<div><h4>Epinephrine dosing strategies during pediatric extracorporeal cardiopulmonary resuscitation reveal novel impacts on survival: a multicenter study utilizing time-stamped epinephrine dosing records.</h4><i>Ortmann LA, Reeder RW, Raymond TT, Brunetti MA, ... di Bari S, Lasa JJ</i><br /><b>Objectives</b><br />To describe epinephrine dosing distribution using time-stamped data and assess the impact of dosing strategy on survival after ECPR in children.<br /><b>Methods</b><br />This was a retrospective study at five pediatric hospitals of children < 18 years with an in-hospital ECPR event. Mean number of epinephrine doses was calculated for each 10-minute CPR interval and compared between survivors and non-survivors. Patients were also divided by dosing strategy into a frequent epinephrine group (dosing interval of ≤ 5 min/dose throughout the first 30 minutes of the event), and a limited epinephrine group (dosing interval of ≤ 5 min/dose for the first 10 minutes then > 5 min/dose for the time between 10 and 30 minutes).<br /><b>Results</b><br />A total of 191 patients were included. Epinephrine was not evenly distributed throughout ECPR, with 66% of doses being given during the first half of the event. Mean number of epinephrine doses was similar between survivors and non-survivors the first 10 minutes (2.7 doses). After 10 minutes, survivors received fewer doses than non-survivors during each subsequent 10-minute interval. Adjusted survival was not different between strategy groups [OR of survival for frequent epinephrine strategy: 0.78 (95% CI 0.36 - 1.69), p=0.53].<br /><b>Conclusions</b><br />Survivors received fewer doses than non-survivors after the first 10 minutes of CPR and although there was no statistical difference in survival based on dosing strategy, the findings of this study question the conventional approach to EPCR analysis that assumes dosing is evenly distributed.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 29 May 2023:109855; epub ahead of print</small></div>

<div><h4>Pediatric in-hospital cardiac arrest: respiratory failure characteristics and association with outcomes.</h4><i>Shepard LN, Reeder RW, O\'Halloran A, Kienzle M, ... Sutton RM, Morgan RW</i><br /><b>Aims</b><br />To characterize respiratory failure prior to pediatric in-hospital cardiac arrest (IHCA) and to associate pre-arrest respiratory failure characteristics with survival outcomes.<br /><b>Methods</b><br />This is a single-center, retrospective cohort study from a prospectively identified cohort of children <18 years in intensive care units (ICUs) who received cardiopulmonary resuscitation (CPR) for ≥ 1 minute between January 1, 2017 and June 30, 2021, and were receiving invasive mechanical ventilation (IMV) in the hour prior to IHCA. Patient characteristics, ventilatory support and gas exchange immediately pre-arrest were described and their association with the return of spontaneous circulation (ROSC) was measured.<br /><b>Results</b><br />In the 187 events among 154 individual patients, the median age was 0.9 [0.2, 2.4] years, and CPR duration was 7.5 [3, 29] minutes. Respiratory failure was acute prior to 106/187 (56.7%) events, and the primary indication for IMV was respiratory in nature in 107/187 (57.2%) events. Immediately pre-arrest, the median positive end-expiratory pressure was 8 [5,10] cmH<sub>2</sub>O; mean airway pressure was 13 [10,18] cmH<sub>2</sub>O; peak inspiratory pressure was 28 [24, 35] cmH<sub>2</sub>O; and fraction of inhaled oxygen (FiO2) was 0.40 [0.25, 0.80]. Pre-arrest FiO2 was lower in patients with ROSC vs. without ROSC (0.30 vs 0.99; p<0.001). Patients without ROSC had greater severity of pre-arrest oxygenation failure (p<0.001) as defined by oxygenation index, oxygen saturation index, P/F ratio or S/F ratio.<br /><b>Conclusions</b><br />There was substantial heterogeneity in respiratory failure characteristics and ventilatory requirements pre-arrest. Higher pre-arrest oxygen requirement and greater degree of oxygenation failure were associated with worse survival outcomes.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 29 May 2023:109856; epub ahead of print</small></div>

<div><h4>Hypothermia after Extracorporeal Cardiopulmonary Resuscitation Not Associated with Improved Neurologic Complications or Survival in Children: an Analysis of the ELSO Registry.</h4><i>Sanford EL, Bhaskar P, Li X, Thiagarajan R, Raman L</i><br /><b>Aim</b><br />To analyze the association between hypothermia and neurologic complications among children who were treated with extracorporeal cardiopulmonary resuscitation (ECPR) using the Extracorporeal Life Support Organization (ELSO) international registry <br /><b>Methods:</b><br/>We conducted a retrospective, multicenter, database study utilizing ELSO data for ECPR encounters from January 1, 2011, through December 31, 2019. Exclusion criteria included multiple ECMO runs and lack of variable data. The primary exposure was hypothermia under 34 degrees Celsius for greater than 24 hours. The primary outcome, determined a priori, was a composite of neurologic complications defined by ELSO registry including brain death, seizures, infarction, hemorrhage, diffuse ischemia. Secondary outcomes were mortality on ECMO and mortality prior to hospital discharge. Multivariable logistic regression determined the odds of neurologic complications, mortality on ECMO or prior to hospital discharge associated with hypothermia after adjustment for available pertinent covariables.<br /><b>Results</b><br />Of the 2,289 ECPR encounters, no difference in odds of neurologic complications were found between the hypothermia and non-hypothermia groups (AOR 1.10, 95% CI 0.80-1.51). However, hypothermia exposure was associated with decreased odds of mortality on ECMO (AOR 0.76, 95% CI 0.59-0.97), but no difference in mortality prior to hospital discharge (AOR 0.96, 95% CI 0.76-1.21) <br /><b>Conclusion:</b><br/>Analysis of a large, multicenter, international dataset demonstrates that hypothermia for greater than 24 hours among children who undergo ECPR is not associated with decreased neurologic complications or mortality benefit at time of hospital discharge.<br /><br />Published by Elsevier B.V.<br /><br /><small>Resuscitation: 26 May 2023:109852; epub ahead of print</small></div>

<div><h4>Hospital ECMO capability is associated with survival in pediatric cardiac arrest.</h4><i>Pollack B, Barbaro RP, Gorga SM, Carlton EF, Gaies M, Kohne JG</i><br /><b>Aim</b><br />Extracorporeal membrane oxygenation (ECMO) provides temporary support in severe cardiac or respiratory failure and can be deployed in children who suffer cardiac arrest. However, it is unknown if a hospital\'s ECMO capability is associated with better outcomes in cardiac arrest. We evaluated the association between pediatric cardiac arrest survival and the availability of pediatric extracorporeal membrane oxygenation (ECMO) at the treating hospital.<br /><b>Methods</b><br />We identified cardiac arrest hospitalizations, including in- and out-of-hospital, in children (0-18 years old) using data from the Health Care Utilization Project (HCUP) National Inpatient Sample (NIS) between 2016-2018. The primary outcome was in-hospital survival. Hierarchical logistic regression models were built to test the association between hospital ECMO capability and in-hospital survival.<br /><b>Results</b><br />We identified 1276 cardiac arrest hospitalizations. Survival of the cohort was 44%; 50% at ECMO-capable hospitals and 32% at non-ECMO hospitals. After adjusting for patient-level factors and hospital factors, receipt of care at an ECMO- capable hospital was associated with higher in-hospital survival, with an odds ratio of 1.49 [95% CI 1.09, 2.02]. Patients who received treatment at ECMO-capable hospitals were younger (median 3 years vs 11 years, p<0.001) and more likely to have a complex chronic condition, specifically congenital heart disease. A total of 10.9% (88/811) of patients at ECMO-capable hospitals received ECMO support.<br /><b>Conclusion</b><br />A hospital\'s ECMO capability was associated with higher in-hospital survival among children suffering cardiac arrest in this analysis of a large United States administrative dataset. Future work to understand care delivery differences and other organizational factors in pediatric cardiac arrest is necessary to improve outcomes.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 26 May 2023:109853; epub ahead of print</small></div>

<div><h4>Racial and Ethnic Disparities in the Treatment and Outcomes for Witnessed Out-of-Hospital Cardiac Arrest in Connecticut.</h4><i>Sutton TS, Bailey DL, Rizvi A, Al-Araji R, ... Hashim S, McKay RG</i><br /><b>Background</b><br />Racial and ethnic disparities in the treatment and outcomes for witnessed out-of-hospital cardiac arrest (OHCA) in the United States have been previously described. We sought to characterize disparities in pre-hospital care, overall survival, and survival with favorable neurological outcomes following witnessed OHCA in the state of Connecticut.<br /><b>Methods</b><br />We performed a cross-sectional study to compare pre-hospital treatment and outcomes for White versus Black and Hispanic (Minority) OHCA patients submitted from Connecticut to the Cardiac Arrest Registry to Enhance Survival (CARES) between 2013 and 2021. Primary outcomes included bystander CPR use, bystander automated external defibrillator (AED) use with attempted defibrillation, overall survival, and survival with favorable cerebral function.<br /><b>Results</b><br />2,809 patients with witnessed OHCA were analyzed (924 Black or Hispanic; 1885 White). Minorities had lower rates of bystander CPR (31.4% vs 39.1%, P=0.002) and bystander AED placement with attempted defibrillation (10.5% vs 14.4%, P=0.004), with lower rates of survival to hospital discharge (10.3% vs 14.8%, P=0.001) and survival with favorable cerebral function (65.3% vs 80.2%, P=0.003). Minorities were less likely to receive bystander CPR in communities with median annual household income >$80, 000 (OR, 0.56; 95% CI, 0.33 - 0.95; P=0.030) and in integrated neighborhoods (OR, 0.70; 95% CI, 0.52 - 0.95; P=0.020).<br /><b>Conclusions</b><br />Black and Hispanic Connecticut patients with witnessed OHCA have lower rates of bystander CPR, attempted AED defibrillation, overall survival, and survival with favorable neurological outcomes compared to White patients. Minorities were less likely to receive bystander CPR in affluent and integrated communities.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 23 May 2023:109850; epub ahead of print</small></div>

<div><h4>The development of a risk-adjustment strategy to benchmark emergency medical service (EMS) performance in relation to out-of-hospital cardiac arrest in Australia and New Zealand.</h4><i>Howell S, Smith K, Finn J, Cameron P, ... Bray J, Aus-ROC OHCA Epistry Management Committee</i><br /><b>Introduction</b><br />The aim of this study was to develop a risk adjustment strategy, including effect modifiers, for benchmarking emergency medical service (EMS) performance for out-of-hospital cardiac arrest (OHCA) in Australia and New Zealand.<br /><b>Method</b><br />Using 2017-2019 data from the Australasian Resuscitation Outcomes Consortium (Aus-ROC) OHCA Epistry, we included adults who received an EMS attempted resuscitation for a presumed medical OHCA. Logistic regression was applied to develop risk adjustment models for event survival (return of spontaneous circulation at hospital handover) and survival to hospital discharge/30 days. We examined potential effect modifiers, and assessed model discrimination and validity.<br /><b>Results</b><br />Both OHCA survival outcome models included EMS agency and the Utstein variables (age, sex, location of arrest, witnessed arrest, initial rhythm, bystander cardiopulmonary resuscitation, defibrillation prior to EMS arrival, and EMS response time). The model for event survival had good discrimination according to the concordance statistic (0.77) and explained 28% of the variation in survival. The corresponding figures for survival to hospital discharge/30 days were 0.87 and 49%. The addition of effect modifiers did little to improve the performance of either model.<br /><b>Conclusion</b><br />The development of risk adjustment models with good discrimination is an important step in benchmarking EMS performance for OHCA. The Utstein variables are important in risk-adjustment, but only explain a small proportion of the variation in survival. Further research is required to understand what factors contribute to the variation in survival between EMS.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 19 May 2023:109847; epub ahead of print</small></div>

<div><h4>Protective positive psychology factors and emotional distress after cardiac arrest.</h4><i>Presciutti AM, Flickinger KL, Coppler PJ, Ratay C, ... Vranceanu AM, Elmer J</i><br /><b>Background</b><br />There is a critical need to identify factors that can prevent emotional distress post-cardiac arrest (CA). CA survivors have previously described benefitting from utilizing positive psychology constructs (mindfulness, existential well-being, resilient coping, social support) to cope with distress. Here, we explored associations between positive psychology factors and emotional distress post-CA.<br /><b>Methods</b><br />We recruited CA survivors treated from 4/2021-9/2022 at a single academic medical center. We assessed positive psychology factors (mindfulness [Cognitive and Affective Mindfulness Scale-Revised], existential well-being [Meaning in Life Questionnaire Presence of Meaning subscale], resilient coping [Brief Resilient Coping Scale], perceived social support [ENRICHD Social Support Inventory]) and emotional distress (posttraumatic stress [Posttraumatic Stress Checklist-5], anxiety and depression symptoms [PROMIS Emotional Distress - Anxiety and Depression Short Forms 4a]) just before discharge from the index hospitalization. We selected covariates for inclusion in our multivariable models based on an association with any emotional distress factor (p < 0.10). For our final, multivariable regression models, we individually tested the independent association of each positive psychology factor and emotional distress factor.<br /><b>Results</b><br />We included 110 survivors (mean age 59 years, 64% male, 88% non-Hispanic White, 48% low income); 36.4% of survivors scored above the cut-off for at least one measure of emotional distress. In separate adjusted models, each positive psychology factor was independently associated with emotional distress (β: -0.20 to -0.42, all p < 0.05).<br /><b>Conclusions</b><br />Higher levels of mindfulness, existential well-being, resilient coping, and perceived social support were each associated with less emotional distress. Future intervention development studies should consider these factors as potential treatment targets.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 17 May 2023:109846; epub ahead of print</small></div>

<div><h4>Prevalence and Geographic Features of Patients Eligible for Extracorporeal Cardiopulmonary Resuscitation.</h4><i>McCloskey C, Zeller J, Berk A, Patil N, ... Curtis A, Curtis J</i><br /><b>Objective</b><br />This study sought to identify Out of Hospital Cardiac Arrests (OHCA) eligible for Extracorporeal Cardiopulmonary Resuscitation (ECPR), use Geographic Information Systems (GIS) to investigate geographic patterns, and investigate if correlation between ECPR candidacy and Social Determinants of Health (SDoH) exist.<br /><b>Methods</b><br />This study is of emergency medical service (EMS) runs for OHCA to an urban medical center from January 1, 2016 to December 31, 2020. All runs were filtered to inclusion criteria for ECPR: age 18-65, initial shockable rhythm, and no return of spontaneous circulation within initial defibrillations. Address level data were mapped in a GIS. Cluster detection assessed for granular areas of high concentration. The Center for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI) was overlaid. The SVI ranges from 0-1 with higher values indicating increasing social vulnerability.<br /><b>Results</b><br />There were 670 EMS transports for OHCA during the study period. 12.7% (85/670) met inclusion criteria for ECPR. 90% (77/85) had appropriate addresses for geocoding. Three geographic clusters of events were detected. Two were residential areas and one was concentrated over a public use area of downtown Cleveland. The SVI for these locations was 0.79, indicative of high social vulnerability. Nearly half (32/77, 41.5%) occurred in neighborhoods with the highest level of social vulnerability (SVI ≥0.9).<br /><b>Conclusion</b><br />A significant proportion of OHCAs were eligible for ECPR based on prehospital criteria. Utilizing GIS to map and analyze ECPR patients provided insights into the locations of these events and the SDoH that may be driving risk in these places.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 17 May 2023:109837; epub ahead of print</small></div>

<div><h4>Emergency Medical Services Handoff of Patients in Cardiac Arrest in the Emergency Department: A Retrospective Video Review Study of Duration and Details of Handoff.</h4><i>Howell DM, Margius D, Li T, Cohen AL, ... Rolston DM, Jafari D</i><br /><b>Study objectives</b><br />We aimed to evaluate the duration and frequency of communication between EMS (Emergency Medical Services) and ED (Emergency Department) staff during handoff and the subsequent time to critical cardiac care (rhythm determination, defibrillation) using CA (cardiac arrest) video review.<br /><b>Methods</b><br />A single-center retrospective study of video-recorded adult CAs between August 2020 and December 2022 was performed. Two investigators assessed the communication of 17 data points, time intervals, EMS initiation of handoff, and type of EMS agency. Median times from initiation of handoff to first ED rhythm determination and defibrillation were compared between the groups above versus below the median number of data points communicated.<br /><b>Results</b><br />Overall, 95 handoffs were reviewed. The handoff was initiated in a median of 2 seconds (interquartile range (IQR) 0-10) after arrival. EMS initiated handoff in 65 (69.2%) patients. The median number of data points communicated was 9 and median duration was 66 seconds (IQR 50-100). Age, location of arrest, estimated down time, and medications administered were communicated >80% of the time, initial rhythm 79%, and bystander cardiopulmonary resuscitation and witnessed arrest <50%. The median times from initiation of handoff to first ED rhythm determination and defibrillation were 188 (IQR 106-256) and 392 (IQR 247-725) seconds, though not statistically different between handoffs with <9 vs. ≥9 data points communicated (p>0.40).<br /><b>Conclusion</b><br />There is no standardization for handoff reports from EMS to ED staff for CA patients. Using video review, we demonstrated the variable communication during handoff. Improvements to this process could reduce the time to critical interventions.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 15 May 2023:109834; epub ahead of print</small></div>

<div><h4>Resuscitation Preferences of Older Acutely Admitted Medical and Mentally Competent Patients with One and Six Months Follow-up.</h4><i>Hanson S, Lassen A, Nielsen D, Ryg J, Forero R, Brabrand M</i><br /><b>Aim</b><br />Determining patients\' cardiopulmonary resuscitation (CPR) preferences in the emergency department (ED) is common practice but the stability of these preferences and their recollection by patients has been questioned. Therefore, this study assessed the stability and recall of CPR preferences of older patients at and following ED discharge.<br /><b>Methods</b><br />This survey-based cohort study was conducted between February and September 2020 at three EDs in Denmark. It consecutively asked mentally competent patients aged 65 years or older who were admitted to hospital through the ED and then one and six months later \"In your current state of health, do you wish that physicians should try to intervene if your heart stops beating?\" Possible responses were confined to \"definitely yes\", \"definitely no\", \"uncertain\", and \"prefer not to answer\".<br /><b>Results</b><br />In total, 3688 patients admitted to hospital via the ED patients were screened, 1766 were eligible and 491 (27.8%) were included: median age was 76 (IQR 71-82) years, and 257 (52.3%) were men. One third of patients who expressed definite yes or no preferences in ED had changed their preference at one month follow-up. Only 90 (27.4%) and 94 (35.7%) patients recalled their preferences at one and six months follow-up, respectively.<br /><b>Conclusion</b><br />and Relevance In this study, one-in-three older ED patients who initially expressed definite resuscitation preferences had changed their minds at one month follow-up. Preferences were more stable at six months but only a minority were able to recall their preferences.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 15 May 2023:109836; epub ahead of print</small></div>

<div><h4>Immediate skin-to-skin contact versus care under radiant warmer at birth in moderate to late preterm neonates- A randomized controlled trial.</h4><i>Singh K, Chawla D, Jain S, Khurana S, Takkar N</i><br /><b>Objective</b><br />To compare the effect of immediate care at birth in skin-to-skin contact (SSC) or under a radiant warmer on cardiorespiratory stability at 60 minutes of age in moderate-to-late preterm neonates.<br /><b>Methods</b><br />In this open-label, parallel-group, randomized controlled trial, neonates born at 33<sup>0/7</sup> to 36<sup>6/7</sup> weeks of gestation by vaginal delivery and breathing or crying were randomized to receive care at birth in SSC (n=50) or under a radiant warmer (n=50). In the SSC group, immediate care at birth including drying and clearing of the airway in SSC over the mother\'s abdomen. SSC was maintained for an observational period of 60 minutes after birth. In the radiant warmer group, care at birth and post-birth observation was performed under an overhead radiant warmer. The primary outcome of the study was the stability of the cardio-respiratory system in late preterm infants (SCRIP) score at 60 minutes of age.<br /><b>Results</b><br />Baseline variables were similar in the two study groups. The SCRIP score at 60 minutes of age was similar in the two study groups (median: 5.0, IQR: 5-6 vs. 5.0, 5-6). The mean axillary temperature at 60 minutes of age was significantly lower in the SSC group (<sup>o</sup>C; 36.4±0.4 vs. 36.6±0.4, P=0.004).<br /><b>Conclusion</b><br />It was feasible to provide immediate care at birth in moderate and late preterm neonates while being positioned in SSC with the mother. However, in comparison to care under a radiant warmer, this did not lead to better cardiorespiratory stability at 60 minutes of age.<br /><b>Trial registration</b><br />Clinical Trial Registry of India (CTRI/2021/09/036730).<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 15 May 2023:109840; epub ahead of print</small></div>

<div><h4>Association between the relationship of bystander and neurologic recovery in pediatric out-of-hospital cardiac arrest.</h4><i>Whan Jung S, Hong Kim K, Ho Park J, Han Kim T, ... Jun Song K, Do Shin S</i><br /><b>Aim</b><br />This study aimed to evaluate whether the relationship between bystanders and victims is associated with neurological outcomes in paediatric out-of-hospital cardiac arrest (OHCA).<br /><b>Methods</b><br />This cross-sectional, retrospective, observational study included patients with non-traumatic paediatric OHCA undergoing emergency medical service treatment between 2014 and 2021. The relationship between bystanders and patients was categorized into first responder, family, and layperson groups. The primary outcome was good neurological recovery. Further sensitivity analyses were conducted subcategorizing the cohort into four groups: first responder, family, friends or colleagues, and layperson, or two groups: family and non-family.<br /><b>Results</b><br />We analysed 1,451 patients. OHCAs in the family group showed lower rate of good neurological outcomes regardless of witness status: 29.4%, 12.3%, and 38.6% in the first responder, family, and layperson groups in the witnessed and 6.7%, 2.0%, and 7.3% in the unwitnessed cohort. Multivariable logistic regression yielded no significant differences between the three groups: the adjusted odds ratios (AOR) and 95% confidence interval (CI) were 0.57 (0.28-1.15) in the family and 1.18 (0.61-2.29) in the layperson compared to the first responder group. The sensitivity analysis yielded a higher probability of good neurologic recovery in the non-family compared to the family member bystander group in witnessed cohort (AOR, 1.96; 95% CI, 1.17-3.30).<br /><b>Conclusion</b><br />Paediatric OHCAs had no significant difference between good neurological recovery and the relationship of bystander.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 15 May 2023:109839; epub ahead of print</small></div>

<div><h4>The Impact Of BMI On Arrest Characteristics and Survival of Patients with Out-Of-Hospital Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation.</h4><i>Kosmopoulos M, Kalra R, Alexy T, Gaisendrees C, ... Bartos JA, Yannopoulos D</i><br /><b>Aim</b><br />To assess the impact of body mass index (BMI) on survival to hospital discharge of patients presenting with refractory ventricular fibrillation treated with extracorporeal cardiopulmonary resuscitation. We hypothesize that due to limitations in pre-hospital care delivery, people with high BMI have worse survival after prolonged resuscitation and ECPR.<br /><b>Methods</b><br />This study is a retrospective single-centre study that included patients suffering refractory VT/VF OHCA from December 2015 to October 2021 and had a BMI calculated at hospital admission. We compared the baseline characteristics and survival between patients with obesity (>30 kg/m<sup>2</sup>) and those without (≤30kg/m<sup>2</sup>).<br /><b>Results</b><br />Two-hundred eighty-three patients were included in this study, and two-hundred twenty-four required mechanical support with veno-arterial extracorporeal cardiopulmonary membrane oxygenation (VA ECMO). Patients with BMI >30 (n = 133) had significantly prolonged CPR duration compared to their peers with BMI ≤30kg/m<sup>2</sup> (n = 150) and were significantly more likely to require support with VA ECMO (85.7% vs 73.3%, p = 0.015). Survival to hospital discharge was significantly higher in patients with BMI≤30 kg/m<sup>2</sup> (48% vs. 29.3%, p <0.001). BMI was an independent predictor of mortality in a multivariable logistic regression analysis. The four-year mortality rate was low and not significantly different between the two groups (p=0.32).<br /><b>Conclusion</b><br />ECPR yields clinically meaningful long-term survival in patients with BMI>30kg/m<sup>2</sup>. However, the resuscitation time is significantly prolonged, and the overall survival significantly lower compared to patients with BMI≤30 kg/m<sup>2</sup>. ECPR should, therefore, not be withheld for this population, but faster transport to an ECMO capable centre is mandated to improve survival to hospital discharge.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 15 May 2023:109842; epub ahead of print</small></div>

<div><h4>Temporarily Removed.</h4><i></i><br /><b>Results</b><br />Schoolchildren are highly motivated to learn basic life support. The CHECK-CALL-COMPRESS algorithm is recommended for all schoolchildren. Regular training in basic life support regardless of age consolidates long-term skills. Young children from 4 years of age are able to assess the first links in the chain of survival. By 10 to 12 years of age, effective chest compression depths and ventilation volumes can be achieved on training manikins. A combination of theoretical and practical training is recommended. Schoolteachers serve as effective basic life support instructors. Schoolchildren also serve as multipliers by passing on basic life support skills to others. The use of age-appropriate social media tools for teaching is a promising approach for schoolchildren of all ages.<br /><b>Conclusions</b><br />Schoolchildren basic life support training has the potential to educate whole generations to respond to cardiac arrest and to increase survival after out-of-hospital cardiac arrest. Comprehensive legislation, curricula, and scientific assessment are crucial to further develop the education of schoolchildren in basic life support.<br /><br />Copyright © 2023 American Heart Association, Inc., International Liaison Committee on Resuscitation, European Resuscitation Council. Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 15 May 2023:109772; epub ahead of print</small></div>

<div><h4>Lower versus higher oxygenation targets in hypoxaemic ICU patients after cardiac arrest.</h4><i>Crescioli E, Lass Klitgaard Klitgaard T, Perner A, Lilleholt Schjørring O, Steen Rasmussen B</i><br /><b>Aim</b><br />To investigate the effects of lower versus higher oxygenation targets in adult intensive care unit (ICU) patients with hypoxaemic respiratory failure after cardiac arrest.<br /><b>Methods</b><br />Subgroup analysis of the international Handling Oxygenation Targets in the ICU (HOT-ICU) trial which randomised 2928 adults with acute hypoxaemia to targets of arterial oxygenation of 8 kPa or 12 kPa in the ICU for up to 90 days. Here, we report all outcomes up to one year in the subgroup of patients enrolled after cardiac arrest.<br /><b>Results</b><br />The HOT-ICU trial included 335 patients after cardiac arrest: 149 in the lower-oxygenation group and 186 in the higher-oxygenation group. At 90 days, 96/147 patients (65.3%) in the lower-oxygenation group and 111/185 patients (60.0%) in the higher-oxygenation group had died (adjusted relative risk (RR) 1.09, 95% confidence interval (CI) 0.92-1.28, p=0.32); similar results were found at one year (adjusted RR 1.05, 95% CI 0.90-1.21, p=0.53). Serious adverse events (SAEs) in the ICU occurred in 23% of patients in the lower-oxygenation group and 38% in the higher-oxygenation group (adjusted RR 0.61, 95% CI 0.43-0.86, p=0.005); the difference was mainly due to more new episodes of shock in the higher-oxygenation group. No statistically significant differences were observed in other secondary outcomes.<br /><b>Conclusion</b><br />A lower oxygenation target in adult ICU patients with hypoxaemic respiratory failure after cardiac arrest did not result in lower mortality, but fewer SAEs occurred in this group compared to the higher-oxygenation group. All analyses are exploratory only, large-scale trials are needed for confirmation.<br /><b>Clinical trial registry</b><br />Clinicaltrials.gov number NCT03174002 (registered May 30, 2017); EudraCT 2017-000632-34 (registered February 14, 2017).<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 15 May 2023:109838; epub ahead of print</small></div>

<div><h4>Cognition, emotional state, and quality of life of survivors after cardiac arrest with rhythmic and periodic EEG patterns.</h4><i>van Gils PCW, Ruijter BJ, Bloo RJK, van Putten MJAM, ... Hofmeijer J, TELSTAR investigators</i><br /><b>Aim</b><br />Rhythmic and periodic patterns (RPPs) on the electroencephalogram (EEG) in comatose patients after cardiac arrest have been associated with high case fatality rates. A good neurological outcome according to the Cerebral Performance Categories (CPC) has been reported in up to 10% of cases. Data on cognitive, emotional, and quality of life outcomes are lacking. We aimed to provide insight into these outcomes at one-year follow-up.<br /><b>Methods</b><br />We assessed outcome of surviving comatose patients after cardiac arrest with RPPs included in the \'treatment of electroencephalographic status epilepticus after cardiopulmonary resuscitation\' (TELSTAR) trial at one-year follow-up, including the CPC for functional neurological outcome, a cognitive assessment, the hospital anxiety and depression scale (HADS) for emotional outcomes, and the 36-item short-form health survey (SF-36) for quality of life. Cognitive impairment was defined as a score of more than 1.5 SD below the mean on ≥ 2 (sub)tests within a cognitive domain.<br /><b>Results</b><br />Fourteen patients were included (median age 58 years, 21% female), of whom 13 had a cognitive impairment. Eleven of 14 were impaired in memory, 9/14 in executive functioning, and 7/14 in attention. The median scores on the HADS and SF-36 were all worse than expected. Based on the CPC alone, 8/14 had a good outcome (CPC 1-2).<br /><b>Conclusion</b><br />Nearly all cardiac arrest survivors with RPPs during the comatose state have cognitive impairments at one-year follow-up. The incidence of anxiety and depression symptoms seem relatively high and quality of life relatively poor, despite \'good\' outcomes according to the CPC.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 12 May 2023:109830; epub ahead of print</small></div>

<div><h4>Electrocardiographic Characteristics Fail to Predict Acute Coronary Occlusions in Out-of-Hospital Cardiac-Arrest Patients Without ST-Segment Elevation.</h4><i>Leeper B, Kern KB, Liu S, Sun X</i><br /><b>Background</b><br />A minority of out-of-hospital cardiac arrest patients have an acutely occluded coronary artery without manifesting ST-segment elevation on their post-resuscitation ECG. Identifying such patients is an issue to providing timely reperfusion therapy. We aimed to evaluate the usefulness of the initial post-resuscitation electrocardiogram in out-of-hospital-cardiac-arrest patients for selection to perform early coronary angiography.<br /><b>Methods</b><br />The study population consisted of 74 of the 99 randomized patients from the PEARL clinical trial with both ECG and angiographic data. The purpose of this study was to investigate initial post-resuscitation electrocardiogram findings from out-of-hospital cardiac arrest patients without ST-segment elevation for any association with the presence of acute coronary occlusions. Secondarily, we aimed to observe the distribution of abnormal electrocardiogram findings and survival to hospital discharge of subjects.<br /><b>Results</b><br />Initial post-resuscitation electrocardiogram findings, including ST-depression, T-wave inversion, bundle branch block, non-specific changes, were not associated with the presence of an acutely occluded coronary. Normal post-resuscitation electrocardiogram findings were associated with patient survival to hospital discharge but were not associated with the presence or absence of an acute coronary occlusion.<br /><b>Conclusions</b><br />Electrocardiogram findings cannot exclude or identify the presence of an acutely occluded coronary in out-of-hospital-cardiac-arrest patients without ST-segment elevation. An acutely occluded coronary may be present regardless of normal electrocardiogram findings.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 11 May 2023:109826; epub ahead of print</small></div>

<div><h4>What is the potential benefit of pre-hospital extracorporeal cardiopulmonary resuscitation for patients with an out-of-hospital cardiac arrest? A predictive modelling study.</h4><i>Vos IA, Deuring E, Kwant M, Bens BWJ, ... Singer B, Ter Avest E</i><br /><b>Aim</b><br />In this predictive modelling study we aimed to investigate how many patients with an out-of-hospital cardiac arrest (OHCA) would benefit from pre-hospital as opposed to in-hospital initiation of extracorporeal cardiopulmonary resuscitation (ECPR).<br /><b>Methods</b><br />A temporal spatial analysis of Utstein data was performed for all adult patients with a non-traumatic OHCA attended by three emergency medical services (EMS) covering the north of the Netherlands during a one-year period. Patients were considered potentially eligible for ECPR if they had a witnessed arrest with immediate bystander CPR, an initial shockable rhythm (or signs of life during resuscitation) and could be presented in an ECPR-centre within 45 minutes of the arrest. Endpoint of interest was defined as the hypothetical number of ECPR eligible patients after 10, 15 and 20 minutes of conventional CPR and upon (hypothetical) arrival in an ECPR-centre as a fraction of the total number of OHCA patients attended by EMS.<br /><b>Results</b><br />During the study period 622 OHCA patients were attended, of which 200 (32%) met ECPR eligibility criteria upon EMS arrival. The optimal transition point between conventional CPR and ECPR was found to be after 15 minutes. Hypothetical intra-arrest transport of all patients in whom no return of spontaneous circulation (ROSC) was obtained after that point (n=84) would have yielded 16/622 (2.5%) patients being potentially ECPR eligible upon hospital arrival (average low-flow time 52 minutes), whereas on-scene initiation of ECPR would have resulted in 84/622 (13.5%) potential candidates (average estimated low-flow time 24 minutes before cannulation).<br /><b>Conclusion</b><br />Even in healthcare systems with relatively short transport distances to hospital, consideration should be given to pre-hospital initiation of ECPR for OHCA as it shortens low-flow time and increases the number of potentially eligible patients.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 11 May 2023:109825; epub ahead of print</small></div>

<div><h4>Resuscitation Quality Improvement® (RQI®) HeartCode® Complete Program Improves Chest Compression Rate in Real World Out-of Hospital Cardiac Arrest Patients.</h4><i>Li T, Essex K, Ebert D, Levinsky B, ... Berkowitz J, Chakraborty P</i><br /><b>Background</b><br />The Resuscitation Quality Improvement® (RQI®) HeartCode© Complete program is designed to enhance cardiopulmonary resuscitation (CPR) training by using real-time feedback manikins. Our objective was to assess the quality of CPR, such as chest compression rate, depth, and fraction, performed on out-of-hospital cardiac arrest (OHCA) patients among paramedics trained with the RQI program vs. paramedics who were not.<br /><b>Methods and results</b><br />Adult OHCA cases from 2021 were analyzed; 353 OHCA cases were classified into one of three groups: 1) 0 RQI®-trained paramedics, 2) 1 RQI®-trained paramedic, and 3) 2-3 RQI®-trained paramedics. We reported the median of the average compression rate, depth, and fraction, as well as percent of compressions that were between 100 to 120/minute and percent of compressions that were 2.0 to 2.4 inches deep. Kruskal-Wallis Tests were used to assess differences in these metrics across the three groups of paramedics. Of 353 cases, the median of the average compression rate/minute among crews with 0, 1, and 2-3 RQI®-trained paramedics was 130, 125, and 125, respectively (p=0.0032). Median percent of compressions between 100 to 120 compressions/minute was 10.3%, 19.7%, and 20.1% among crews with 0, 1, and 2-3 RQI®-trained paramedics, respectively (p=0.0010). Median of the average compression depth was 1.7 inches across all three groups (p=0.4881). Median compression fraction was 86.4%, 84.6%, and 85.5% among crews with 0, 1, and 2-3 RQI-trained paramedics, respectively (p=0.6371).<br /><b>Conclusions</b><br />RQI® training was associated with statistically significant improvement in chest compression rate, but not improved chest compression depth or fraction in OHCA.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 11 May 2023:109833; epub ahead of print</small></div>

<div><h4>Validation of the rCAST Score and Comparison to the PCAC and FOUR Scores for Prognostication after Out-of-Hospital Cardiac Arrest.</h4><i>Kim N, Kitlen E, Garcia G, Khosla A, ... Gilmore EJ, Beekman R</i><br /><b>Aim</b><br />Early, accurate outcome prediction after out-of-hospital cardiac arrest (OHCA) is critical for clinical decision-making and resource allocation. We sought to validate the revised post-Cardiac Arrest Syndrome for Therapeutic hypothermia (rCAST) score in a United States cohort and compare its prognostic performance to the Pittsburgh Cardiac Arrest Category (PCAC) and Full Outline of UnResponsiveness (FOUR) scores.<br /><b>Methods</b><br />This is a single-center, retrospective study of OHCA patients admitted between January 2014-August 2022. Area under the receiver operating curve (AUC) was computed for each score for predicting poor neurologic outcome at discharge and in-hospital mortality. We compared the scores\' predictive abilities via Delong\'s test.<br /><b>Results</b><br />Of 505 OHCA patients with all scores available, the medians [IQR] for rCAST, PCAC, and FOUR scores were 9.5 [6.0, 11.5], 4 [3,4], and 2 [0, 5], respectively. The AUC [95% confidence interval] of the rCAST, PCAC, and FOUR scores for predicting poor neurologic outcome were 0.815 [0.763 - 0.867], 0.753 [0.697 - 0.809], and 0.841 [0.796 - 0.886], respectively. The AUC [95% confidence interval] of the rCAST, PCAC, and FOUR scores for predicting mortality were 0.799 [0.751 - 0.847], 0.723 [0.673 - 0.773], and 0.813 [0.770 - 0.855], respectively. The rCAST score was superior to the PCAC score for predicting mortality (p=0.017). The FOUR score was superior to the PCAC score for predicting poor neurological outcome (p<0.001) and mortality (p<0.001).<br /><b>Conclusion</b><br />The rCAST score can reliably predict poor outcome in a United States cohort of OHCA patients regardless of TTM status and outperforms the PCAC score.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 11 May 2023:109832; epub ahead of print</small></div>

<div><h4>Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest; The effect on post-intervention serum concentrations of sedatives and analgesics and time to awakening.</h4><i>Annborn M, Ceric A, Borgquist O, During J, Moseby-Knappe M, Lybeck A</i><br /><b>Background</b><br />This study investigated the association of two levels of targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) with administered doses of sedative and analgesic drugs, serum concentrations, and the effect on time to awakening.<br /><b>Methods</b><br />This substudy of the TTM2-trial was conducted at three centers in Sweden, with patients randomized to either hypothermia or normothermia. Deep sedation was mandatory during the 40-hour intervention. Blood samples were collected at the end of TTM and end of protocolized fever prevention (72 hours). Samples were analysed for concentrations of propofol, midazolam, clonidine, dexmedetomidine, morphine, oxycodone, ketamine and esketamine. Cumulative doses of administered sedative and analgesic drugs were recorded.<br /><b>Results</b><br />Seventy-one patients were alive at 40 hours and had received the TTM-intervention according to protocol. 33 patients were treated at hypothermia and 38 at normothermia. There were no differences between cumulative doses and concentration and of sedatives/analgesics between the intervention groups at any timepoint. Time until awakening was 53 hours in the hypothermia group compared to 46 hours in the normothermia group (p=0.09).<br /><b>Conclusion</b><br />This study of OHCA patients treated at normothermia versus hypothermia found no significant differences in dosing or concentration of sedatives or analgesic drugs in blood samples drawn at the end of the TTM intervention, or at end of protocolized fever prevention, nor the time to awakening.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 11 May 2023:109831; epub ahead of print</small></div>

<div><h4>Duration of cardiopulmonary resuscitation and phenotype of post-cardiac arrest brain injury.</h4><i>Coppler PJ, Elmer J, Doshi A, Guyette FX, ... University of Pittsburgh PostCardiac Arrest, Service</i><br /><b>Background</b><br />Patients resuscitated from cardiac arrest have variable severity of primary hypoxic ischemic brain injury (HIBI). Signatures of primary HIBI on brain imaging and electroencephalography (EEG) include diffuse cerebral edema and burst suppression with identical bursts (BSIB). We hypothesize distinct phenotypes of primary HIBI are associated with increasing cardiopulmonary resuscitation (CPR) duration.<br /><b>Methods</b><br />We identified from our prospective registry of both in-and out-of-hospital CA patients treated between January 2010 to January 2020 for this cohort study. We abstracted CPR duration, neurological examination, initial brain computed tomography gray to white ratio (GWR), and initial EEG pattern. We considered four phenotypes on presentation: awake; comatose with neither BSIB nor cerebral edema (non-malignant coma); BSIB; and cerebral edema (GWR ≤ 1.20). BSIB and cerebral edema were considered as non-mutually exclusive outcomes. We generated predicted probabilities of brain injury phenotype using localized regression.<br /><b>Results</b><br />We included 2,440 patients, of whom 545 (23%) were awake, 1,065 (44%) had non-malignant coma, 548 (23%) had BSIB and 438 (18%) had cerebral edema. Only 92 (4%) had both BSIB and edema. Median CPR duration was 16 [IQR 8-28] minutes. Median CPR duration increased in a stepwise manner across groups: awake 6 [3-13] minutes; non-malignant coma 15 [8-25] minutes; BSIB 21 [13-31] minutes; cerebral edema 32 [22-46] minutes. Predicted probability of phenotype changes over time.<br /><b>Conclusions</b><br />Brain injury phenotype is related to CPR duration, which is a surrogate for severity of HIBI. The sequence of most likely primary HIBI phenotype with progressively longer CPR duration is awake, coma without BSIB or edema, BSIB, and finally cerebral edema.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 08 May 2023:109823; epub ahead of print</small></div>

<div><h4>EEG in a four-electrode frontotemporal montage reliably predicts outcome after cardiac arrest.</h4><i>Admiraal MM, van Merkerk M, Horn J, Koelman JHTM, ... Hoedemaekers CW, van Rootselaar AF</i><br /><b>Aim</b><br />To increase efficiency of continuous EEG monitoring for prognostication of neurological outcome in patients after cardiac arrest, we investigated the reliability of EEG in a four-electrode frontotemporal (4-FT) montage, compared to our standard nine-electrode (9-EL) montage.<br /><b>Methods</b><br />EEG recorded with Ag/AgCl cup-electrodes at 12 and/or 24h after cardiac arrest of 153 patients was available from a previous study. 220 EEG epochs of 5 minutes were reexamined in a 4-FT montage according to the ACNS criteria. <br /><b>Background:</b><br/>classification was compared to the available 9-EL classification using Cohens kappa. Reliability for prognostication was assessed in 151 EEG epochs at 24h after CA using sensitivity and specificity for prediction of poor (cerebral performance categories (CPC) 3-5) and good (CPC 1-2) neurological outcome.<br /><b>Results</b><br />Agreement for EEG background classification between the two montages was substantial with a kappa of 0.85 (95%-CI 0.81-0.90). Specificity for prediction of poor outcome was 100% (95%-CI 95-100) for both montages, sensitivity was 31% (95%-CI 21-43) for the 4-FT montage and 35% (95%-CI 24-47) for the 9-EL montage. Good outcome was predicted with 65% specificity (95%-CI 53-76) and 81% sensitivity (95%-CI 71-89) for the 4-FT montage, similar to the 9-EL montage.<br /><b>Conclusion</b><br />In this cohort, EEG background patterns determined in a four-electrode frontotemporal montage predict both poor and good outcome after CA with similar reliability. Our results may contribute to decreasing the workload of EEG monitoring in patients after CA without compromising reliability of outcome prediction. However, validation in a larger cohort is necessary, as is a multimodal approach.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 08 May 2023:109817; epub ahead of print</small></div>

<div><h4>Quantifying physician\'s bias to terminate resuscitation. The TERMINATOR Study.</h4><i>Laurenceau T, Marcou Q, Agostinucci JM, Martineau L, ... Adnet F, Lapostolle F</i><br /><b>Unlabelled</b><br />Context Deciding on \"termination of resuscitation\" (TOR) is a dilemma for any physician facing cardiac arrest. Due to the lack of evidence-based criteria and scarcity of the existing guidelines, crucial arbitration to interrupt resuscitation remains at the practitioner\'s discretion.<br /><b>Aim</b><br />Evaluate with a quantitative method the existence of a physician internal bias to terminate resuscitation.<br /><b>Method</b><br />We extracted data concerning OHCAs managed between January 2013 and September 2021 from the RéAC registry. We conducted a statistical analysis using generalized linear mixed models to model the binary TOR decision. Utstein data were used as fixed effect terms and a random effect term to model physicians personal bias towards TOR.<br /><b>Results</b><br />5,144 OHCAs involving 173 physicians were included. The cohort\'s average age was 69 (SD 18) and was composed of 62% of women. Median no-flow and low-flow times were respectively 6 (IQR [0,12]) and 18 (IQR [10,26]) minutes. Our analysis showed a significant (p<0.001) physician effect on TOR decision. Odds ratio for the \"doctor effect\" was 2.48 [2.13-2.94] for a doctor one SD above the mean, lower than that of dependency for activities of daily living (41.18 [24.69-65.50]), an age of more than 85 years (38.60 [28.67-51.08]), but higher than that of oncologic, cardiovascular, respiratory disease or no-flow duration between 10 to 20 minutes (1.60 [1.26-2.00]).<br /><b>Conclusions</b><br />We demonstrate the existence of individual physician biases in their decision about TOR. The impact of this bias is greater than that of a no-flow duration lasting ten to twenty minutes. Our results plead in favor developing tools and guidelines to guide physicians in their decision.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 05 May 2023:109818; epub ahead of print</small></div>

<div><h4>Associations between comorbidity and health-related quality of life among in-hospital cardiac arrest survivors - A cross-sectional nationwide registry study.</h4><i>Israelsson J, Koistinen L, Årestedt K, Rooth M, Bremer A</i><br /><b>Aim</b><br />The aim of this study was to explore associations between comorbidities and health-related quality of life (HRQoL) among in-hospital cardiac arrest (IHCA) survivors.<br /><b>Methods</b><br />This registry study is based on data from the Swedish Registry of Cardiopulmonary Resuscitation (SRCR) collected during 2014-2017. HRQoL was assessed using the EQ-5D-5L, the EQ Visual Analogue Scale (EQ VAS) and the Hospital Anxiety and Depression Scale (HADS). In total, 1,278 IHCA survivors were included in the study, 3-6 months after the cardiac arrest (CA). Data were analyzed with descriptive and inferential statistics. The comorbidities analysed in this study were the patients\' status for diabetes, previous myocardial infarction, previous stroke, respiratory insufficiency, and heart failure.<br /><b>Results</b><br />Overall, the IHCA survivors reported high levels of HRQoL, but there was great variation within the population, e.g., EQ VAS median (q1-q3)=70 (50-80). Survivors with one or more comorbidities reported worse HRQoL in 6 out of 8 outcomes (p<0.001). All studied comorbidities were each associated with worse HRQoL, but no comorbidity was associated with every outcome measure. Previous stroke and respiratory insufficiency were significantly associated with every outcome measure except for HADS Anxiety. The linear regression models explained 4-8 % of the total variance in HRQoL (p<0.001).<br /><b>Conclusion</b><br />Since IHCA survivors with comorbidities report worse HRQoL compared to those without comorbidities, it is important to pay directed attention to them when developing and providing post-CA care, especially in those with respiratory insufficiency and previous stroke.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 05 May 2023:109822; epub ahead of print</small></div>

<div><h4>The implementation of a real time early warning system using machine learning in an Australian hospital to improve patient outcomes.</h4><i>Bassin L, Raubenheimer J, Bell D</i><br /><b>Background</b><br />Early Warning Scores (EWS) monitor inpatient deterioration predominantly using vital signs. We evaluated inpatient outcomes after implementing an Artificial Intelligence (AI) based intervention in our local EWS.<br /><b>Methods</b><br />A prior study calculated a Deterioration Index (DI) with logistic regression utilising demographics, vital signs, and laboratory results at multiple time points to predict any major adverse event (MAE-all cause mortality, ICU admission, or medical emergency team activation). The current study is a single hospital, pre-post study in Australia comparing the DI plus the existing EWS (Between the Flags-BTF) to only BTF. Data were collected on all eligible inpatients (≥ 16 years, admitted ≥ 24 hours, in general non-palliative wards). Controls were inpatients in the same hospital between January and December 2019. The DI was integrated into the electronic medical record and alerts were sent to senior ward nurse phones (July 2020 -April 2021).<br /><b>Results</b><br />We enrolled 28,639 patients (median age 73 years, IQR:60-83) with 52.3% female. The intervention and control groups did not show any statistically significant differences apart from reduced admissions via the emergency department in the intervention group (40.4% vs 41.6%, P=0.03). Risk for an MAE was lower in intervention than control (RR: 0.81; 95%CI: 0.74-0.89). Length of hospital stay was significantly reduced in the intervention group (3.74 days, IQR 1.84-7.26) compared to the control group (3.86 days, IQR 1.86-7.86, P=0.002) <br /><b>Conclusions:</b><br/>Implementing the DI in one hospital in Australia was associated with some improved patient outcomes. Future RCTs are needed for further validation.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 05 May 2023:109821; epub ahead of print</small></div>

<div><h4>Association Between Bystander Physical Limitations, Delays in Chest Compression During Telecommunicator-Assisted Cardiopulmonary Resuscitation, and Outcome After Out-of-Hospital Cardiac Arrest.</h4><i>Missel AL, Drucker CJ, Kume K, Shin J, ... Kudenchuk PJ, Rea T</i><br /><b>Background</b><br />Promptly initiated bystander cardiopulmonary resuscitation (CPR) improves survival from out-of-hospital cardiac arrest (OHCA). Many OHCA patients require repositioning to a firm surface. We examined the association between repositioning, chest compression (CC) delay, and patient outcomes.<br /><b>Methods</b><br />We used a quality improvement registry from review of 9-1-1 dispatch audio recordings of OHCA among adults eligible for telecommunicator-assisted CPR (T-CPR) between 2013 and 2021. OHCA was categorized into 3 groups: CC not delayed, CC delayed due to bystander physical limitations to reposition the patient, or CC delayed for other (non-physical) reasons. The primary outcome was the repositioning interval, defined as the interval between the start of positioning instructions and CC onset. We used logistic regression to assess the odds ratio of survival according to CPR group, adjusting for potential confounders.<br /><b>Results</b><br />Of the 3,482 OHCA patients eligible for T-CPR, CPR was not delayed in 1,223 (35%), delayed due to repositioning in 1,413 (41%), and delayed for other reasons in 846 (24%). The repositioning interval was longest for the physical limitation delay group (137 secs, IQR-148) compared to the other delay group (81 secs, IQR-70) and the no delay group (51 secs, IQR-32) (p<0.001). Unadjusted survival was lowest in the physical limitation delay group (11%) versus the no delay (17%) and other delay (19%) groups and persisted after adjustment (p =0.009).<br /><b>Conclusion</b><br />Bystander physical limitations are a common barrier to repositioning patients to begin CPR and are associated with lower likelihood of receiving CPR, longer times to begin CC, and lower survival.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 03 May 2023:109816; epub ahead of print</small></div>

<div><h4>Reply to Letter: Merigo et al., \"De trop\" meta-analyses and systematic reviews in cardiopulmonary resuscitation - a way to rapidly improve authors\' citation index at a price of real science.</h4><i>Daniel Patterson P, Yealy DM</i><br /><AbstractText>Reply to Letter: Merigo et al., \"De trop\" meta-analyses and systematic reviews in cardiopulmonary resuscitation - a way to rapidly improve authors\' citation index at a price of real science Merigo and colleagues argue that the meta-analyses and systematic reviews published in scientific journals in recent years is excessive, and that the primary goal is often more author-centric rather than to advance science. We agree that author benefits are not trivial, but some are foundational and important, especially for trainees. Trainees learn how to judge the quality of published evidence and create a comprehensive understanding in a selected topic, allowing for skill acquisition and a strong base for later work. This can stoke a future career and better insights by many, starting with the people who create these pieces.</AbstractText><br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 28 Apr 2023:109815; epub ahead of print</small></div>

<div><h4>A retrospective comparison of the King Laryngeal Tube and iGel supraglottic airway devices: a study for the CARES surveillance group.</h4><i>Smida T, Menegazzi J, Scheidler J, Martin PS, ... Bardes J, CARES Surveillance Group</i><br /><b>Objective</b><br />Supraglottic airway devices are increasingly used during the resuscitation of out-of-hospital cardiac arrest (OHCA) patients in the United States and worldwide. In this study, we aimed to compare the neurologic outcomes of OHCA patients managed with the King Laryngeal Tube (King LT) to the neurologic outcomes of patients managed with the iGel.<br /><b>Methods</b><br />We used the Cardiac Arrest Registry to Enhance Survival (CARES) public use research dataset for our analysis. Non-traumatic OHCA cases with attempted EMS resuscitation enrolled from 2013-2021 were included. We used two-level mixed effects multivariable logistic regression analyses with treating EMS agency as the random effect to determine the association between supraglottic airway device and outcome. The primary outcome was survival with a Cerebral Performance Category (CPC) score of 1 or 2 at discharge. Secondary outcomes included survival to hospital admission and survival to hospital discharge. Age, sex, calendar year of OHCA, initial ECG rhythm, witnessed status (unwitnessed, bystander witnessed, 9-1-1 responder witnessed), bystander CPR, response interval, and OHCA location (private/home, public, institutional) were used as covariables.<br /><b>Results</b><br />In comparison to use of the King LT, use of the iGel was associated with greater neurologically favorable survival (aOR: 1.45 [1.33, 1.58]). In addition, use of the iGel was associated with greater survival to hospital admission (1.07 [1.02, 1.12]) and survival to hospital discharge (1.35 [1.26, 1.46]).<br /><b>Conclusions</b><br />This study adds to the body of literature suggesting that use of the iGel during OHCA resuscitation is associated with better outcomes than use of the King LT.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 27 Apr 2023:109812; epub ahead of print</small></div>

<div><h4>Use of healthcare services before and after out-of-hospital cardiac arrest.</h4><i>Alm-Kruse K, Tjelmeland I, Reiner A, Kvåle R, Kramer-Johansen J</i><br /><b>Introduction</b><br />Knowledge about the use of healthcare services in patients experiencing out-of-hospital cardiac arrest (OHCA) is limited. We aimed to describe and compare the use of healthcare by OHCA survivors two years before and one year after cardiac arrest.<br /><b>Methods</b><br />Adult patients with OHCA of medical cause, who survived >30 days, were identified in the Norwegian Cardiac Arrest Registry. The Norwegian Patient Registry, The Cause of Death Registry, and The Norwegian Registry for Primary Healthcare provided data on survival and the use of healthcare services. We investigated the use of primary, specialist and mental healthcare, as well as rehabilitation services.<br /><b>Results</b><br />In 2015-2018, 13,112 OHCA cases were identified; 1435 (14%) patients survived >30 days (6.8/100,000 patients/year). The proportion of patients in the cohort that used primary healthcare each month increased form 43% before to 69% after OHCAto (p<0.001). We found a doubling of monthly healthcare contacts in both specialist healthcare (from 26% to 57%, p<0.001) and mental healthcare (from 3% to 8%, p>0.001). The observed increases in primary, specialist and mental healthcare use started two weeks, six months, and eight months before OHCA, respectively. Half of the patients had contact with primary healthcare services on the same day as the cardiac arrest. Two out of five patients were registered for rehabilitation after OHCA.<br /><b>Conclusion</b><br />The use of primary, specialist and mental healthcare services increased before OHCA and remained significantly higher the year after OHCA. Less than half of the patients surviving cardiac arrest were registered for rehabilitation.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 21 Apr 2023:109805; epub ahead of print</small></div>

<div><h4>Food choking incidents in the hospital: incidents, characteristics, effectiveness of interventions, and mortality and morbidity outcomes.</h4><i>Norii T, Igarashi Y, Akaiwa M, Yoshino Y, ... Sklar DP, Crandall C</i><br /><b>Aim</b><br />Foreign body airway obstruction (FBAO) due to food can occur wherever people eat, including in hospitals. We characterized in-hospital FBAO incidents and their outcomes.<br /><b>Methods</b><br />We searched the Japan Council for Quality Health Care nationwide in-hospital adverse events database for relevant events from 1,549 institutions. We included all patients with FBAO incidents due to food in the hospital from January 2010 to June 2021 and collected data on the characteristics, interventions, and outcomes. FBAO from non-food materials were excluded. Our primary outcomes were mortality and morbidity from FBAO incidents.<br /><b>Results</b><br />We identified 300 patients who had a FBAO incident from food. The most common age group was 80 - 89 years old (32.3%, n = 97/300). One-half (50.0%, n = 150/300) were witnessed events. Suction was the most common first intervention (31.3%, n = 94/300) and resulted in successful removal of foreign body in 17.0% of cases (n = 16/94). Back blows (16.0%, n = 48/300) and abdominal thrusts (8.1%, n = 24/300) were less frequently performed as the first intervention and the success rates were 10.4% (n = 5/48) and 20.8% (n = 5/24), respectively. About one-third of the patients (31%, n = 93/300) died and 26.7% (n = 80/300) had a high potential of residual disability from the incidents.<br /><b>Conclusion</b><br />FBAO from food in the hospital is an uncommon but life-threatening event. The majority of patients who suffered from the in-hospital FBAO incidents did not receive effective interventions initially and many of them died or suffered residual disability.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 21 Apr 2023:109806; epub ahead of print</small></div>

<div><h4>An unbroken ring of the chain of survival.</h4><i>Norii T, Igarashi Y</i><br /><AbstractText>This is a commentary on the study conducted by Kennedy et al. from Victoria, Australia, that analyzed the cohort of all adult EMS-witnessed out-of-hospital cardiac arrest (OHCA) patients in the region and compared patients treated during the COVID-19 period to a historical comparator period. The commentary summarizes the study findings and discusses the importance of the study in the context of the chain of survival and changes in airway management for OHCA patients during the COVID-19 pandemic.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 21 Apr 2023:109803; epub ahead of print</small></div>

<div><h4>Clinician-Reported Physiologic Monitoring of Cardiopulmonary Resuscitation Quality During Pediatric In-Hospital Cardiac Arrest: A Propensity-Weighted Cohort Study.</h4><i>Kienzle MF, Morgan RW, Alvey JS, Reeder R, ... Sutton RM, American Heart Association\'s Get With The Guidelines®-Resuscitation Investigators</i><br /><b>Aims</b><br />The primary objective was to determine the association between clinician-reported use of end-tidal CO2 (ETCO2) or diastolic blood pressure (DBP) to monitor cardiopulmonary resuscitation (CPR) quality during pediatric in-hospital cardiac arrest (pIHCA) and survival outcomes.<br /><b>Design</b><br />A retrospective cohort study was performed in two cohorts: 1) Patients with an invasive airway in place at the time of arrest to evaluate ETCO2 use, and 2) patients with an arterial line in place at the time of arrest to evaluate DBP use. The primary exposure was clinician-reported use of ETCO2 or DBP. The primary outcome was return of spontaneous circulation (ROSC). Propensity-weighted logistic regression evaluated the association between monitoring and outcomes.<br /><b>Setting</b><br />Hospitals reporting to the American Heart Association\'s Get With The Guidelines®- Resuscitation registry (2007-2021).<br /><b>Patients</b><br />Children with index IHCA with an invasive airway or arterial line at the time of arrest.<br /><b>Results</b><br />Between January 2007 and May 2021, there were 15,280 pediatric CPR events with an invasive airway or arterial line in place at the time of arrest. Of 7159 events with an invasive airway, 6829 were eligible for analysis. Of 2978 events with an arterial line, 2886 were eligible. Clinicians reported using ETCO2 in 1335/6829 (20%) arrests and DBP in 1041/2886 (36%). Neither exposure was associated with ROSC. ETCO2 monitoring was associated with higher odds of 24-hour survival (aOR 1.17 [1.02, 1.35], p = 0.03).<br /><b>Conclusions</b><br />Neither clinician-reported ETCO2 monitoring nor DBP monitoring during pIHCA were associated with ROSC. Monitoring of ETCO2 was associated with 24-hour survival.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 21 Apr 2023:109807; epub ahead of print</small></div>

<div><h4>Discrepancies in the late auditory potentials of post-anoxic patients: watch out for focal brain lesions, a pilot retrospective study.</h4><i>Lévi-Strauss J, Hmeydia G, Benzakoun J, Bouchereau E, ... Gavaret M, Pruvost-Robieux E</i><br /><b>Aims</b><br />Late auditory evoked potentials, and notably mismatch negativity (MMN) and P3 responses, can be used as part of the multimodal prognostic evaluation in post-anoxic disorders of consciousness (DOC). MMN response preferentially stems from the temporal cortex and the arcuate fasciculus. Situations with discrepant evaluations, for example MMN absent but P3 present, are frequent and difficult to interpret. We hypothesize that discrepant MMN-/P3+ results could reflect a higher prevalence of lesions in MMN generating regions. This study presents correlations between neurophysiological and neuroradiological results.<br /><b>Methods</b><br />This retrospective study was conducted on 38 post-anoxic DOC patients. Brain lesions were analyzed on 3T MRI both anatomically and through computation of the local arcuate fasciculus fractional anisotropy values on Diffusion Tensor Imaging sequences. Neurophysiological data and outcome were also analyzed.<br /><b>Results</b><br />Our cohort included 8 MMN-/P3+, 7 MMN+/P3+, 21 MMN-/P3- and 2 MMN-/P3+ patients, assessed at a median delay of 20.5 days since cardiac arrest. Our results show that MMN-/P3+ patients tended to have fewer temporal and basal ganglia lesions than MMN-/P3- patients, and more than MMN+/P3+ patients (p-values for trend: p=0.02 for temporal and p=0.02 for basal ganglia lesions). There was a statistical difference across groups for mean fractional anisotropy values in the arcuate fasciculus (p=0.008). The percentage of patients regaining consciousness at three months in MMN-/P3+ patients was higher than in MMN-/P3- patients and lower than in MMN+/P3+ patients.<br /><b>Conclusion</b><br />This study suggests that discrepancies in late auditory evoked potentials may be linked to focal post-anoxic brain lesions, visible on brain MRI.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 19 Apr 2023:109801; epub ahead of print</small></div>

<div><h4>Determinants of survival in sudden cardiac arrest manifesting with pulseless electrical activity.</h4><i>Holmstrom L, Chugh H, Uy-Evanado A, Salvucci A, ... Reinier K, Chugh SS</i><br /><b>Objective</b><br />The proportion of sudden cardiac arrests (SCA) manifesting with pulseless electrical activity (PEA) has increased significantly, and the survival rate remains lower than ventricular fibrillation (VF). However, a subgroup of PEA-SCA cases does survive and may yield key predictors of improved outcomes when compared to non-survivors. We aimed to identify key predictors of survival from PEA-SCA.<br /><b>Methods</b><br />Our study sample is drawn from two ongoing community-based, prospective studies of out-of-hospital SCA: Oregon SUDS from the Portland, OR metro area (Pop. approx. 1 million; 2002-2017) and Ventura PRESTO from Ventura County, CA (Pop. approx. 850,000, 2015-2021). For the present sub-study, we included SCA cases with PEA as the presenting rhythm where emergency medical services (EMS) personnel attempted resuscitation.<br /><b>Results</b><br />We identified 1,704 PEA-SCA cases, of which 173 (10.2%) were survivors and 1,531 (89.8%) non-survivors. Patients whose PEA-SCA occurred in a healthcare unit (16.9%) or public location (18.1%) had higher survival than those whose PEA-SCA occurred at home (9.3%) or in a care facility (5.7%). Young age, witness status, PEA-SCA location and pre-existing COPD/asthma were independent predictors of survival. Among witnessed cases the survival rate was 10% even if EMS response time was >10 minutes.<br /><b>Conclusions</b><br />Key determinants for survival from PEA-SCA were young age, witnessed status, public location and pre-existing COPD/asthma. Survival outcomes in witnessed PEA cases were better than expected, even with delayed EMS response.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 18 Apr 2023:109798; epub ahead of print</small></div>

<div><h4>Interaction between Bystander Sex and Patient Sex in Bystander Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrests.</h4><i>Lee G, Sun Ro Y, Ho Park J, Jeong Hong K, Jun Song K, Do Shin S</i><br /><b>Background</b><br />Bystander cardiopulmonary resuscitation (CPR) is a critical factor in improving out-of-hospital cardiac arrest (OHCA) survival. The aim of this study was to investigate the interaction effect of bystander sex and patient sex on the provision of bystander CPR.<br /><b>Methods</b><br />This was a retrospective cohort study using national OHCA registry in Korea. The inclusion criteria were adult bystander-witnessed OHCA patients with presumed cardiac etiology from January 2016 to December 2020. The primary outcome was the provision of bystander CPR. Multivariable logistic regression and interaction analysis were conducted to evaluate the impact of bystander sex on bystander CPR provision based on patient sex.<br /><b>Results</b><br />The study included 24,919 patients with OHCA, 58.2% with male-bystanders and 41.8% with female-bystanders. Female bystanders were less likely to perform bystander CPR than male bystanders (68.0% vs. 78.8%, adjusted OR (95% CI): 0.62 (0.58-0.66)). Among patients with CPR-trained bystanders, female bystanders had lower odds of bystander CPR (0.85 (0.73-0.97)). In the interaction analysis between bystander and patient sex, a significant difference was observed in the likelihood of bystander CPR according to the patient sex. Female bystanders had lower odds of bystander CPR than male bystanders for male patients (0.47 (0.43-0.50)). However, there were no significant differences between male and female bystanders for female patients (0.91 (0.88-1.07)).<br /><b>Conclusion</b><br />Female bystanders have a lower likelihood of providing bystander CPR than male bystanders. Additionally, an interaction was observed between bystander sex and patient sex in the providing bystander CPR, with the association being more pronounced in male OHCA patients.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 18 Apr 2023:109797; epub ahead of print</small></div>

<div><h4>\"De trop\" meta-analyses and systematic reviews in cardiopulmonary resuscitation - a way to rapidly improve authors\' citation index at a price of real science.</h4><i>Merigo G, Silvestri I, Magliocca A, Fumagalli F, Ristagno G</i><br /><AbstractText>Meta-analyses and systematic reviews (MSR) have been conceived as tools to summarize evidence on a specific health question. However, in the last years, an exaggerated number of MSRs published by scientific journals has been observed, i.e. 286 MSRs in the field of Resuscitation Science over the last 3 years, i.e. approximately 95 per year. Thus, doubts on the real scientific need of such a high number of MSRs may arise, potentially being only a way to rapidly improve authors\' citation index and fame and sometimes the journals\' impact factor.</AbstractText><br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 18 Apr 2023:109799; epub ahead of print</small></div>

<div><h4>Change of target temperature from 36°C to strict fever avoidance only in comatose cardiac arrest survivors - A before and after study.</h4><i>Tirkkonen J, Skrifvars MB</i><br /><b>Aim</b><br />The guidelines on temperature control for comatose cardiac arrest survivors were recently changed from recommending targeted temperature management (32-36°C) to fever control (≤37.7℃). We investigated the effect of implementing a strict fever control strategy on prevalence of fever, protocol adherence, and patient outcome in a Finnish tertiary academic hospital.<br /><b>Methods</b><br />Comatose cardiac arrest survivors treated with either mild device-controlled therapeutic hypothermia (≤36℃, years 2020-2021) or strict fever control (≤37℃, year 2022) for the first 36h were included in this before-after cohort study. Good neurological outcome was defined as a cerebral performance category score of 1-2.<br /><b>Results</b><br />The cohort consisted of 120 patients (≤36℃ group n=77, ≤37℃ group n=43). Cardiac arrest characteristics, severity of illness scores, and intensive care management including oxygenation, ventilation, blood pressure management and lactate remained similar between the groups. The median highest temperatures for the 36h sedation period were 36.3℃ (≤36℃ group) vs. 37.2℃ (≤37℃ group) (p<0.001). Time of the 36h sedation period spent >37.7℃ was 0.90% vs. 1.1% (p=0.496). External cooling devices were used in 90% vs. 44% of the patients (p<0.001). Good neurological outcome at 30 days was similar between the groups (47% vs. 44%, p=0.787). In multivariable model the ≤37℃ strategy was not associated with any change in outcome (OR 0.88, 95% CI 0.33-2.3).<br /><b>Conclusions</b><br />The implementation strict fever control strategy was feasible and did not result in increased prevalence of fever, poorer protocol adherence, or worse patient outcomes. Most patients in the fever control group did not require external cooling.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 12 Apr 2023:109796; epub ahead of print</small></div>

<div><h4>Determinants of health-related quality of life after out-of-hospital cardiac arrest (OHCA): A systematic review.</h4><i>Pin Pek P, Cheng Fan K, Eng Hock Ong M, Luo N, ... Lynn Lim S, Fuwah Ho A</i><br /><b>Objective</b><br />With a growing number of out-of-hospital cardiac arrest (OHCA) survivors globally, the focus of OHCA management has now broadened to survivorship. An outcome central to survivorship is health-related quality of life (HRQoL). This systematic review aimed to synthesise evidence related to the determinants of HRQoL of OHCA survivors.<br /><b>Methods</b><br />We systematically searched MEDLINE, Embase, and Scopus from inception to 15 August 2022 to identify studies investigating the association of at least one determinant and HRQoL in adult OHCA survivors. All articles were independently reviewed by two investigators. We abstracted data pertaining to determinants and classified them using a well-established HRQoL theoretical framework - the Wilson and Cleary (revised) model.<br /><b>Results</b><br />31 articles assessing a total of 35 determinants were included. Determinants were classified into the five domains in the HRQoL model. 26 studies assessed determinants related to individual characteristics (n=3), 12 studied biological function (n=7), nine studied symptoms (n=3), 16 studied functioning (n=5), and 35 studied characteristics of the environment (n=17). In studies that included multivariable analyses, most reported that individual characteristics (older age, female sex), symptoms (anxiety, depression), and functioning (impaired neurocognitive function) were significantly associated with poorer HRQoL.<br /><b>Conclusions</b><br />Individual characteristics, symptoms, and functioning played significant roles in explaining the variability in HRQoL. Significant non-modifiable determinants such as age and sex could be used to identify populations at risk of poorer HRQoL, while significant modifiable determinants such as psychological health and neurocognitive functioning could serve as targets for post-discharge screening and rehabilitation plans. PROSPERO registration number: CRD42022359303.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 12 Apr 2023:109794; epub ahead of print</small></div>

<div><h4>Drowning in the United States: Patient and Scene Characteristics using the novel CARES Drowning Variables.</h4><i>Ryan K, Bui MD, Johnson B, Eddens KS, Schmidt A, Ramos WD</i><br /><b>Introduction</b><br />Drowning results in more than 360,000 deaths annually, making it the 3rd leading cause of unintentional injury death worldwide. Prior studies examining drowning internationally have reviewed factors surrounding drowning however in the U.S. limited data exists. This study evaluated the novel drowning elements collected in the Cardiac Arrest Registry to Enhance Survival (CARES) during the first 2 years of data collection.<br /><b>Methods</b><br />A retrospective analysis of the CARES database identified cases of drowning etiology for the two years 2020 and 2021. Demographics and incident characteristics were collected. Characteristics included items such as body of water, precipitating event, and who extracted patients. Survival to hospital discharge and neurological outcomes were compared between groups based on who initiated CPR using Pearson\'s Chi-Squared tests.<br /><b>Results</b><br />Among 1,767 drowning cases, 69.7% were male, 47.1% white and 11.9% survived to hospital discharge. Body of water was often natural body (36.2%) or swimming pool (25.9%) and bystanders removed the patient in 42.7% of incidents. Swimming was the most common activity at time of submersion (18.6%) however in 50.2% of cases, activity was unknown or missing. When compared to EMS/First Responder initiating CPR, odds of neurologically favorable survival were significantly higher in the Bystander initiated CPR group (OR=2.85, 95% confidence interval [CI] 2.02-4.01).<br /><b>Conclusion</b><br />In this national cohort of drowning patients in cardiac arrest, the novel CARES drowning elements provide additional detail of epidemiological factors. Bystander CPR was associated with improved neurological outcomes. Future studies utilizing the drowning elements can inform injury prevention strategies.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 06 Apr 2023:109788; epub ahead of print</small></div>

<div><h4>Use of a novel smartphone-based application tool for enrolment and randomisation in pre-hospital clinical trials.</h4><i>Bloom JE, Patrovi A, Bernard S, Okyere D, ... Nehme Z, Stub D</i><br /><AbstractText>The effective recruitment and randomisation of patients in pre-hospital clinical trials presents unique challenges. Owing to the time critical nature of many pre-hospital emergencies and limited resourcing, the use of traditional methods of randomisation that may include centralised telephone or web-based systems are often not practicable or feasible. Previous technological limitations have necessitated that pre-hospital trialists strike a compromise between implementing pragmatic, deliverable study designs, and robust enrolment and randomisation methodologies. In this commentary piece, we present a novel smartphone-based solution that has the potential to align pre-hospital clinical trial recruitment processes to that of best-in-practice in-hospital and ambulatory care setting studies. Running title: Smartphone application based randomisation in pre-hospital clinical trials.</AbstractText><br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 05 Apr 2023:109787; epub ahead of print</small></div>

<div><h4>Delayed neurologic improvement and long-term survival of patients with poor neurologic status after out-of-hospital cardiac arrest: a retrospective cohort study in Japan.</h4><i>Hayamizu M, Kodate A, Sageshima H, Tsuchida T, ... Maekawa K, Hayakawa M</i><br /><b>Aim</b><br />To assess survival duration and frequency of delayed neurologic improvement in patients with poor neurologic status at discharge from emergency hospitals after out-of-hospital cardiac arrest (OHCA).<br /><b>Methods</b><br />This retrospective cohort study included OHCA patients admitted to two tertiary emergency hospitals in Japan between January 2014 and December 2020. Pre-hospital, tertiary emergency hospital, and post-acute care hospital data, were retrospectively collected by reviewing medical records. Neurologic improvements were defined as an improvement of Cerebral Performance Category (CPC) scores from 3 or 4 at hospital discharge to 1 or 2. The primary outcome was neurologic improvement after discharge, while the secondary outcome was survival time after cardiac arrest.<br /><b>Results</b><br />Of all patients (n=1,012) admitted to tertiary emergency hospitals after OHCA during the observation period, 239 with CPC 3 or 4 at discharge were included, and all were Japanese. Median age was 75 years, 64% were male, and 31% had initially shockable rhythms. Neurologic improvements were observed in nine patients (3.6%), higher in CPC 3 (31%) than CPC 4 (1.3%) patients, but not after 6 months from cardiac arrest. The median survival time after cardiac arrest was 386 days (95% confidence interval: 303-469).<br /><b>Conclusion</b><br />Survival probability in patients with CPC 3 or 4 was 50% at 1-year and 20% at 3-year. Neurologic improvements were observed in 3.6% patients, higher in CPC 3 than in CPC 4 patients. During the first 6 months after OHCA, the neurologic status may improve in patients with CPC 3 or 4.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 04 Apr 2023:109790; epub ahead of print</small></div>

<div><h4>Diagnostic Yield, Safety, and Outcomes of Head-to-Pelvis Sudden Death CT Imaging in Post Arrest Care: The CT FIRST Cohort Study.</h4><i>R H Branch K, Gatewood MO, Kudenchuk PJ, Maynard C, ... Johnson N, Gunn ML</i><br /><b>Aim</b><br />Our aim was to test whether a head-to-pelvis CT scan improves diagnostic yield and speed to identify causes for out of hospital circulatory arrest (OHCA).<br /><b>Methods</b><br />CT FIRST was a prospective observational pre-/post-cohort study of patients successfully resuscitated from OHCA. Inclusion criteria included unknown cause for arrest, age>18 years, stability to undergo CT, and no known cardiomyopathy or obstructive coronary artery disease. A head-to-pelvis sudden death CT (SDCT) scan within 6 hours of hospital arrival was added to the standard of care for patients resuscitated from OHCA (post-cohort) and compared to standard of care (SOC) alone (pre-cohort). The primary outcome was SDCT diagnostic yield. Secondary outcomes included time to identifying OHCA cause and time-critical diagnoses, SDCT safety, and survival to hospital discharge.<br /><b>Results</b><br />Baseline characteristics between the SDCT (N=104) and the SOC (N=143) cohorts were similar. CT scans (either head, chest, and/or abdomen) were ordered in 74 (52%) of SOC patients. Adding SDCT scanning identified 92% of causes for arrest compared to 75% (SOC-cohort; p value <0.001) and reduced the time to diagnosis by 78% (SDCT 3.1 hours, SOC alone 14.1 hours, p <0.0001). Identification of critical diagnoses was similar between cohorts, but SDCT reduced delayed (>6 hours) identification of critical diagnoses by 81% (p<0.001). SDCT safety endpoints were similar including acute kidney injury. Patient survival to discharge was similar between cohorts.<br /><b>Discussion</b><br />SDCT scanning early after OHCA resuscitation safely improved the efficiency and diagnostic yield for causes of arrest compared to the standard of care alone.<br /><b>Clinical trials number</b><br />NCT03111043.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 03 Apr 2023:109785; epub ahead of print</small></div>

<div><h4>Impact of Number of Defibrillation Attempts on Neurologically Favourable Survival Rate in Patients with Out-of-Hospital Cardiac Arrest.</h4><i>Tateishi K, Saito Y, Kitahara H, Shiko Y, ... Kobayashi Y, Japanese Circulation Society Resuscitation Science Study JCS-ReSS Group</i><br /><b>Aim</b><br />of the study: Defibrillation plays a crucial role in early return of spontaneous circulation (ROSC) and survival of patients with out-of-hospital cardiac arrest (OHCA) and shockable rhythm. Prehospital adrenaline administration increases the probability of prehospital ROSC. However, little is known about the relationship between number of prehospital defibrillation attempts and neurologically favourable survival in patients treated with and without adrenaline.<br /><b>Methods</b><br />Using a nationwide Japanese OHCA registry database from 2006 to 2020, 1,802,084 patients with OHCA were retrospectively analysed, among whom 81,056 with witnessed OHCA and initial shockable rhythm were included. The relationship between the number of defibrillation attempts before hospital admission and neurologically favourable survival rate (cerebral performance category score of 1 or 2) at 1 month was evaluated with subgroup analysis for patients treated with and without adrenaline.<br /><b>Results</b><br />At 1 month, 18,080 (22.3%) patients had a cerebral performance category score of 1 or 2. In the study population, the probability of prehospital ROSC and favourable neurological survival rate were inversely associated with number of defibrillation attempts. Similar trends were observed in patients treated without adrenaline, whereas a greater number of defibrillation attempts was counterintuitively associated with favourable neurological survival rate in patients treated with prehospital adrenaline.<br /><b>Conclusions</b><br />Overall, a greater number of prehospital defibrillation attempts was associated with lower neurologically favourable survival at 1 month in patients with OHCA and shockable rhythm. However, an increasing number of shocks (up to the 4th shock) was associated with better neurological outcomes when considering only patients treated with adrenaline.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 22 Mar 2023:109779; epub ahead of print</small></div>

<div><h4>Left-ventricular Unloading in Extracorporeal Cardiopulmonary Resuscitation due to Acute Myocardial Infarction - A Multicenter Study.</h4><i>Thevathasan T, Kenny MA, Krause FJ, Paul J, ... Balzer F, Skurk C</i><br /><AbstractText><br /><b>Background:</b><br/>Guidelines advocate the use of extracorporeal cardio-pulmonary resuscitation with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in selected patients with cardiac arrest. Effects of concomitant left-ventricular (LV) unloading with Impella® (ECMELLA) remain unclear. This is the first study to investigate whether treatment with ECMELLA was associated with improved outcomes in patients with refractory cardiac arrest caused by acute myocardial infarction (AMI). Methods This study was approved by the local ethical committee. Patients treated with ECMELLA at three centers between 2016 and 2021 were propensity score (PS)-matched to patients receiving VA-ECMO based on age, electrocardiogram rhythm, cardiac arrest location and Survival After Veno-Arterial ECMO (SAVE) score. Cox proportional-hazard and Poisson regression models were used to analyse 30-day mortality rate (primary outcome), hospital and intensive care unit (ICU) length of stay (LOS) (secondary outcomes). Sensitivity analyses on patient demographics and cardiac arrest parameters were performed. Results 95 adult patients were included in this study, out of whom 34 pairs of patients were PS-matched. ECMELLA treatment was associated with decreased 30-day mortality risk (Hazard Ratio [HR] 0.53 [95% Confidence Interval (CI) 0.31-0.91], P=0.021), prolonged hospital (Incidence Rate Ratio (IRR) 1.71 [95% CI 1.50-1.95], P<0.001) and ICU LOS (IRR 1.81 [95% CI 1.57-2.08], P<0.001). LV ejection fraction significantly improved until ICU discharge in the ECMELLA group. Especially patients with prolonged low-flow time and high initial lactate benefited from additional LV unloading. <br /><b>Conclusions:</b><br/>LV unloading with Impella® concomitant to VA-ECMO therapy in patients with therapy-refractory cardiac arrest due to AMI was associated with improved patient outcomes.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 21 Mar 2023:109775; epub ahead of print</small></div>

<div><h4>Did lockdown influence bystanders\' willingness to perform cardiopulmonary resuscitation? A worldwide registry-based perspective.</h4><i>B M Tjelmeland I, Wnent J, Masterson S, Kramer-Johansen J, ... Lockdown, bystander CPR group</i><br /><b>Aim</b><br />Bystander cardiopulmonary resuscitation (CPR) significantly increases the survival rate after out-of-hospital cardiac arrest. Using population-based registries, we investigated the impact of lockdown due to Covid-19 on the provision of bystander CPR, taking background changes over time into consideration.<br /><b>Methods</b><br />Using a registry network, we invited all registries capable of delivering data from 1. January 2017 to 31. December 2020 to participate in this study. We used negative binominal regression for the analysis of the overall results. We also calculated the rates for bystander CPR. For every participating registry, we analysed the incidence per 100000 inhabitants of bystander CPR and EMS-treated patients using Poisson regression, including time trends.<br /><b>Results</b><br />Twenty-six established OHCA registries reported 742 923 cardiac arrest patients over a four-year period covering 1.3 billion person-years. We found large variations in the reported incidence between and within continents. There was an increase in the incidence of bystander CPR of almost 5% per year. The lockdown in March/April 2020 did not impact this trend. The increase in the rate of bystander CPR was also seen when analysing data on a continental level. We found large variations in incidence of bystander CPR before and after lockdown when analysing data on a registry level.<br /><b>Conclusion</b><br />There was a steady increase in bystander CPR from 2017 to 2020, not associated with an increase in the number of ambulance-treated cardiac arrest patients. We did not find an association between lockdown and bystanders\' willingness to start CPR before ambulance arrival, but we found inconsistent patterns of changes between registries.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 17 Mar 2023:109764; epub ahead of print</small></div>

<div><h4>Global prevalence of basic life support training: A systematic review and meta-analysis.</h4><i>Priscilla Ng T, Wai-Onn Eng S, Xin Rui Ting J, Bok C, ... Fu Wah Ho A, GOALS Workgroup</i><br /><b>Background:</b><br/>and aims</b><br />Out-of-hospital cardiac arrest exerts a large disease burden, which may be mitigated by bystander cardiopulmonary resuscitation and automated external defibrillation. We aimed to estimate the global prevalence and distribution of bystander training among laypersons, which are poorly understood, and to identify their determinants.<br /><b>Methods</b><br />We searched electronic databases for cross-sectional studies reporting the prevalence of bystander training from representative population samples. Pooled prevalence was calculated using random-effects models. Key outcome was cardiopulmonary resuscitation training (training within two-years and those who were ever trained). We explored determinants of interest using subgroup analysis and meta-regression.<br /><b>Results</b><br />28 studies were included, representing 53,397 laypersons. Among national studies, the prevalence of cardiopulmonary resuscitation training within two-years and among those who were ever trained, and automated external defibrillator training was 10.02% (95% CI 6.60-14.05) and 39.64% (95%CI 29.11-50.67), and 15.70% (95% CI 10.17-22.18) respectively. Subgroup analyses by continent revealed pooled prevalence estimates of 31.58% (95%CI 18.70-46.09), 52.62% (95%CI 38.40-66.63), 18.93 (95%CI 0.00-62.94), 64.97% (95%CI 64.00-65.93), and 50.56% (95%CI 47.57-53.54) in Asia, Europe, Middle East, North America, and Oceania respectively, with significant subgroup differences (p<0.01). A country\'s income and cardiopulmonary resuscitation training (ever trained) (p=0.033) were positively correlated. Similarly, this prevalence was higher among the employed (p<0.00001) and highly educated (p<0.00001).<br /><b>Conclusions</b><br />Large regional variation exists in data availability and bystander training prevalence. Socioeconomic status correlated with prevalence of bystander training, and regional disparities were apparent between continents. Bystander training should be promoted, particularly in Asia, Middle East, and low-income regions. Data availability should be encouraged from under-represented regions.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 17 Mar 2023:109771; epub ahead of print</small></div>

<div><h4>The effect of the COVID-19 pandemic on the incidence and survival outcomes of EMS-witnessed out-of-hospital cardiac arrest.</h4><i>Kennedy C, Alqudah Z, Stub D, Anderson D, Nehme Z</i><br /><b>Aim</b><br />We sought to examine the impact of the COVID-19 pandemic on the incidence and survival outcomes of emergency medical service (EMS)-witnessed out-of-hospital cardiac arrest (OHCA) in Victoria, Australia.<br /><b>Methods</b><br />We performed an interrupted time-series analysis of adult EMS-witnessed OHCA patients of medical aetiology. Patients treated during the COVID-19 period (1<sup>st</sup> March 2020 to 31<sup>st</sup> December 2021) were compared to a historical comparator period (1<sup>st</sup> January 2012 and 28<sup>th</sup> February 2020). Multivariable poisson and logistic regression models were used to examine changes in incidence and survival outcomes during the COVID-19 pandemic, respectively.<br /><b>Results</b><br />We included 5,034 patients, 3,976 (79.0%) in the comparator period and 1,058 (21.0%) in the COVID-19 period. Patients in the COVID-19 period had longer EMS response times, fewer public location arrests and were significantly more likely to receive mechanical CPR and laryngeal mask airways compared to the historical period (all p<0.05). There were no significant differences in the incidence of EMS-witnessed OHCA between the comparator and COVID-19 periods (incidence rate ratio 1.06, 95% CI: 0.97 - 1.17, p = 0.19). Also, there was no difference in the risk-adjusted odds of survival to hospital discharge for EMS-witnessed OHCA occurring during COVID-19 period compared to the comparator period (adjusted odd ratio 1.02, 95% CI: 0.74 - 1.42; p = 0.90).<br /><b>Conclusion</b><br />Unlike the reported findings in non-EMS-witnessed OHCA populations, changes during the COVID-19 pandemic did not influence incidence or survival outcomes in EMS-witnessed OHCA. This may suggest that changes in clinical practice that sought to limit the use of aerosol generating procedures did not influence outcomes in these patients.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 16 Mar 2023:109770; epub ahead of print</small></div>

<div><h4>Long-term function, quality of life and healthcare utilization among survivors of pediatric out-of-hospital cardiac arrest.</h4><i>Hickson MR, Winters M, Thomas NH, Gardner MM, ... Pinto NP, Topjian A</i><br /><b>Background</b><br />Survival following pediatric out-of-hospital cardiac arrest (OHCA) has improved over the past 2 decades but data on survivors\' long-term outcomes are limited. We aimed to evaluate long-term outcomes in pediatric OHCA survivors more than one year after cardiac arrest.<br /><b>Methods</b><br />OHCA survivors < 18 years old who received post-cardiac arrest care in the PICU at a single center between 2008 - 2018 were included. Parents of patients <18 years and patients ≥18 years at least one year after cardiac arrest completed a telephone interview. We assessed neurologic outcome (Pediatric Cerebral Performance Category [PCPC]), activities of daily living (Pediatric Glasgow Outcomes Scale-Extended, Functional Status Scale (FSS)), HRQL (Pediatric Quality of Life Core and Family Impact Modules), and healthcare utilization. Unfavorable neurologic outcome was defined as PCPC > 1 or worsening from pre-arrest baseline to discharge.<br /><b>Findings</b><br />Forty four patients were evaluable. Follow-up occurred at a median of 5.6 years [IQR 4.4, 8.9] post-arrest. Median age at arrest was 5.3 [1.3,12.6] years; median CPR duration was 5 [1.5, 7] minutes. Survivors with unfavorable outcome at discharge had worse FSS Sensory and Motor scores and higher rates of rehabilitation service utilization. Parents of survivors with unfavorable outcome reported greater disruption to family functioning. Healthcare utilization and educational support requirements were common among all survivors.<br /><b>Conclusions</b><br />Survivors of pediatric OHCA with unfavorable outcome at discharge have more impaired function multiple years post-arrest. Survivors with favorable outcome may experience impairments and significant healthcare needs not fully captured by the PCPC at hospital discharge.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 16 Mar 2023:109768; epub ahead of print</small></div>

<div><h4>Supraglottic Airway Devices are Associated with Asphyxial Physiology After Prolonged CPR in Patients with Refractory Out-of-Hospital Cardiac Arrest Presenting for Extracorporeal Cardiopulmonary Resuscitation.</h4><i>Bartos JA, Clare Agdamag A, Kalra R, Nutting L, ... Sipprell K, Yannopoulos D</i><br /><b>Background</b><br />Multiple randomized clinical trials have compared specific airway management strategies during ACLS with conflicting results. However, patients with refractory cardiac arrest died in almost all cases without the availability of extracorporeal cardiopulmonary resuscitation (ECPR). Our aim was to determine if endotracheal intubation (ETI) was associated with improved outcomes compared to supraglottic airways (SGA) in patients with refractory cardiac arrest presenting for ECPR.<br /><b>Methods</b><br />We retrospectively studied 420 consecutive adult patients with refractory out-of-hospital cardiac arrest due to shockable presenting rhythms presenting to the University of Minnesota ECPR program. We compared outcomes between patients receiving ETI (n=179) and SGA (n=204). The primary outcome was the pre-cannulation arterial PaO<sub>2</sub> upon arrival to the ECMO cannulation center. Secondary outcomes included neurologically favorable survival to hospital discharge and eligibility for VA-ECMO based upon resuscitation continuation criteria applied upon arrival to the ECMO cannulation center.<br /><b>Results</b><br />Patients receiving ETI had significantly higher median PaO<sub>2</sub> (71 vs. 58 mmHg, p=0.001), lower median PaCO<sub>2</sub> (55 vs. 75 mmHg, p<0.001), and higher median pH (7.03 vs. 6.93, p<0.001) compared to those receiving SGA. Patients receiving ETI were also significantly more likely to meet VA-ECMO eligibility criteria (85% vs. 74%, p=0.008). Of patients eligible for VA-ECMO, patients receiving ETI had significantly higher neurologically favorable survival compared to SGA (42% vs. 29%, p=0.02).<br /><b>Conclusions</b><br />ETI was associated with improved oxygenation and ventilation after prolonged CPR. This resulted in increased rate of candidacy for ECPR and increased neurologically favorable survival to discharge with ETI compared to SGA. Short Title: Airway Effects in Refractory Cardiac Arrest.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 16 Mar 2023:109769; epub ahead of print</small></div>

<div><h4>Mechanical ventilation with ten versus twenty breaths per minute during cardio-pulmonary resuscitation for out-of-hospital cardiac arrest: a randomised controlled trial.</h4><i>Prause G, Zoidl P, Eichinger M, Eichlseder M, ... Metnitz PGH, Zajic P</i><br /><b>Aim</b><br />of the Study: This study sought to assess the effects of increasing the ventilatory rate from 10 min<sup>-1</sup> to 20 min<sup>-1</sup> using a mechanical ventilator during cardio-pulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) on ventilation, acid-base-status, and outcomes.<br /><b>Methods</b><br />This was a randomised, controlled, single-centre trial in adult patients receiving CPR including advanced airway management and mechanical ventilation offered by staff of a prehospital physician response unit (PRU). Ventilation was conducted using a turbine-driven ventilator (volume-controlled ventilation, tidal volume 6ml per kg of ideal body weight, positive end-expiratory pressure (PEEP) 0 mmHg, inspiratory oxygen fraction (FiO<sub>2</sub>) 100%), frequency was pre-set at either 10 or 20 breaths per minute according to week of randomisation. If possible, an arterial line was placed and blood gas analysis was performed.<br /><b>Results</b><br />The study was terminated early due to slow recruitment. 46 patients (23 per group) were included. Patients in the 20min<sup>-1</sup> group received higher expiratory minute volumes [8.8 (6.8-9.9) vs. 4.9 (4.2-5.7) litres, p<0.001] without higher mean airway pressures [11.6 (9.8-13.6) vs. 9.8 (8.5-12.0) mmHg, p=0.496] or peak airway pressures [42.5 (36.5-45.9) vs. 41.4 (32.2-51.7) mmHg, p=0.895]. Rates of ROSC [12 of 23 (52%) vs. 11 of 23 (48%), p=0.768], median pH [6.83 (6.65-7.05) vs. 6.89 (6.80-6.97) mmHg, p=0.913], and median pCO<sub>2</sub> [78 (51-105) vs. 86 (73-107) mmHg, p>0.999] did not differ between groups.<br /><b>Conclusion</b><br />20 instead of 10 mechanical ventilations during CPR increase ventilation volumes per minute, but do not improve CO<sub>2</sub> washout, acidaemia, oxygenation, or rate of ROSC.<br /><b>Clinicaltrials</b><br />gov Identifier: NCT04657393.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 15 Mar 2023:109765; epub ahead of print</small></div>

<div><h4>Prognostic Association Between Frailty and Post-Arrest Health Outcomes in Patients Receiving Home Care: A Population-Based Retrospective Cohort Study.</h4><i>Mowbray FI, Turcotte L, Strum RP, de Wit K, ... Gayowsky A, Costa AP</i><br /><b>Aim</b><br />To evaluate the association between frailty and post-cardiac arrest survival, functional decline, and cognitive decline, among patients receiving home care <br /><b>Methods:</b><br/>Frailty was measured using the Clinical Frailty Scale (CFS) and a valid frailty index. We used multivariable logistic regression to measure the association between frailty and post-arrest outcomes after adjusting for age, sex, and arrest setting. Functional independence and cognitive performance were measured using the interRAI ADL Long-Form and Cognitive Performance Scale, respectively. We conducted sub-group analytics of in-hospital and out-of-hospital arrests <br /><b>Results:</b><br/>Our cohort consisted of 7,901 home care clients; most patients arrested out-of-hospital (55.4%) and were 75 years or older (66.3%). Most of the cohort was classified as frail (94.2%), with a CFS score of 5 or greater. The 30-day survival rate was higher for in-hospital (26.6%) than out-of-hospital cardiac arrests (5.2%). Most patients who survived to discharge had declines in post-arrest functional independence (65.8%) and cognitive performance (46.5%). A one-point increase in the CFS decreased the odds of 30-day survival by 8% (aOR=0.92; 95%CI = 0.87-0.97). A 0.1 unit increase in the frailty index reduced 30-day survival odds by 9% (aOR = 0.91; 95%CI = 0.86-0.96). The frailty index was associated with declines in functional independence (OR = 1.16; 95%CI = 1.02-1.31) and cognitive performance (OR = 1.24; 95%CI = 1.09-1.42), while the CFS was not.<br /><b>Conclusion</b><br />Frailty is associated with cardiac arrest survival and post-arrest cognitive and functional status in patients receiving home care. Post-cardiac arrest cognitive and functional status are best predicted using more comprehensive frailty indices.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Resuscitation: 15 Mar 2023:109766; epub ahead of print</small></div>

<div><h4>Impact of the 2015 European guidelines for resuscitation on traumatic cardiac arrest outcomes and prehospital management: a French nationwide interrupted time-series analysis.</h4><i>Benhamed A, Mercier E, Freyssenge J, Heidet M, ... Tazarourte K, RéAC investigators</i><br /><b>Aim</b><br />To evaluate the impact of the 2015 European Resuscitation Council (ERC) guidelines on patient outcomes following traumatic cardiac arrest (TCA) and on advanced life support interventions carried out by physician-staffed ambulances.<br /><b>Methods</b><br />Data of TCA patients aged ≥18 years were extracted from the French nationwide cardiac arrest registry. A pre- (2011-2015) and a post-publication period (2016-2020) were defined. In the guidelines, a specific TCA management algorithm was introduced to prioritise the treatment of reversible causes. Its impact was evaluated using adjusted interrupted time series analysis.<br /><b>Results</b><br />4,980 patients were treated (2,145 during the pre-publication period and 2,739 during the post-publication period). There was no significant change in the rates of prehospital ROSC (22.4% vs. 20.2%, p=0.07 in the pre- and post- intervention respectively), survival (1.4% vs. 1.4%, p=0.87) or good neurological outcome (71.4% vs. 66.7%, p=0.93) or in the incidence of organ donation (1.6% vs. 1.3%, p=0.50). There were nonsignificant changes in the adjusted temporal trend for ROSC (aOR 0.88; 95% CI [0.77;1.00]), survival (aOR 1.34; 95% CI [0.83;2.17]), good neurological outcome (aOR 1.57; 95% CI [0.82;3.05]), and organ donation (aOR 1.06; 95% CI [0.71;1.60]). The use of intraosseous catheters (13.0% vs. 19.2%, p<0.001), external haemorrhage control measures (23.9% vs. 64.8%, p<0.001), bilateral chest decompression (13.7% vs. 16.5%, p=0.009), and packed red cell transfusion (2.7% vs. 6.5%, p<0.001) increased in the post-publication period.<br /><b>Conclusions</b><br />Despite the increased frequency of trauma rescue interventions performed by on-scene physicians, no change in patient-centred outcomes was associated with the publication of the 2015 ERC guidelines in France.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 14 Mar 2023:109763; epub ahead of print</small></div>

<div><h4>Paucity of neuroprognostic testing after cardiac arrest in the United States.</h4><i>Elmer J, Steinberg A, Callaway CW</i><br /><b>Background</b><br />Withdrawal of life-sustaining therapies for perceived poor neurological prognosis is the most common cause of death for patients hospitalized after resuscitation from cardiac arrest. Accurate neuroprognostication is challenging and high stakes, so guidelines recommend multimodality testing. We quantified the frequency and timing with which guideline recommended diagnostics were acquired prior to in-hospital death after cardiac arrest.<br /><b>Methods</b><br />We performed a retrospective cohort study using the Optum® deidentified Electronic Health Record dataset for 2010 to 2021. We included in-hospital decedents admitted after resuscitation from non-traumatic cardiac arrest. We quantified the number of decedents who underwent head computed tomographic imaging, electroencephalography, somatosensory evoked potentials, brain magnetic resonance imaging, or evaluation by a neurologist, as well as the timing of these tests.<br /><b>Results</b><br />Of 34,585 included patients, median age was 66 [interquartile range 53 - 79] years and 13,609 (39%) were female. Median hospital length of stay was 0 days [0 - 1] days, and only 16% of deaths occurred on or after day three. Only 3,245 patients (9%) had at least one neurodiagnostic test acquired and only 1,708 (5%) were evaluated by a neurologist. The most common neurological diagnostic test to be obtained was CT imaging, acquired in 3,004 (9%) of the overall cohort. Only 852 patients (2%) of patients had at least two diagnostic modalities obtained.<br /><b>Discussion</b><br />In this retrospective cohort, we found few patients hospitalized after out-of-hospital cardiac arrest underwent guideline-recommended prognostic testing. If validated in prospective cohorts with more granular clinical information, better guideline adherence and more frequent use of multimodality neuroprognostication offer an opportunity to improve quality of post-arrest care.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 14 Mar 2023:109762; epub ahead of print</small></div>

<div><h4>Association between the extent of diffusion restriction on brain diffusion-weighted imaging and neurological outcomes after an out-of-hospital cardiac arrest.</h4><i>Yoon Park J, Hwan Kim Y, Jun Ahn S, Ho Lee J, ... Youn Hwang S, Gyu Song Y</i><br /><b>Background</b><br />This study evaluated the association between the extent of diffusion restriction on brain diffusion-weighted imaging (DWI) and neurological outcomes in patients who underwent targeted temperature management (TTM) after an out-of-hospital cardiac arrest (OHCA).<br /><b>Methods</b><br />Patients who underwent brain magnetic resonance imaging within 10 days of OHCA between 2012 and 2021 were analysed. The extent of diffusion restriction was described according to the modified DWI Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS). The 35 predefined brain regions were assigned a score if diffuse signal changes were concordantly present in DWI scans and apparent diffusion coefficient maps. The primary outcome was an unfavourable neurological outcome at 6 months. The sensitivity, specificity, and receiver operating characteristic (ROC) curves for the measured parameters were analysed. Cut-off values were determined to predict the primary outcome. The predictive cut-off DWI-ASPECTS was internally validated using five-fold cross-validation.<br /><b>Results</b><br />Of the 301 patients, 108 (35.9%) had 6-month favourable neurological outcomes. Patients with unfavourable outcomes had higher whole-brain DWI-ASPECTS (median, 31 [26-33] vs. 0 [0-1], P < 0.001) than those with favourable outcomes. The area under the ROC curve (AUROC) of whole-brain DWI-ASPECTS was 0.957 (95% confidence interval [CI] 0.928-0.977). A cut-off value of ≥8 for unfavourable neurological outcomes had specificity and sensitivity of 100% (95% CI 96.6-100) and 89.6% (95% CI 84.4-93.6), respectively. The mean AUROC was 0.956.<br /><b>Conclusion</b><br />More extensive diffusion restriction on DWI-ASPECTS in patients with OHCA who underwent TTM was associated with 6-month unfavourable neurological outcomes. Running title: Diffusion restriction and neurological outcomes after cardiac arrest.<br /><br />Copyright © 2023 Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 08 Mar 2023:109761; epub ahead of print</small></div>

<div><h4>Evaluating Current Guidelines for Cardiopulmonary Resuscitation using an Integrated Computational Model of the Cardiopulmonary System.</h4><i>Daudre-Vignier C, Bates DG, Scott TE, Hardman JG, Laviola M</i><br /><b>Objective</b><br />We aimed to use a high-fidelity computational model that captures key interactions between the cardiovascular and pulmonary systems to investigate whether current CPR protocols could potentially be improved.<br /><b>Methods</b><br />We developed and validated the computational model against available human data. We used a global optimisation algorithm to find CPR protocol parameters that optimise the outputs associated with return of spontaneous circulation in a cohort of 10 virtual subjects.<br /><b>Results</b><br />Compared with current protocols, myocardial tissue oxygen volume was more than 5 times higher, and cerebral tissue oxygen volume was nearly doubled, during optimised CPR. While the optimal maximal sternal displacement (5.5 cm) and compression ratio (51%) found using our model agreed with the current American Heart Association guidelines, the optimal chest compression rate was lower (67 compressions min<sup>-1</sup>). Similarly, the optimal ventilation strategy was more conservative than current guidelines, with an optimal minute ventilation of 1500 ml min<sup>-1</sup> and inspired fraction of oxygen of 80%. The end compression force was the parameter with the largest impact on CO, followed by PEEP, the compression ratio and the CC rate.<br /><b>Conclusions</b><br />Our results indicate that current CPR protocols could potentially be improved. Excessive ventilation could be detrimental to organ oxygenation during CPR, due to the negative haemodynamic effect of increased pulmonary vascular resistance. Particular attention should be given to the chest compression force to achieve satisfactory CO. Future clinical trials aimed at developing improved CPR protocols should explicitly consider interactions between chest compression and ventilation parameters.<br /><br />Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.<br /><br /><small>Resuscitation: 03 Mar 2023:109758; epub ahead of print</small></div>