayal B, Kragholm KH, Masmoudi Y, ... Sogaard P, Qureshi WT
Resuscitation: 29 Sep 2020; 155:6-12 | PMID: 32653575
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Abstract

Seizure-like presentation in OHCA creates barriers to dispatch recognition of cardiac arrest.

Schwarzkoph M, Yin L, Hergert L, Drucker C, Counts CR, Eisenberg M
Purpose
Early recognition of out-of-hospital cardiac arrest (OHCA) by 9-1-1 dispatchers is a critical first step along the resuscitation pathway. Barriers to recognition may lead to adverse outcomes among patients. This study aims to determine the impact of seizure-like activity among OHCA patients during 9-1-1 calls.
Methods
We evaluated a retrospective cohort study of all adult, non-traumatic OHCAs that occurred prior to emergency medical services (EMS) arrival on scene in a major metropolitan area from 2014-2018. Dispatch recordings were reviewed to determine if seizure-like activity was reported by the caller using key descriptor phrases such as \"seizing,\" \"shaking,\" or \"convulsing.\" We compared patient demographics, arrest factors, and hospital outcomes using a regional OHCA quality improvement database.
Results
Among 3502 OHCAs meeting our inclusion criteria, 149 (4.3%) contained seizure-like activity. When compared to patients without seizure-like activity (3353; 95.7%), patients presenting with seizure-like activity were younger (54 vs. 66 years old; p < 0.05), had a witnessed arrest (88% vs 45%; p < 0.05), presented with an initial shockable rhythm (52% vs. 24%; p < 0.05), and survived to hospital discharge (44% vs. 16%; p < 0.05). The seizure-like activity group also had a longer median time to dispatcher identification of the cardiac arrest [130 s (72,193) vs 62 s (43,102); p < 0.05].
Conclusions
Reported seizure-like activity among patients in cardiac arrest poses a barrier to recognition of cardiac arrests by dispatchers leading to delays in resuscitation instructions.

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

Resuscitation: 30 Oct 2020; 156:230-236
Schwarzkoph M, Yin L, Hergert L, Drucker C, Counts CR, Eisenberg M
Resuscitation: 30 Oct 2020; 156:230-236 | PMID: 32673735
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Abstract

Sustained inflation with 21% versus 100% oxygen during cardiopulmonary resuscitation of asphyxiated newborn piglets - A randomized controlled animal study.

Hidalgo CG, Solevag AL, Kim SY, Shim GH, ... O\'Reilly M, Schmölzer GM
Background
Current neonatal resuscitation guidelines recommend using 100% oxygen during chest compressions (CC), however the most effective oxygen concentration during cardiopulmonary resuscitation remains controversial.
Aim
In term newborn piglets with asphyxia-induced cardiac arrest does 21% oxygen compared to 100% oxygen during resuscitation using CC during sustained inflation (SI; CC + SI) will have a reduced time to return of spontaneous circulation (ROSC).
Intervention and measurements
Twenty-two mixed breed piglets (1-3 days old, 1.7-2.4 kg), were obtained on the day of the experiment and anesthetized, intubated, instrumented, and exposed to 30-min normocapnic hypoxia followed by asphyxia. Piglets were resuscitated using CC + SI and randomized to 21% oxygen (n = 8) or 100% oxygen (n = 8). Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment.
Main results
Baseline parameters were similar between 21% and 100% oxygen groups. There was no difference in asphyxiation (duration and degree) between groups. Time to ROSC was similar between 21% and 100% oxygen groups: median (interquartile range - IQR) 80 (70-190)sec vs. 90 (70-324)sec, (p = 0.56). There was no significant difference in the rate of ROSC between 21% and 100% oxygen groups: 7/8 (88%) vs. 5/8 (63%), (p = 0.569). All piglets that achieved ROSC survived to four hours post-resuscitation. Hemodynamics and regional perfusion were not significantly different between groups.
Conclusions
In term newborn piglets resuscitated by CC + SI, the use of 21% oxygen resulted in a similar time to ROSC, short-term survival, and hemodynamic recovery compared to 100% oxygen.

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

Resuscitation: 29 Sep 2020; 155:39-47
Hidalgo CG, Solevag AL, Kim SY, Shim GH, ... O'Reilly M, Schmölzer GM
Resuscitation: 29 Sep 2020; 155:39-47 | PMID: 32712173
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Abstract

Survival and functional outcome at hospital discharge following in-hospital cardiac arrest (IHCA): A prospective multicentre observational study.

Pound G, Jones D, Eastwood GM, Paul E, Hodgson CL
Aim
To evaluate the functional outcome of patients after in-hospital cardiac arrest (IHCA) and to identify associations with good functional outcome at hospital discharge.
Method
Emergency calls were prospectively screened and data collected for IHCAs in seven Australian hospitals. Patients were included if aged > 18 years, admitted as an acute care hospital in-patient and experienced IHCA; defined by a period of unresponsiveness with no observed respiratory effort and commencement of external cardiac compressions. Data collected included patient demographics, clinical and cardiac arrest characteristics, survival and functional outcome at hospital discharge using the modified Rankin Scale (mRS) and Katz Index of Independence in ADLs (Katz-ADL).
Results
152 patients suffered 159 IHCAs (male 66.4%; mean age 70.2 (± 13.9) years). Sixty patients (39.5%) survived, of whom 43 (71.7%) had a good functional outcome (mRS ≤ 3) and 38 (63.3%) were independent with activities of daily living (ADLs) at hospital discharge (Katz-ADL = 6). Younger age (OR 0.95; 95% CI 0.91-0.98; p = 0.003), shorter duration of CPR (OR 0.84; 95% CI 0.77-0.91; p < 0.0001) and shorter duration of hospital admission prior to IHCA (OR 0.96; 95% CI 0.93-0.998; p = 0.04) were independently associated with a good functional outcome at hospital discharge.
Conclusion
The majority of survivors had a good functional outcome and were independent with their ADLs at hospital discharge. Factors associated with good functional outcome at hospital discharge were identified.

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

Resuscitation: 29 Sep 2020; 155:48-54
Pound G, Jones D, Eastwood GM, Paul E, Hodgson CL
Resuscitation: 29 Sep 2020; 155:48-54 | PMID: 32697963
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Abstract

Adherence to guidelines is associated with improved survival following in-hospital cardiac arrest.

Hessulf F, Herlitz J, Rawshani A, Aune S, ... Lundgren P, Engdahl J
Background
Most resuscitation guidelines have recommendations regarding maximum delay times from collapse to calling for the rescue team and initiation of treatment following cardiac arrest. The aim of the study was to investigate the association between adherence to guidelines for cardiopulmonary resuscitation (CPR) after in-hospital cardiac arrest (IHCA) and survival with a focus on delay to treatment.
Methods
We used the Swedish Registry for CPR to study 3212 patients with a shockable rhythm and 9113 patients with non-shockable rhythm from January 1, 2008 to December 31, 2017. Adult patients older than or equal to 18 years with a witnessed IHCA where resuscitation was initiated were included. We assessed trends in adherence to guidelines and their associations with 30-day survival and neurological function. Adherence to guidelines was defined as follows: time from collapse to calling for the rescue team and CPR within 1 min for non-shockable rhythms. For shockable rhythms, adherence was defined as the time from collapse to calling for the rescue team and CPR within 1 min and defibrillation within 3 min.
Results
In patients with a shockable rhythm, the 30-day survival for those treated according to guidelines was 66.1%, as compared to 46.5% among those not treated according to guidelines on one or more parameters, adjusted odds ratio 1.84 (95% CI 1.52-2.22). Among patients with a non-shockable rhythm the 30-day survival for those treated according to guidelines was 22.8%, as compared to 16.0% among those not treated according to guidelines on one or more parameters, adjusted odds ratio 1.43 (95% CI 1.24-1.65). Neurological function (cerebral performance category 1-2) among survivors was better among patients treated in accordance with guidelines for both shockable (95.7% vs 91.1%, <0.001) and non-shockable rhythms (91.0% vs 85.5%, p < 0.008). Adherence to the Swedish guidelines for CPR increased slightly 2008-2017.
Conclusions
Adherence to guidelines was associated with increased probability of survival and improved neurological function in patients with a shockable and non-shockable rhythm, respectively. Increased adherence to guidelines could increase cardiac arrest survival.

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

Resuscitation: 29 Sep 2020; 155:13-21
Hessulf F, Herlitz J, Rawshani A, Aune S, ... Lundgren P, Engdahl J
Resuscitation: 29 Sep 2020; 155:13-21 | PMID: 32707144
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Impact:
Abstract

Changes in the incidence of out-of-hospital cardiac arrest: Differences between cardiac and non-cardiac aetiologies.

Alqahtani S, Nehme Z, Williams B, Bernard S, Smith K
Aim
We aimed to assess temporal changes in the incidence of OHCAs of presumed cardiac and non-cardiac aetiologies.
Methods
We conducted a retrospective cohort study of OHCAs in Victoria, Australia between 2000-2017. Annual adjusted incidence rates in presumed cardiac and non-cardiac OHCA were calculated with 95% confidence intervals (95% CI), assuming a Poisson distribution. Annual percent changes in the adjusted rates were calculated from Poisson regression models.
Results
During an 18-year period, 90,688 emergency medical service (EMS)-attended OHCAs were included. Of those, 64,422 (71.0%) were of presumed cardiac and 26,266 (29.0%) were of non-cardiac aetiology. Over the 18-year period, there was a 12.6% (95% CI: 10.8%, 14.4%) relative decline in presumed cardiac events and this was driven largely by a reduction in cases with an initial shockable rhythm (23.4%; 95% CI: 19.8%, 27.0%) and cases in patients aged 65-79 years (48.6%; 95% CI: 45.0%, 50.4%). Conversely, there was a 28.8% (95% CI: 27.0%, 32.4%) relative increase in non-cardiac events over the 18-year period, and this was driven by an increase in initial pulseless electrical activity events (93.6%; 95% CI: 86.4%, 100.8%) and cases in patients aged ≥80 years (93.6%; 95% CI: 86.4%, 100.8%). Precipitating events with the largest 18-year increase in incidence were non-traumatic exsanguination (115.2%; 95% CI: 95.4%, 133.2%), respiratory (66.6%; 95% CI: 59.4%, 73.8%), and neurological (63.0%; 95% CI: 50.4%, 77.4%).
Conclusion
Our data indicates that by 2052, non-cardiac aetiologies could be the leading cause of OHCA in our region. These findings have important EMS-system and public health implications.

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

Resuscitation: 29 Sep 2020; 155:125-133
Alqahtani S, Nehme Z, Williams B, Bernard S, Smith K
Resuscitation: 29 Sep 2020; 155:125-133 | PMID: 32710916
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Impact:
Abstract

Optimal combination of clinical examinations for neurologic prognostication of out-of-hospital cardiac arrest patients.

Kim JH, Park I, Chung SP, Kim HY, ... Park YS,
Aim
Targeted temperature management (TTM) may alter the results of clinical examination and delay motor response recovery; hence, re-establishing the accuracy and optimal timing of performing clinical examinations are crucial. Therefore, we aimed to identify the optimal combination and timing of clinical examinations for predicting the neurologic outcomes in patients undergoing TTM.
Methods
We conducted a retrospective analysis of prospectively collected multicentre registry data. All enrolled patients were supposed to undergo pupil light reflex (PLR), corneal reflex (CR), and Glasgow Coma Scale for 7 days after return of spontaneous circulation (ROSC). We investigated the timing of each examination based on the ROSC and rewarming completion times. The primary outcome was poor neurologic outcome (cerebral performance category 3,4, or 5) at 6 months after cardiac arrest.
Results
A total of 715 patients treated with TTM within 2 years, were enrolled. The PLR is more specific than the other examinations, and the specificity of the combination of PLR with CR was 100% 72 h after the ROSC or 24 h after rewarming completion. The sensitivity for the combination of PLR with CR 72 h after the ROSC was 55.3 (49.8-60.7) %, which was not different from that noted 24 h after rewarming completion (P = 0.65).
Conclusion
The combination of PLR with CR showed specificity approaching 100% 72 h after the ROSC or 24 h after rewarming completion. These findings can provide a clinical reference for predicting the neurological outcomes in patients undergoing TTM, especially in institutions without up-to-date facilities.

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

Resuscitation: 29 Sep 2020; 155:91-99
Kim JH, Park I, Chung SP, Kim HY, ... Park YS,
Resuscitation: 29 Sep 2020; 155:91-99 | PMID: 32710915
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Impact:
Abstract

Implementation of the Los Angeles Tiered Dispatch System is associated with an increase in telecommunicator-assisted CPR.

Sanko S, Kashani S, Lane C, Eckstein M
Background
In 2015, the Los Angeles Fire Department (LAFD) replaced the Medical Priority Dispatch System® (MPDS) with a new, homegrown Los Angeles Tiered Dispatch System (LA-TDS). The objective of this study was to assess the impact of this new dispatch system on telecommunicator-assisted CPR (T-CPR).
Methods
This was an interrupted time series study of out-of-hospital cardiac arrest (OHCA) cases where resuscitation was attempted with LAFD 9-1-1 telecommunicators using either MPDS® (January 1, 2014 to March 31, 2014) or LA-TDS (January 1, 2015 to March 31, 2015). Trained non-LAFD abstractors listened to all 9-1-1 calls and recorded if T-CPR was initiated, and the elapsed time from the start of the call until key events. The primary outcome was prevalence of T-CPR.
Results
Of 1027 calls during the study period, 597 9-1-1 calls met study inclusion/exclusion criteria (including 289 in MPDS cohort, 308 in LA-TDS cohort). The prevalence of T-CPR was significantly greater using LA-TDS (57%) vs. MPDS (43%) (OR 1.86, 95% CI 1.3-2.6). The LA-TDS cohort demonstrated a significant decrease (p < 0.001) in time to recognition of cardiac arrest, time to dispatch, and time to first T-CPR chest compression while there was no significant difference in the elapsed time to first description of agonal breathing. For cases where the telecommunicator had the opportunity to assess consciousness and breathing, there was a significant improvement in cardiac arrest recognition in < 1 min, prevalence of T-CPR (p < 0.001), and T-CPR started in <2 min (p < 0.001).
Conclusion
Implementation of the new Los Angeles Tiered Dispatch System was associated with decreased time to recognition of cardiac arrest and an increased rate of T-CPR compared to the previously used Medical Priority Dispatch System®.

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

Resuscitation: 29 Sep 2020; 155:74-81
Sanko S, Kashani S, Lane C, Eckstein M
Resuscitation: 29 Sep 2020; 155:74-81 | PMID: 32721415
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Impact:
Abstract

Analysis of prehospital perimortem caesarean deliveries performed by Helicopter Emergency Medical Services in the Netherlands and recommendations for the future.

Moors X, Biesheuvel TH, Cornette J, Van Vledder MG, ... Weelink E, Duvekot JJ
Background
Prehospital perimortem caesarean delivery (PCD) is a rarely performed procedure. In this study, we aimed to examine all PCDs performed by the four Helicopter Emergency Medical Services in the Netherlands; to describe the procedures, outcomes, complications, and compliance with the recommended guidelines; and to formulate recommendations.
Methods
We performed a population-based retrospective cohort study of all consecutive maternal out-of-hospital cardiac arrests that underwent PCD in the prehospital setting between May 1995 and December 2019. Registered data included patient demographics, operator background, advanced life support interventions, and timelines. Resuscitation performance was evaluated according to the 2015 European Resuscitation Guidelines.
Results
Seven patients underwent a prehospital PCD. Three mothers died on the scene, while four were transported to a hospital but died in the hospital. Seven neonates were born by PCD. One neonate died on the scene and six were transported to a hospital. Three neonates were eventually discharged from the hospital. Among the three surviving neonates, the periods from dispatch to start of PCD were 13, 14, and 21 min.
Conclusions
There was a low incidence of maternal perimortem caesarean deliveries in The Netherlands. Only some neonates survived after PCD. It is recommended that PCD be performed as quickly as possible. Due to the delay, the mother has a far lower chance of survival than the neonate. In fatal cases, autopsy is strongly recommended.

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

Resuscitation: 29 Sep 2020; 155:112-118
Moors X, Biesheuvel TH, Cornette J, Van Vledder MG, ... Weelink E, Duvekot JJ
Resuscitation: 29 Sep 2020; 155:112-118 | PMID: 32745580
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Impact:
Abstract

Effects of real-time feedback on cardiopulmonary resuscitation quality on outcomes in adult patients with cardiac arrest: A systematic review and meta-analysis.

Wang SA, Su CP, Fan HY, Hou WH, Chen YC
Aim
To investigate the relationship between the implementation of real-time audiovisual cardiopulmonary resuscitation (CPR) feedback devices with cardiac arrest patient outcomes, such as return of spontaneous circulation (ROSC), short-term survival, and neurological outcome.
Methods
We systematically searched PubMed, Embase, and the Cochrane CENTRAL from inception date until April 30, 2020, for eligible randomized and nonrandomized studies. Pooled odds ratio (OR) for each binary outcome was calculated using R system. The primary patient outcome was ROSC. The secondary outcomes were short-term survival and favorable neurological outcomes (cerebral performance category scores: 1 or 2).
Results
We identified 11 studies (8 nonrandomized and 3 randomized studies) including 4851 patients. Seven studies documented patients with out-of-hospital cardiac arrest and four studies documented patients with in-hospital cardiac arrest. The pooled results did not confirm the effectiveness of CPR feedback device, possibly because of the high heterogeneity in ROSC (OR: 1.42, 95% CI: 1.03-1.94, I: 80%, tau: 0.1875, heterogeneity test p <  0.01) and survival-to-discharge (OR: 1.27, 95% CI: 0.74-2.18, I: 86%, tau: 0.4048, heterogeneity test p <  0.01). The subgroup analysis results revealed that heterogeneity was due to the types of devices used. Patient outcomes were more favorable in studies investigating portable devices than in studies investigating automated external defibrillator (AED)-associated devices.
Conclusions
Whether real-time CPR feedback devices can improve patient outcomes (ROSC and short-term survival) depend on the type of device used. Portable devices led to better outcomes than did AED-associated devices. Future studies comparing different types of devices are required to reach robust conclusion.
Protocol registration
Prospero registration ID CRD42020155388.

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

Resuscitation: 29 Sep 2020; 155:82-90
Wang SA, Su CP, Fan HY, Hou WH, Chen YC
Resuscitation: 29 Sep 2020; 155:82-90 | PMID: 32755666
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Impact:
Abstract

Cardiogenic shock and cardiac arrest complicating ST-segment elevation myocardial infarction in the United States, 2000-2017.

Vallabhajosyula S, Dunlay SM, Prasad A, Sangaralingham LR, ... Shah ND, Jentzer JC
Background
There are limited data on the outcomes of cardiogenic shock (CS) and cardiac arrest (CA) complicating ST-segment-elevation myocardial infarction (STEMI).
Methods
Adult (>18 years) STEMI admissions were identified using the National Inpatient Sample (2000-2017) and classified as CS + CA, CS only, CA only and no CS/CA. Outcomes of interest included temporal trends, in-hospital mortality, hospitalization costs, use of do-not-resuscitate (DNR) status and palliative care referrals across the four cohorts.
Results
Of the 4,320,117 STEMI admissions, CS, CA and both were noted in 5.8%, 6.2% and 2.7%, respectively. In 2017, compared to 2000, there was an increase in CA (adjusted odds ratio [aOR] 1.83 [95% confidence interval {CI} 1.79-1.86]), CS (aOR 3.92 [95% CI 3.84-4.01]) and both (aOR 4.09 [95% CI 3.94-4.24]) (all p < 0.001). The CS+CA (77.2%) cohort had higher rates of multiorgan failure than CS only (59.7%) and CA only (26.3%), p < 0.001. The CA only cohort had lower rates (64%) of coronary angiography compared to the other groups (>70%), p < 0.001. In-hospital mortality was higher in CS+CA compared to CS alone (adjusted OR 1.87 [95% CI 1.83-1.91]), CA alone (adjusted OR 1.99 [95% CI 1.95-2.03]) or neither (aOR 18.37 [95% CI 18.02-18.71]). The CS+CA cohort had higher use of palliative care and DNR status. The presence of CS, either alone or in combination with CA, was associated with higher hospitalization costs.
Conclusions
The combination of CS and CA was associated with higher rates of non-cardiac organ failure and in-hospital mortality in STEMI compared to those with either CS or CA alone.

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

Resuscitation: 29 Sep 2020; 155:55-64
Vallabhajosyula S, Dunlay SM, Prasad A, Sangaralingham LR, ... Shah ND, Jentzer JC
Resuscitation: 29 Sep 2020; 155:55-64 | PMID: 32755665
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Impact:
Abstract

Prognostic value of repeated thromboelastography measurement for favorable neurologic outcome during targeted temperature management in out-of-hospital cardiac arrest survivors.

Yu G, Kim YJ, Kim JS, Kim SI, ... Ahn S, Kim WY
Background
Cardiac arrest can activate blood coagulation, which clinically manifests as obstruction of the microcirculation and multiple organ dysfunction. Thromboelastography (TEG) provides a rapid and comprehensive assessment of hemostatic processes, but there are limited data on the use of sequential TEG values during targeted temperature management (TTM) in out-of-hospital cardiac arrest (OHCA) survivors. The aim of this study was to investigate the prognostic value of coagulopathy assessed by repeated TEG to predict neurologically intact survival.
Methods
A prospective cohort of consecutive non-trauma OHCA patients who were successfully resuscitated and treated with TTM. Patients with a target temperature of 36 ℃, no TEG data, and who declined appropriate treatment were excluded. TEG was measured at three time points of TTM (initial phase, target phase, and rewarming phase). The primary outcome was 28 day favorable neurologic function, defined as a Cerebral Performance Category of 1 or 2.
Results
A total of 125 patients (mean age, 61 years; 63.2% male) were analyzed. A favorable neurologic outcome at 28 days was seen in 40 patients (32.0%). TEG values of R and LY30 in the initial phase were significantly lower in the favorable neurologic outcome group than in the unfavorable group (5.8 vs. 8.1 and 0.1 vs. 0.7, respectively; p < 0.01). TEG values of R < 5 or LY30 < 7.5 in the initial phase were more frequently seen in the favorable outcomes group than in the unfavorable group (37.5% vs. 12.9%, p = 0.002 and 95.0% vs. 72.9%, p = 0.004, respectively). However, no significant differences were seen between the two groups in other TEG values (R, K, alpha, and MA) in the target and rewarming phases (p > 0.05 for all). Univariate analysis showed higher D-dimer levels, prothrombin time, and activated partial thromboplastin time in the unfavorable outcome group. In the multivariable analysis, TEG values of combination of R < 5 and LY30 < 7.5 in the initial phase were the only coagulation profiles seen to be independently associated with favorable neurologic outcome (OR, 4.508, 95% CI, 1.254-16.210).
Conclusion
TEG results are available within minutes, and shorted R values or the absence of prolonged LY30 values in the initial phase are an early predictor of neurologically intact survival in successfully resuscitated OHCA patients.

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

Resuscitation: 29 Sep 2020; 155:65-73
Yu G, Kim YJ, Kim JS, Kim SI, ... Ahn S, Kim WY
Resuscitation: 29 Sep 2020; 155:65-73 | PMID: 32755664
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Impact:
Abstract

The optimal surface for delivery of CPR: A systematic review and meta-analysis.

Holt J, Ward A, Mohamed TY, Chukowry P, ... Morley P, Perkins GD
Aim
To determine the effect of CPR delivery surface (e.g. firm mattress, floor, backboard) on patient outcomes and CPR delivery.
Methods
We searched Medline, Cochrane Library and Web of Science for studies published since 2009 that evaluated the effect of CPR delivery surface in adults and children on patient outcomes and quality of CPR. We included randomised controlled trials only. We identified pre-2010 studies from the 2010 ILCOR evaluation of this topic. Two reviewers independently screened titles/ abstracts and full-text papers, extracted data and assessed risk of bias. Evidence certainty for each outcome was evaluated using GRADE methodology. Where appropriate, we pooled data in a meta-analysis, using a random-effects model.
Results
Database searches identified 2701 citations. We included seven studies published since 2009. We analysed these studies together with the four studies included in the previous ILCOR review. All included studies were randomised controlled trials in manikins. Certainty of evidence was very low. Increasing mattress stiffness or moving the manikin from the bed to the floor did not improve compression depth. Use of a backboard marginally improved compression depth (mean difference 3 mm (95% CI 1-4).
Conclusion
The use of a backboard led to a small increase in chest compression depth in manikin trials. Different mattress types or delivery of CPR on the floor did not affect chest compression depth. PROSPERO CRD42019154791.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 29 Sep 2020; 155:159-164
Holt J, Ward A, Mohamed TY, Chukowry P, ... Morley P, Perkins GD
Resuscitation: 29 Sep 2020; 155:159-164 | PMID: 32755663
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Impact:
Abstract

The landscape of paediatric in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit.

Skellett S, Orzechowska I, Thomas K, Fortune PM
Aim
To report the patient characteristics and clinical outcome of paediatric in-hospital cardiac arrest in the United Kingdom (UK) National Cardiac Arrest Audit (NCAA) database.
Methods
Analysis of all recorded paediatric cardiac arrests in the NCAA dataset over a seven-year period ending on 31 December 2018, within acute children\'s hospitals (including standalone paediatric hospitals and hospitals with tertiary paediatric services) and acute general hospitals participating in NCAA. In this period 1456 patients (with 1580 events), 1 month to 16 years of age, received chest compressions and/or defibrillation and were attended by a hospital-based resuscitation team in response to an emergency call. The main outcome measure was survival to discharge.
Results
For this cohort of paediatric in-hospital cardiac arrest patients the overall rates of sustained return of spontaneous circulation (ROSC) were 69.1% with unadjusted survival to hospital discharge of 54.2%. The presenting rhythm was shockable in 4.3% of events and non-shockable in 82.1% (remainder undetermined); rates of survival to hospital discharge associated with these rhythms were 63.9% and 51.7%. A difference in outcomes was observed between Children\'s hospitals and acute general hospitals with ROSC rates of 79.1% and 55.5% respectively and survival to hospital discharge rates of 57.7% and 49.3% respectively.
Conclusions
These first results from the NCAA database describing the outcome of paediatric in-hospital cardiac arrest in UK hospitals will serve as a benchmark from which to assess the future impact of changes in service delivery, organisation and treatment for in-hospital cardiac arrest in young people. Outcomes for specialist paediatric centres should be studied further as higher rates of ROSC and survival to hospital discharge were observed.

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

Resuscitation: 29 Sep 2020; 155:165-171
Skellett S, Orzechowska I, Thomas K, Fortune PM
Resuscitation: 29 Sep 2020; 155:165-171 | PMID: 32768496
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Impact:
Abstract

Is there inter-observer variation in the interpretation of SSEPs in comatose cardiac arrest survivors? Further considerations following the Italian multicenter ProNeCa study.

Celani MG, Carrai R, Cantisani TA, Scarpino M, ... Grippo A,
Background
Bilateral absence of N20 peak in median nerve Somatosensory Evoked Potentials (SSEPs) is considered the most valid predictor of poor outcome in comatose survivors after cardiopulmonary resuscitation. We investigated the consistency in interpreting SSEP recordings in a multicentre study.
Methods
44 SSEP recordings randomly extracted from 600 recordings of 392 patients included in the \"Prognostication of Neurological outcome after Cardiac Arrest (ProNeCa) study\" were blindly read by three expert neurophysiologists. Agreement between raters, and individual agreement of each rater vs. reference standard (RS), were calculated using Kappa Coefficients. Inter-rater reliability was calculated with Intra-class Correlation Coefficient (ICC).
Results
When raters had to evaluate the presence of N20 with normal amplitude, the inter-rater agreement was very high (Kappa = 0.84). In the case of N20 absence the agreement was good (Kappa = 0.66), but when N20 amplitude was low, the agreement decreased to moderate (Kappa = 0.579) becoming even weaker when it was \"Non Assessable\" (Kappa = 0.107). The agreement of each rater with the RS had a range from moderate to very good; rater1 Kappa = 0.589 (95%CI 0.397-0.781; p < 0.001), rater2 Kappa = 0.644 (95%CI 0.460-0.828; p < 0.001), rater3 Kappa = 0.859 (95%CI 0.698-1.000; p < 0.001). The ICC was barely good, 0.682 (95%CI 0.539-0.798; p = 0.0075).
Conclusion
Different health professionals, using different equipment in a multicentre study, had very good inter-rater agreement in interpreting SSEP records. The interpretation of \"Non Assessable\" SEPPs, mainly in relation to noise level, is still a crucial issue because it increases rater uncertainty. For this reason, it is important to focus on improving recording quality and interpretation of records.

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

Resuscitation: 29 Sep 2020; 155:207-210
Celani MG, Carrai R, Cantisani TA, Scarpino M, ... Grippo A,
Resuscitation: 29 Sep 2020; 155:207-210 | PMID: 32795599
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Impact:
Abstract

Brain networks involved in generalized periodic discharges (GPD) in post-anoxic-ischemic encephalopathy.

De Stefano P, Carboni M, Pugin D, Seeck M, Vulliémoz S
Aim
Generalized periodic discharge (GPD) is an EEG pattern of poor neurological outcome, frequently observed in comatose patients after cardiac arrest. The aim of our study was to identify the neuronal network generating ≤2.5 Hz GPD using EEG source localization and connectivity analysis.
Methods
We analyzed 40 comatose adult patients with anoxic-ischemic encephalopathy, who had 19 channel-EEG recording. We computed electric source analysis based on distributed inverse solution (LAURA) and we estimated cortical activity in 82 atlas-based cortical brain regions. We applied directed connectivity analysis (Partial Directed Coherence) on these sources to estimate the main drivers.
Results
Source analysis suggested that the GPD are generated in the cortex of the limbic system in the majority of patients (87.5%). Connectivity analysis revealed main drivers located in thalamus and hippocampus for the large majority of patients (80%), together with important activation also in amygdala (70%).
Conclusions
We hypothesize that the anoxic-ischemic dysfunction, leading to hyperactivity of the thalamo-cortical (limbic presumably) circuit, can result in an oscillatory thalamic activity capable of inducing periodic cortical (limbic, mostly medial-temporal and orbitofrontal) discharges, similarly to the case of generalized rhythmic spike-wave discharge in convulsive or non-convulsive status epilepticus.

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

Resuscitation: 29 Sep 2020; 155:143-151
De Stefano P, Carboni M, Pugin D, Seeck M, Vulliémoz S
Resuscitation: 29 Sep 2020; 155:143-151 | PMID: 32795598
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Impact:
Abstract

Racial disparities in out-of-hospital cardiac arrest interventions and survival in the Pragmatic Airway Resuscitation Trial.

Lupton JR, Schmicker RH, Aufderheide TP, Blewer A, ... Wang H, Daya MR
Background
Prior studies have reported racial disparities in survival from out-of-hospital cardiac arrest (OHCA). However, these studies did not evaluate the association of race with OHCA course of care and outcomes. The purpose of this study was to evaluate racial disparities in OHCA airway placement success and patient outcomes in the multicenter Pragmatic Airway Resuscitation Trial (PART).
Method
We conducted a secondary analysis of adult OHCA patients enrolled in PART. The parent trial randomized subjects to initial advanced airway management with laryngeal tube or endotracheal intubation. For this analysis, the primary independent variable was patient race categorized by emergency medical services (EMS) as white, black, Hispanic, other, and unknown. We used general estimating equations to examine the association of race with airway attempt success, 72-h survival, and survival to hospital discharge, adjusting for sex, age, witness status, bystander cardiopulmonary resuscitation (CPR), initial rhythm, arrest location, and PART randomization cluster.
Results
Of 3002 patients, EMS-assessed race as 1537 white, 860 black, 163 Hispanic, 90 other, and 352 unknown. Initial shockable rhythms (13.8% vs. 21.5%, p < 0.001), bystander CPR (35.6% vs. 51.4%, p < 0.001), and survival to hospital discharge (7.6% vs. 10.8%, p = 0.011) were lower for black compared to white patients. After adjustment for confounders, no difference was seen in airway success, 72-h survival, and survival to hospital discharge by race.
Conclusions
In one of the largest studies evaluating differences in prehospital airway interventions and outcomes by EMS-assessed race for OHCA patients, we found no significant adjusted differences between airway success or survival outcomes.

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

Resuscitation: 29 Sep 2020; 155:152-158
Lupton JR, Schmicker RH, Aufderheide TP, Blewer A, ... Wang H, Daya MR
Resuscitation: 29 Sep 2020; 155:152-158 | PMID: 32795597
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Impact:
Abstract

Prospective evaluation of airway management in pediatric out-of-hospital cardiac arrest.

Hansen M, Wang H, Le N, Lin A, ... Schmicker R, Daya M
Objective
The objective of the study was to identify the association between airway management modality and time to the initial dose of epinephrine in pediatric out-of-hospital cardiac arrest (OHCA).
Methods
This was a prospective observational study conducted between April 2016 to April 2018. Ten Emergency Medical Services (EMS) agencies in 2 US metropolitan areas, which were part of the Resuscitation Outcomes Consortium research network, participated in the study. We included all EMS-treated OHCA patients less than 18 years of age during the study period. Study outcomes included time to the initial dose of epinephrine, airway management success rates, rescue techniques, and complications (e.g. pneumothorax, pneumonia).
Results
The study included a total of 155 patients, 67% were male, and 55% were less than age one. The airway management modality (TI, SGA, BMV) was not associated with the time to the intial dose of epinephrine in the adjusted analysis. Tracheal intubation (TI) was the most common airway management modality (47.1%) followed by bag-mask-ventilation (BMV) (40.7%), and supraglottic airways (SGA) (12.3%). Success was 65.7% for TI and 94.7% for SGA. We found a significant difference in the proportion of initial survivors diagnosed with pneumonia on chest X-ray between those with BMV (1/19) versus TI (13/21) p < 0.001.
Conclusions
In this prospective study, the airway management modality was not associated with the time to the initial dose of epinephrine. Unexpectedly, pneumonia was significantly more common among children treated with TI compared to BMV. SGAs had high first-attempt success rates, while intubation success rates were low.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 30 Oct 2020; 156:53-60
Hansen M, Wang H, Le N, Lin A, ... Schmicker R, Daya M
Resuscitation: 30 Oct 2020; 156:53-60 | PMID: 32795596
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Impact:
Abstract

Extracorporeal cardiopulmonary resuscitation for acute aortic dissection during cardiac arrest: A nationwide retrospective observational study.

Ohbe H, Ogura T, Matsui H, Yasunaga H
Aim
Acute aortic dissection (AAD) has been considered a contraindication for extracorporeal cardiopulmonary resuscitation (ECPR). However, studies are lacking regarding the epidemiology and effectiveness of ECPR for AAD. We aimed to examine whether ECPR for AAD during refractory cardiac arrest is effective.
Methods
Using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018, we identified all emergently hospitalized adults who received ECPR on the day of admission and all AAD patients who received cardiopulmonary resuscitation on the day of admission. ECPR was defined as receiving both cardiopulmonary resuscitation and percutaneous extracorporeal membrane oxygenation. Outcomes were in-hospital mortality and neurological outcomes. We calculated the incremental cost-effectiveness ratio of ECPR for AAD.
Results
We identified 398 AAD patients with ECPR, 9840 non-AAD patients with ECPR, and 9709 AAD patients with cardiopulmonary resuscitation but not ECPR. The incidence of AAD among the patients with ECPR on the day of admission was 3.9%. In-hospital mortality was 98% in AAD patients with ECPR, 79% in non-AAD patients with ECPR, and 98% in AAD patients with cardiopulmonary resuscitation but not ECPR. Seven AAD patients survived to discharge after ECPR; of these, six patients had good neurological outcomes at discharge. The incremental cost-effectiveness ratio of ECPR for AAD was estimated at 161,504 US dollars per quality-adjusted life year gained.
Conclusion
ECPR successfully improved outcomes and/or facilitated surgery for a small number of AAD patients with refractory cardiac arrest; however, the cost burden of ECPR for AAD patients may be unacceptably high.

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

Resuscitation: 30 Oct 2020; 156:237-243
Ohbe H, Ogura T, Matsui H, Yasunaga H
Resuscitation: 30 Oct 2020; 156:237-243 | PMID: 32800864
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Impact:
Abstract

Association between sex and mortality in adults with in-hospital and out-of-hospital cardiac arrest: A systematic review and meta-analysis.

Parikh PB, Hassan L, Qadeer A, Patel JK
Objectives
Conflicting data exists regarding the association between sex and mortality in adults with in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA). We therefore conducted a meta-analysis to investigate the association between sex and mortality in adults with IHCA and OHCA.
Methods
We systematically searched MEDLINE and Cochrane databases to identify studies reporting sex-specific mortality in adults following IHCA or OHCA from inception to April 2020. Data were pooled using random-effects models. The primary outcome of interest was in-hospital (or 30-day) all-cause mortality.
Results
We included 21 observational studies with a total of 1,029,978 adult patients - 622,085 men and 407,893 women. Seven studies included patients only with IHCA and 14 studies included patients only with OHCA. Female sex was associated with significantly higher mortality following OHCA [odds ratio (OR) 1.56, 95% confidence interval (CI) 1.32-1.84, p < 0.001) and a trend toward higher mortality following IHCA (OR 1.10, 95%CI 1.00-1.20, p = 0.052).
Conclusions
In adults with cardiac arrest, female sex was associated with significantly higher mortality following OHCA and a trend toward higher mortality following IHCA.

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

Resuscitation: 29 Sep 2020; 155:119-124
Parikh PB, Hassan L, Qadeer A, Patel JK
Resuscitation: 29 Sep 2020; 155:119-124 | PMID: 32810560
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Impact:
Abstract

Feedback in advanced life support: A quality improvement initiative.

Thorne CJ, Kimani PK, Hampshire S, Begum-Ali S, Perkins GD
Aim
To identify participant, course characteristics and centre factors associated with participant satisfaction and ALS outcomes.
Methods
17,690 participants enrolled on ALS courses between 1st December 2017 and 30th November 2018. Participant, course and centre characteristics were explored in relation to course learning outcomes and participant experience. Learning outcomes were assessed through a post-course MCQ score and technical and non-technical skills through a cardiac arrest simulation test (CAS-Test). Successful completion of knowledge and skill-based assessments led to overall course success. Participant feedback was collected on a post-course questionnaire. Multivariable analyses identified variables associated with course outcomes and feedback. Adjusted funnel plots compared inter-course centre outcomes.
Results
Mean post-course MCQ score was 86.7% (SD = 6.7). First attempt CAS-Test pass rate was 82.6% and overall course pass rate 94.4%. Participant characteristics explained the majority of variation between course centres. Characteristics associated with knowledge, skill and course outcomes were age, prior experience, pre-course MCQ score, course type, ethnicity, place of work, profession and seniority. Feedback scores were predicted by course type, pre-course MCQ, ethnicity, profession and seniority.
Conclusion
This is the first study to identify variables associated with both ALS feedback scores and assessment outcomes. It has demonstrated that both course outcomes and participant experience are similar across a large number of course centres. Identifying the demographic traits of participants who may struggle with ALS, may enable bespoke support from an earlier stage. Analysis of feedback scores and outcomes enables ongoing appraisal and targeted improvement of the Resuscitation Council UK ALS course.

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

Resuscitation: 29 Sep 2020; 155:189-198
Thorne CJ, Kimani PK, Hampshire S, Begum-Ali S, Perkins GD
Resuscitation: 29 Sep 2020; 155:189-198 | PMID: 32827586
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Impact:
Abstract

Macrophage-specific protein perforin-2 is associated with poor neurological recovery and reduced survival after sudden cardiac arrest.

Kattel S, Bhatt H, Xu S, Gurung S, Pokharel S, Sharma UC
Background
Biomarkers involved in inflammation and stress response were implicated in patients who were successfully resuscitated from out of hospital cardiac arrest (sR-OHCA). Here we report that macrophage-expressed gene, perforin-2, an evolutionarily conserved protein with membrane attack domain, is associated with poor neurological outcomes and mortality after sR-OHCA.
Objectives
To examine the association between circulating perforin-2 protein measured within 6-h of sR-OHCA, mortality and neurological outcomes.
Methods
We prospectively enrolled 144 sR-OHCA patients from 4 different tertiary care centers. We measured perforin-2 and other conventional clinical biomarkers and compared between survivors vs. non-survivors. The neurological outcomes were dichotomized as poor or good according to the cereberal performance score.
Results
At the end of the hospital stay, 45% of the patients had died and 46% had poor neurological outcomes. Serum perforin-2 levels were significantly higher in patients with poor neurological recovery, compared to the ones with good neurological recovery (ng/mL, 13.7 ± 45.9 vs. 1.2 ± 7.0, p = 0.01). There were no differences in other routinely measured biomarkers and left ventricular ejection fraction. On multivariate logistic regression, elevated perforin-2 (OR: 12.78, 95% CI: 1.0-17.8, p = 0.02), comatose on presentation (OR: 27.82, 95% CI: 0.2-19.5, p = 0.02) and non-shockable rhythm (OR: 17.04, 95% CI: 0.7-15.7, p = 0.01) were the significant predictors of poor neurological outcome.
Conclusions
This study reports a novel macrophage-expressed circulating biomarker perforin-2 to be strongly associated with reduced survival and poor neurological outcomes in sR-OHCA. These data can guide clinicians to prognosticate survival and neurological outcomes in sR-OHCA, and also form the basis for future therapeutic approaches.

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

Resuscitation: 29 Sep 2020; 155:180-188
Kattel S, Bhatt H, Xu S, Gurung S, Pokharel S, Sharma UC
Resuscitation: 29 Sep 2020; 155:180-188 | PMID: 32828820
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Impact:
Abstract

Is your unconscious patient in cardiac arrest? A New protocol for telephonic diagnosis by emergency medical call-takers: A national study.

Mao DR, Ee AZQ, Leong PWK, Leong BS, ... Siddiqui FJ, Ong MEH
Background
Worldwide, call-taker recognition of out-of-hospital cardiac arrests (CA) suffers from poor accuracy, leading to missed opportunities for dispatcher-assisted cardiopulmonary resuscitation (DACPR) in CA patients and inappropriate DACPR in non-CA patients. Diagnostic protocols typically ask 2 questions in sequence: \'Is the patient conscious?\' and \'Is the patient breathing normally?\' As part of quality improvement efforts, our national emergency medical call centre changed the breathing question to an instruction for callers to place their hand onto the patient\'s abdomen to evaluate for the presence of breathing.
Methods
We performed a prospective before-and-after study of all unconscious cases from the national call centre database over a 31-day period in 2018. Cases were placed in 2 groups: 1) \'Before\' group (standard protocol) where call-takers asked \'Is the patient breathing normally?\' and 2) \'After\' group (modified protocol) where callers were instructed to place their hand on the patient\'s abdomen. In an intention-to-treat analysis, the accuracy, sensitivity and specificity of both protocols for determining CA were compared.
Results
1557 calls presented with unconsciousness, of which 513 cases were included. 231 cases were in the \'Before\' group and 282 cases were in the \'After\' group. The \'After\' showed superior accuracy (84.4% vs 67.5%), sensitivity (75.0% vs 40.4%) and specificity (87.9% vs 75.4%) when compared to the standard protocol. Adherence in the \'Before\' group to the standard protocol was 100%. However, adherence in the \'After\' group to the modified protocol was 50.4%. Per protocol analysis comparing the modified protocol with the standard protocol showed vastly improved accuracy (96.5% vs 69.3%), sensitivity (94.1% vs 39.0%) and specificity (97.8% vs 77.2%) of the modified protocol. In patients with true cardiac arrest, the median time to 1st compression was 32.5 s longer in the modified protocol group when compared to the standard protocol group, approaching significance (199.5 s vs 167.0 s, p = 0.059). Median time to recognize CA was similar in both groups.
Conclusion
Dispatch assessment using the hand on abdomen method appeared feasible but uptake by dispatch staff was moderate. Diagnostic performance of this method should be verified in randomised trials.

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

Resuscitation: 29 Sep 2020; 155:199-206
Mao DR, Ee AZQ, Leong PWK, Leong BS, ... Siddiqui FJ, Ong MEH
Resuscitation: 29 Sep 2020; 155:199-206 | PMID: 32841678
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Impact:
Abstract

Circadian variation of in-hospital cardiac arrest.

Tripathi A, Girotra S, Toft LEB
Background
Out of hospital cardiac arrests, especially those due to ventricular tachyarrhythmias, have higher incidence in the morning. It is unknown whether in-hospital cardiac arrests follow a similar pattern.
Aim of the study
The purpose of this study was to analyze the circadian variation of in-hospital cardiac arrest incidence.
Methods
This retrospective review of data from the multicenter Get With The Guidelines-Resuscitation registry between 2000 and 2014 used multivariable hierarchical logistic regression analysis to examine circadian rhythm of in-hospital cardiac arrest over a 24-h cycle, stratified by initial shockable versus non-shockable rhythm.
Results
Among 154,038 patients, initial rhythm was recorded as asystole or pulseless electrical activity (non-shockable) in 124,918 (81%), and ventricular fibrillation or ventricular tachycardia (shockable) in 29,120 (19%). Among non-shockable events, the highest relative proportion occurred during 0400-0759 (17.9%), followed by 0000-0359 (17.1%). For shockable rhythms the greatest relative proportion occurred between 2000-2359 (17.0%), followed by 1200-1559 (16.9%). Multivariable analysis showed that the relative risk of non-shockable compared to shockable arrest was slightly higher from midnight through 0359 (aOR 1.13; 95% CI 1.06-1.20, p < 0.001) and from 0400 through 0759 h (aOR 1.14; 95% CI 1.07-1.22, p < 0.001). Although statistically significant, the magnitude of difference in incidence by time of day was small in both groups.
Conclusions
Although small differences in the relative frequency of in-hospital cardiac arrest (both shockable and non-shockable rhythms) were noted during different time intervals, in-hospital cardiac arrest occurs with nearly equal frequency throughout the day. Our findings have important implications for hospital staffing models to ensure that quality of resuscitation care is consistent regardless of time.

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

Resuscitation: 30 Oct 2020; 156:19-26
Tripathi A, Girotra S, Toft LEB
Resuscitation: 30 Oct 2020; 156:19-26 | PMID: 32853726
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Impact:
Abstract

Income is associated with the probability to receive early coronary angiography after out-of-hospital cardiac arrest.

Lagedal R, Jonsson M, Elfwén L, Smekal D, ... James S, Rubertsson S
Introduction
Low socioeconomic status has been associated with worse outcome after cardiac arrest. This study aims to investigate if patients´ income influences the probability to receive early coronary angiography in out-of-hospital cardiac arrest (OHCA) patients.
Methods
In this nationwide retrospective observational study, 3906 OHCA patients admitted alive and registered in the Swedish Registry for Cardiopulmonary Resuscitation were included. Individual data on income and educational level, prehospital parameters, coronary angiography results and comorbidity were linked from SWEDEHEART and other national registers.
Results
Patients were divided into quarters depending on their income level. In the unadjusted model there was a strong correlation between income level and rate of early coronary angiography where 35.5% of patients in the highest income quarters received early angiography compared to 15.4% in the lowest income quarters. When adjusting for educational level, sex, age, comorbidity and hospital type, there were still higher chance of receiving early coronary angiography with increasing income, OR 1.31 (CI 1.01-1.68) and 1.67 (CI 1.29-2.16) for the two highest income quarters respectively compared to the lowest income quarter. When adding potential mediators to the model (first recorded ECG rhythm by the EMS, location, response time, bystander cardiopulmonary resuscitation and if the arrest was witnessed) no difference in early angiography related to income level where found. The main mediator was first recorded ECG rhythm.
Conclusion
Income level is associated with the probability to undergo early coronary angiography in OHCA patients. This association seems to be mediated by the initial ECG rhythm.

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

Resuscitation: 30 Oct 2020; 156:35-41
Lagedal R, Jonsson M, Elfwén L, Smekal D, ... James S, Rubertsson S
Resuscitation: 30 Oct 2020; 156:35-41 | PMID: 32853725
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Impact:
Abstract

Rate of intra-arrest epinephrine administration and early post-arrest organ failure after in-hospital cardiac arrest.

Baird A, Coppler PJ, Callaway CW, Dezfulian C, ... Elmer J,
Introduction
Data supporting epinephrine administration during resuscitation of in-hospital cardiac arrest (IHCA) are limited. We hypothesized that more frequent epinephrine administration would predict greater early end-organ dysfunction and worse outcomes after IHCA.
Methods
We performed a retrospective cohort study including patients resuscitated from IHCA at one of 67 hospitals between 2010 and 2019 who were ultimately cared for at a single tertiary care hospital. Our primary exposure of interest was rate of intra-arrest epinephrine bolus administration (mg/min). We considered several outcomes, including severity of early cardiovascular failure (modeled using Sequential Organ Failure Assessment (SOFA) cardiovascular subscore), early neurological and early global illness severity injury (modeled as Pittsburgh Cardiac Arrest Category (PCAC)). We used generalized linear models to test for independent associations between rate of epinephrine administration and outcomes.
Results
We included 695 eligible patients. Mean age was 62 ± 15 years, 416 (60%) were male and 172 (26%) had an initial shockable rhythm. Median arrest duration was 16 [IQR 9-25] min, and median rate of epinephrine administration was 0.2 [IQR 0.1-0.3] mg/min. Higher rate of epinephrine predicted worse PCAC, and lower survival in patients with initial shockable rhythms. There was no association between rate of epinephrine and other outcomes.
Conclusion
Higher rates of epinephrine administration during IHCA are associated with more severe early global illness severity.

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

Resuscitation: 30 Oct 2020; 156:15-18
Baird A, Coppler PJ, Callaway CW, Dezfulian C, ... Elmer J,
Resuscitation: 30 Oct 2020; 156:15-18 | PMID: 32853724
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Impact:
Abstract

Protein S100B as a reliable tool for early prognostication after cardiac arrest.

Deye N, Nguyen P, Vodovar N, Sadoune M, ... Mégarbane B, Mebazaa A
Purpose
Early and reliable prognostication after cardiac arrest (CA) remains crucial. We hypothesized that protein-S100B (PS100B) could predict more accurately outcome in the early phase of CA compared with other current biomarkers.
Methods
This prospective single-center study included 330 adult comatose non-traumatic successfully resuscitated CA patients, treated with targeted temperature management but not extra-corporeal life support. Lactate, pH, creatinine, NSE, and PS100B were sampled in ICU early after return of spontaneous circulation (ROSC) corresponding to admission (Adm). Serial measurements were also performed at H24 and H48. PS100B was the sole biomarker blinded to physicians.
Measurements and main results
The median delay between ROSC and first PS100B sampling was 220 min. At admission, all biomarkers were significantly associated with good outcome (CPC1-2; 109 patients) at 3-month follow-up (P ≤ 0.001, except for NSE: P = 0.03). PS100B-Adm showed the best AUC of ROC curves for outcome prediction at 3-month (AUC 0.83 [95%-CI: 0.78-0.88]), compared with other biomarkers (P < 0.0001), while AUC for lactate-Adm was higher than for NSE-Adm. AUC for PS100B-H24 was significantly higher than for other biomarkers except NSE-H24 (P ≤ 0.0001), while AUC for NSE-H24 was higher than for lactate-H24 and pH-H24. AUCs for PS100-H48 and NSE-H48 were significantly higher than for all other biomarkers (P < 0.001). Compared to patients with decreased PS100B values over time, an increasing PS100B value between admission and H24 was significantly associated with poor outcome at 3 months (P = 0.001). No-flow, initial non-shockable rhythm, PS100B-Adm, lactate-Adm, pH-Adm, clinical seizures, and absence of therapeutic hypothermia were independent predictors associated with poor outcome at 3-month in multivariate analysis. Net-Reclassification-Index was 70%, 64%, and 81% when PS100B-Adm was added to the clinical model, to clinical model with NSE-Adm, and to clinical model with standard biological parameters, respectively.
Conclusions
Early PS100B compared with other biomarkers was independently correlated with outcome after CA, with an interesting added value.

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

Resuscitation: 30 Oct 2020; 156:251-259
Deye N, Nguyen P, Vodovar N, Sadoune M, ... Mégarbane B, Mebazaa A
Resuscitation: 30 Oct 2020; 156:251-259 | PMID: 32858156
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Impact:
Abstract

Interfaces for non-invasive neonatal resuscitation in the delivery room: A systematic review and meta-analysis.

Machumpurath S, O\'Currain E, Dawson JA, Davis PG
Objective
To perform a systematic review of trials comparing interfaces for delivering non-invasive PPV to a newborn in the delivery room (DR).
Methods
MEDLINE, PUBMED, EMBASE, CINAHL and COCHRANE databases were searched on March 1, 2020 and 2826 articles were screened. The review was conducted using the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Primary outcomes were intubation in the DR and mortality. Secondary outcomes were chest compressions, intraventricular haemorrhage (IVH), necrotising enterocolitis (NEC) and mask leak.
Results
Five randomized-control trials were eligible for inclusion. Sample size and gestational age varied amongst the trials, ranging from 56 to 617 infants and 24-39 weeks\' respectively. Three trials compared nasal cannulae (NC) with face masks (FMs). Pooled analysis showed that NC were associated with a decreased use of chest compressions (RR 0.2 (95% CI 0.08-0.47). A reduction in rate of intubation in the DR was statistically significant only in the trial in which bi-nasal rather than single nasal cannulae were used (RR 0.10, 95% CI 0.02-0.44). However, there was no important difference in mortality (RR 0.72, 95% CI 0.47-1.13). Two trials compared different FM models (Laerdal versus Fisher & Paykel and Laerdal versus Resusi-sure) and both found no significant difference in primary and secondary outcomes.
Conclusion
There is little high-quality evidence to guide clinicians choosing an interface to provide PPV during newborn resuscitation. Nasal interfaces, particularly binasal cannulae, appear to offer some advantages over FMs but need further testing in larger, well designed trials.
Study registration
PROSPERO CRD42020151870.

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

Resuscitation: 30 Oct 2020; 156:244-250
Machumpurath S, O'Currain E, Dawson JA, Davis PG
Resuscitation: 30 Oct 2020; 156:244-250 | PMID: 32858155
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Impact:
Abstract

Acute clinical deterioration and consumer escalation in the hospital setting: A literature review.

Thiele L, Flabouris A, Thompson C
Background
Consumer escalation systems that allow patients and/or their family/carers to escalate concerns about clinical deterioration have been proposed as a way of enhancing patient safety. However, evidence to guide implementation or to support system effectiveness remains unclear.
Aim
To critically evaluate the current evidence surrounding consumer escalation within the context of clinical deterioration to identify the strengths, weaknesses and gaps in existing knowledge, essential themes, and directions for further investigation.
Method
Database searches were conducted within Cumulative Index of Nursing and Allied Health Literature, PubMed, and the Cochrane Library for articles directly relating to consumer escalation systems published, in English, within the previous 10 year-period. Titles and abstracts were screened and relevant full-text articles included. Content was examined to identify breadth of knowledge, essential themes, and the effectiveness of current systems.
Results
27 articles, containing a mixture of both quantitative and qualitative findings, were identified. Within the context of limitations in the overall depth and quality of current evidence, four key areas (relating to consumer understanding and awareness of clinical deterioration, confidence and ability to escalate concerns, education, and staff attitudes) were identified as potentially critical to the foundation, functioning, and success of consumer escalation systems. Consumer escalation processes may contribute positive effects beyond mortality rates; however, an agreed method of assessing effectiveness remains undetermined.
Conclusions
The ability of consumer escalation processes to achieve their underlying goals is still to be adequately assessed. Further research is required to inform how to best implement, support and optimise consumer escalation systems.

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

Resuscitation: 30 Oct 2020; 156:72-83
Thiele L, Flabouris A, Thompson C
Resuscitation: 30 Oct 2020; 156:72-83 | PMID: 32858153
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Impact:
Abstract

Association between patient race and staff resuscitation efforts after cardiac arrest in outpatient dialysis clinics: A study from the CARES surveillance group.

Hofacker SA, Dupre ME, Vellano K, McNally B, ... Svetkey LP, Pun PH
Background
Cardiac arrest is the leading cause of death among patients receiving hemodialysis. Despite guidelines recommending CPR training and AED presence in dialysis clinics, rates of CPR and AED use by dialysis staff are suboptimal. Given that racial disparities exist in bystander CPR administration in non-healthcare settings, we examined the relationship between patient race/ethnicity and staff-initiated CPR and AED application within dialysis clinics.
Methods
We analyzed data prospectively collected in the Cardiac Arrest Registry to Enhance Survival across the U.S. from 2013 to 2017 and the Centers for Medicare & Medicaid Services dialysis facility database to identify outpatient dialysis clinic cardiac arrest events. Using multivariable logistic regression models, we examined relationships between patient race/ethnicity and dialysis staff-initiated CPR and AED application.
Results
We identified 1568 cardiac arrests occurring in 809 hemodialysis clinics. The racial/ethnic composition of patients was 31.3% white, 32.9% Black, 10.7% Hispanic/Latinx, 2.7% Asian, and 22.5% other/unknown. Overall, 88.0% of patients received CPR initiated by dialysis staff, but rates differed by race: 91% of white patients, 85% of black patients, and 77% of Asian patients (p = 0.005). After adjusting for differences in patient and clinic characteristics, black (OR = 0.41, 95% CI 0.25-0.68) and Asian patients (OR = 0.28, 95% CI 0.12-0.65) were significantly less likely than white patients to receive staff-initiated CPR. No significant difference between staff-initiated CPR rates among white, Hispanic/Latinx, and other/unknown patients was observed. An AED was applied by dialysis staff in 62% of patients. In adjusted models, there was no relationship between patient race/ethnicity and staff AED application.
Conclusions
Black and Asian patients are significantly less likely than white patients to receive CPR from dialysis staff. Further understanding of practices in dialysis clinics and increased awareness of this disparity are necessary to improve resuscitation practices.

Published by Elsevier B.V.

Resuscitation: 30 Oct 2020; 156:42-50
Hofacker SA, Dupre ME, Vellano K, McNally B, ... Svetkey LP, Pun PH
Resuscitation: 30 Oct 2020; 156:42-50 | PMID: 32860854
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Impact:
Abstract

Resuscitative endovascular balloon occlusion of the aorta (REBOA) during cardiopulmonary resuscitation: A pilot study.

Levis A, Greif R, Hautz WE, Lehmann LE, ... Fehr T, Haenggi M
Aim
Resuscitative endovascular balloon occlusion of the aorta (REBOA) during cardiopulmonary resuscitation (CPR) increases coronary and cerebral perfusion pressure, which might improve neurologically intact survival after refractory cardiac arrest. We investigated the feasibility of REBOA during CPR in the emergency department.
Methods
Patients in refractory cardiac arrest not qualifying for extracorporeal CPR were included in this pilot study. An introducer sheath was placed by ultrasound-guided puncture of the femoral artery, and a REBOA catheter was advanced to the thoracic aorta in 15 patients undergoing CPR. Primary outcome was correct placement within 10 min of skin disinfection. Secondary outcomes included perfusion markers (mean central arterial blood pressure, end-tidal CO, non-invasively measured cerebral oxygenation) and procedural information (number and duration of attempts, complications, verification of correct position and occlusion).
Results
Successful catheter placement was achieved in 9 of the 15 patients (median 9 min 30 s). Median interval from dispatch to start of the procedure was 59 min. A small, albeit significant increase in non-invasively measured cerebral oxygenation was found, but none in blood pressure or end-tidal CO. However, two patients with pulseless electrical activity of more than 20 min achieved return of spontaneous circulation immediately after REBOA.
Conclusion
In this pilot trial, REBOA during CPR was successful in 60% of attempts. Long resuscitation times before start of the procedure might explain difficult insertion and missing effects. Nevertheless, insertion of REBOA in patients suffering from non-traumatic cardiac arrest is feasible and might increase coronary and cerebral perfusion pressures and perfusion.

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

Resuscitation: 30 Oct 2020; 156:27-34
Levis A, Greif R, Hautz WE, Lehmann LE, ... Fehr T, Haenggi M
Resuscitation: 30 Oct 2020; 156:27-34 | PMID: 32866549
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Impact:
Abstract

The Copenhagen Tool a research tool for evaluation of basic life support educational interventions.

Jensen TW, Lockey A, Perkins GD, Granholm A, ... Chamberlain D, Lippert F
Introduction
Over the past decades, major changes have been made in basic life support (BLS) guidelines and manikin technology. The aim of this study was to develop a BLS evaluation tool based on international expert consensus and contemporary validation to enable more valid comparison of research on BLS educational interventions.
Methods
A modern method for collecting validation evidence based on Messick\'s framework was used. The framework consists of five domains of evidence: content, response process, internal structure, relations with other variables, and consequences. The research tool was developed by collecting content evidence based on international consensus from an expert panel; a modified Delphi process decided items essential for the tool. Agreement was defined as identical ratings by 70% of the experts.
Results
The expert panel established consensus on a three-levelled score depending on expected response level: laypersons, first responders, and health care personnel. Three Delphi rounds with 13 experts resulted in 16 \"essential\" items for laypersons, 21 for first responders, and 22 for health care personnel. This, together with a checklist for planning and reporting educational interventional studies within BLS, serves as an example to be used for researchers.
Conclusions
An expert panel agreed on a three-levelled score to assess BLS skills and the included items. Expert panel consensus concluded that the tool serves its purpose and can act to guide improved research comparison on BLS educational interventions.

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

Resuscitation: 30 Oct 2020; 156:125-136
Jensen TW, Lockey A, Perkins GD, Granholm A, ... Chamberlain D, Lippert F
Resuscitation: 30 Oct 2020; 156:125-136 | PMID: 32889023
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Impact:
Abstract

Afferent limb failure revisited - A retrospective, international, multicentre, cohort study of delayed rapid response team calls.

Tirkkonen J, Skrifvars MB, Tamminen T, Parr MJA, ... Efendijev I, Aneman A
Aim
The efficiency of rapid response teams (RRTs) is decreased by delays in activation of RRT (afferent limb failure, ALF). We categorized ALF by organ systems and investigated correlations with the vital signs subsequently observed by the RRT and associations with mortality.
Methods
International, multicentre, retrospective cohort study including adult RRT patients without treatment limitations in 2017-2018 in one Australian and two Finnish tertiary hospitals.
Results
A total of 5,568 RRT patients\' first RRT activations were included. In 927 patients (17%) ALF was present within 4 h before the RRT call, most commonly for respiratory criteria (419 patients, 7.5%). In 3516 patients (63%) overall, and in 756 (82%) of ALF patients, the RRT observed abnormal vital signs upon arrival. The organ-specific ALF corresponded to the RRT observations in 52% of cases for respiratory criteria, in 60% for haemodynamic criteria, in 55% for neurological criteria and in 52% of cases for multiple organ criteria. Only ALF for respiratory criteria was associated with increased hospital mortality (OR 1.71, 95% CI 1.29-2.27), whereas all, except haemodynamic, criteria at the time of RRT review were associated with increased hospital mortality.
Conclusions
Vital signs were rarely normal upon RRT arrival in patients with ALF, while organ-specific ALF corresponded to subsequent RRT observations in just over half of cases. Our results suggest that systems mandating timely responses to abnormal respiratory criteria in particular may have potential to improve deteriorating patient outcomes.

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

Resuscitation: 30 Oct 2020; 156:6-14
Tirkkonen J, Skrifvars MB, Tamminen T, Parr MJA, ... Efendijev I, Aneman A
Resuscitation: 30 Oct 2020; 156:6-14 | PMID: 32882311
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Impact:
Abstract

Survival after dispatcher-assisted cardiopulmonary resuscitation in out-of-hospital cardiac arrest.

Riva G, Jonsson M, Ringh M, Claesson A, ... Nord A, Hollenberg J
Aim
Strategies to increase provision of bystander CPR include mass education of laypersons. Additionally, programs directed at emergency dispatchers to provide CPR instructions during emergency calls to untrained bystanders have emerged. The aim of this study was to evaluate the association between dispatcher-assisted CPR (DA- CPR) and 30-day survival compared with no CPR or spontaneously initiated CPR by lay bystanders prior to emergency medical services in out of hospital cardiac arrest (OHCA).
Methods
Nationwide observational cohort study including all consecutive lay bystander witnessed OHCAs reported to the Swedish Register for Cardiopulmonary Resuscitation in 2010-2017. Exposure was categorized as: no CPR (NO-CPR), DA-CPR and spontaneously initiated CPR (SP-CPR) prior to EMS arrival. Propensity-score matched cohorts were used for comparison between groups. Main Outcome was 30-day survival.
Results
A total of 15 471 patients were included and distributed as follows: NO-CPR 6440 (41.6%), DA-CPR 4793 (31.0%) and SP-CPR 4238 (27.4%). Survival rates to 30 days were 7.1%, 13.0% and 18.3%, respectively. In propensity-score matched analysis (DA-CPR as reference), NO-CPR was associated with lower survival (conditional OR 0.61, 95% CI 0.52-0.72) and SP-CPR was associated with higher survival (conditional OR 1.21 (95% CI 1.05-1.39).
Conclusions
DA-CPR was associated with a higher survival compared with NO-CPR. However, DA-CPR was associated with a lower survival compared with SP-CPR. These results reinforce the vital role of DA-CPR, although continuous efforts to disseminate CPR training must be considered a top priority if survival after out of hospital cardiac arrest is to continue to increase.

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

Resuscitation: 09 Sep 2020; epub ahead of print
Riva G, Jonsson M, Ringh M, Claesson A, ... Nord A, Hollenberg J
Resuscitation: 09 Sep 2020; epub ahead of print | PMID: 32918983
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Impact:
Abstract

Spaced learning versus massed learning in resuscitation - A systematic review.

Yeung J, Djarv T, Hsieh MJ, Sawyer T, ... Greif R,
Aim
Skill decay is a recognised problem in resuscitation training. Spaced learning has been proposed as an intervention to optimise resuscitation skill performance compared to traditional massed learning. A systematic review was performed to answer \'In learners taking resuscitation courses, does spaced learning compared to massed learning improve educational outcomes and clinical outcomes?\'
Methods
This systematic review followed the PRISMA guidelines. We searched bibliographic databases (Embase, MEDLINE and the Cochrane Library (CENTRAL)) from inception to 2 December 2019. Randomised controlled trials and non-randomised studies were eligible for inclusion. Two reviewers independently scrutinized studies for relevance, extracted data and assessed quality of studies. Risk of bias of studies and quality of evidence were assessed using RoB, ROBINS-I tool and GRADEpro respectively. Educational outcomes studied were skill retention and performance 1 year after completion of training; skill performance between completion of training and 1 year; and knowledge at course conclusion. Clinical outcomes were skill performance at actual resuscitation, patient survival to discharge with favourable neurological outcome. This systematic review was registered in PROSPERO (CRD42019150358).
Results
From 2,042 references, we included data from 17 studies (13 randomised studies, 4 cohort studies) in courses with manikins and simulation in the narrative synthesis. Eight studies reported results from basic life support training (with or without automatic external defibrillator); three studies reported from paediatric life support training; five were in neonatal resuscitation and one study reported results from a bespoke emergency medicine course which included resuscitation teaching. Fifteen out of seventeen studies reported improved performance with the use of spaced learning. The overall certainty of evidence was rated as very low for all outcomes primarily due to a very serious risk of bias. Heterogeneity across studies precluded any meta-analyses. There was a lack of data on the effectiveness of spaced learning on skill acquisition compared to maintaining skill performance and/or preventing skill decay. There was also insufficient data to examine the effectiveness of spaced learning on laypeople compared to healthcare providers.
Conclusions
Despite the very low certainty of evidence this systematic review suggests that spaced learning can improve skill performance at 1 year post course conclusion and skill performance between course conclusion and 1 year. There is a lack of data from this educational intervention on skill performance in clinical resuscitation and patient survival at discharge with favourable neurological outcomes.

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

Resuscitation: 30 Oct 2020; 156:61-71
Yeung J, Djarv T, Hsieh MJ, Sawyer T, ... Greif R,
Resuscitation: 30 Oct 2020; 156:61-71 | PMID: 32926969
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Impact:
Abstract

Epidemiology of intensive care unit cardiac arrest: Characteristics, comorbidities, and post-cardiac arrest organ failure - A prospective observational study.

Roedl K, Jarczak D, Blohm R, Winterland S, ... Söffker G, Kluge S
Background
Critically ill patients in intensive care units can frequently suffer from cardiac arrest (ICU-CA), the incidence of ICU-CA is associated with high mortality. Most studies on ICU-CA focused on risk factors and intra-arrest determinants. However, there is a lack of data on organ failure after ICU-CA and its clinical implications for outcome. This study aimed to investigate ICU-CA incidence, outcome and the occurrence of organ failure after ICU-CA.
Methods
We conducted a prospective observational study over a 1-year at 12 intensive care units of a tertiary care university hospital. We included all consecutive adult patients suffering cardiac arrest (CA) during the ICU stay. Incidence, clinical and neurological outcome, as well as organ failure and support were assessed.
Results
Out of 7690 patients, 176 (2%) with ICU-CA were identified during the study period. Male patients comprised 63% and the median age was 70 (58-78) years. The median ICU stay before ICU-CA was 3 (1-8) days. The initial cardiac rhythm was shockable (VT/VF) in 23% of patients; defibrillation during CPR was performed in 19%. The presumed cause of CA was cardiac in 24%, and sustained ROSC was observed in 80% of patients. Before CA 57% (n = 100) of patients were sedated, 63% (n = 110) mechanically ventilated, 70% needed vasopressor therapy and renal replacement therapy was necessary in 27% (n = 48) of patients. Organ failure after ICU-CA was common, 70% suffered from post-CA cardiac failure, renal replacement therapy was newly initiated in 26% of patients and liver failure occurred in 24% of patients. Mortality at ICU-discharge and at hospital discharge was 66 % and 68 %, respectively. Multivariate regression analysis identified the SOFA score [HR 1.09, 95% CI (0.92-3.18); p < 0.05] and liver failure [HR 2.44, 95% CI (1.39-4.26); p < 0.001] after ICU-CA as independent predictors of mortality.
Conclusion
The incidence of ICU-CA is rare in critically ill patients. Organ failure before and after ICU-CA is common; liver failure incidence and severity of illness after ICU-CA are independent predictors of mortality and should be considered in further decisions on ICU therapy.

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

Resuscitation: 30 Oct 2020; 156:92-98
Roedl K, Jarczak D, Blohm R, Winterland S, ... Söffker G, Kluge S
Resuscitation: 30 Oct 2020; 156:92-98 | PMID: 32920114
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Impact:
Abstract

Clinical outcomes from out-of-hospital cardiac arrest in low-resource settings - A scoping review.

Schnaubelt S, Monsieurs KG, Semeraro F, Schlieber J, ... Greif R,
Aim of the scoping review
Scientific recommendations on resuscitation are typically formulated from the perspective of an ideal resource environment, with little consideration of applicability in lower-income countries. We aimed to determine clinical outcomes from out-of-hospital cardiac arrest (OHCA) in low-resource countries, to identify shortcomings related to resuscitation in these areas and possible solutions, and to suggest future research priorities.
Data sources
This scoping review was part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR), and was performed following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. We identified low-resource countries as countries with a low- or middle gross national income per capita (World Bank data). We performed a literature search on outcomes after OHCA in these countries, and we extracted data on the outcome. We applied descriptive statistics and conducted a post-hoc correlation analysis of cohort size and ROSC rates.
Results
We defined 24 eligible studies originating from middle-income countries, but none from low-income regions, suggesting a reporting bias. The number of reported patients in these studies ranged from 54 to 3214. Utstein-style reporting was rarely used. Return of spontaneous circulation varied from 0% to 62%. Fifteen studies reported on survival to hospital discharge (between 1.0 and 16.7%) or favourable neurological outcome (between 1.0 and 9.3%). An inverse correlation was found for study cohort size and the rate of return of spontaneous circulation (ρ = -0.48, p = 0.034).
Conclusion
Studies of OHCA outcomes in low-resource countries are heterogeneous and may be compromised by reporting bias. Minimum cardiopulmonary resuscitation standards for low-resource settings should be developed collaboratively involving local experts, respecting culture and context while balancing competing health priorities.

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

Resuscitation: 30 Oct 2020; 156:137-145
Schnaubelt S, Monsieurs KG, Semeraro F, Schlieber J, ... Greif R,
Resuscitation: 30 Oct 2020; 156:137-145 | PMID: 32920113
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Impact:
Abstract

The cut-off value of a qualitative brain diffusion-weighted image (DWI) scoring system to predict poor neurologic outcome in out-of-hospital cardiac arrest (OHCA) patients after target temperature management.

An C, You Y, Park JS, Min JH, ... Oh SK, Lee IH
Aim
We presented the cut-off value of a diffusion-weighted image (DWI) scoring system to predict poor neurologic outcome using DWI taken 72-96 h after out-of-hospital cardiac arrest (OHCA) patients underwent target temperature management (TTM).
Methods
This was a prospective single-centre observational study, conducted from March 2018 to April 2020 in OHCA patients after TTM. Neurological status was assessed 6 months after return of spontaneous circulation (ROSC) using the Glasgow-Pittsburgh cerebral performance categories (CPC) scale. CPC of 1-2 demonstrated good neurologic outcomes whilst a CPC of 3-5 was related to poor neurologic outcomes. The receiver operating characteristic curves and DeLong method were used to evaluate the cut-off value of the DWI scoring system to predict poor neurologic outcome.
Results
The good and poor neurologic outcome groups consisted of 38 (54.3%) and 32 (45.7%) patients, respectively. The area under the receiver operating characteristic curve (AUROC) of the overall, cortex, deep grey nuclei, and cortex plus deep grey nuclei scores, white matter, brainstem, and cerebellum measured 72-96 h after ROSC were 0.96, 0.96, 0.97, 0.96, 0.95, 0.95, and 0.93 respectively. For 100.0% specificity to predict poor neurologic outcome, the overall scores of the DWI scoring system measured 72-96 h after ROSC with a cut-off value of 52 had a sensitivity of 81.3% (95% CI: 63.6-92.8).
Conclusion
This study demonstrated that the DWI scoring systems measured between 72 and 96 h after ROSC were valuable tools to predict poor neurologic outcome in post-OHCA patients treated with TTM.

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

Resuscitation: 11 Sep 2020; epub ahead of print
An C, You Y, Park JS, Min JH, ... Oh SK, Lee IH
Resuscitation: 11 Sep 2020; epub ahead of print | PMID: 32931850
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Impact:
Abstract

\"Sorry, what did you say?\" Communicating defibrillator retrieval and use in OHCA emergency calls.

Perera N, Ball S, Birnie T, Morgan A, ... Bailey P, Finn J
Background
The defibrillator prompt, which directs callers to retrieve a defibrillator during out-of-hospital cardiac arrest, is crucial to the emergency call because it can save lives. We evaluated communicative effectiveness of the prompt instated by the Medical Priority Dispatch System™ Version 13, namely: if there is a defibrillator (AED) available, send someone to get it now, and tell me when you have it.
Methods
Using Conversation Analysis and descriptive statistics, we examined linguistic features of the defibrillator sequences (call-taker prompt and caller response) in 208 emergency calls where non-traumatic out-of-hospital cardiac arrest was confirmed by the emergency medical services, and they attempted resuscitation, in the first six months of 2019. Defibrillator sequence durations were measured to determine impact on time to CPR prompt. The proportion of cases where bystanders retrieved defibrillators was also assessed.
Results
There was low call-taker adoption of the Medical Priority Dispatch System™ Version 13 prompt (99/208) compared to alternative prompts (86/208) or no prompt (23/208). Caller responses to the Version 13 prompt tended to be longer, more ambiguous or unrelated, and have more instances of repair (utterances to address comprehension trouble). Defibrillators were rarely brought to the scene irrespective of defibrillator prompt utilised.
Conclusion
While the Version 13 prompt aims to ensure the use of an available automatic external defibrillator, its effectiveness is undermined by the three-clause composition of the prompt and exclusion of a question structure. We recommend testing of a re-phrased defibrillator prompt in order to maximise comprehension and caller action.

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

Resuscitation: 30 Oct 2020; 156:182-189
Perera N, Ball S, Birnie T, Morgan A, ... Bailey P, Finn J
Resuscitation: 30 Oct 2020; 156:182-189 | PMID: 32949675
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Impact:
Abstract

Removal of foreign body airway obstruction: A systematic review of interventions.

Couper K, Abu Hassan A, Ohri V, Patterson E, ... Perkins GD,
Objective
To summarise in a systematic review the effectiveness of interventions to treat foreign body airway obstructions (FBAO).
Methods
We searched MEDLINE, EMBASE, and the Cochrane library from inception on 30th September 2019 for studies that described the effectiveness of interventions to treat FBAO in adults and children. We included randomised controlled trials, observational studies and case series (≥5 cases) that described evidence of benefit. For evidence of harm/complications, we included case reports. Two reviewers independently assessed study eligibility, extracted study data, and assessed risk of bias. Data are summarised in a narrative synthesis. The GRADE system is used to assess evidence certainty.
Results
We included 69 publications, comprising three cross-sectional studies (557 patients); eight case series (755 patients), and 59 were case reports (64 patients). One paper was included as a case series and cross-sectional study. For all interventions and associated outcomes, evidence certainty was very low. Early removal of FBAO by bystanders was associated with improved neurological survival (odds ratio 6.0, 95% confidence interval 1.5 to 23.4). Identified evidence showed that key interventions (back blows, abdominal thrusts, chest thrusts/compressions, Magill forceps, manual removal of obstructions from the mouth, suction-based airway clearance devices) are effective in relieving FBAO. We identified reports of harm in relation to back blows, abdominal thrusts, chest thrusts/compressions, and blind finger sweeps.
Conclusions
Key interventions successfully relieve FBAO, but may be associated with important harms. Guidelines for FBAO management should balance the benefits and harms of interventions.

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

Resuscitation: 30 Oct 2020; 156:174-181
Couper K, Abu Hassan A, Ohri V, Patterson E, ... Perkins GD,
Resuscitation: 30 Oct 2020; 156:174-181 | PMID: 32949674
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Impact:
Abstract

Vitamin C levels amongst initial survivors of out of hospital cardiac arrest.

Gardner R, Liu X, Wang Y, Cole A, ... Donnino MW, Moskowitz A
Introduction
Vitamin C deficiency has been described in patients with sepsis. The post-cardiac arrest syndrome shares similarities to sepsis, however vitamin C levels in post-arrest patients have been incompletely characterized. We assessed vitamin C levels in a post-arrest population.
Methods
This was a retrospective observational study at a tertiary care center. A convenience sample of post-arrest, sepsis, and healthy control patients was selected from prior studies. Vitamin C levels were measured from samples obtained within 6-h of emergency department admission. A subset of cardiac arrest patients had vitamin C levels additionally measured 24-h later.
Results
A total of 84 patients (34 healthy controls, 25 post-arrest, and 25 septic patients) were included. The median baseline vitamin C level in cardiac arrest patients was 0.33 mg/dL (0.05-0.83), as compared to 0.91 mg/dL (0.69-1.48) in the healthy control group (p < 0.01) and 0.28 mg/dL (0.11-0.59) in the septic group (p = 0.36). Vitamin C levels for cardiac arrest patients fell between the two time points, but the change was not statistically significant (median decrease 0.26 mg/dL, p = 0.08).
Conclusions
Serum vitamin C levels were lower in post-arrest patients compared to controls and were similar to patients with sepsis. Future studies of vitamin C levels and supplementation following cardiac arrest may be warranted.

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

Resuscitation: 30 Oct 2020; 156:190-193
Gardner R, Liu X, Wang Y, Cole A, ... Donnino MW, Moskowitz A
Resuscitation: 30 Oct 2020; 156:190-193 | PMID: 32946985
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Impact:
Abstract

A paramilitary retrieval team for accidental hypothermia. Insights gained from a simple classification with advanced treatment over 16 years in Denmark.

Kjaergaard B, Danielsen AV, Simonsen C, Wiberg S
Aim
To present the results from 16 years of nationwide cooperation between the Danish Airforce Search and Rescue Service and a Tertiary Heart Centre for the classification and treatment of accidental hypothermia.
Methods
A mobile extracorporeal membrane oxygenation (ECMO) retrieval team was developed and could be contacted for nationwide advice and if indicated retrieval and/or treatment of patients by means of ambulance and/or helicopter. Accidental hypothermia was classified as mild, moderate, and severe, corresponding to awake, unconscious, and lifeless. The exact temperature was not considered relevant in the primary assessment. The mild group was treated with blankets and minimal invasive with warm i.v. infusions. The moderate group was primarily treated with an ABC approach, and if circulation was unstable due to arrhythmias or bleeding, invasive warming was performed with pleural lavage under ECMO preparedness. The severe group was treated with CPR followed by ECMO. All patients were examined for underlying disorders.
Results
The team was involved in 204 patients, but for 47 patients treatment was stopped as they were considered beyond therapeutic reach, leaving 157 treated patients with 108 (69%) survivors. Among 54 ECMO patients, 21 (39%) survived to hospital discharge.
Conclusions
We successfully implemented a simplified classification of accidental hypothermia and initiated a nationwide cooperation for retrieval and/or treatment of accidental hypothermic patients.

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

Resuscitation: 30 Oct 2020; 156:114-119
Kjaergaard B, Danielsen AV, Simonsen C, Wiberg S
Resuscitation: 30 Oct 2020; 156:114-119 | PMID: 32946984
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Impact:
Abstract

The use of drones and a machine-learning model for recognition of simulated drowning victims-A feasibility study.

Claesson A, Schierbeck S, Hollenberg J, Forsberg S, ... Jansson A, Nord A
Background
Submersion time is a strong predictor for death in drowning, already 10 min after submersion, survival is poor. Traditional search efforts are time-consuming and demand a large number of rescuers and resources. We aim to investigate the feasibility and effectiveness of using drones combined with an online machine learning (ML) model for automated recognition of simulated drowning victims.
Methods
This feasibility study used photos taken by a drone hovering at 40 m altitude over an estimated 3000 m surf area with individuals simulating drowning. Photos from 2 ocean beaches in the south of Sweden were used to (a) train an online ML model (b) test the model for recognition of a drowning victim.
Results
The model was tested for recognition on n = 100 photos with one victim and n = 100 photos with no victims. In drone photos containing one victim (n = 100) the ML model sensitivity for drowning victim recognition was 91% (95%CI 84.9%-96.2%) with a median probability score that the finding was human of 66% (IQR 52-71). In photos with no victim (n = 100) the ML model specificity was 90% (95%CI: 83.9%-95.6%). False positives were present in 17.5% of all n = 200 photos but could all be ruled out manually as false objects.
Conclusions
The use of a drone and a ML model was feasible and showed satisfying effectiveness in identifying a submerged static human simulating drowning in open water and favorable environmental conditions. The ML algorithm and methodology should be further optimized, again tested and validated in a real-life clinical study.

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

Resuscitation: 30 Oct 2020; 156:196-201
Claesson A, Schierbeck S, Hollenberg J, Forsberg S, ... Jansson A, Nord A
Resuscitation: 30 Oct 2020; 156:196-201 | PMID: 32976963
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Impact:
Abstract

OHCA (Out-of-Hospital Cardiac Arrest) and CAHP (Cardiac Arrest Hospital Prognosis) scores to predict outcome after in-hospital cardiac arrest: Insight from a multicentric registry.

Chelly J, Mpela AG, Jochmans S, Brunet J, ... Deye N, Monchi M
Aim
We assessed the ability of the Out-of-Hospital Cardiac Arrest (OHCA) and the Cardiac Arrest Hospital Prognosis (CAHP) scores to predict neurological outcome following in-hospital cardiac arrest (IHCA).
Methods
Retrospective review of a seven-year French multicentric database including ten intensive care units. Primary endpoint was the outcome at hospital discharge using the Cerebral Performance Category score (CPC) in all IHCA patients. OHCA and CAHP scores, sequential organ failure assessment (SOFA) score and the simplified acute physiological score 2 (SAPS-2) were compared using area under ROC curves (AUROC) and Delong tests.
Results
Among 381 included patients, 125 (33%) were discharged alive with favourable outcome (CPC 1-2). Among 256 patients (77%) with unfavourable outcome (CPC 3-5), 10 were discharged alive with CPC 3 (4%), 130 died from withdrawal of life sustaining therapies because of severe neurological impairment (51%), 107 died from multiorgan failure (42%) and 9 died after discharge from complications and comorbidities (3%). OHCA and CAHP scores were independently associated with unfavourable outcome. The AUROCs to predict unfavourable outcome for OHCA, CAHP, SAPS-2 and SOFA scores were 0.76 [0.70-0.80], 0.74 [0.69-0.79], 0.72 [0.67-0.77], and 0.69 [0.64-0.74] respectively, with a significant difference observed only between OHCA and SOFA scores AUROCs (p = 0.04).
Conclusion
In parallel with CAHP score, OHCA score could be used to early predict outcome at hospital discharge after IHCA. However, prediction accuracy for all scores remains modest, suggesting the use of other dedicated means to early predict IHCA patients\' outcome.

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

Resuscitation: 30 Oct 2020; 156:167-173
Chelly J, Mpela AG, Jochmans S, Brunet J, ... Deye N, Monchi M
Resuscitation: 30 Oct 2020; 156:167-173 | PMID: 32976962
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Impact:
Abstract

Community lessons to understand resuscitation excellence (culture): Association between emergency medical services (EMS) culture and outcome after out-of-hospital cardiac arrest.

Dyson K, Brown SP, May S, Sayre M, ... Roth R, Nichol G
Background
The large geographic variation in outcome after out-of-hospital cardiac arrest (OHCA) is not well explained by traditional patient and emergency medical services (EMS) characteristics. A \'culture of excellence\' in resuscitation within an EMS is believed to be an important factor that influences quality of care and outcome in patients with OHCA. However, whether a culture of excellence is associated with improved survival after OHCA is not known.
Methodology
We linked survey responses from EMS agency medical directors related to resuscitation culture to a retrospective analysis of prospectively collected data from the Resuscitation Outcomes Consortium (ROC) Epistry - Cardiac Arrest. We used a multivariable random effects model to assess whether EMS culture strategies were associated with OHCA survival to hospital discharge.
Results
Of the 46 EMS medical directors surveyed, 35 (76%) provided a complete response. Included were n = 66,597 cases of OHCA who received attempted resuscitation by one of n = 123 EMS agencies from July 1, 2010, through June 30, 2015. Overall survival to discharge was 11%. Organizational values and goals were independently associated with survival to hospital discharge in all OHCAs (adjusted odds ratio [AOR] 1.27, 95% confidence interval [CI] 1.09-1.48) and the subgroup restricted to bystander witnessed OHCAs with initial shockable rhythm (AOR 1.55, 95% CI 1.21-1.99).
Conclusions
An organizational goal to improve OHCA survival was independently associated with improved survival to discharge. EMS agencies looking to improve OHCA survival should consider implementing an organizational goal to improve OHCA survival and empower quality improvement personnel to drive that goal.

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

Resuscitation: 30 Oct 2020; 156:202-209
Dyson K, Brown SP, May S, Sayre M, ... Roth R, Nichol G
Resuscitation: 30 Oct 2020; 156:202-209 | PMID: 32979404
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Impact:
Abstract

First experience with the abdominal aortic and junctional tourniquet in prehospital traumatic cardiac arrest.

Balian F, Garner AA, Weatherall A, Lee A
Introduction
The Abdominal Aortic and Junctional Tourniquet (AAJT) increased systemic vascular resistance, mean arterial pressure, carotid blood flow and rate of return of spontaneous circulation (ROSC) in animals with hypovolaemic traumatic cardiac arrest (TCA). The objective of this study was to report the first experience of the use of the AAJT as part of a pre-hospital TCA algorithm.
Methods
This is a descriptive case series of the use of the AAJT in patients with TCA in a civilian physician-led pre-hospital trauma service in Sydney, Australia between June 2015 to August 2019. Cases were identified and data sourced from routinely collected data sets within the retrieval service.
Results
During the study, 44 TCAs were attended, 22 with AAJT application. Mean time (standard deviation) to AAJT application since last signs of life was 16 (9) min. Eighteen (16 males, 2 females) patients, with median age (interquartile range) of 40 (25-58) years, were included for analysis. Seventeen patients (94%) had blunt trauma. Sixteen patients (89%) were in TCA at the time of service contact, 11 (61%) had a change in electrical activity, 4 (22%) had ROSC, and of the 6 with documented end-tidal carbon dioxide, the mean rise was 24.0 mmHg (95% CI 12.6-35.4) (P = 0.003). Three patients (17%) had sustained ROSC on arrival to the Emergency Department. No patients survived to hospital discharge.
Conclusion
Physiological changes were demonstrated but there were no survivors. Further research focusing on faster application times may be associated with improved outcomes.

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

Resuscitation: 30 Oct 2020; 156:210-214
Balian F, Garner AA, Weatherall A, Lee A
Resuscitation: 30 Oct 2020; 156:210-214 | PMID: 32979403
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Impact:
Abstract

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

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

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

Resuscitation: 06 Oct 2020; epub ahead of print
Couper K, Quinn T, Booth K, Lall R, ... Yeung J, Perkins GD
Resuscitation: 06 Oct 2020; epub ahead of print | PMID: 33038438
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Impact:
Abstract

Association of measures of socioeconomic position with survival following out-of-hospital cardiac arrest: A systematic review.

Chamberlain RC, Barnetson C, Clegg GR, Halbesma N
Background
Survival following out-of-hospital cardiac arrest (OHCA) is low, and poor survival appears associated with low socioeconomic position (SEP). We aimed to synthesise the evidence regarding association of specific SEP measures with OHCA survival, as well as effect modification and potential mediators, with the goal of informing efforts to improve survival by highlighting characteristics of populations requiring additional resources, and identifying modifiable factors.
Methods
MEDLINE and Embase databases were searched on 23 May 2019. Quantitative primary studies considering the association of any SEP measure with any OHCA survival measure were eligible. SEP could be measured at the level of the patient, their residential area, or OHCA location. Data on study characteristics and outcomes were extracted and a narrative review performed; this considered the evidence for overall SEP-survival association, variation in association of different SEP measures with survival, effect modification, and mediation.
Results
Twenty-three studies were included. These were highly heterogeneous, particularly regarding SEP measures and eligibility criteria. Several studies report a SEP-survival association, with this being almost exclusively in the direction of lower survival with lower SEP. There is some indication that the education-survival association is particularly consistent but further work is needed to increase confidence here. No evidence of effect modification by age, sex or other factors was seen, although few studies considered this. No mediators were conclusively identified.
Conclusions
Low SEP is associated with poorer OHCA survival in at least some settings. It may be appropriate to consider populations\' socioeconomic characteristics when targeting interventions to improve OHCA survival.

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

Resuscitation: 30 Sep 2020; 157:49-59
Chamberlain RC, Barnetson C, Clegg GR, Halbesma N
Resuscitation: 30 Sep 2020; 157:49-59 | PMID: 33010372
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Impact:
Abstract

Randomized trial of the i-gel supraglottic airway device versus tracheal intubation during out of hospital cardiac arrest (AIRWAYS-2): Patient outcomes at three and six months.

Benger JR, Lazaroo MJ, Clout M, Voss S, ... Wordsworth S, Rogers CA
Aim
The AIRWAYS-2 cluster randomised controlled trial compared the i-gel supraglottic airway device (SGA) with tracheal intubation (TI) as the first advanced airway management (AAM) strategy used by Emergency Medical Service clinicians (paramedics) treating adult patients with non-traumatic out-of-hospital cardiac arrest (OHCA). It showed no difference between the two groups in the primary outcome of modified Rankin Scale (mRS) score at 30 days/hospital discharge. This paper reports outcomes to 6 months.
Methods
Paramedics from four ambulance services in England were randomised 1:1 to use an i-gel SGA (759 paramedics) or TI (764 paramedics) as their initial approach to AAM. Adults who had a non-traumatic OHCA and were attended by a participating paramedic were enrolled automatically under a waiver of consent. Survivors were invited to complete questionnaires at three and six months after OHCA. Outcomes were analysed using regression methods.
Results
767/9296 (8.3%) enrolled patients survived to 30 days/hospital discharge and 317/767 survivors (41.3%) consented and were followed-up to six months. No significant differences were found between the two treatment groups in the primary outcome measure (mRS score: 3 months: odds ratio (OR) for good recovery (i-gel/TI, OR) 0.89, 95% CI 0.69-1.14; 6 months OR 0.91, 95% CI 0.71-1.16). EQ-5D-5L scores were also similar between groups and sensitivity analyses did not alter the findings.
Conclusion
There were no statistically significant differences between the TI and i-gel groups at three and six months. We therefore conclude that the initially reported finding of no significant difference between groups at 30 days/hospital discharge was sustained when the period of follow-up was extended to six months.

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

Resuscitation: 30 Sep 2020; 157:74-82
Benger JR, Lazaroo MJ, Clout M, Voss S, ... Wordsworth S, Rogers CA
Resuscitation: 30 Sep 2020; 157:74-82 | PMID: 33010371
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Impact:
Abstract

Time to change the times? Time of recurrence of ventricular fibrillation during OHCA.

Spies DM, Kiekenap J, Rupp D, Betz S, Kill C, Sassen MC
Aim of the study
For out-of-hospital-cardiac-arrest (OHCA) due to ventricular fibrillation (VF) guidelines recommend early defibrillation followed by chest compressions for two minutes before analyzing shock success. If rhythm analysis reveals VF again, it is obscure whether VF persisted or reoccurred within the two-minutes-cycle of chest compressions after successful defibrillation. We investigated the time of VF-recurrence in OHCA.
Methods
We examined all cases of OHCA presenting with initial VF rhythm at arrival of ALS-ambulance (Marburg-Biedenkopf-County, 246.648 inhabitants) from January 2014 to March 2018. Three independent investigators analyzed corpuls3® ECG-recordings. We included ECG-data from CPR-beginning until four minutes after the third shock. VF termination was defined as the absence of a VF-waveform within 5 s of shock delivery. VF recurrence was defined as the presence of a VF-waveform in the interval 5 s post shock delivery.
Results
We included 185 shocks in 82 patients. 74.1% (n = 137) of all shocks terminated VF, but VF recurred in 81% (n = 111). The median (IQR) time of VF-recurrences was 27 s (13.5 s/80.5 s) after shock. 51.4% (n = 57) of VF-recurrence occurred 5-30 s after shock, 13.5% (n = 15) VF-recurrence occurred 31-60 s after shock, 21.6% (n = 24) of VF-recurrence occurred 61-120 s after shock, 13.5% (n = 15) of VF-recurrence occurred 121-240 s after shock.
Conclusions
Although VF was terminated by defibrillation in 74.1%, VF recurred in 81% subsequent to the chest compression interval. Thus, VF reappears frequently and early. It is unclear to which extend chest compressions influence VF-relapse. Further studies need to re-evaluate the algorithm, timing of antiarrhythmic therapy or novel defibrillation strategies to minimize refibrillation during shockable OHCA.

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

Resuscitation: 02 Oct 2020; epub ahead of print
Spies DM, Kiekenap J, Rupp D, Betz S, Kill C, Sassen MC
Resuscitation: 02 Oct 2020; epub ahead of print | PMID: 33022311
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Impact:
Abstract

Testing the effects of checklists on team behaviour during emergencies on general wards: An observational study using high-fidelity simulation.

De Bie Dekker AJR, Dijkmans JJ, Todorovac N, Hibbs R, ... Brabrand M, Subbe CP
Introduction
Clinical teams struggle on general wards with acute management of deteriorating patients. We hypothesized that the Crisis Checklist App, a mobile application containing checklists tailored to crisis-management, can improve teamwork and acute care management.
Methods
A before-and-after study was undertaken in high-fidelity simulation centres in the Netherlands, Denmark and United Kingdom. Clinical teams completed three scenarios with a deteriorating patient without checklists followed by three scenarios using the Crisis Checklist App. Teamwork performance as the primary outcome was assessed by the Mayo High Performance Teamwork scale. The secondary outcomes were the time required to complete all predefined safety-critical steps, percentage of omitted safety-critical steps, effects on other non-technical skills, and users\' self-assessments. Linear mixed models and a non-parametric survival test were conducted to assess these outcomes.
Results
32 teams completed 188 scenarios. The Mayo High Performance Teamwork scale mean scores improved to 23.4 out of 32 (95% CI: 22.4-24.3) with the Crisis Checklist App compared to 21.4 (20.4-22.3) with local standard of care. The mean difference was 1.97 (1.34-2.6; p < 0.001). Teams that used the checklists were able to complete all safety-critical steps of a scenario in more simulations (40/95 vs 21/93 scenarios) and these steps were completed faster (stratified log-rank test χ = 8.0; p = 0.005). The self-assessments of the observers and users showed favourable effects after checklist usage for other non-technical skills including situational awareness, decision making, task management and communication.
Conclusions
Implementation of a novel mobile crisis checklist application among clinical teams was associated in a simulated general ward setting with improved teamwork performance, and a higher and faster completion rate of predetermined safety-critical steps.

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

Resuscitation: 03 Oct 2020; 157:3-12
De Bie Dekker AJR, Dijkmans JJ, Todorovac N, Hibbs R, ... Brabrand M, Subbe CP
Resuscitation: 03 Oct 2020; 157:3-12 | PMID: 33027620
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Impact:
Abstract

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

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

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

Resuscitation: 03 Oct 2020; epub ahead of print
Moore JC, Salverda B, Rojas-Salvador C, Lick M, Debaty G, G Lurie K
Resuscitation: 03 Oct 2020; epub ahead of print | PMID: 33027619
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Impact:
Abstract

Frequency, Risk Factors, and Outcomes of Non-Occlusive Mesenteric Ischaemia after Cardiac Arrest.

Paul M, Bougouin W, Legriel S, Charpentier J, ... Grimaldi D, Cariou A
Purpose
Mesenteric ischaemia after successfully resuscitated cardiac arrest (CA) has been insufficiently studied. We aimed to assess the frequency, risk factors, and outcomes of non-occlusive mesenteric ischaemia (NOMI) after CA.
Methods
We retrospectively included patients admitted to a CA centre with sustained return of spontaneous circulation between 2007 and 2017. NOMI was suspected based on clinical symptoms and classified as possible if no tests were feasible or the only test was a negative abdominal computed tomography (CT) scan and as confirmed if diagnosed by endoscopy, CT, or surgery.
Results
Of 1343 patients, 82 (6%) had suspected NOMI, including 33 (2.5%) with confirmed NOMI. Investigations for suspected NOMI were done in 47/82 (57%) patients (CT, n=30; lower digestive endoscopy, n=14; and upper digestive endoscopy, n=12); 11 patients underwent surgery. By multivariate analysis, factors associated with suspected NOMI were female sex (OR, 1.8; 95%CI, 1.1-2.9, p=0.02), cardiovascular comorbidities (OR, 1.6; 95%CI, 1.0-2.7; p=0.047), admission lactate >5 mmol/L (OR, 2.0; 95%CI, 1.2-3.4; p=0.01), low flow >17minutes (OR, 2.2; 95%CI, 1.3-3.8; p=0.003), and inotropic score >7μg/kg/min (OR, 1.8; 95%CI, 1.1- 3.2; p=0.03). ICU mortality was 96% (79/82), with 61% of patients dying from multi-organ failure (MOF) and 35% from post-anoxic brain injury. Of the eight patients who regained consciousness, 5 finally died from MOF, leaving 3 patients discharged alive from the ICU with a good neurologic outcome.
Conclusions
NOMI may affect 2.5% to 6% of patients after CA. Mortality was extremely high in patients, and very few survived with a good neurological outcome.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 03 Oct 2020; epub ahead of print
Paul M, Bougouin W, Legriel S, Charpentier J, ... Grimaldi D, Cariou A
Resuscitation: 03 Oct 2020; epub ahead of print | PMID: 33027618
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Impact:
Abstract

Roll up the tape? Laser and optical technologies improve paediatric weight estimation.

Czarnecki RW, Harik LG, Malthaner LQ, Shi J, Leonard JC
Background
A robust estimation method is needed to prevent medication dosing and equipment sizing errors and improve time to administration during paediatric resuscitation. An electronic measurement with computer interface may improve accuracy and alleviate cognitive burden. This study evaluates the accuracy of two electronic height measurement methods, a laser and an optical device, and compares them to the Broselow™ Pediatric Emergency Tape (BT) for weight estimation.
Methods
We enrolled children ages 0-14 years from the emergency department of a free-standing, academic children\'s hospital. We obtained sex, body habitus, true weight, true height, BT colour, and experimental heights. We converted experimental height measurements into weight estimates using standardised growth charts. We calculated Pearson correlations between experimental and actual measurements and the percentages of weight estimates within 10% and 20% of true weights. We repeated analyses on a restricted cohort of children 0-11 years, the intended BT age range.
Results
We enrolled 198 children. The laser, optical device and BT weight estimates had strong positive correlations with the actual weight measurements with Pearson\'s correlation coefficients of 0.946, p < 0.0001, 0.965, p < 0.0001, and 0.825, p < 0.0001 respectively. 47.8% of optical weight estimates fell within 10% of actual weight and 80.6% within 20%, compared to 40.5% and 75.4% of laser estimates and 39.8% and 65.1% of BT estimates.
Conclusion
Electronic-based weight estimates were more accurate than the BT. The accuracy of medication dosing and equipment sizing during paediatric resuscitation may be improved by integrating optical height-based weight estimates with electronic clinical decision support.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 05 Oct 2020; 157:41-48
Czarnecki RW, Harik LG, Malthaner LQ, Shi J, Leonard JC
Resuscitation: 05 Oct 2020; 157:41-48 | PMID: 33031873
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Impact:
Abstract

Influence of the Covid-19 pandemic on out-of-hospital cardiac arrest. A Spanish nationwide prospective cohort study.

Rosell Ortiz F, Fernández Del Valle P, Knox EC, Jiménez Fábrega X, ... Daponte Codina A,
Aims
The influence of the COVID-19 pandemic on attendance to out-of-hospital cardiac arrest (OHCA) has only been described in city or regional settings. The impact of COVID-19 across an entire country with a high infection rate is yet to be explored.
Methods
The study uses data from 8629 cases recorded in two time-series (2017/2018 and 2020) of the Spanish national registry. Data from a non-COVID-19 period and the COVID-19 period (February 1st to April 30th 2020) were compared. During the COVID-19 period, data a further analysis comparing non-pandemic and pandemic weeks (defined according to the WHO declaration on March 11th, 2020) was conducted. The chi-squared analysis examined differences in OHCA attendance and other patient and resuscitation characteristics. Multivariate logistic regression examined survival likelihood to hospital admission and discharge. The multilevel analysis examined the differential effects of regional COVID-19 incidence on these same outcomes.
Results
During the COVID-19 period, the incidence of resuscitation attempts declined and survival to hospital admission (OR = 1.72; 95%CI = 1.46-2.04; p < 0.001) and discharge (OR = 1.38; 95%CI = 1.07-1.78; p = 0.013) fell compared to the non-COVID period. This pattern was also observed when comparing non-pandemic weeks and pandemic weeks. COVID-19 incidence impinged significantly upon outcomes regardless of regional variation, with low, medium, and high incidence regions equally affected.
Conclusions
The pandemic, irrespective of its incidence, seems to have particularly impeded the pre-hospital phase of OHCA care. Present findings call for the need to adapt out-of-hospital care for periods of serious infection risk.
Study registration number
ISRCTN10437835.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 09 Oct 2020; epub ahead of print
Rosell Ortiz F, Fernández Del Valle P, Knox EC, Jiménez Fábrega X, ... Daponte Codina A,
Resuscitation: 09 Oct 2020; epub ahead of print | PMID: 33049385
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Impact:
Abstract

Neuro-anatomical localization of EEG identical bursts in patients with and without post-anoxic myoclonus.

Kusztos AE, Coppler PJ, Salcido DD, Callaway CW, Elmer J
Background
The electroencephalograph (EEG) pattern of burst suppression with identical bursts (BSIB), with or without myoclonus, occurs often after resuscitation from cardiac arrest. These patterns are associated with severe brain injury but their neuropathological basis is unknown. Using EEG source localization, we tested whether post-cardiac arrest myoclonus was associated with specific anatomical distribution of BSIB.
Methods
We performed a single center, case-control study of EEG-monitored post-cardiac arrest patients with BSIB. We determined the presence of myoclonus from clinical notes and video recordings. We generated normalized source density maps (sLORETA) for the first 0.5 s of each burst projected onto a standard anatomic model, and compared proportion of EEG power in the precentral gyrus (motor cortex) to the rest of the brain.
Results
We included 20 patients, 10 with and 10 without myoclonus. Patients with myoclonus had greater electrical activation localized to the precentral gyrus compared to those without (median 3.25 [IQR 2.74-3.59] vs 2.68 [IQR 2.66-2.71], P = 0.04). There was no difference between groups in region of burst origin.
Conclusion
Among patients with BSIB after cardiac arrest, those with clinical myoclonus have more electrocortical activation in the precentral gyrus.

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

Resuscitation: 26 Oct 2020; epub ahead of print
Kusztos AE, Coppler PJ, Salcido DD, Callaway CW, Elmer J
Resuscitation: 26 Oct 2020; epub ahead of print | PMID: 33127440
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Impact:
Abstract

Long-term outcomes after in-hospital cardiac arrest: 30-day survival and 1-year follow-up of mortality, anoxic brain damage, nursing home admission and in-home care.

Yonis H, Ringgren KB, Andersen MP, Wissenberg M, ... Folke F, Kragholm KH
Aims
Long-term functional outcomes after in-hospital cardiac arrest (IHCA) are scarcely studied. However, survivors are at risk of neurological impairment from anoxic brain damage which could affect quality of life and lead to need of care at home or in a nursing home.
Methods
We linked data on ICHAs in Denmark with nationwide registries to report 30-day survival as well as factors associated with survival. Furthermore, among 30-day survivors we reported the one-year cumulative risk of anoxic brain damage or nursing home admission with mortality as the competing risk.
Results
In total, 517 patients (27.3%) survived to day 30 out of 1892 eligible patients; 338 (65.9%) were men and median age was 68 (interquartile range 58-76). Lower age, witnessed arrest by health care personnel, monitored arrest and presumed cardiac cause of arrest were associated with 30-day survival. Among 454 30-day survivors without prior anoxic brain damage or nursing home admission, the risk of anoxic brain damage or nursing home admission within the first-year post-arrest was 4.6% (n = 21; 95% CI 2.7-6.6%) with a competing risk of death of 15.6% (n = 71; 95% CI 12.3-19.0%), leaving 79.7% (n = 362) alive without anoxic brain damage or nursing home admission. When adding the risk of need of in-home care among 343 30-day survivors without prior home care needs, 68.8% (n = 236) were alive without any of the composite events one-year post-arrest.
Conclusion
The majority of 30-day survivors of IHCA are alive at one-year follow-up without anoxic brain damage, nursing home admission or need of in-home care.

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

Resuscitation: 14 Oct 2020; 157:23-31
Yonis H, Ringgren KB, Andersen MP, Wissenberg M, ... Folke F, Kragholm KH
Resuscitation: 14 Oct 2020; 157:23-31 | PMID: 33069866
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Impact:
Abstract

A Rapid Review of Advanced Life Support Guidelines for Cardiac Arrest Associated with Anaphylaxis.

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

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 13 Oct 2020; epub ahead of print
McLure M, Eastwood K, Parr M, Bray J
Resuscitation: 13 Oct 2020; epub ahead of print | PMID: 33068641
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Impact:
Abstract

Assessing the validity of two-dimensional carotid ultrasound to detect the presence and absence of a pulse.

Sanchez S, Miller M, Asha S
Background
Traditional assessment of return of cardiac output in cardiac arrest by manual palpation has poor accuracy. Point of care ultrasound of a major artery has been suggested as an alternative. We conducted a diagnostic accuracy study of two-dimensional carotid ultrasound to detect the presence or absence of a pulse, using cardiopulmonary bypass patients for pulse and pulseless states.
Methods
A cross-sectional multi-patient, multi-reader repeated measures diagnostic study was conducted. For patients undergoing routine cardiopulmonary bypass, a portable ultrasound was used to record four 10-s videos the common carotid artery, three aimed for a pulse in high (>90 mmHg), medium (70-90 mmHg) and low (<70 mmHg) systolic blood pressure (SBP) ranges, and a pulseless video was recorded on cardiopulmonary bypass. Critical care physicians viewed the videos and were asked to nominate within 10 s if a pulse was present. True pulse-status was determined via the arterial-line waveform.
Results
Twenty-three patients had all four videos collected. Median patient age was 64 (IQR 14), sixteen were male (70%) and median BMI was 27. The median SBP in high-, medium- and low-SBP groups were 120 mmHg, 83 mmHg and 69 mmHg respectively. Forty-six physicians reviewed a subset of 24 videos. Overall sensitivity was 0.91 (95% confidence interval 0.89-0.93) and specificity 0.90 (95% CI 0.86-0.93). Sensitivity was highest in the high-SBP group (0.96, 95% CI 0.93-0.98) and lowest in the low-SBP group (0.83, 95% CI 0.78-0.87).
Conclusion
2D ultrasound of the common carotid artery is both sensitive and specific for detection of the presence or absence of a pulse.

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

Resuscitation: 11 Oct 2020; 157:67-73
Sanchez S, Miller M, Asha S
Resuscitation: 11 Oct 2020; 157:67-73 | PMID: 33058995
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Impact:
Abstract

Traumatic and hemorrhagic complications after extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest.

Nguyen ML, Gause E, Mills B, Tonna JE, ... Johnson NJ,
Introduction
Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging invasive rescue therapy for treatment of refractory out-of-hospital cardiac arrests (OHCA). We aim to describe the incidence of traumatic and hemorrhagic complications among patients undergoing ECPR for OHCA and examine the association between CPR duration and ECPR-related injuries or bleeding.
Methods
We examined prospectively collected data from the Extracorporeal Resuscitation Outcomes Database (EROD), which includes ECPR-treated OHCAs from participating hospitals (October 2014 to August 2019). The primary outcome was traumatic or hemorrhagic complications, defined any of the following: pneumothorax, pulmonary hemorrhage, major bleeding, cannula site bleeding, gastrointestinal bleeding, thoracotomy, cardiac tamponade, aortic dissection, or vascular injury during hospitalization. The primary exposure was the cardiac arrest to ECPR initiation interval (CA-ECPR interval), measured as the time from arrest to initiation of ECPR. Descriptive statistics were used to compare demographic, cardiac arrest, and ECPR characteristics among patients with and without CPR-related traumatic or bleeding complications. Multivariable logistic regression was used to examine the association between CA-ECPR interval and traumatic or bleeding complications.
Results
A total of 68 patients from 4 hospitals receiving ECPR for OHCA were entered into EROD and met inclusion criteria. Median age was 51 (interquartile range 38-58), 81% were male, 40% had body mass index > 30, and 70% had pre-existing medical comorbidities. A total of 65% had an initial shockable cardiac rhythm, mechanical CPR was utilized in at least 29% of patients, and 27% were discharged alive. The median time from arrest to ECPR initiation was 73 min (IQR 60-104). A total of 37% experienced a traumatic or bleeding complication, with major bleeding (32%), vascular injury (18%), and cannula site bleeding (15%) being the most common. Compared to patients with shorter CPR times, patients with a longer CA-ECPR interval had 18% (95% confidence interval - 2-42%) higher odds of suffering a mechanical or bleeding complication, but this did not reach statistical significance (p = 0.08).
Conclusions
Traumatic injuries and bleeding complications are common among patients undergoing ECPR. Further study is needed to investigate the relation between arrest duration and complications. Clinicians performing ECPR should anticipate and assess for injuries and bleeding in this high-risk population.

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

Resuscitation: 11 Oct 2020; epub ahead of print
Nguyen ML, Gause E, Mills B, Tonna JE, ... Johnson NJ,
Resuscitation: 11 Oct 2020; epub ahead of print | PMID: 33058992
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Impact:
Abstract

Conservative or liberal oxygen therapy in adults after cardiac arrest: An individual-level patient data meta-analysis of randomised controlled trials.

Young PJ, Bailey M, Bellomo R, Bernard S, ... Skrifvars MB, Thomas M
Aim
The effect of conservative versus liberal oxygen therapy on mortality rates in post cardiac arrest patients is uncertain.
Methods
We undertook an individual patient data meta-analysis of patients randomised in clinical trials to conservative or liberal oxygen therapy after a cardiac arrest. The primary end point was mortality at last follow-up.
Results
Individual level patient data were obtained from seven randomised clinical trials with a total of 429 trial participants included. Four trials enrolled patients in the pre-hospital period. Of these, two provided protocol-directed oxygen therapy for 60 min, one provided it until the patient was handed over to the emergency department staff, and one provided it for a total of 72 h or until the patient was extubated. Three trials enrolled patients after intensive care unit (ICU) admission and generally continued protocolised oxygen therapy for a longer period, often until ICU discharge. A total of 90 of 221 patients (40.7%) assigned to conservative oxygen therapy and 103 of 206 patients (50%) assigned to liberal oxygen therapy had died by this last point of follow-up; absolute difference; odds ratio (OR) adjusted for study only; 0.67; 95% CI 0.45 to 0.99; P = 0.045; adjusted OR, 0.58; 95% CI 0.35 to 0.96; P = 0.04.
Conclusion
Conservative oxygen therapy was associated with a statistically significant reduction in mortality at last follow-up compared to liberal oxygen therapy but the certainty of available evidence was low or very low due to bias, imprecision, and indirectness.
Prospero registration number
CRD42019138931.

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

Resuscitation: 11 Oct 2020; 157:15-22
Young PJ, Bailey M, Bellomo R, Bernard S, ... Skrifvars MB, Thomas M
Resuscitation: 11 Oct 2020; 157:15-22 | PMID: 33058991
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Impact:
Abstract

Delivery of Automated External Defibrillators via Drones in Simulated Cardiac Arrest: Users\' Experiences and the Human-Drone Interaction.

Zègre-Hemsey JK, Grewe ME, Johnson AM, Arnold E, ... Bogle BM, Rosamond WD
Background
Survival after out-of-hospital cardiac arrest (OHCA) in the United States is approximately 10%. Automatic external defibrillators (AEDs) are effective when applied early, yet public access AEDs are used in <2% of OHCAs. AEDs are often challenging for bystanders to locate and are rarely available in homes, where 70% of OHCAs occur. Drones have the potential to deliver AEDs to bystanders efficiently; however, little is known about the human-drone interface in AED delivery.
Objectives
To describe user experiences with AED-equipped drones in a feasibility study of simulated OHCA in a community setting.
Methods
We simulated an OHCA in a series of trials with age-group/sex-matched participant pairs, with one participant randomized to search for a public access AED and the other to call a mock 9-1-1 telephone number that initiated the dispatch of an AED-equipped drone. We investigated user experience of 17 of the 35 drone recipient participants via semi-structured qualitative interviews and analyzed audio-recordings for key aspects of user experience.
Results
Drone recipient participants reported largely positive experiences, highlighting that this delivery method enabled them to stay with the victim and continue cardiopulmonary resuscitation. Concerns were few but included drone arrival timing and direction as well as bystander safety. Participants provided suggestions for improvements in the AED-equipped drone design and delivery procedures.
Conclusion
Participants reported positive experiences interacting with an AED-equipped drone for a simulated OHCA in a community setting. Early findings suggest a role for drone-delivered AEDs to improve bystander AED use and improve outcomes for OHCA victims.

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

Resuscitation: 16 Oct 2020; 157:83-88
Zègre-Hemsey JK, Grewe ME, Johnson AM, Arnold E, ... Bogle BM, Rosamond WD
Resuscitation: 16 Oct 2020; 157:83-88 | PMID: 33080371
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Impact:
Abstract

Cost-effectiveness of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A multi-centre prospective cohort study.

Matsuoka Y, Goto R, Atsumi T, Morimura N, ... Sakamoto T,
Aim
Extracorporeal cardiopulmonary resuscitation (ECPR) is an evolving resuscitative method for refractory cardiopulmonary arrests. However, considering the substantial healthcare costs and resources involved, there is an urgent need for a full economic evaluation. We therefore assessed the cost-effectiveness of ECPR for refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT).
Methods
We developed a decision model to estimate lifetime costs and outcomes for out-of-hospital cardiac arrest patients with VF/pVT who received either ECPR or conventional cardiopulmonary resuscitation. Quality-adjusted life-years (QALY) was used as the main outcome measure. This model was a combination of a decision tree model for the acute phase based on a prospective observational study (SAVE-J study), together with a Markov model for long-term follow-up periods extrapolated from published data. To evaluate the robustness of this model, we conducted a comprehensive deterministic sensitivity analysis (DSA) and a probabilistic sensitivity analysis (PSA).
Results
ECPR was cost-effective, with an incremental cost of ¥3,521,189 (Є30,227), an incremental effectiveness of 1.34 QALY, and an incremental cost-effectiveness ratio of ¥2,619,692 (Є22,489) per QALY gained. DSA revealed that the present model was most sensitive to probability of Cerebral Performance Category 1 after ECPR (¥2,153,977/QALY to ¥3,186,475/QALY), patient age (¥2,170,112/QALY to ¥3,334,252/QALY), and long-term medical cost for modified Rankin Scale 0 (¥2,280,352/QALY to ¥2,855,330/QALY). PSA indicated ECPR to be cost-effective and below the willingness-to-pay threshold of ¥5,000,000 with an 86.7 % possibility.
Conclusions
ECPR was an economically acceptable resuscitative strategy, and the results of the present study were robust even when considering the uncertainty of all parameters.

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

Resuscitation: 16 Oct 2020; 157:32-38
Matsuoka Y, Goto R, Atsumi T, Morimura N, ... Sakamoto T,
Resuscitation: 16 Oct 2020; 157:32-38 | PMID: 33080369
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Impact:
Abstract

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

Halling C, Raymond T, Brown LS, Ades A, ... Wyckoff MH,
Background
Cardiopulmonary resuscitation (CPR) in the delivery room (DR) after birth is rare. We hypothesized that factors related to maternal, delivery, infant and resuscitation event characteristics associated with outcomes could be identified. We also hypothesized there would be substantial variation from the Neonatal Resuscitation Program (NRP) algorithm.
Methods
Retrospective review of all neonates receiving chest compressions in the DR from the AHA Get With The Guidelines-Resuscitation registry from 2001 to 2014. The primary outcome was return of spontaneous circulation (ROSC) in the DR. Secondary outcome was survival to hospital discharge. Descriptive statistics were used to characterize data. Odds ratios with confidence intervals were calculated as appropriate to compare survivors and non-survivors.
Results
There were 1153 neonates who received chest compressions in the DR. ROSC was achieved in 968 (84%) newborns and 761 (66%) survived to hospital discharge. Fifty-one percent of the cohort received chest compressions without medications. Cardiac compressions were initiated within the first minute of life in 76% of the events, and prior to endotracheal intubation in 79% of the events. In univariate analysis, factors such as prematurity, number of endotracheal intubation attempts, increased time to first adrenaline dose, and CPR duration were associated with decreased odds of ROSC in the DR. Longer CPR duration was associated with decreased odds of ROSC in multivariate analysis.
Conclusion
In this cohort of infants receiving chest compressions following delivery, recognizable pre-birth risk factors as well as resuscitation interventions associated with increased and decreased odds of achieving ROSC were identified. Chest compressions were frequently initiated in the first minute of the event and often prior to endotracheal intubation. Further investigations should focus on methods to decrease time to critical resuscitation interventions, such as successful endotracheal intubation and administration of the first dose of adrenaline, in order to improve DR-CPR outcomes.

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

Resuscitation: 16 Oct 2020; epub ahead of print
Halling C, Raymond T, Brown LS, Ades A, ... Wyckoff MH,
Resuscitation: 16 Oct 2020; epub ahead of print | PMID: 33080368
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Impact:
Abstract

Comparing the effect of two different interfaces on breathing of preterm infants at birth: A matched-pairs analysis.

Kuypers KLAM, Lamberska T, Martherus T, Dekker J, ... Plavka R, Te Pas AB
Objective
Applying a face mask could provoke a trigeminocardiac reflex. We compared the effect of applying bi-nasal prongs with a face mask on breathing and heart rate of preterm infants at birth.
Methods
In a retrospective matched-pairs study of infants <32 weeks of gestation, the use of bi-nasal prongs for respiratory support at birth was compared to the use of a face mask. Infants who were initially breathing at birth and subsequently received respiratory support were matched for gestational age (±4 days), birth weight (±300 g), general anaesthesia and gender. Breathing, heart rate and other parameters were collected before and after interface application and in the first 5 min thereafter.
Results
In total, 130 infants were included (n = 65 bi-nasal prongs, n = 65 face mask) with a median (IQR) gestational age of 27 (25-28) vs 26 (25-28) weeks. The proportion of infants who stopped breathing after applying the interface was not different between the groups (bi-nasal prongs 43/65 (66%) vs face mask 46/65 (71%), p = 0.70). Positive pressure ventilation was given more often when bi-nasal prongs were used (55/65 (85%) vs 40/65 (62%), p < 0.001). Heart rate (101 (75-145) vs 110 (68-149) bpm, p = 0.496) and oxygen saturation (59% (48-87) vs 56% (35-84), p = 0.178) were similar in the first 5 min after an interface was applied in the infants who stopped breathing.
Conclusion
Apnoea and bradycardia occurred often after applying either bi-nasal prongs or a face mask on the face for respiratory support in preterm infants at birth.

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

Resuscitation: 16 Oct 2020; 157:60-66
Kuypers KLAM, Lamberska T, Martherus T, Dekker J, ... Plavka R, Te Pas AB
Resuscitation: 16 Oct 2020; 157:60-66 | PMID: 33075437
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Impact:
Abstract

Cardiac arrest and related mortality in emergency departments in the United States: Analysis of the nationwide emergency department sample.

Ravindran R, Kwok CS, Wong CW, Siller-Matula JM, ... Michos ED, Mamas MA
Aims
The aim of this study is to analyse the causes of cardiac arrests (CA) in the emergency departments (ED) in the United States and their clinical outcomes according to whether they had a primary or a secondary diagnosis of CA.
Methods
Data from the Nationwide Emergency Department Sample was assessed for episodes of CA in the emergency department (ED) for adults from 2006 to 2014. Primary and secondary diagnoses of CA and mortality outcomes were evaluated in ED, inpatient and the combined in-hospital setting.
Results
There were 2,852,347 ED episodes with a diagnosis of CA (50.5% primary diagnosis, 49.5% secondary diagnosis). Among patients with a secondary diagnosis of CA, ∼33% patients had a primary cardiac diagnosis, followed by infectious and respiratory diagnoses. The survival to ED discharge was 53.2%; lower for primary versus secondary CA diagnosis (20.4% vs 86.7%). The in-hospital survival rate for all CA was 28.7%, and was lower for primary versus secondary CA diagnosis (15.7% vs 41.9%). Survival to hospital discharge was highest in the age group of 41-60 years (33.0%) and was least among >80 years (20.9%). Survival was also noted to be lower among female patients (27.9% vs 29.2%) and in the winter months.
Conclusions
Survival with CA in ED is <30% of patients and is greater among patients with a secondary diagnosis of CA. CAs are associated with significant mortality in ED and hospital settings and measures should be taken to better manage cardiac, infection and respiratory causes particularly in the winter months.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 18 Oct 2020; 157:166-173
Ravindran R, Kwok CS, Wong CW, Siller-Matula JM, ... Michos ED, Mamas MA
Resuscitation: 18 Oct 2020; 157:166-173 | PMID: 33086085
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Impact:
Abstract

Perinatal characteristics and delivery room management of infants born through MSAF.

Reed RL, Chang C, Perlman JM

The immediate delivery room (DR) management of non-vigorous (NV) infants with meconium stained amniotic fluid (MSAF) is controversial. A recent ILCOR suggestion is not to perform routine direct laryngoscopy (DL) with or without tracheal suctioning in NV infants. Our practice is to perform DL and endotracheal (ET) suctioning in targeted NV infants. The study objective was to describe the perinatal characteristics and DR Management of infants born through MSAF and admitted to the neonatal intensive care unit (NICU).
Methods
Retrospective study evaluating the DR management of infants >35 weeks delivered through MSAF. Data retrieved included fetal heart rate abnormalities (FTHR), presence of thick/thin MSAF, DR management and postnatal course.
Results
118 infants were resuscitated and directly admitted to the NICU, including 58 intubated for meconium, 29 receiving immediate PPV (n = 25) or CPAP (n = 4) and 31 (17%) initially stable developed delayed respiratory symptoms and administered CPAP. Sixty-four (35.2%) infants initially stable in the DR were subsequently admitted to NICU. ET suctioning was performed in 58/182 infants with meconium obtained in 41/58; meconium aspiration syndrome (MAS) was diagnosed in 21 infants. ET suctioning was positive in 10/21 cases. FHRT abnormalities (n = 50) were noted with thick meconium and associated with a 2.8-fold increased risk for meconium below the cords, and 3.1-fold increased risk of MAS.
Conclusion
NV infants delivered through thick versus thin meconium were more likely to be intubated with a high yield of recovery. Serious pulmonary morbidity was uncommon. Most respiratory symptomatology were not related to MAS.

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

Resuscitation: 20 Oct 2020; 157:99-105
Reed RL, Chang C, Perlman JM
Resuscitation: 20 Oct 2020; 157:99-105 | PMID: 33096159
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Abstract

Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations.

Soar J, Berg KM, Andersen LW, Böttiger BW, ... Nolan JP,

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 30 Oct 2020; 156:A80-A119
Soar J, Berg KM, Andersen LW, Böttiger BW, ... Nolan JP,
Resuscitation: 30 Oct 2020; 156:A80-A119 | PMID: 33099419
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Impact:
Abstract

Adult Advanced Life Support: International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

Berg KM, Soar J, Andersen LW, Böttiger BW, ... Sasson C, Zelop CM

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 20 Sep 2020; epub ahead of print
Berg KM, Soar J, Andersen LW, Böttiger BW, ... Sasson C, Zelop CM
Resuscitation: 20 Sep 2020; epub ahead of print | PMID: 33098922
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Impact:
Abstract

Adult Basic Life Support: International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

Olasveengen TM, Mancini ME, Perkins GD, Avis S, ... Morley PT,

This 2020 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care Science With Treatment Recommendations on basic life support summarizes evidence evaluations performed for 20 topics that were prioritized by the Basic Life Support Task Force of the International Liaison Committee on Resuscitation. The evidence reviews include 16 systematic reviews, 3 scoping reviews, and 1 evidence update. Per agreement within the International Liaison Committee on Resuscitation, new or revised treatment recommendations were only made after a systematic review. Systematic reviews were performed for the following topics: dispatch diagnosis of cardiac arrest, use of a firm surface for CPR, sequence for starting CPR (compressions-airway-breaths versus airway-breaths-compressions), CPR before calling for help, duration of CPR cycles, hand position during compressions, rhythm check timing, feedback for CPR quality, alternative techniques, public access automated external defibrillator programs, analysis of rhythm during chest compressions, CPR before defibrillation, removal of foreign-body airway obstruction, resuscitation care for suspected opioid-associated emergencies, drowning, and harm from CPR to victims not in cardiac arrest. The topics that resulted in the most extensive task force discussions included CPR during transport, CPR before calling for help, resuscitation care for suspected opioid-associated emergencies, feedback for CPR quality, and analysis of rhythm during chest compressions. After discussion of the scoping reviews and the evidence update, the task force prioritized several topics for new systematic reviews.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 30 Oct 2020; 156:A35-A79
Olasveengen TM, Mancini ME, Perkins GD, Avis S, ... Morley PT,
Resuscitation: 30 Oct 2020; 156:A35-A79 | PMID: 33098921
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Impact:
Abstract

2020 International Consensus on First Aid Science With Treatment Recommendations.

Singletary EM, Zideman DA, Bendall JC, Berry DA, ... Lee CC,

This is the summary publication of the International Liaison Committee on Resuscitation\'s 2020 International Consensus on First Aid Science With Treatment Recommendations. It addresses the most recent published evidence reviewed by the First Aid Task Force science experts. This summary addresses the topics of first aid methods of glucose administration for hypoglycemia; techniques for cooling of exertional hyperthermia and heatstroke; recognition of acute stroke; the use of supplementary oxygen in acute stroke; early or first aid use of aspirin for chest pain; control of life- threatening bleeding through the use of tourniquets, haemostatic dressings, direct pressure, or pressure devices; the use of a compression wrap for closed extremity joint injuries; and temporary storage of an avulsed tooth. Additional summaries of scoping reviews are presented for the use of a recovery position, recognition of a concussion, and 6 other first aid topics. The First Aid Task Force has assessed, discussed, and debated the certainty of evidence on the basis of Grading of Recommendations, Assessment, Development, and Evaluation criteria and present their consensus treatment recommendations with evidence-to-decision highlights and identified priority knowledge gaps for future research. The 2020 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science With Treatment Recommendations (CoSTR) is the fourth in a series of annual summary publications from the International Liaison Committee on Resuscitation (ILCOR). This 2020 CoSTR for first aid includes new topics addressed by systematic reviews performed within the past 12 months. It also includes updates of the first aid treatment recommendations published from 2010 through 2019 that are based on additional evidence evaluations and updates. As a result, this 2020 CoSTR for first aid represents the most comprehensive update since 2010.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 30 Oct 2020; 156:A240-A282
Singletary EM, Zideman DA, Bendall JC, Berry DA, ... Lee CC,
Resuscitation: 30 Oct 2020; 156:A240-A282 | PMID: 33098920
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Impact:
Abstract

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

Greif R, Bhanji F, Bigham BL, Bray J, ... Ward A, Zace D

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 30 Oct 2020; 156:A188-A239
Greif R, Bhanji F, Bigham BL, Bray J, ... Ward A, Zace D
Resuscitation: 30 Oct 2020; 156:A188-A239 | PMID: 33098918
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Impact:
Abstract

Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, ... Weiner GM,

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid. Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed. All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published. Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 30 Oct 2020; 156:A156-A187
Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, ... Weiner GM,
Resuscitation: 30 Oct 2020; 156:A156-A187 | PMID: 33098917
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Impact:
Abstract

Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

Maconochie IK, Aickin R, Hazinski MF, Atkins DL, ... de Caen AR,

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 30 Oct 2020; 156:A120-A155
Maconochie IK, Aickin R, Hazinski MF, Atkins DL, ... de Caen AR,
Resuscitation: 30 Oct 2020; 156:A120-A155 | PMID: 33098916
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Impact:
Abstract

Postanoxic electrographic status epilepticus and serum biomarkers of brain injury.

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

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

Resuscitation: 27 Oct 2020; epub ahead of print
Lybeck A, Friberg H, Nielsen N, Rundgren M, ... Cronberg T, Westhall E
Resuscitation: 27 Oct 2020; epub ahead of print | PMID: 33127439
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Impact:
Abstract

Trends in survival and introduction of the 2010 and 2015 guidelines for adult in-hospital cardiac arrest.

Holmberg MJ, Granfeldt A, Girotra S, Donnino MW, Andersen LW
Aims
To examine trends in survival from 2006 to 2018 and to assess whether the introduction of resuscitation guidelines was associated with a change in survival after adult in-hospital cardiac arrest.
Methods
Using the Get With The Guidelines® - Resuscitation registry, we included adult patients with an in-hospital cardiac arrest between 2006 and 2018. The primary outcome was survival to hospital discharge. An interrupted time series analysis was used to compare survival before and after publication of the 2010 and 2015 resuscitation guidelines.
Results
The analysis included 231,739 patients. Survival changed annually by 1.09% (95% CI, 0.74% to 1.43%; P < 0.001) from 2006 to 2010, 0.26% (95% CI, -0.11% to 0.64%; P = 0.17) from 2011 to 2015, and -0.43% (95% CI, -0.96% to 0.11%; P = 0.12) from 2016 to 2018. The survival trend was lower within the post-2010 compared to the pre-2010 period (risk difference, -0.82% per year; 95% CI, -1.35% to -0.30%; P = 0.002) and within the post-2015 compared to the pre-2015 period (risk difference, -0.69% per year; 95% CI, -1.33% to -0.04%; P = 0.04). There was no immediate change in survival after publication of the 2010 and 2015 guidelines.
Conclusions
In-hospital cardiac arrest survival increased from 2006 to 2010, after which the trend plateaued. The annual survival trend was lower following publication of the 2010 and 2015 guidelines. Research targeting in-hospital cardiac arrest as a unique entity may be necessary to improve outcomes.

Copyright © 2020. Published by Elsevier B.V.

Resuscitation: 30 Oct 2020; 157:112-120
Holmberg MJ, Granfeldt A, Girotra S, Donnino MW, Andersen LW
Resuscitation: 30 Oct 2020; 157:112-120 | PMID: 33137419
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Impact:
Abstract

Incidence and outcome of out-of-hospital cardiac arrests in the COVID-19 era: A systematic review and meta-analysis.

Lim ZJ, Ponnapa Reddy M, Afroz A, Billah B, Shekar K, Subramaniam A
Background
The impact of COVID-19 on pre-hospital and hospital services and hence on the prevalence and outcomes of out-of-hospital cardiac arrests (OHCA) remain unclear. The review aimed to evaluate the influence of the COVID-19 pandemic on the incidence, process, and outcomes of OHCA.
Methods
A systematic review of PubMed, EMBASE, and pre-print websites was performed. Studies reporting comparative data on OHCA within the same jurisdiction, before and during the COVID-19 pandemic were included. Study quality was assessed based on the Newcastle-Ottawa Scale.
Results
Ten studies reporting data from 35,379 OHCA events were included. There was a 120% increase in OHCA events since the pandemic. Time from OHCA to ambulance arrival was longer during the pandemic (p = 0.036). While mortality (OR = 0.67, 95%-CI 0.49-0.91) and supraglottic airway use (OR = 0.36, 95%-CI 0.27-0.46) was higher during the pandemic, automated external defibrillator use (OR = 1.78 95%-CI 1.06-2.98), return of spontaneous circulation (OR = 1.63, 95%CI 1.18-2.26) and intubation (OR = 1.87, 95%-CI 1.12--3.13) was more common before the pandemic. More patients survived to hospital admission (OR = 1.75, 95%-CI 1.42-2.17) and discharge (OR = 1.65, 95%-CI 1.28-2.12) before the pandemic. Bystander CPR (OR = 1.18, 95%-CI 0.95-1.46), unwitnessed OHCA (OR = 0.84, 95%-CI 0.66-1.07), paramedic-resuscitation attempts (OR = 1.19 95%-CI 1.00-1.42) and mechanical CPR device use (OR = 1.57 95%-CI 0.55-4.55) did not defer significantly.
Conclusions
The incidence and mortality following OHCA was higher during the COVID-19 pandemic. There were significant variations in resuscitation practices during the pandemic. Research to define optimal processes of pre-hospital care during a pandemic is urgently required.
Review registration
PROSPERO (CRD42020203371).

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

Resuscitation: 31 Oct 2020; epub ahead of print
Lim ZJ, Ponnapa Reddy M, Afroz A, Billah B, Shekar K, Subramaniam A
Resuscitation: 31 Oct 2020; epub ahead of print | PMID: 33137418
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Impact:
Abstract

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

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

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

Resuscitation: 01 Nov 2020; epub ahead of print
Lind PC, Johannsen CM, Vammen L, Magnussen A, Andersen LW, Granfeldt A
Resuscitation: 01 Nov 2020; epub ahead of print | PMID: 33147523
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Impact:
Abstract

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

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

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

Resuscitation: 01 Nov 2020; epub ahead of print
Ross CE, Moskowitz A, Grossestreuer AV, Holmberg MJ, ... Donnino MW,
Resuscitation: 01 Nov 2020; epub ahead of print | PMID: 33147522
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Impact:
Abstract

Effects of COVID-19 pandemic on out-of-hospital cardiac arrests: A systematic review.

Scquizzato T, Landoni G, Paoli A, Lembo R, ... Likhvantsev V, Zangrillo A
Introduction
In addition to the directly attributed mortality, COVID-19 is also likely to increase mortality indirectly. In this systematic review, we investigate the direct and indirect effects of COVID-19 on out-of-hospital cardiac arrests.
Methods
We searched PubMed, BioMedCentral, Embase and the Cochrane Central Register of Controlled Trials for studies comparing out-of-hospital cardiac arrests occurring during the pandemic and a non-pandemic period. Risk of bias was assessed with the ROBINS-I tool. The primary endpoint was return of spontaneous circulation. Secondary endpoints were bystander-initiated cardiopulmonary resuscitation, survival to hospital discharge, and survival with favourable neurological outcome.
Results
We identified six studies. In two studies, rates of return of spontaneous circulation and survival to hospital discharge decreased significantly during the pandemic. Especially in Europe, bystander-witnessed cases, bystander-initiated cardiopulmonary resuscitation and resuscitation attempted by emergency medical services were reduced during the pandemic. Also, ambulance response times were significantly delayed across all studies and patients presenting with non-shockable rhythms increased in two studies. In 2020, 3.9-5.9% of tested patients were SARS-CoV-2 positive and 4.8-26% had suggestive symptoms (fever and cough or dyspnoea).
Conclusions
Out-of-hospital cardiac arrests had worse short-term outcomes during the pandemic than a non-pandemic period suggesting direct effects of COVID-19 infection and indirect effects from lockdown and disruption of healthcare systems. Patients at high risk of deterioration should be identified outside the hospital to promptly initiate treatment and reduce fatalities. Study registration PROSPERO CRD42020195794.

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

Resuscitation: 28 Oct 2020; epub ahead of print
Scquizzato T, Landoni G, Paoli A, Lembo R, ... Likhvantsev V, Zangrillo A
Resuscitation: 28 Oct 2020; epub ahead of print | PMID: 33130157
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Impact:
Abstract

The effect of system performance improvement on patients with cardiac arrest: A systematic review.

Ko YC, Hsieh MJ, Ma MH, Bigham B, Bhanji F, Greif R
Aim
The aim of our review was to understand the effect of interventions to improve system-level performance on the clinical outcomes of patients with cardiac arrest.
Methods
We searched PubMed, Ovid EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify randomised controlled trials and non-randomised studies published before July 21, 2020 reporting systems interventions to improve outcomes. Characteristics, study design, evaluation methods and outcomes of included studies were extracted. (PROSPERO registration CRD42020161882).
Results
One cluster randomised trial and 26 non-randomised studies were included. There were 18 studies focusing on interventions for patients with out-of-hospital cardiac arrest and 9 studies for patients with in-hospital cardiac arrest. Interventions included implementation of a bundle of care strategy, evaluation of cardiopulmonary resuscitation (CPR) quality with feedback/debriefing, data surveillance, and CPR training programs. Although improved survival with favorable neurologic outcome at discharge after the implementation of specific interventions was found in 13 studies, improved survival to hospital discharge in 14 studies and improved survival to admission in 3 studies, there were still 7 studies showing no significant improvement of clinical outcomes after interventions.
Conclusion
Although only moderate to very low certainty of evidence exists to support the effect of system-level performance improvement on the clinical outcomes of patients, we recommend that organisations or communities evaluate their performance and target key areas with the goal to improve performance because of no known risks and the potential for a large beneficial effect.

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

Resuscitation: 27 Oct 2020; 157:156-165
Ko YC, Hsieh MJ, Ma MH, Bigham B, Bhanji F, Greif R
Resuscitation: 27 Oct 2020; 157:156-165 | PMID: 33129915
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This program is still in alpha version.