Journal: Resuscitation

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Abstract

Rehabilitation Outcomes of Survivors of Cardiac Arrest Admitted to ICUs in Australia and New Zealand (ROSC ANZ): A Data Linkage Study.

Bhagyalakshmi Nanjayya V, Doherty Z, Gupta N, Alexander T, ... Pilcher D, Bray J
Introduction
Rehabilitation outcomes in cardiac survivors are largely unknown, with no data comparing out-of-hospital cardiac arrests (OHCA) and in-hospital cardiac arrests (IHCA). This study aimed to describe and compare inpatient rehabilitation outcomes in these patients who were admitted from intensive care units (ICU).
Methods
A retrospective linkage and analysis of cardiac arrest patients in the Australian and New Zealand Intensive Care Society Adult Patient Database and the Australasian Rehabilitation Outcomes Centre inpatient dataset discharged to inpatient rehabilitation between January 2017 and June 2018. Primary outcome was the functional improvement during rehabilitation (difference between the Functional Independence Measurement (FIM) score on admission and discharge). Multivariate regression analyses were performed to determine factors associated with functional improvement.
Results
In the 240 (84 OHCA and 156 IHCA) patients included, the median length of inpatient rehabilitation was 15 days [1st - 3rd quartile (Q1-Q3): 9-24]. OHCA patients were more likely to be admitted to rehabilitation for neurological issues (41.7%) and IHCA for medical reasons (51.9%). Median (Q1-Q3) change in total FIM scores was similar between the two groups (24.5[10-37]) vs 21[11-31], adjusted p=0.20), with most of the FIM change seen in the motor items, and this was only associated with a lower admission FIM score. The majority of OHCA and IHCA patients were discharged home (91.5% and 89.7%, respectively), although with an increased need for a carer at home compared to baseline (27.2% to 55.6%).
Conclusion
Patients discharged from ICU following OHCA and IHCA achieved reasonable and similar functional improvement during inpatient rehabilitation.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 14 Sep 2021; epub ahead of print
Bhagyalakshmi Nanjayya V, Doherty Z, Gupta N, Alexander T, ... Pilcher D, Bray J
Resuscitation: 14 Sep 2021; epub ahead of print | PMID: 34536560
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Impact:
Abstract

Effectiveness of near-infrared spectroscopy-guided continuous chest compression resuscitation without rhythm check in patients with out-of-hospital cardiac arrest: The prospective multicenter TripleCPR 16 study.

Takegawa R, Taniuchi S, Ohnishi M, Muroya T, ... Shimazu T, Shiozaki T
Background
The proportion of adult patients with return of spontaneous circulation (ROSC) following out-of-hospital cardiac arrest (OHCA) remains unchanged since 2012. A better resuscitation strategy is needed. This study evaluated the effectiveness of a regional cerebral oxygen saturation (rSO2)-guided resuscitation protocol without rhythm check based on our previous study.
Methods
Because defibrillation is the definitive therapy that should be performed without delay for shockable rhythm, the study subjects were OHCA patients with non-shockable rhythm on hospital arrival at three emergency departments. They were divided into three groups based on their baseline rSO2 value (%): ≥50, ≥40 to <50, or <40. Continuous chest compression without rhythm checks was performed for 16 minutes or until a maximum increase in rSO2 of 10%, 20%, or 35% was achieved in each group, respectively. This intervention cohort was compared with a historical control cohort regarding the probability of ROSC using inverse probability of treatment weighting (IPTW) with propensity score.
Results
The control and intervention cohorts respectively included 86 and 225 patients. The rate of ROSC was not significantly different between the groups (adjusted OR 0.91 [95% CI, 0.64-1.29], P=0.60), but no serious adverse events occurred. Sensitivity analyses 1 and 2 showed a significant difference or positive tendency for higher probability of ROSC (adjusted OR 1.63 [95% CI, 1.22-2.17], P<0.001) (adjusted OR 1.25 [95% CI, 0.95-1.63], P=0.11).
Conclusions
This trial suggested that a new cardiopulmonary resuscitation protocol with different rhythm check timing could be created using the rSO2 value. Clinical trial number: UMIN000025684.

Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 14 Sep 2021; epub ahead of print
Takegawa R, Taniuchi S, Ohnishi M, Muroya T, ... Shimazu T, Shiozaki T
Resuscitation: 14 Sep 2021; epub ahead of print | PMID: 34536559
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Abstract

Pulmonary hypertension among children with in-hospital cardiac arrest: a multicenter study.

Morgan RW, Himebauch AS, Griffis H, Quarshie WO, ... Nishisaki A, Sutton RM
Aims
To determine the prevalence of pulmonary hypertension (PH) among children with in-hospital cardiac arrest (IHCA) and its association with survival.
Methods
Children (<18 years) admitted to ICUs participating in the Virtual Pediatric Systems multicenter registry between January 2011 and December 2017 who had an IHCA during their hospitalization were included. Patients were classified by whether they had a documented diagnosis of PH at the time of IHCA. Clinical characteristics were compared between patients with and without PH. After propensity score matching, conditional logistic regression within the matched cohort determined the association between PH and survival to hospital discharge.
Results
Of 18,575 children with IHCA during the study period, 1,590 (8.6%) had a pre-arrest diagnosis of PH. Patients with PH were more likely to be 29 days to 2 years of age, female, Black/African American, and American Indian/Alaskan Native, and to be treated in a cardiac ICU or mixed PICU/cardiac ICU. At ICU admission, PH patients had a lower probability of death as determined by the Pediatric Index of Mortality 2 (PIM-2) score. Patients with PH were more likely to be receiving inhaled nitric oxide (13.0% vs. 2.1%; p<0.001). Propensity score matching successfully matched 1,302 PH patients with 3,604 non-PH patients. Patients with PH were less likely to survive to hospital discharge (aOR 0.83; 95% CI: 0.72-0.95; p=0.01) than non-PH patients.
Conclusions
In this large multicenter study, 8.6% of children with IHCA had pre-existing documented PH. These children were less likely to survive to hospital discharge than those without PH.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 14 Sep 2021; epub ahead of print
Morgan RW, Himebauch AS, Griffis H, Quarshie WO, ... Nishisaki A, Sutton RM
Resuscitation: 14 Sep 2021; epub ahead of print | PMID: 34536558
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Impact:
Abstract

Live video from bystanders\' smartphones to improve cardiopulmonary resuscitation.

Linderoth G, Rosenkrantz O, Lippert F, Østergaard D, ... Folke F, Christensen HC
Aim
To investigate whether live video streaming from the bystander\'s smartphone to a medical dispatcher can improve the quality of bystander cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OHCA).
Methods
After CPR was initiated, live video was added to the communication by the medical dispatcher using smartphone technology. From the video recordings, we subjectively evaluated changes in CPR quality after themedical dispatcher had used live video to dispatcher-assisted CPR (DA-CPR). CPR quality was registered for each bystander and compared with CPR quality after video-instructed DA-CPR. Data were analysed using logistic regression adjusted for bystander\'s relation to the patient and whether the arrest was witnessed.
Results
CPR was provided with live video streaming in 52 OHCA calls, with 90 bystanders who performed chest compressions. Hand position was incorrect for 38 bystanders (42.2%) and improved for 23 bystanders (60.5%) after video-instructed DA-CPR. The compression rate was incorrect for 36 bystanders (40.0%) and improved for 27 bystanders (75.0%). Compression depth was incorrect for 57 bystanders (63.3%) and improved for 33 bystanders (57.9%). The adjusted odds ratios for improved CPR after video-instructed DA-CPR were; hand position 5.8 (95% CI: 2.8-12.1), compression rate 7.7 (95% CI: 3.4-17.3), and compression depth 7.1 (95% CI: 3.9-12.9). Hands-off time was reduced for 34 (37.8%) bystanders.
Conclusions
Live video streaming from the scene of a cardiac arrest to medical dispatchers is feasible. It allowed an opportunity for dispatchers to coach those providing CPR which was associated with a subjectively evaluated improvement in CPR performance.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 08 Sep 2021; epub ahead of print
Linderoth G, Rosenkrantz O, Lippert F, Østergaard D, ... Folke F, Christensen HC
Resuscitation: 08 Sep 2021; epub ahead of print | PMID: 34509558
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Abstract

Emergency medical services employing intra-arrest transport less frequently forout-of-hospital cardiac arresthave highersurvival and favorable neurological outcomes.

Grunau B, Kawano T, Rea T, Okubo M, ... Twaites Als B, Christenson J
Background
There is substantial regional variation in out-of-hospital cardiac arrest (OHCA) survival. We investigated whether regional emergency medical services (EMS) intra-arrest transport (IAT) practices are associated with patient outcomes.
Methods
We performed a secondary analysis of a multi-center North American clinical trial dataset, which enrolled EMS-treated adult OHCA cases from 49 regional population-based clusters. The exposure of interest was regional-level intra-arrest transport (IAT), calculated as the proportion of cases in each cluster transported to hospital prior to return of spontaneous circulation, examined as quartiles and as a continuous variable. Multilevel mixed-effects logistic regression modeling estimated the association between regional IAT with survival to hospital discharge and favorable neurologic status (modified Rankin Scale ≤ 3) at hospital discharge.
Results
Of 26,148 subjects (median age 68 years; 36% female; 23% shockable initial rhythm) 2,424 (9.3%), survived to hospital discharge and 1,993 (7.6%) had favourable neurological outcomes. Across regional clusters, IAT ranged from 0.84% to 75% (quartiles <6.2%, 6.2 - 19.6%, 19.6 - 30.4%, and ≥ 30.4%). For each quartile, 13.3%, 7.9%, 7.4%, and 4.8% survived, and 10.4%, 7.8%, 7.4%, and 4.8% had favourable neurological status. Regional IAT (per 10% change) was associated with decreased probability of survival (AOR 0.86, 95% CI 0.82-0.91) and favorable neurological outcome (AOR 0.80, 95% CI 0.76-0.85).
Conclusion
Treatment within a region that utilizes IAT less frequently was associated with improved clinical outcomes at hospital discharge. These findings may account for some of the known regional variation in OHCA outcomes.

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

Resuscitation: 08 Sep 2021; epub ahead of print
Grunau B, Kawano T, Rea T, Okubo M, ... Twaites Als B, Christenson J
Resuscitation: 08 Sep 2021; epub ahead of print | PMID: 34509554
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Impact:
Abstract

Methodology and framework for the analysis of cardiopulmonary resuscitation quality in large and heterogeneous cardiac arrest datasets.

Jaureguibeitia X, Aramendi E, Irusta U, Alonso E, ... Idris AH, Wang HE
Background
Out-of-hospital cardiac arrest (OHCA) data debriefing and clinical research often require the retrospective analysis of large datasets containing defibrillator files from different vendors and clinical annotations by the emergency medical services.
Aim
To introduce and evaluate a methodology to automatically extract cardiopulmonary resuscitation (CPR) quality data in a uniform and systematic way from OHCA datasets from multiple heterogeneous sources.
Methods
A dataset of 2236 OHCA cases from multiple defibrillator models and manufacturers was analyzed. Chest compressions were automatically identified using the thoracic impedance and compression depth signals. Device event time-stamps and clinical annotations were used to set the start and end of the analysis interval, and to identify periods with spontaneous circulation. A manual audit of the automatic annotations was conducted and used as gold standard. Chest compression fraction (CCF), rate (CCR) and interruption ratio were computed as CPR quality variables. The unsigned error between the automated procedure and the gold standard was calculated.
Results
Full-episode median errors below 2% in CCF, 1min-1 in CCR, and 1.5% in interruption ratio, were measured for all signals and devices. The proportion of cases with large errors (>10% in CCF and interruption ratio, and >10min-1 in CCR) was below 10%. Errors were lower for shorter sub-intervals of interest, like the airway insertion interval.
Conclusions
An automated methodology was validated to accurately compute CPR metrics in large and heterogeneous OHCA datasets. Automated processing of defibrillator files and the associated clinical annotations enables the aggregation and analysis of CPR data from multiple sources.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 08 Sep 2021; epub ahead of print
Jaureguibeitia X, Aramendi E, Irusta U, Alonso E, ... Idris AH, Wang HE
Resuscitation: 08 Sep 2021; epub ahead of print | PMID: 34509553
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Impact:
Abstract

Neuron-Specific Enolase and long-term neurological outcome after OHCA - a validation study.

Lissner Östlund E, Levin H, Nielsen N, Frigyesi A, Lybeck A
Aims
To investigate what NSE levels predict long-term neurological prognosis at 24, 48 and 72 hours after ROSC in a cohort of out-of-hospital cardiac arrest and to validate previously suggested NSE cut-offs, including the latest ERC guidelines (2021).
Methods
Patients admitted to intensive care units in four hospitals in Southern Sweden between 2014-2018 were included. Blood samples were handled by a single local laboratory. The primary outcome was neurological outcome according to the Cerebral Performance Category (CPC) scale at 2-6 months after cardiac arrest.
Results
368 patients were included for analysis. A ≤2% false positive rate for the prediction of poor neurological outcome was achieved with an NSE cut-off value of >101 μg/L at 48 hours and >80 μg/L at 72 hours. The cut-off suggested by the recent ERC guidelines of >60 μg/L at 48 and/or 72 hours generated a false positive rate of 4.3% (95%CI 0.9-7.4%).
Conclusion
A local validation study of the ability of serum levels of neuron-specific enolase to predict long-term poor neurological outcome after out-of-hospital cardiac arrest generated higher cut-offs than suggested by previous publications.

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

Resuscitation: 07 Sep 2021; epub ahead of print
Lissner Östlund E, Levin H, Nielsen N, Frigyesi A, Lybeck A
Resuscitation: 07 Sep 2021; epub ahead of print | PMID: 34508799
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Abstract

Peripheral perfusion index and diagnostic accuracy of the post-ROSC electrocardiogram in patients with medical out-of-hospital cardiac arrest.

Compagnoni S, Romana Gentile F, Baldi E, Contri E, ... Oltrona Visconti L, Savastano S
Aim
A 12-lead electrocardiogram (ECG) after the return of spontaneous circulation (ROSC) is recommended to diagnose a ST-segment elevation myocardial infarction (STEMI). In the early post-ROSC phase, the ECG can show signs of ischemia not necessarily of coronary origin and post-ROSC hypoperfusion could affect ECG reliability. We sought for an association between peripheral perfusion index (PI) values after ROSC and the percentage of false-positive ECG for STEMI.
Methods
We considered all the consecutive patients with sustained ROSC after OHCA, admitted to the Fondazione IRCCS Policlinico San Matteo (Pavia) between January 1st, 2015 and December 31st, 2020. ECGs were defined false-positive if meeting the STEMI criteria but without a critical obstructive coronary artery disease worthy of treatment. The mean value of PI over 30 min-monitoring (MPI30) were calculated.
Results
Among 351 eligible patients post-ROSC ECG, PI monitoring and an invasive coronary angiography (ICA) were available in 84 cases. The rate of false positive was 16/54 (29.6%) and it differed significantly in the three MPI30 tertiles [T1 (0.2-1): 28.6%; T2 (1.1-2.5): 24.1%; T3 (2.6-6.9): 3.7%, p=.04; p for trend=.02]. Cardiac arrest duration [OR 1.06 (95%CI 1-1.1), p=.007] and MPI30 [T3 vs T1: OR 0.09 (95%CI 0.01-0.8), p=.03] were significantly associated with the probability of acquiring a false-positive ECG. This association was also confirmed when MPI30 was adjusted for cardiac arrest duration [OR 0.2 (95%CI 0.1-0.6), p=<.001].
Conclusions
The rate of false-positive ECG for STEMI after ROSC is related with low perfusion. Our results could help to identify the adequate candidates for an immediate ICA.

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

Resuscitation: 06 Sep 2021; epub ahead of print
Compagnoni S, Romana Gentile F, Baldi E, Contri E, ... Oltrona Visconti L, Savastano S
Resuscitation: 06 Sep 2021; epub ahead of print | PMID: 34506876
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Abstract

The effect of fluid bolus administration on cerebral tissue oxygenation in post-cardiac arrest patients.

Bogaerts E, Ferdinande B, Palmers PJ, Malbrain M, ... Dupont M, Ameloot K
Purpose
Fluid boluses (FB) are often used in post-cardiac arrest (CA) patients with haemodynamic instability. Although FB may improve cardiac output (CO) and mean arterial pressure (MAP), FB may also increase central venous pressure (CVP), reduce arterial PaO2, dilute haemoglobin and cause interstitial oedema. The aim of the present study was to investigate the net effect of FB administration on cerebral tissue oxygenation saturation (SctO2) in post-CA patients
Methods:
Pre-planned sub-study of the Neuroprotect post-CA trial (NCT02541591). Patients with anticipated fluid responsiveness based on stroke volume variation (SVV) or passive leg raising test were administered a FB of 500ml plasma-lyte A (Baxter Healthcare) and underwent pre- and post-FB assessments of stroke volume, CO, MAP, CVP, haemoglobin, PaO2 and SctO2.
Results
52 patients (mean age 64 ± 12 years, 75% male) received a total of 115 FB. Although administration of a FB resulted in a significant increase of stroke volume (63 ± 22 vs 67 ± 23 mL, p=0.001), CO (4,2 ± 1,6 vs 4,4 ± 1,7 L/min, p=0.001) and MAP (74,8 ± 13,2 vs 79,2 ± 12,9 mmHg, p=0.004), it did not improve SctO2 (68.54 ± 6.99 vs 68.70 ± 6.80 %, p=0.49). Fluid bolus administration also resulted in a significant increase of CVP (10,0 ± 4,5 vs 10,7 ± 4,9 mmHg, p=0.02), but did not affect PaO2 (99 ± 31 vs 94 ± 31 mmHg, p=0.15) or haemoglobin concentrations (12,9 ± 2,1 vs 12,8 ± 2,2 g/dL, p=0.10). In a multivariate model, FB-induced changes in CO (beta 0,77; p=0.004) and in CVP (beta -0,23; p=0.02) but not in MAP (beta 0,02; p=0.18) predicted post-FB ΔSctO2.
Conclusions
despite improvements in CO and MAP, FB administration did not improve SctO2 in post-cardiac arrest patients.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 06 Sep 2021; epub ahead of print
Bogaerts E, Ferdinande B, Palmers PJ, Malbrain M, ... Dupont M, Ameloot K
Resuscitation: 06 Sep 2021; epub ahead of print | PMID: 34506875
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Impact:
Abstract

Novel Application of Thoracic Impedance to Characterize Ventilations During Cardiopulmonary Resuscitation in the Pragmatic Airway Resuscitation Trial.

Mj Nassal M, Jaureguibeitia X, Aramendi E, Irusta U, ... Wang HE, Idris A
Background
Significant challenges exist in measuring ventilation quality during out-of-hospital cardiopulmonary arrest (OHCA) outcomes. Since ventilation is associated with outcomes in cardiac arrest, tools that objectively describe ventilation dynamics are needed. We sought to characterize thoracic impedance (TI) oscillations associated with ventilation waveforms in the Pragmatic Airway Resuscitation Trial (PART).
Methods
We analyzed CPR process files collected from adult OHCA enrolled in PART. We limited the analysis to cases with simultaneous capnography ventilation recordings at the Dallas-Fort Worth site. We identified ventilation waveforms in the thoracic impedance signal by applying automated signal processing with adaptive filtering techniques to remove overlying artifacts from chest compressions. We correlated detected ventilations with the end-tidal capnography signals. We determined the amplitudes (Ai, Ae) and durations (Di, De) of both insufflation and exhalation phases. We compared differences between laryngeal tube (LT) and endotracheal intubation (ETI) airway management during mechanical or manual chest compressions using Mann-Whitney U-test.
Results
We included 303 CPR process cases in the analysis; 209 manual (77 ETI, 132 LT), 94 mechanical (41 ETI, 53 LT). Ventilation Ai and Ae were higher for ETI than LT in both manual (ETI: Ai 0.71Ω, Ae 0.70Ω vs LT: Ai 0.46Ω, Ae 0.45Ω; p<0.01 respectively) and mechanical chest compressions (ETI: Ai 1.22Ω, Ae 1.14Ω VS LT: Ai 0.74Ω, Ae 0.68Ω; p<0.01 respectively). Ventilations per minute, duration of TI amplitude insufflation and exhalation did not differ among groups.
Conclusion
Compared with LT, ETI thoracic impedance ventilation insufflation and exhalation amplitude were higher while duration did not differ. TI may provide a novel approach to characterizing ventilation during OHCA.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 06 Sep 2021; epub ahead of print
Mj Nassal M, Jaureguibeitia X, Aramendi E, Irusta U, ... Wang HE, Idris A
Resuscitation: 06 Sep 2021; epub ahead of print | PMID: 34506874
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Impact:
Abstract

Outcomes for Patients with Anterior Myocardial Infarction and Prior Cardiac Arrest in the Home Automated External Defibrillator Trial (HAT).

Anderson Starks M, Jackson LR, Hellkamp A, Al-Khatib SM, ... Johnson G, Bardy GH
Background
Patients with sudden cardiac arrest occurring in the acute phase of myocardial infarction (MI-SCA) are believed to be at similar risk of death after revascularization compared with MI patients without SCA (MI-no SCA). Among patients with anterior MI, we examined whether those with MI-SCA were at greater risk of all-cause mortality or sudden cardiac death (SCD) than MI-no SCA patients.
Methods
The Home Automated External Defibrillator Trial enrolled patients with anterior MI who had not received or were candidates for an implantable cardioverter defibrillator (ICD). Our cohort included patients with a reported SCA event, in the acute phase of an MI, prior to HAT trial enrollment. Cox proportional hazards models examined the adjusted association between MI-SCA versus MI-no SCA patients and all-cause mortality and sudden cardiac death (SCD). We also determined whether the relationship between prior SCA and outcomes changed with subsequent events (syncope, revascularization, and recurrent MI) during follow-up.
Results
Of 6849 patients, 650 (9.5%) had MI-SCA before trial enrollment. Approximately 48% of patients had the MI-SCA event ≤ 1 year prior to enrollment; 71% of SCA events were in-hospital. MI-SCA patients were younger, more frequently white, and had higher rates of prior PCI versus MI-no SCA patients. There were no differences in adjusted all-cause mortality (hazard ratio [HR 0.95; 95% CI 0.65-1.38]) or SCD (HR 1.12; 95% CI 0.68-1.83) for MI-SCA vs. MI-no SCA. After ICD implantation, MI-SCA patients experienced higher all-cause mortality risk (HR 5.01, 95% CI 1.05-23.79) versus MI-no SCA patients; there was no mortality difference between MI-SCA and MI-no SCA patients without ICD implantation (HR 0.89, 95% CI 0.60- 1.31), [interaction p=0.035].
Conclusions
Patients with MI-SCA had similar adjusted risk of all-cause mortality and SCD compared with MI-no SCA. After ICD implantation, MI-SCA patients had higher mortality compared with MI-no SCA patients.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 05 Sep 2021; epub ahead of print
Anderson Starks M, Jackson LR, Hellkamp A, Al-Khatib SM, ... Johnson G, Bardy GH
Resuscitation: 05 Sep 2021; epub ahead of print | PMID: 34500022
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Impact:
Abstract

The effect of the localisation of an underlying ST-elevation myocardial infarction on the VF-waveform: A multi-centre cardiac arrest study.

Nas J, van Dongen LH, Thannhauser J, Hulleman M, ... Brouwer MA, Blom MT
Introduction
In cardiac arrest, ventricular fibrillation (VF) waveform characteristics such as amplitude spectrum area (AMSA) are studied to identify an underlying myocardial infarction (MI). Observational studies report lower AMSA-values in patients with than without underlying MI. Moreover, experimental studies with 12-lead ECG-recordings show lowest VF-characteristics when the MI-localisation matches the ECG-recording direction. However, out-of-hospital cardiac arrest (OHCA)-studies with defibrillator-derived VF-recordings are lacking.
Methods
Multi-centre (Amsterdam/Nijmegen, the Netherlands) cohort-study on the association between AMSA, ST-elevation MI (STEMI) and its localisation. AMSA was calculated from defibrillator pad-ECG recordings (proxy for lead II, inferior vantage point); STEMI-localisation was determined using ECG/angiography/autopsy findings.
Results
We studied AMSA-values in 754 OHCA-patients. There were statistically significant differences between no STEMI, anterior STEMI and inferior STEMI (Nijmegen: no STEMI 13.0mVHz [7.9-18.6], anterior STEMI 7.5mVHz [5.6-13.8], inferior STEMI 7.5mVHz [5.4-11.8], p=0.006. Amsterdam: 11.7mVHz [5.0-21.9], 9.6mVHz [4.6-17.2], and 6.9mVHz [3.2-16.0], respectively, p=0.001). Univariate analyses showed significantly lower AMSA-values in inferior STEMI vs. no STEMI; there was no significant difference between anterior and no STEMI. After correction for confounders, adjusted absolute AMSA-values were numerically lowest for inferior STEMI in both cohorts, and the relative differences in AMSA between inferior and no STEMI was 1.4-1.7 times larger than between anterior and no STEMI.
Conclusion
This multi-centre VF-waveform OHCA-study showed significantly lower AMSA in case of underlying STEMI, with a more pronounced difference for inferior than for anterior STEMI. Confirmative studies on the impact of STEMI-localisation on the VF-waveform are warranted, and might contribute to earlier diagnosis of STEMI during VF.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 05 Sep 2021; epub ahead of print
Nas J, van Dongen LH, Thannhauser J, Hulleman M, ... Brouwer MA, Blom MT
Resuscitation: 05 Sep 2021; epub ahead of print | PMID: 34500021
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Impact:
Abstract

Neurological outcome in adult out-of-hospital cardiac arrest - not all doom and gloom!

Mckenzie N, Ball S, Bailey P, Finn L, ... Dobb G, Finn J
Aims
To describe neurological and functional outcomes among out-of-hospital cardiac arrest (OHCA) patients who survived to hospital discharge; to determine the association between neurological outcome at hospital discharge and 12-month survival.
Methods
Our cohort comprised adult OHCA patients (≥18 years) attended by St John WA (SJWA) paramedics in Perth, Western Australia (WA), who survived to hospital discharge, between 1st January 2004 and 31st December 2019. Neurological and functional status at hospital discharge (and before the arrest) was determined by medical record review using the five-point \'Cerebral Performance Category (CPC)\' and \'Overall Performance Category (OPC)\' scores. Adjusted multivariable logistic regression analysis was used to estimate the association of CPC score at hospital discharge with 12-month survival, adjusted for prognostic variables.
Results
Over the study period, SJWA attended 23,712 OHCAs. Resuscitation was attempted in 43.4% of cases (n=10,299) with 2171 subsequent admissions, 99.4% (n=2158) of these were admitted to a study hospital. Of the 1062 hospital survivors, 71.3% (n=757) were CPC1 (highest category of neurological performance), 21.4% (n=227) CPC2, 6.3% (n=67) CPC3 and 1.0% (n=11) CPC4. OPC scores followed a similar distribution. Of the 1,011 WA residents who survived to hospital discharge, 92.3% (n=933) survived to 12-months. A CPC1-2 at hospital discharge was significantly associated with 12-month survival (adjusted odds ratio 3.28, 95% confidence interval 1.69-6.39).
Conclusion
Whilst overall survival is low, most survivors of OHCA have a good neurological outcome at hospital discharge and are alive at 12-months.

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

Resuscitation: 31 Aug 2021; epub ahead of print
Mckenzie N, Ball S, Bailey P, Finn L, ... Dobb G, Finn J
Resuscitation: 31 Aug 2021; epub ahead of print | PMID: 34480975
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Impact:
Abstract

Tidal volume measurements via transthoracic impedance waveform characteristics: the effect of age, body mass index and gender. A single centre interventional study.

Berve PO, Irusta U, Kramer-Johansen J, Skålhegg T, Aramendi E, Wik L
Background:
and aim
Measuring tidal volumes (TV) during bag-valve ventilation is challenging in the clinical setting. The ventilation waveform amplitude of the transthoracic impedance (TTI-amplitude) correlates well with TV for an individual, but poorer between patients. We hypothesized that TV to TTI-amplitude relations could be improved when adjusted for morphometric variables like body mass index (BMI), gender or age, and that TTI-amplitude cut-offs for ventilations with adequate TV (>400ml) could be established.
Materials and methods
Twenty-one consenting adults (9 female, and 9 overall overweight) during positive pressure ventilation in anaesthesia before scheduled surgery were included. Seventeen ventilator modes were used (⩾five breaths per mode) to adjust different TVs (150-800ml), ventilation frequencies (10-30min-1) and insufflation times (0.5-3.5s). TTI from the defibrillation pads was filtered to obtain ventilation TTI-amplitudes. Linear regression models were fitted between target and explanatory variables, and compared (coefficient of determination, R2).
Results
The TV to TTI-amplitude slope was 1.39Ω/l (R2=0.52), with significant differences (p<0.05) between male/female (1.04Ω/l vs 1.84Ω/l) and normal/overweight subjects (1.65Ω/l vs 1.04Ω/l). The median (interquartile range) TTI-amplitude cut-off for adequate TV was 0.51Ω(0.14-1.20) with significant differences between males and females (0.58Ω/0.39Ω), and normal and overweight subjects (0.52Ω/0.46Ω). The TV to TTI-amplitude model improved (R2=0.66) when BMI, age and gender were included.
Conclusions
TTI-amplitude to TV relations were established and cut-offs for ventilations with adequate TV determined. Patient morphometric variables related to gender, age and BMI explain part of the variability in the measurements.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 31 Aug 2021; epub ahead of print
Berve PO, Irusta U, Kramer-Johansen J, Skålhegg T, Aramendi E, Wik L
Resuscitation: 31 Aug 2021; epub ahead of print | PMID: 34480974
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Impact:
Abstract

Targeted Temperature Management in Adult Cardiac Arrest: Systematic Review and Meta-Analysis.

Granfeldt A, Holmberg MJ, Nolan JP, Soar J, Andersen LW
Aim
To perform a systematic review and meta-analysis on targeted temperature management in adult cardiac arrest patients.
Methods
PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched on June 17, 2021 for clinical trials. The population included adult patients with cardiac arrest. The review included all aspects of targeted temperature management including timing, temperature, duration, method of induction and maintenance, and rewarming. Two investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Data were pooled using random-effects models. Certainty of evidence was evaluated using GRADE.
Results
The systematic search identified 32 trials. Risk of bias was assessed as intermediate for most of the outcomes. For targeted temperature management with a target of 32-34°C vs. normothermia (which often required active cooling), 9 trials were identified, with six trials included in meta-analyses. Targeted temperature management with a target of 32-34°C did not result in an improvement in survival (risk ratio: 1.08 [95%CI: 0.89, 1.30]) or favorable neurologic outcome (risk ratio: 1.21 [95%CI: 0.91, 1.61]) at 90 to 180 days after the cardiac arrest (low certainty of evidence). Three trials assessed different hypothermic temperature targets and found no difference in outcomes (low certainty of evidence). Ten trials were identified comparing prehospital cooling vs. no prehospital cooling with no improvement in survival (risk ratio: 1.01 [95%CI: 0.92, 1.11]) or favorable neurologic outcome (risk ratio: 1.00 [95%CI: 0.90, 1.11]) at hospital discharge (moderate certainty of evidence).
Conclusions
Among adult patients with cardiac arrest, the use of targeted temperature management at 32-34°C, when compared to normothermia, did not result in improved outcomes in this meta-analysis. There was no effect of initiating targeted temperature management prior to hospital arrival. These findings warrant an update of international cardiac arrest guidelines.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 29 Aug 2021; epub ahead of print
Granfeldt A, Holmberg MJ, Nolan JP, Soar J, Andersen LW
Resuscitation: 29 Aug 2021; epub ahead of print | PMID: 34474143
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Impact:
Abstract

A COMPARATIVE EVALUATION AND APPRAISAL OF 2020 AMERICAN HEART ASSOCIATION AND 2021 EUROPEAN RESUSCITATION COUNCIL NEONATAL RESUSCITATION GUIDELINES.

Vadakkencherry Ramaswamy V, Abiramalatha T, Weiner GM, Trevisanuto D
Aim
The International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support forms the basis for guidelines developed by regional councils such as the American Heart Association (AHA) and the European Resuscitation Council (ERC). We aimed to determine if the updated guidelines are congruent, identify the source of variation, and score their quality.
Methods
We compared the approach to developing recommendations, final recommendations, and cited evidence in the AHA 2020 and ERC 2021 neonatal resuscitation guidelines. Two investigators scored guideline quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool.
Results
Differences in the recommendations were found between AHA 2020 and ERC 2021 neonatal resuscitation guidelines. The councils gave differing recommendations for practices that had sparse evidence and made recommendations based on expert consensus or observational studies. AGREE II assessment revealed that AHA scored better for the domain \'rigour of development\', but ERC had a higher score for \'stakeholder involvement\'. Both AHA and ERC scored relatively less for \'applicability\'.
Conclusion
AHA and ERC guidelines are predominantly based on the ILCOR CoSTR. Differences in recommendations between the two were largely related to the evidence gathering process for questions not reviewed by ILCOR, paucity of evidence for some recommendations based on existing regional practices and supported by expert opinion, and different interpretation or application of same evidence. Overall, both guidelines scored well on the AGREE II assessment, but each had domains that could be improved in future editions.

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

Resuscitation: 27 Aug 2021; epub ahead of print
Vadakkencherry Ramaswamy V, Abiramalatha T, Weiner GM, Trevisanuto D
Resuscitation: 27 Aug 2021; epub ahead of print | PMID: 34464679
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Impact:
Abstract

Chest compression release and recoil dynamics in prolonged manual cardiopulmonary resuscitation.

Knox Russell J, Leturiondo M, González-Otero DM, Julio Gutiérrez J, Ramzan Daya M, Ruiz de Gauna S
Aim
of the study Characterize release and recoil dynamics in chest compressions during prolonged cardiopulmonary resuscitation (CPR) efforts, which are increasingly prevalent.
Methods
Force and depth of chest compressions, and their rates of change, were calculated from records extracted from CPR monitors used during prolonged resuscitation efforts for out-of-hospital cardiac arrest and tracked over time. Metrics were normalized to the median of the first 100 compressions. Kruskal-Wallis ANOVA and Jonckheere-Terpstra trend analyses were used for differences and trends. Averages are reported as median (interquartile range). Correlations among metrics are reported as coefficients of determination.
Results
In 471 cases of adult subjects receiving at least 1000 compressions, peak depths varied modestly over the course of extended resuscitation efforts, staying within a narrow range without a trend over the course of resuscitation efforts. Increases in recoil velocity and decreases in recoil interval also remained within limited ranges (5%, 6% variation respectively). By contrast, force waveforms changed substantially. Peak force decreased monotonically reaching a 38% decrease for compression numbers > 3500, similar to a decrease in release rate (39%) and an increase in release interval (39%).
Conclusion
Depth waveforms change markedly less than do force waveforms over the course of prolonged CPR. With the benefit of feedback, CPR providers effectively adjust the application of force to compensate for changes in chest stiffness, documented previously. Despite slowing release and quickening recoil, interference between release of force and recoil of depth appears limited. Spontaneous chest recoil is well preserved in prolonged duration manual CPR.

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

Resuscitation: 26 Aug 2021; epub ahead of print
Knox Russell J, Leturiondo M, González-Otero DM, Julio Gutiérrez J, Ramzan Daya M, Ruiz de Gauna S
Resuscitation: 26 Aug 2021; epub ahead of print | PMID: 34461206
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Impact:
Abstract

Increasing mean arterial pressure or cardiac output in comatose out-of-hospital cardiac arrest patients undergoing targeted temperature management: effects on cerebral tissue oxygenation and systemic hemodynamics.

Grand J, Wiberg S, Kjaergaard J, Wanscher M, Hassager C
Introduction
Few data exist on the effects of increasing norepinephrine doses or increasing arterial CO2 (PaCO2) on hemodynamics and cerebral oxygenation in comatose out-of-hospital cardiac arrest (OHCA) patients.
Methods
We prospectively studied 10 resuscitated OHCA-patients undergoing targeted temperature management (36C°). The trial consisted of 5 phases with 20 minutes steady state in-between: Phase 1-4 were increasing doses of norepinephrine to reach targets of mean arterial pressure (MAP). First 65, second 75, third 85, fourth 65 mmHg again. In the fifth phase, MAP was constant while PaCO2 was increased to 6.5-7.3 kPa to increase cardiac output. Primary outcome was cerebral near-infrared spectroscopy (NIRS). Secondary outcomes were hemodynamic variables from Swan-Ganz catheters and blood samples from the radial artery and jugular bulb.
Results
To reach a MAP at 85 mmHg, norepinephrine was increased from 0.11±0.02 to 0.18±0.02 µg/kg/min (P < 0.001). Norepinephrine uptitration significantly increased systemic vascular resistance (SVR) and pulmonary vascular resistance, without affecting cardiac output, heart rate or cerebral oxygenation. Increasing PaCO2, resulted in a significant increase in cardiac output and cerebral NIRS, but arterial-venous cerebral oxygen-uptake decreased. Norepinephrine demand to keep MAP at 65 mmHg was unaffected by increasing PaCO2.
Conclusions
A short-term increase in MAP with norepinephrine in resuscitated comatose cardiac arrest-patients is associated with increased SVR and pulmonary vascular resistance without affecting cardiac output or cerebral NIRS. Increased cardiac output caused by an increase in PaCO2 increased cerebral NIRS, but not cerebral oxygen uptake.

Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 26 Aug 2021; epub ahead of print
Grand J, Wiberg S, Kjaergaard J, Wanscher M, Hassager C
Resuscitation: 26 Aug 2021; epub ahead of print | PMID: 34461205
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Impact:
Abstract

Early recognition of a caller\'s emotion in out-of-hospital cardiac arrest dispatching: An artificial intelligence approach.

Chin KC, Hsieh TC, Chiang WC, Chien YC, ... Chen AY, Huei-Ming Ma M
Aim
This study aimed to develop an AI model for detecting a caller\'s emotional state during out-of-hospital cardiac arrest calls by processing audio recordings of dispatch communications.
Methods
Audio recordings of 337 out-of-hospital cardiac arrest calls from March-April 2011 were retrieved. The callers\' emotional state was classified based on the emotional content and cooperative scores. Mel-frequency cepstral coefficients extracted essential information from the voice signals. A support vector machine was utilised for the automatic judgement, and repeated random sub-sampling cross validation (RRS-CV) was applied to evaluate robustness. The results from the artificial intelligence classifier were compared with the consensus of expert reviewers.
Results
The audio recordings were classified into five emotional content and cooperative score levels. The proposed model had an average positive predictive value of 72.97%, a negative predictive value of 93.47%, sensitivity of 38.76%, and specificity of 98.29%. If only the first 10 seconds of the recordings were considered, it had an average positive predictive value of 84.62%, a negative predictive value of 93.57%, sensitivity of 52.38%, and specificity of 98.64%. The artificial intelligence model\'s performance maintained preferable results for emotionally stable cases.
Conclusion
Artificial intelligence models can possibly facilitate the judgement of callers\' emotional states during dispatch conversations. This model has the potential to be utilised in practice, by pre-screening emotionally stable callers, thus allowing dispatchers to focus on cases that are judged to be emotionally unstable. Further research and validation are required to improve the model\'s performance and make it suitable for the general population.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 26 Aug 2021; epub ahead of print
Chin KC, Hsieh TC, Chiang WC, Chien YC, ... Chen AY, Huei-Ming Ma M
Resuscitation: 26 Aug 2021; epub ahead of print | PMID: 34461203
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Impact:
Abstract

Sex differences in the association of comorbidity with shockable initial rhythm in out-of-hospital cardiac arrest.

van Dongen LH, Oving I, Dijkema PW, Beesems SG, Blom MT, Tan HL
Background
Lower survival chances after out-of-hospital cardiac arrest (OHCA) in women is associated with lower odds of a shockable initial rhythm (SIR). We hypothesized that sex differences in the prevalence of SIR are due to sex differences in comorbidities. We aimed to establish to what extent sex differences in the cumulative comorbidity burden, measured using the Charlson Comorbidity Index (CCI), or in individual comorbidities, account for the lower proportion of SIR in women.
Methods
The association between CCI or its constituent comorbidities, and presence of SIR was studied using data (2010-2014) from a Dutch community-based OHCA registry, and included 2510 OHCA patients aged ≥18y with presumed cardiac cause.
Results
The mean age was 67.8±13.8y, 71% were men. Women were more often in high CCI categories than men. However, moderate or high disease burden was associated with lower odds of SIR compared to no disease burden only in men (OR 99%CI 0.73 [0.53-1.00] and OR 0.54 [0.37-0.80] P-trend<0.001), but not in women (1.00 [0.58-1.72] and 1.02 [0.57-1.84 P-trend 0.93). Adding CCI to a multivariable model did not alter the OR of sex with SIR. Of the individual comorbidities, only previous myocardial infarction was both differently distributed between sexes (men 22.7% vs. women 13.1%, p<0.001) and associated with odds of SIR (higher in both sexes). Adding this variable to the model changed the association of sex with initial rhythm from 0.49 (0.38-0.64) to 0.53 (0.41-0.69)
Conclusion:
Sex differences in comorbidities explained lower odds of SIR in women only modestly: differences in previous myocardial infarction contributed little, and cumulative comorbidity not at all.

Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 25 Aug 2021; epub ahead of print
van Dongen LH, Oving I, Dijkema PW, Beesems SG, Blom MT, Tan HL
Resuscitation: 25 Aug 2021; epub ahead of print | PMID: 34455022
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Impact:
Abstract

Accessibility of automatic external defibrillators and survival rate of people with out-of-hospital cardiac arrest: a systematic review of real-world studies.

Ruan Y, Sun G, Li C, An Y, ... Zou K, Chen D
Objective
To evaluate the relationship between the accessibility of automatic external defibrillators (AEDs) and the survival rate of patients who have out-of-hospital cardiac arrest (OHCA).
Methods
The systematic review was conducted according to the Cochrane Handbook of Systematic Reviews. We searched the Chinese and English literature databases from 2009 to 2019. Study selection and data collection were conducted by three reviewers. One-month survival rates of OHCA with different AEDs accessibility were estimated using meta-analysis.
Results
Overall 16 studies with 55537 participants were included. The overall one-month survival rate for OHCA was 27.4%. The one-month survival rate was 35.2% for people receiving AEDs within 5min, 36.6% between 5min to 10min, and 28.4% for longer than 10min. By distance between the location of the AEDs and the location of the cardiac arrest, the one-month survival rate was 37.1% for those ≤100m, 22.0% for 100m-200m, and 12.8% for >200m, respectively. The one-month survival rate was 39.3% in schools, sports venues and airports compared with 23.5% in other sites. The number of AEDs allocation was positively correlated, while the time and distance were negatively correlated with the one-month survival rate adjusted for other factors, but they were all non-significant correlations.
Conclusion
The improvement of accessibility of AEDs may increase the survival rate of OHCA and the survival rate may be higher in playgrounds, airports, and schools equipped with AEDs. However, the strength of evidence was limited by the considerably heterogeneity of included studies. Verification of these findings in further studies is warranted.

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

Resuscitation: 24 Aug 2021; epub ahead of print
Ruan Y, Sun G, Li C, An Y, ... Zou K, Chen D
Resuscitation: 24 Aug 2021; epub ahead of print | PMID: 34453997
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Impact:
Abstract

Back rubs or foot flicks for neonatal stimulation at birth in a low-resource setting: A randomized controlled trial.

Cavallin F, Lochoro P, Ictho J, Nsubuga JB, ... Putoto G, Trevisanuto D
Background
Approximately 15% of infants require stimulation in low-resource settings, but data on effectiveness of different stimulation approaches are limited. We aimed to compare two recommended approaches of stimulation (back rubs vs. foot flicks) in reducing the need for face-mask ventilation in newly born infants who were not crying immediately after birth in a low-resource setting.
Methods
A single center, open-label, randomized, superiority trial was conducted at St. Kizito Hospital in Matany (Uganda) between November 2019 and May 2020. Newly born infants with expected birthweight > 1500 grams who were not crying immediately after birth were randomly assigned to stimulation using back rubs or foot flicks. The primary outcome measure was the success rate of the stimulation, defined as the achievement of an effective crying preventing the need for face-mask ventilation.
Results
Success of stimulation was achieved in 76/93 neonates (82%) using back rubs and 68/93 neonates (73%) using foot flicks (risk ratio 1.12, 95% confidence interval 0.96-1.31). No procedure-associated complications arose during the study. Time to first cry was not statistically different between the two arms (mean difference -11 seconds, 95% confidence interval -39 to 18).
Conclusions
In newly born infants who were not crying immediately after birth, this trial did not provide a conclusive message in favor of back rubs or foot flicks. Nonetheless, we could not exclude a possible benefit of back rubs in avoiding the need for positive pressure ventilation and, possibly, further advanced resuscitative maneuvers.
Clinical trials registration
clinicalTrial.gov: NCT04056091.

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

Resuscitation: 22 Aug 2021; 167:137-143
Cavallin F, Lochoro P, Ictho J, Nsubuga JB, ... Putoto G, Trevisanuto D
Resuscitation: 22 Aug 2021; 167:137-143 | PMID: 34438002
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Impact:
Abstract

Is point-of-care ultrasound a reliable predictor of outcome during traumatic cardiac arrest? A systematic review and meta-analysis from the SHoC investigators.

Lalande E, Burwash-Brennan T, Burns K, Harris T, ... Woo MY, Atkinson P
Aim
Point-of-care ultrasound (POCUS) has been shown to assist in predicting outcomes in cardiac arrest. We evaluated the test characteristics of POCUS in predicting poor outcomes: failure of return of spontaneous circulation (ROSC), survival to hospital admission (SHA), survival to hospital discharge (SHD) and neurologically intact survival to hospital discharge (NISHD) in adult and paediatric patients with blunt and penetrating traumatic cardiac arrest (TCA) in out-of-hospital or emergency department settings.
Methods
We conducted a systematic review and meta-analysis using the PRISMA guidelines. We searched Clinicaltrials.gov, CINAHL, Cochrane library, EMBASE, Medline and the World Health Organization-International Clinical Trials Registry from 1974 to November 9, 2020. Risk of bias was assessed using QUADAS-2 tool. We used a random-effects meta-analysis model with 95% confidence intervals with I2 statistics for heterogeneity.
Results
We included 8 studies involving 710 cases of TCA. For all blunt and penetrating TCA patients who failed to achieve ROSC, the specificity (proportion of patients with cardiac activity on POCUS who achieved ROSC) was 98% (95% CI 0.13 to 1.0). The sensitivity (proportion of patients with cardiac standstill on POCUS who failed to achieve ROSC) was 91% (95% CI 0.67 to 0.98). No patient with cardiac standstill survived. Substantial level of heterogeneity was noted.
Conclusions
Patients in TCA without cardiac activity on POCUS have a high likelihood of death and negligible chance of SHD. The numbers of patients included in published studies remains too low for practice recommendations for termination of resuscitation based solely upon the absence of cardiac activity on POCUS.

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

Resuscitation: 22 Aug 2021; 167:128-136
Lalande E, Burwash-Brennan T, Burns K, Harris T, ... Woo MY, Atkinson P
Resuscitation: 22 Aug 2021; 167:128-136 | PMID: 34437998
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Impact:
Abstract

Caregiver burden and health-related quality of life amongst caregivers of out-of-hospital cardiac arrest survivors.

Bohm M, Cronberg T, Årestedt K, Friberg H, ... Wise MP, Lilja G
Aims
To describe burden and health-related quality of life amongst caregivers of out-of-hospital cardiac arrest survivors and explore the potential association with cognitive function of the survivors. Caregivers of patients with ST-elevation myocardial infarction were used as controls.
Methods
Data were collected from the cognitive substudy of the Targeted Temperature Management-trial. Caregiver burden was assessed with the 22-item Zarit Burden Interview, with scores ≤20 considered as no burden. Health-related quality of life was assessed with the SF-36v2®, with T-scores 47-53 representing the norm. Cardiac arrest survivors were categorized based on the results from cognitive assessments as having \"no cognitive impairment\" or \"cognitive impairment\".
Results
Follow-up 6 months post event was performed for caregivers of 272 cardiac arrest survivors and 108 matched myocardial infarction controls, included at an intended ratio of 2:1. In general, caregivers of cardiac arrest survivors and controls reported similar caregiver burden. The overall scores for quality of life were within normative levels and similar for caregivers of cardiac arrest survivors and control patients. Compared to those with no cognitive impairment, caregivers of cognitively impaired cardiac arrest survivors (n = 126) reported higher levels of burden (median 18 versus 8, p < 0.001) and worse quality of life in five of eight domains, particularly \"Role-Emotional\" (mean 45.7 versus 49.5, p = 0.002).
Conclusions
In general, caregivers of cardiac arrest survivors and myocardial infarction controls reported similar levels of burden and quality of life. Cognitive outcome and functional dependency of the cardiac arrest survivor impact burden and quality of life of the caregiver.

Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 22 Aug 2021; 167:118-127
Bohm M, Cronberg T, Årestedt K, Friberg H, ... Wise MP, Lilja G
Resuscitation: 22 Aug 2021; 167:118-127 | PMID: 34437997
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Impact:
Abstract

Less is More: Detecting Clinical Deterioration in the Hospital with Machine Learning Using Only Age, Heart Rate, and Respiratory Rate.

Akel MA, Carey KA, Winslow CJ, Churpek MM, Edelson DP
Aim
We sought to develop a machine learning analytic (eCART Lite) for predicting clinical deterioration using only age, heart rate, and respiratory data, which can be pulled in real-time from patient monitors and updated continuously without need for additional inputs or cumbersome electronic health record integrations.
Methods
We utilized a multicenter dataset of adult admissions from five hospitals. We trained a gradient boosted machine model using only current and 24-hour trended heart rate, respiratory rate, and patient age to predict the probability of intensive care unit (ICU) transfer, death, or the combined outcome of ICU transfer or death. The area under the receiver operating characteristic curve (AUC) was calculated in the validation cohort and compared to those for the Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), and eCARTv2, a previously-described, 27-variable, cubic spline, logistic regression model without trends.
Results
Of the 556,848 included admissions, 19,509 (3.5%) were transferred to an ICU and 5,764 (1.0%) died within 24 hours of a ward observation. eCART Lite significantly outperformed the MEWS, NEWS, and eCART v2 for predicting ICU transfer (0.792 vs 0.711, 0.743, and 0.775, respectively; p<0.01) and the combined outcome (0.795 vs 0.722, 0.755, 0.786, respectively; p<0.01). Two of the strongest predictors were respiratory rate and heart rate.
Conclusion
Using only three inputs, we developed a tool for predicting clinical deterioration that is similarly or more accurate than commonly-used algorithms, with potential for use in inpatient settings with limited resources or in scenarios where low-cost tools are needed.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 22 Aug 2021; epub ahead of print
Akel MA, Carey KA, Winslow CJ, Churpek MM, Edelson DP
Resuscitation: 22 Aug 2021; epub ahead of print | PMID: 34437996
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Impact:
Abstract

Incidence of Cardiac Interventions and Associated Cardiac Arrest Outcomes in Patients with Nonshockable Initial Rhythms and No ST Elevation Post Resuscitation.

Harhash AA, May T, Hsu CH, Seder DB, ... Mooney MR, Kern KB
Background
Out of Hospital Cardiac arrest (OHCA) survivors with ST elevation (STE) with or without shockable rhythms often benefit from coronary angiography (CAG) and, if indicated, percutaneous coronary intervention (PCI). However, the benefits of CAG and PCI in OHCA survivors with nonshockable rhythms (PEA/asystole) and no STE are debated.
Methods
Using the International Cardiac Arrest Registry (INTCAR 2.0), representing 44 centers in the US and Europe, comatose OHCA survivors with known presenting rhythms and post resuscitation ECGs were identified. Survival to hospital discharge, neurological recovery on discharge, and impact of CAG with or without PCI on such outcome were assessed and compared with other groups (shockable rhythms with or without STE).
Results
Total of 2,113 OHCA survivors were identified and described as; nonshockable/no STE (Nsh-NST) (n=940, 44.5%), shockable/no STE (Sh-NST) (n=716, 33.9%), nonshockable/STE (Nsh-ST) (n=110, 5.2%), and shockable/STE (Sh-ST) (n=347, 16.4%). Of Nsh-NST, 13.7% (129) were previously healthy before CA and only 17.3% (161) underwent CAG; of those, 30.4% (52) underwent PCI. A total of 18.6% (174) Nsh-NST patients survived to hospital discharge, with 57.5% (100) of such survivors having good neurological recovery (cerebral performance category 1 or 2) on discharge. Coronary angiography was associated with improved odds for survival and neurological recovery among all groups, including those with NSh-NST.
Conclusions
Nonshockable initial rhythms with no ST elevation post resuscitation was the most common presentation after OHCA. Although most of these patients did not undergo coronary angiography, among those who did, 1 in 4 patients had a culprit lesion and underwent revascularization. Invasive CAG should be at least considered for all OHCA survivors, including those with nonshockable rhythms and no ST elevation post resuscitation. Brief Abstract Out of hospital cardiac arrest (OHCA) survivors with ST elevation and/or shockable rhythms benefit from coronary angiography and revascularization. Nonshockable cardiac arrest survivors with no ST elevation have the worst prognosis and rarely undergo coronary angiography. Nonshockable rhythms with no ST elevation was the most common presentation after OHCA and among a small subgroup underwent coronary angiography, 1 in 4 patients with had culprit lesion and underwent revascularization. Coronary angiography was associated with high prevalence of acute culprit coronary lesions and should be considered for those with a probably cardiac cause for their arres.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 22 Aug 2021; epub ahead of print
Harhash AA, May T, Hsu CH, Seder DB, ... Mooney MR, Kern KB
Resuscitation: 22 Aug 2021; epub ahead of print | PMID: 34437992
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Impact:
Abstract

Association of outborn versus inborn birth status on the in-hospital outcomes of neonates treated with therapeutic hypothermia: A propensity score-weighted cohort study.

Stetson RC, Brumbaugh JE, Weaver AL, Mara KC, ... Carey WA, Fang JL
Objective
To compare the risk of in-hospital mortality and morbidity between outborn and inborn neonates treated with whole body hypothermia.
Methods
The association of outborn birth status with in-hospital mortality and morbidity, prior to NICU discharge or transfer, was assessed in a large historical cohort of neonates who had therapeutic hypothermia initiated on the day of birth. The cohort was restricted to neonates born at ≥35 weeks gestational age from 2007 to 2018. Since the sample was non-random, inverse probability weighting (IPW) derived from propensity scores was used to reduce imbalance in baseline maternal and neonatal characteristics between outborn and inborn neonates. Cox proportional hazards regression was used to assess the association between outborn status and in-hospital mortality.
Results
There were 4447 neonates included in the study (2463 outborn). Outborn status was not significantly associated with an increased risk of in-hospital mortality in the unadjusted cohort (HR = 1.17, 95% CI 0.97-1.42, p = 0.10) or IPW cohort (HR = 1.09, 95% CI 0.95-1.26, p = 0.22). However, in the IPW cohort, outborn neonates were significantly more likely to have seizures (28% vs 24%, p = 0.006), anticonvulsant exposure (46% vs 41%, p = 0.002), and gastrostomy tube placement (5.8% vs 3.8%, p = 0.009) during their newborn hospitalization.
Conclusion
Outborn status was not significantly associated with increased in-hospital mortality among neonates treated with whole body hypothermia. However, outborn neonates were more likely to have seizures, receive anticonvulsant treatment, and undergo gastrostomy tube placement. Further study is needed to better understand the etiologies of these outcome disparities and potential implications for long-term neurodevelopmental outcomes.

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

Resuscitation: 20 Aug 2021; 167:82-88
Stetson RC, Brumbaugh JE, Weaver AL, Mara KC, ... Carey WA, Fang JL
Resuscitation: 20 Aug 2021; 167:82-88 | PMID: 34425153
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Impact:
Abstract

aOutcomes of Delivery Room Resuscitation of Bradycardic Preterm Infants: A Retrospective Cohort Study of Randomised Trials of High vs Low Initial Oxygen Concentration and an Individual Patient Data Analysis.

Kapadia V, Lee Oei J, Finer N, Rich W, ... Saugstad OD, Vento M
Objective
To determine whether hospital mortality (primary outcome) is associated with duration of bradycardia without chest compressions during delivery room (DR) resuscitation in a retrospective cohort study of randomized controlled trials (RCTs) in preterm infants assigned low versus high initial oxygen concentration.
Methods
Medline and EMBASE were searched from 01/01/1990 to 12/01/2020. RCTs of low vs high initial oxygen concentration which recorded serial heart rate (HR) and oxygen saturation (SpO2) during resuscitation of infants <32 weeks gestational age were eligible. Individual patient level data were requested from the authors. Newborns receiving chest compressions in the DR and those with no recorded HR in the first 2 minutes after birth were excluded. Prolonged bradycardia (PB) was defined as HR < 100 bpm for ≥ 2 min. Individual patient data analysis and pooled data analysis were conducted.
Results
Data were collected from 720 infants in 8 RCTs. Neonates with PB had higher odds of hospital death before [OR 3.8 (95% CI 1.5, 9.3)] and after [OR 1.7 (1.2, 2.5)] adjusting for potential confounders. Bradycardia occurred in 58% infants, while 38% had PB. Infants with bradycardia were more premature and had lower birth weights. The incidence of bradycardia in infants resuscitated with low (≤ 30%) and high (≥ 60%) oxygen was similar. Neonates with both, PB and SpO2<80% at 5 minutes after birth had higher odds of hospital mortality. [OR 18.6 (4.3, 79.7)]
Conclusion:
In preterm infants who did not receive chest compressions in the DR, prolonged bradycardia is associated with hospital mortality.

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

Resuscitation: 19 Aug 2021; epub ahead of print
Kapadia V, Lee Oei J, Finer N, Rich W, ... Saugstad OD, Vento M
Resuscitation: 19 Aug 2021; epub ahead of print | PMID: 34425156
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Impact:
Abstract

Endotracheal intubation versus supraglottic procedure in paediatric out-of-hospital cardiac arrest: a registry-based study.

Le Bastard Q, Rouzioux J, Montassier E, Baert V, ... Javaudin F, GR-RéAC
Background
Out-of-hospital cardiac arrest (OHCA) in children is associated with a low survival rate.
Conclusions:
in the literature are conflicting regarding the best way to handle ventilation. The purpose of this study was to assess the impact of two airway management strategies, endotracheal intubation (ETI) vs. supraglottic procedure, during cardiopulmonary resuscitation (CPR) on 30-day survival in paediatric OHCA.
Methods
This was a retrospective, observational, multicentre, registry-based study conducted from July 2011 to March 2018. All paediatric OHCA patients under 18 years of age and managed by a mobile intensive care unit were included. The primary endpoint was 30-day survival in a weighted population (based on propensity scores).
Results
Of 1579 children, 1355 (85.8%) received ETI and 224 (14.2%) received supraglottic ventilation during CPR. We observe a lower 30-day survival in the ETI group compared to the supraglottic group (7.7% vs. 14.3%, absolute difference, 6.6 percentage points; 95% confidence interval [CI], 2.3-12.0; propensity-adjusted odds ratio [paOR], 0.39; 95% CI, 0.25-0.62; p < 0.001), and also a poorer neurological outcome (paOR, 0.32; 95% CI, 0.19-0.54; p < 0.001). However, we did not identify any significant association between airway management strategy and return of spontaneous circulation (paOR, 1.15; 95% CI, 0.80-1.65; p = 0.46).
Conclusions
The findings of this large cohort study suggest that ETI in paediatric OHCA, although performed by trained physicians, is associated with a worse outcome, regardless of traumatic or non-traumatic aetiology.

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

Resuscitation: 17 Aug 2021; epub ahead of print
Le Bastard Q, Rouzioux J, Montassier E, Baert V, ... Javaudin F, GR-RéAC
Resuscitation: 17 Aug 2021; epub ahead of print | PMID: 34418479
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Impact:
Abstract

Ethics of ECPR research.

Suverein MM, Shaw D, Lorusso R, Delnoij TSR, ... van de Poll MCG, Maessen JG
The design of emergency medicine trials can raise several ethical concerns - risks may be greater, and randomisation may have to occur before consent. Research in emergency medicine is thus an illuminating context to explore the interplay between risk and randomisation, and the consequences for consent. Using a currently running trial, we describe possible concerns, considerations, and solutions to reconcile the conflicting interests of scientific inquiry, ethical principles, and clinical reality in emergency medicine research.

Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 16 Aug 2021; epub ahead of print
Suverein MM, Shaw D, Lorusso R, Delnoij TSR, ... van de Poll MCG, Maessen JG
Resuscitation: 16 Aug 2021; epub ahead of print | PMID: 34411691
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Impact:
Abstract

Hypothermic Cardiac Arrest - Retrospective cohort study from the International Hypothermia Registry.

Walpoth BH, Maeder MB, Courvoisier DS, Meyer M, ... Lovis C, Mair P
Aim
The International Hypothermia Registry (IHR) was created to increase knowledge of accidental hypothermia, particularly to develop evidence-based guidelines and find reliable outcome predictors. The present study compares hypothermic patients with and without cardiac arrest included in the IHR.
Methods
Demographic, pre-hospital and in-hospital data, method of rewarming and outcome data were collected anonymously in the IHR between 2010 and 2020.
Results
Two hundred and one non-consecutive cases were included. The major causeof hypothermia was mountain accidents, predominantly in young men. Hypothermic Cardiac Arrest (HCA) occurred in 73 of 201 patients. Core temperature was significantly lower in the patients in cardiac arrest (25.0 vs. 30.0 °C, p < 0.001). One hundred and fifteen patients were rewarmed externally (93% with ROSC), 53 by extra-corporeal life support (ECLS) (40% with ROSC) and 21 with invasive internal techniques (71% with ROSC). The overall survival rate was 95% for patients with preserved circulation and 36% for those in cardiac arrest. Witnessed cardiac arrest and ROSC before rewarming were positive outcome predictors, asphyxia, coagulopathy, high potassium and lactate negative outcome predictors.
Conclusions
This first analysis of 201 IHR patients with moderate to severe accidental hypothermia shows an excellent 95% survival rate for patients with preserved circulation and 36% for HCA patients. Witnessed cardiac arrest, restoration of spontaneous circulation, low potassium and lactate and absence of asphyxia were positive survival predictors despite hypothermia in young, healthy adults after mountaineering accidents. However, accidental hypothermia is a heterogenous entity that should be considered in both treatment strategies and prognostication.

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

Resuscitation: 16 Aug 2021; 167:58-65
Walpoth BH, Maeder MB, Courvoisier DS, Meyer M, ... Lovis C, Mair P
Resuscitation: 16 Aug 2021; 167:58-65 | PMID: 34416307
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Impact:
Abstract

The association between end-tidal CO2 and return of spontaneous circulation after out-of-hospital cardiac arrest with pulseless electrical activity.

Crickmer M, Drennan IR, Turner L, Cheskes S
Introduction
End-tidal carbon dioxide (ETCO2) has been suggested to have prognostic implications during out-of-hospital cardiac arrest (OHCA). Our objective was to determine if the change in ETCO2 (delta ETCO2) during resuscitation was predictive of future return of spontaneous circulation (ROSC) in patients with pulseless electrical activity (PEA) arrests.
Methods
We performed a retrospective, observational study of adult (≥18 years of age) non-traumatic PEA OHCAs in two Canadian EMS systems over a two-year time frame beginning on January 1, 2018. Cases were excluded if there was a Do Not Resuscitate order (DNR), had no advanced airway, or had less than two ETCO2 recordings. We performed multivariable logistic regression to examine the association between ETCO2 measures and ROSC. Second, we examined the prognostic performance (sensitivity, specificity, NPV, PPV) for ETCO2 at specific thresholds for predicting ROSC.
Results
A total of 208 OHCA met inclusion criteria of which 67 (32%) obtained ROSC. After adjusting for pre-determined confounders, there was an association between delta ETCO2 and ROSC (odds ratio [OR] per 10 mmHg increase in ETCO2 of 1.74 (95% confidence interval [CI] 1.35 to 2.24); P value < 0.001). We also found significant associations between both initial ETCO2 and final ETCO2 with ROSC.
Conclusion
Our analysis indicates that there is a positive linear relationship between delta ETCO2 and ROSC with values of delta ETCO2 > 20 mmHg being highly specific for ROSC in PEA patients. As such, patients with up-trending ETCO2 values should have resuscitation continued unless there is overwhelming clinical evidence to the contrary.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 16 Aug 2021; 167:76-81
Crickmer M, Drennan IR, Turner L, Cheskes S
Resuscitation: 16 Aug 2021; 167:76-81 | PMID: 34416306
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Impact:
Abstract

Physician\'s presence in pre-hospital setting improves one-month favorable neurological survival after out-of-hospital cardiac arrest: A propensity score matching analysis of the JAAM-OHCA Registry.

Hatakeyama T, Kiguchi T, Sera T, Nachi S, ... Otomo Y, Iwami T
Background
Using the out-of-hospital cardiac arrest (OHCA) registry in Japan, we evaluated the effectiveness of physicians\' presence in pre-hospital settings after adjusting in-hospital treatments.
Methods
This was a multicenter cohort study. We registered all consecutive OHCA patients in Japan who, from 1 June 2014 through 31 December 2017, were transported to institutions participating in the Japanese Association for Acute Medicine OHCA registry. We included OHCA patients aged at least 18 years, with medical etiology, and who received resuscitation from emergency medical services (EMS) personnel and medical professionals in hospitals. The primary outcome was one-month favorable neurological survival. We estimated the propensity score by fitting a logistic regression model that was adjusted for several variables before the arrival of EMS personnel and/or pre-hospital physician. A multivariable logistic regression analysis in propensity score-matched patients was used to adjust confounders, including extracorporeal membrane oxygenation, percutaneous coronary intervention, intra-aortic balloon pumping, and targeted temperature management.
Results
We analyzed 19,247 patients. Among them, 5.4% (N = 1040) had a neurologically favorable outcome. The adjusted odds ratio (AOR) of the physicians\' presence compared with their absence for primary outcome was 1.84 (95% confidence interval (CI): 1.43-2.37). Among first documented non-shockable cardiac rhythm, the AOR was 1.51 (95% CI: 1.04-2.22). Among first documented shockable cardiac rhythm, the AOR of the physicians\' presence for primary outcome was 1.15 (95% CI: 0.83-1.59).
Conclusion
The improved one-month favorable neurological survival was significantly associated with the physicians\' presence in pre-hospital settings, compared with the physicians\' absence.

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

Resuscitation: 11 Aug 2021; 167:38-46
Hatakeyama T, Kiguchi T, Sera T, Nachi S, ... Otomo Y, Iwami T
Resuscitation: 11 Aug 2021; 167:38-46 | PMID: 34390825
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Impact:
Abstract

Transoesophageal echocardiography in cardiac arrest: A systematic review.

Hussein L, Rehman MA, Jelic T, Berdnikov A, ... Jarman R, SHoC Investigators and the Resuscitative TEE Collaborative Registry Investigators
Aims
To identify, appraise and synthesize all available clinical evidence to evaluate the diagnostic role of transoesophageal echocardiography (TEE) during resuscitation of in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) in the identification of reversible causes of cardiac arrest and cardiac contractility.
Methods
We conducted a systematic review following PRISMA guidelines. Medline, EMBASE, Web of Science Core Collection, Proquest Dissertations, Open Grey, CDSR, Cochrane Central, Cochrane Clinical Answers, and the clinicaltrials.gov registry were searched for eligible studies. Studies involving adult patients, with non-traumatic cardiac arrest in whom TEE was used for intra-arrest evaluation, were included. Case studies and case series, animal studies, reviews, guidelines and editorials were excluded. The QUADAS-2 tool was used for quality assessment of all studies.
Results
Eleven studies with a total of 358 patients were included. Four studies involved perioperative IHCA, three involved OHCA, and four were mixed population settings. Overall, the risk of bias in the selected studies was either high or unclear due to evidence or lack of information. In all 11 studies, TEE allowed the identification of reversible causes of arrest. We found significant heterogeneity in the criteria used to interpret findings, TEE protocol used, and timing of TEE.
Conclusion
Due to heterogeneity of studies, small sample size and inconsistent reference standard, the evidence for TEE in cardiac arrest resuscitation is of low certainty and is affected by a high risk of bias. Further studies are needed to better understand the true diagnostic accuracy of TEE in identifying reversible causes of arrest and cardiac contractility.

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

Resuscitation: 11 Aug 2021; epub ahead of print
Hussein L, Rehman MA, Jelic T, Berdnikov A, ... Jarman R, SHoC Investigators and the Resuscitative TEE Collaborative Registry Investigators
Resuscitation: 11 Aug 2021; epub ahead of print | PMID: 34390824
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Impact:
Abstract

Does cerebral near-infrared spectroscopy (NIRS) help to predict futile cannulation in extracorporeal cardiopulmonary resuscitation (ECPR)?

Wiest C, Philipp A, Foltan M, Lunz D, ... Müller T, Lubnow M
Aim of the study
Extracorporeal cardiopulmonary resuscitation (ECPR) is an evolving technique to improve cardiopulmonary resuscitation (CPR) outcomes. Identifying a readily available tool helpful for predicting patient\'s outcome is warranted. The aim of the study was to evaluate the capability of cranial near-infrared spectroscopy (cNIRS) to identify non-survivors or patients with unfavorable neurologic outcome prior to cannulation for ECPR to avoid futile cannulations.
Methods
Retrospective analysis (2015-2021) of 97 patients requiring ECPR due to cardiac arrest with prior cNIRS measurement, which was performed immediately after ECPR team arrived on scene. Lowest possible regional cerebral oxygen saturation (rSO2) is 15%.
Results
Mortality was 72.1% (70/97). Survivors showed in 88.9% (24/27) good neurological outcome (Cerebral Performance Category (CPC) 1 + 2). rSO2 = 15% (11/97) prior to cannulation was only found in non-survivors. Among survivors, initial rSO2 was not associated with neurological outcome. Non-shockable initial rhythm was associated with higher mortality (44/50). In survivors, time to ECPR was shorter (p = 0.006), and initial lactate was significantly lower, whereas initial pH and hemoglobin levels were higher (p = 0.001). Survivors and those with favorable neurological outcome showed lower maximal NSE levels in the first 72 hours (p < 0.001; p = 0.041).
Conclusion
In our patient cohort, rSO2 = 15% immediately prior to cannulation for ECPR did not result in any survivors, thus might be a marker for futile cannulation in ECPR. Higher rSO2 values were not associated with favorable neurologic outcome. Lower initial lactate and lower maximal NSE within the first 72 h after arrest were associated with favorable outcome.

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

Resuscitation: 11 Aug 2021; epub ahead of print
Wiest C, Philipp A, Foltan M, Lunz D, ... Müller T, Lubnow M
Resuscitation: 11 Aug 2021; epub ahead of print | PMID: 34391868
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Impact:
Abstract

Longitudinal two years evaluation of neuropsychological outcome in children after out of hospital cardiac arrest.

Hunfeld M, Dulfer K, Rietman A, Pangalila R, ... Tibboel D, Buysse C
Aim
To investigate longitudinal functional and neuropsychological outcomes 3-6 and 24 months after paediatric out-of-hospital cardiac arrest (OHCA). Further, to explore the association between paediatric cerebral performance category (PCPC) and intelligence.
Methods
Prospective longitudinal single center study including children (0-17 years) with OHCA, admitted to the PICU of a tertiary care hospital between 2012 and 2017. Survivors were assessed during an outpatient multidisciplinary follow-up program 3-6 and 24 months post-OHCA. Functional and neuropsychological outcomes were assessed through interviews, neurological exam, and validated neuropsychological testing.
Results
The total eligible cohort consisted of 49 paediatric OHCA survivors. The most common cause of OHCA was arrhythmia (33%). Median age at time of OHCA was 48 months, 67% were males. At 3-6 and 24 months post-OHCA, respectively 74 and 73% had a good PCPC score, defined as 1-2. Compared with normative data, OHCA children obtained worse sustained attention and processing speed scores 3-6 (n = 26) and 24 (n = 27) months post-OHCA. At 24 months, they also obtained worse intelligence, selective attention and cognitive flexibility scores. In children tested at both time-points (n = 19), no significant changes in neuropsychological outcomes were found over time. Intelligence scores did not correlate with PCPC.
Conclusion
Although paediatric OHCA survivors had a good PCPC score 3-6 and 24 months post-OHCA, they obtained worse scores on important neuropsychological domains such as intelligence and executive functioning (attention and cognitive flexibility). Follow-up should continue over a longer life span in order to fully understand the long-term impact of OHCA in childhood.

Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 09 Aug 2021; 167:29-37
Hunfeld M, Dulfer K, Rietman A, Pangalila R, ... Tibboel D, Buysse C
Resuscitation: 09 Aug 2021; 167:29-37 | PMID: 34389455
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Impact:
Abstract

The association of intraosseous vascular access and survival among pediatric patients with out-of-hospital cardiac arrest.

Besserer F, Kawano T, Dirk J, Meckler G, ... Grunau B, Canadian Resuscitation Outcomes Consortium
Introduction
In pediatric out-of-hospital cardiac arrest (OHCA) the effect of intraosseous (IO) or intravenous (IV) access on outcomes is unclear.
Methods
We analyzed prospectively collected data of non-traumatic OHCA in the Resuscitation Outcomes Consortium registry from 2011 to 2015. We included EMS-treated patients ≤17 years of age, classified patients based on vascular access routes, and calculated success rates of IO and IV attempts. After excluding patients with obvious non-cardiac etiologies and those with unsuccessful vascular access or multiple routes, we fit a logistic regression model to evaluate the association of IO vascular access (reference IV access) with the primary outcome of survival, using multiple imputation to address missing data. We analyzed a subgroup of patients at least 2 years of age.
Results
There were 1549 non-traumatic OHCA: 895 (57.8%) patients had an IO line attempted with 822 (91.8%) successful; 488 (31.5%) had an IV line attempted with 345 (70.7%) successful (difference 21%, 95% CI 17 to 26%). Of the 761 patients included in our logistic regression, 601 received IO (30 [5.2%] survived) and 160 received IV (40 [25%] survived) vascular access. Intraosseous access was associated with a decreased probability of survival (adjusted OR 0.46; 95% CI 0.21-0.98). Patients at least 2 years of age showed a similar association (adjusted OR 0.36; CI 0.15-0.86).
Conclusions
Intraosseous access was associated with decreased survival among pediatric non-traumatic OHCA. These results are exploratory and support the need for further study to evaluate the effect of intravascular access method on outcomes.

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

Resuscitation: 09 Aug 2021; 167:49-57
Besserer F, Kawano T, Dirk J, Meckler G, ... Grunau B, Canadian Resuscitation Outcomes Consortium
Resuscitation: 09 Aug 2021; 167:49-57 | PMID: 34389454
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Impact:
Abstract

Modeling severe functional impairment or death following ECPR in pediatric cardiac patients: Planning for an interventional trial.

Sperotto F, Saengsin K, Danehy A, Godsay M, ... Thiagarajan RR, Kheir JN
Aim
We aimed to characterize extracorporeal CPR (ECPR) outcomes in our center and to model prediction of severe functional impairment or death at discharge.
Methods
All ECPR events between 2011 and 2019 were reviewed. The primary outcome measure was severe functional impairment or death at discharge (Functional Status Score [FSS] ≥ 16). Organ dysfunction was graded using the Pediatric Logistic Organ Dysfunction Score-2, neuroimaging using the modified Alberta Stroke Program Early Computed Tomography Score. Multivariable logistic regression was used to model FSS ≥ 16 at discharge.
Results
Of the 214 patients who underwent ECPR, 182 (median age 148 days, IQR 14-827) had an in-hospital cardiac arrest and congenital heart disease and were included in the analysis. Of the 110 patients who underwent neuroimaging, 52 (47%) had hypoxic-ischemic injury and 45 (41%) had hemorrhage. In-hospital mortality was 52% at discharge. Of these, 87% died from the withdrawal of life-sustaining therapies; severe neurologic injury was a contributing factor in the decision to withdraw life-sustaining therapies in 50%. The median FSS among survivors was 8 (IQR 6-8), and only one survivor had severe functional impairment. At 6 months, mortality was 57%, and the median FSS among survivors was 6 (IQR 6-8, n = 79). Predictive models identified FSS at admission, single ventricle physiology, extracorporeal membrane oxygenation (ECMO) duration, mean PELOD-2, and worst mASPECTS (or DWI-ASPECTS) as independent predictors of FSS ≥ 16 (AUC = 0.931) and at 6 months (AUC = 0.924).
Conclusion
Mortality and functional impairment following ECPR in children remain high. It is possible to model severe functional impairment or death at discharge with high accuracy using daily post-ECPR data up to 28 days. This represents a prognostically valuable tool and may identify endpoints for future interventional trials.

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

Resuscitation: 09 Aug 2021; 167:12-21
Sperotto F, Saengsin K, Danehy A, Godsay M, ... Thiagarajan RR, Kheir JN
Resuscitation: 09 Aug 2021; 167:12-21 | PMID: 34389452
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Impact:
Abstract

The emergency medical service has a crucial role to unravel the genetics of sudden cardiac arrest in young, out of hospital resuscitated patients: Interim data from the MAP-IT study.

Tiesmeier J, Gaertner A, Homm S, Jakob T, ... Fox H, Milting H
Background
Genetics of sudden cardiac deaths (SCD) remains frequently undetected. Genetic analysis is recommended in undefined selected cases in the 2021 ERC-guideline. The emergency medical service and physicians (EMS) may play a pivotal role for unraveling SCD by saving biomaterial for later molecular autopsy. Since for high-throughput DNA-sequencing (NGS) high quality genomic DNA is needed. We investigated in a prospective proof-of-concept study the role of the EMS for the identification of genetic forms of SCDs in the young.
Methods
We included patients aged 1-50 years with need for cardiopulmonary resuscitation attempts (CPR). Cases with non-natural deaths were excluded. In two German counties with 562,904 residents 39,506 services were analysed. Paired end panel-sequencing was performed, and variants were classified according to guidelines of the American College of Medical Genetics (ACMG).
Results
769 CPR-attempts were recorded (1.95% of all EMS-services; CPR-incidence 68/100,000). In 103 cases CPR were performed in patients < 50y. 58% died on scene, 26% were discharged from hospital. 24 subjects were included for genotyping. Of these 33% died on scene, 37.5% were discharged from hospital. 25% of the genotyped patients were carriers of (likely) pathogenic (ACMG-4/-5) variants. 67% carried variants with unknown significance (ACMG-3). 2 of them had familial history for arrhythmogenic cardiomyopathy or had to be re-classified as ACMG-4 carriers due to whole exome sequencing.
Conclusion
The EMS contributes especially in fatal OHCA-cases to increase the yield of identified genetic conditions by collecting a blood sample on scene. Thus, the EMS can contribute significantly to primary and secondary prophylaxis in affected families.

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

Resuscitation: 09 Aug 2021; epub ahead of print
Tiesmeier J, Gaertner A, Homm S, Jakob T, ... Fox H, Milting H
Resuscitation: 09 Aug 2021; epub ahead of print | PMID: 34389451
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Impact:
Abstract

Annual and lifetime economic productivity loss due to adult out-of-hospital cardiac arrest in the United States: A study for the CARES Surveillance Group.

Coute RA, Nathanson BH, Kurz MC, DeMasi S, McNally B, Mader TJ
Objective
To estimate the annual and lifetime economic productivity loss due to adult out-of-hospital cardiac arrest (OHCA) in the United States (U.S.).
Methods
All adult (age ≥ 18 years) non-traumatic EMS-treated OHCA with complete data for age, sex, race, and survival outcomes from the CARES database for 2013-2018 were included. Annual and lifetime labor productivity values, based on age and gender, were obtained from previously published national economic data. Productivity losses for OHCA events were calculated by year in U.S. dollars. Productivity losses for survivors were assigned by cerebral performance category score (CPC): CPC 1 and 2 = 0% productivity loss; CPC 3-5 = 100% productivity loss. Sensitivity analyses were performed assigning CPC 2 varying productivity losses (0-100%) based on CPC score and discharge location. Lifetime productivity values assumed 1% annual growth and 3% discount rate and were adjusted for inflation based on 2016 values. Results were extrapolated to annual U.S. population estimates for the study period.
Results
A total of 338,492 (96.5%) cases met inclusion criteria. The mean annual and lifetime productivity losses per OHCA in 2018 were $48,224 and $638,947 respectively. The total annual economic productivity loss due to OHCA in the U.S. increased from $7.4B in 2013 to $11.3B in 2018. Lifetime economic productivity loss increased from $95.2B in 2013 to $150.2B in 2018. Sensitivity analyses yielded similar findings. Per annual death, OHCA ranked third ($10.2B) in annual economic productivity loss in the U.S. behind cancer ($22.9B) and heart disease ($20.3B) in 2018.
Conclusion
Adult non-traumatic OHCA events are associated with significant annual and lifetime economic productivity losses and should be the focus of public health resources to improve preventative measures and survival outcomes.

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

Resuscitation: 09 Aug 2021; 167:111-117
Coute RA, Nathanson BH, Kurz MC, DeMasi S, McNally B, Mader TJ
Resuscitation: 09 Aug 2021; 167:111-117 | PMID: 34389450
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Impact:
Abstract

A pragmatic parallel group implementation study of a prehospital-activated ECPR protocol for refractory out-of-hospital cardiac arrest.

Grunau B, Bashir J, Cheung A, Boone R, ... Kanji H, Christenson J
Objectives
Extracorporeal membrane oxygenation within CPR (ECPR) may improve survival among patients with refractory out-of-hospital cardiac arrest (OHCA). We evaluated outcomes after incorporating ECPR into a conventional resuscitation system.
Methods
We introduced a prehospital-activated ECPR protocol for select refractory OHCAs into one of four metropolitan regions in British Columbia. We prospectively identified ECPR-eligible patients in both the ECPR region and the three other regions to serve as the control group. We compared the proportion with favorable neurological outcomes at hospital discharge (cerebral performance category ≤2) and used logistic regression to estimate the association with treatment region.
Results
The study was terminated prematurely due to changes in hospital protocols and COVID-19. In the ECPR region, 15/58 (25.9%) patients had favourable neurological outcomes owing to conventional resuscitation and 2/58 (3.4%) owing to ECPR, for a total of 17/58 (29.3%). In the control regions, 67/250 (26.8%) patients had a favourable outcome owing to conventional resuscitation, for a between-group difference of 2.5% (95% CI -10 to 15%). We did not detect a statistically significant association between treatment region and outcomes.
Conclusion
In this prematurely-terminated study of ECPR for refractory OHCA, we did not detect an association between a regional ECPR protocol and neurologically favorable outcomes. However, our data suggests that outcomes owing to conventional resuscitation were similar, with the potential for additional survivors due to ECPR therapies.

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

Resuscitation: 08 Aug 2021; 167:22-28
Grunau B, Bashir J, Cheung A, Boone R, ... Kanji H, Christenson J
Resuscitation: 08 Aug 2021; 167:22-28 | PMID: 34384821
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Impact:
Abstract

Variation in time to notification of enrollment and rates of withdrawal in resuscitation trials conducted under exception from informed consent.

Nichol G, Zhuang R, Russell R, Holcomb JB, ... Weisfeldt ML, May S
Importance
Emergency research is challenging to do well as it involves time sensitive interventions in unstable patients. There is limited time to obtain informed consent from the patient or their legally authorized representative (LAR). Such research is permitted under exception from informed consent (EFIC) if specific criteria are met, including notification after enrollment. Some question whether the risks of EFIC outweighs its benefits. To date, there is limited empiric information about time to notification (TTN) and rates of withdrawal in such trials.
Objective
To describe variation in TTN and rates of withdrawal among that patients enrolled in EFIC trials over a twelve-year period.
Design
We performed post hoc descriptive analyses of data from five trials conducted under EFIC.
Setting
Emergency medical services and receiving hospitals participating in the Resuscitation Outcomes Consortium in the United States and Canada.
Participants
Patients with out-of-hospital cardiac arrest or life-threatening traumatic injury.
Exposures
Notification strategies were specified at each site before initiation of enrollment by a local institutional review board. We monitored TTN within each site centrally throughout each study\'s enrollment period.
Outcomes
TTN was defined as time from randomization to first-reported notification of patient or LAR of enrollment. Withdrawal was defined as patient or LAR opt out of ongoing participation at the time of notification.
Results
Of 35,442 patients enrolled in five trials, 33,805 had cardiac arrest; and 1636 had traumatic injury. TTN varied overall and by patient outcome. Among those with cardiac arrest, TTN ranged from median (5%ile, 95%ile) of 6 (1,27) days to 28 (2, 53) days across sites. 0.3% of notified patients with cardiac arrest withdrew. Among those with traumatic injury, TTN ranged from 0 (0, 5) days to 36 (5, 68) days across sites. 7.7% of notified patients with traumatic injury withdrew.

Conclusions:
and relevance
There is large variation in TTN in trials conducted under EFIC for emergency research. This may be due to several factors. It may or may not be modifiable. Overall rates of withdrawal are low, which suggests current practices related to EFIC are acceptable to those who have participated in emergency research.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 08 Aug 2021; epub ahead of print
Nichol G, Zhuang R, Russell R, Holcomb JB, ... Weisfeldt ML, May S
Resuscitation: 08 Aug 2021; epub ahead of print | PMID: 34384820
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Impact:
Abstract

Between-hospital variability in organ donation after resuscitation from out-of-hospital cardiac arrest.

Elmer J, Weisgerber AR, Wallace DJ, Horne E, ... Shutterly K, Callaway CW
Introduction
Survival and recovery after out-of-hospital cardiac arrest (OHCA) varies between hospitals, with better outcomes associated with high-volume and specialty care. We evaluated if there is a similar relationship with organ donation after OHCA.
Methods
We studied a cohort of adults resuscitated from OHCA from 2010 to 2018, treated at one of 112 hospitals served by a regional organ procurement organization (OPO). We obtained hospital-level characteristics from Centers for Medicare and Medicaid Services and Health Resources and Services Administration and obtained patients\' clinical information from the OPO health record. We excluded patients with no potential to donate on initial referral. Our primary exposure was treatment at a high-volume hospital (defined > 500 eligible cases during the study period) and our primary outcomes were suitability to donate after full medical evaluation, successful organ procurement and organ transplantation. We used mixed effects models to quantify between-hospital variability in the primary outcomes.
Results
Overall, 9792 patients were included and 796 (8%) were organ donors. We identified significant between-hospital variation in odds of donation (median odds ratio 1.64 [95% CI 1.42-2.02]). Hospital volume explained the greatest proportion of variability. High volume centers had a higher proportion of referrals with potential to donate (16.9 vs 12.2%), actual donation (10.3 vs 6.2%), and successful transplantation (9.4 vs 5.7%). Overall, 2032/7763 (26%) of recovered transplantable organs in this region were procured from OHCA patients.
Conclusion
High volume centers are more likely to refer and procure transplantable organs from patients with non-survivable OHCA.

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

Resuscitation: 03 Aug 2021; epub ahead of print
Elmer J, Weisgerber AR, Wallace DJ, Horne E, ... Shutterly K, Callaway CW
Resuscitation: 03 Aug 2021; epub ahead of print | PMID: 34363855
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Impact:
Abstract

Adrenaline improves regional cerebral blood flow, cerebral oxygenation and cerebral metabolism during CPR in a porcine cardiac arrest model using low-flow extracorporeal support.

Putzer G, Martini J, Spraider P, Abram J, ... Helbok R, Mair P
Background
The effects of adrenaline on cerebral blood vessels during cardiopulmonary resuscitation (CPR) are not well understood. We developed an extracorporeal CPR model that maintains constant low systemic blood flow while allowing adrenaline-associated effects on cerebral vasculature to be assessed at different mean arterial pressure (MAP) levels independently of the effects on systemic blood flow.
Methods
After eight minutes of cardiac arrest, low-flow extracorporeal life support (ECLS) (30 ml/kg/min) was started in fourteen pigs. After ten minutes, continuous adrenaline administration was started to achieve MAP values of 40 (n = 7) or 60 mmHg (n = 7). Measurements included intracranial pressure (ICP), cerebral perfusion pressure (CePP), laser-Doppler-derived regional cerebral blood flow (CBF), cerebral regional oxygen saturation (rSO2), brain tissue oxygen tension (PbtO2) and extracellular cerebral metabolites assessed by cerebral microdialysis.
Results
During ECLS without adrenaline, regional CBF increased by only 5% (25th to 75th percentile: -3 to 14; p = 0.2642) and PbtO2 by 6% (0-15; p = 0.0073) despite a significant increase in MAP to 28 mmHg (25-30; p < 0.0001) and CePP to 10 mmHg (8-13; p < 0.0001). Accordingly, cerebral microdialysis parameters showed a profound hypoxic-ischemic pattern. Adrenaline administration significantly improved regional CBF to 29 ± 14% (p = 0.0098) and 61 ± 25% (p < 0.001) and PbtO2 to 15 ± 11% and 130 ± 82% (both p < 0.001) of baseline in the MAP 40 mmHg and MAP 60 mmHg groups, respectively. Importantly, MAP of 60 mmHg was associated with metabolic improvement.
Conclusion
This study shows that adrenaline administration during constant low systemic blood flow increases CePP, regional CBF, cerebral oxygenation and cerebral metabolism.

Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 03 Aug 2021; epub ahead of print
Putzer G, Martini J, Spraider P, Abram J, ... Helbok R, Mair P
Resuscitation: 03 Aug 2021; epub ahead of print | PMID: 34363854
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Impact:
Abstract

Influence of sex on survival, neurologic outcomes, and neurodiagnostic testing after out-of-hospital cardiac arrest.

Vogelsong MA, May T, Agarwal S, Cronberg T, ... Xiong W, Hirsch KG
Aim
Previous studies evaluating the relationship between sex and post-resuscitation care and outcomes following out-of-hospital cardiac arrest (OHCA) are conflicting. We investigated the association between sex and outcomes as well as neurodiagnostic testing in a prospective multicenter international registry of patients admitted to intensive care units following OHCA.
Methods
OHCA survivors enrolled in the International Cardiac Arrest Registry (INTCAR) from 2012 to 2017 were included. We assessed the independent association between sex and survival to hospital discharge, good neurologic outcome (Cerebral Performance Category 1 or 2), neurodiagnostic testing, and withdrawal of life-sustaining therapy (WLST).
Results
Of 2407 eligible patients, 809 (33.6%) were women. Baseline characteristics differed by sex, with less bystander CPR and initial shockable rhythms among women. Women were less likely to survive to hospital discharge, however significance abated following adjusted analysis (30.1% vs 42.7%, adjusted OR 0.85, 95% CI 0.67-1.08). Women were less likely to have good neurologic outcome at discharge (21.4% vs 34.0%, adjusted OR 0.74, 95% CI 0.57-0.96) and at six months post-arrest (16.7% vs 29.4%, adjusted OR 0.73, 95% CI 0.54-0.98) that persisted after adjustment. Neuroimaging (75.5% vs 74.3%, p = 0.54) and other neurophysiologic testing (78.8% vs 78.6%, p = 0.91) was similar across sex. Women were more likely to undergo WLST (55.6% vs 42.8%, adjusted OR 1.35, 95% CI 1.09-1.66).
Conclusions
Women with cardiac arrest have lower odds of good neurologic outcomes and higher odds of WLST, despite comparable rates of neurodiagnostic testing and after controlling for baseline differences in clinical characteristics and cardiac arrest features.

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

Resuscitation: 03 Aug 2021; 167:66-75
Vogelsong MA, May T, Agarwal S, Cronberg T, ... Xiong W, Hirsch KG
Resuscitation: 03 Aug 2021; 167:66-75 | PMID: 34363853
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Impact:
Abstract

Regional cerebral oxygen saturation in cardiac arrest survivors undergoing targeted temperature management 36 °C versus 33 °C: A randomized clinical trial.

Kwon WY, Jung YS, Suh GJ, Kim T, ... Lee HJ, You KM
Aim of study
To investigate whether regional cerebral oxygen saturation (rSO2) differs in out-of-hospital cardiac arrest (OHCA) survivors undergoing targeted temperature management (TTM) 36 °C versus 33 °C.
Methods
A randomized clinical trial was conducted at intensive care units in two referral hospitals. Fifty-seven comatose OHCA survivors were randomized into either a 36 °C or 33 °C group. Patients were cooled and maintained at an oesophageal temperature of either 36 °C or 33 °C for 24 hours, rewarmed at a rate of 0.25 °C/hour, and maintained at <37.5 °C until 72 hours. During 72 hours of TTM, rSO2 was continuously monitored on the left forehead using near-infrared spectroscopy (INVOSTM 5100C). The rSO2 level at 72 hours was compared between the two groups. Next, serial rSO2 levels for 72 hours were compared using mixed effects regression. The association between rSO2 levels and 6-month neurological outcomes was also evaluated.
Results
There were no significant differences in the rSO2 level at 72 hours between the 36 °C and 33 °C groups (p = 0.372). Furthermore, serial rSO2 levels for 72 hours of TTM were not different between the two groups (p = 0.733). However, low rSO2 levels, particularly at 24 hours of TTM, were significantly associated with poor 6-month neurological outcomes (odds ratio = 0.899, 95% confidence interval: 0.831-0.974). The area under the receiver operating characteristic curve of the rSO2 level at 24 hours for poor neurological outcomes was 0.800.
Conclusions
Regardless of target temperatures, low rSO2 levels during TTM were significantly associated with poor 6-month neurological outcomes in OHCA survivors.

Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 28 Jul 2021; epub ahead of print
Kwon WY, Jung YS, Suh GJ, Kim T, ... Lee HJ, You KM
Resuscitation: 28 Jul 2021; epub ahead of print | PMID: 34331985
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Impact:
Abstract

Compression depth measured by accelerometer vs. outcome in patients with out-of-hospital cardiac arrest.

Nichol G, Daya MR, Morrison LJ, Aufderheide TP, ... Idris A, Brown S
Background
Analyses of data recorded by monitor-defibrillators that measure CPR depth with different methods show significant relationships between the process and outcome of CPR. Our objective was to evaluate whether chest compression depth was significantly associated with outcome based on accelerometer-recordings obtained with monitor-defibrillators from a single manufacturer, and to assess whether an accelerometer-based analysis corroborated evidence-based practice guidelines on performance of CPR.
Methods and results
We included 5434 adult patients treated from seven US and Canadian cities between January 2007 and May 2015. These had mean (SD) age of 64.2 (17.2) years, mean compression depth of 45.9 (12.7) mm, ROSC sustained to ED arrival of 26%, and survival to hospital discharge of 8%. For survival to discharge, the adjusted odds ratios were 1.15 (95% CI, 0.86, 1.55) for cases within 2005 depth range (38-51 mm), and 1.17 (95% CI, 0.91, 1.50) for cases within 2010 depth range (>50 mm) compared to those with an average depth of <38 mm. The adjusted odds ratio of survival was 1.33 (95% CI, 1.01, 1.75) for cases within 2015 depth range (50 to 60 mm) for at least 60% of minutes.
Conclusions
This analysis of patients with OHCA demonstrated that increased chest compression depth measured by accelerometer is associated with better survival. It confirms that current evidence-based recommendations to compress within 50-60 mm are likely associated with greater survival than compressing to another depth.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 28 Jul 2021; 167:95-104
Nichol G, Daya MR, Morrison LJ, Aufderheide TP, ... Idris A, Brown S
Resuscitation: 28 Jul 2021; 167:95-104 | PMID: 34331984
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Impact:
Abstract

Electrical rhythm degeneration in adults with out-of-hospital cardiac arrest according to the no-flow and bystander low-flow time.

Cournoyer A, Chauny JM, Paquet J, Potter B, ... Castonguay V, Daoust R
Aims
For out-of-hospital cardiac arrest (OHCA) patients, the influence of the delay before the initiation of resuscitation, termed the no-flow time (NFT), and duration of bystander-only resuscitation low-flow time (BLFT) on the type of electrical rhythm observed has not been well described. The objective of this study is to determine the relationship between NFT, BLFT and the likelihood of a shockable rhythm over time.
Methods
Using a North American prospective registry (2005-2015; mostly urban settings), we selected adult (18 years and over) patients who experienced a witnessed OHCA from a suspected cardiac etiology. Patients with an emergency medical services witnessed OHCA were only included in sensitivity analyses. The association between the NFT, BLFT and the presence of a shockable rhythm was evaluated using a multivariable logistic regression adjusting for the registry version, age, sex, and public location.
Results
A total of 229,632 patients were logged in the registry, 50,957 of whom were included. Of these, 17,704 (34.7%) had an initial shockable rhythm. After the first minute, a significant decrease over time in the occurrence of shockable rhythm is observed but is slower when bystander cardiopulmonary resuscitation (CPR) is provided (each supplemental minute of BLFT: adjusted odds ratio = 0.95, 95 %CI = 0.94-0.95; each supplemental minute of NFT: adjusted odds ratio = 0.91, 95 %CI = 0.90-0.91]).
Conclusions
In this large observational study, we were able to demonstrate that longer NFT were associated with lower odds of shockable presenting rhythms. Bystander CPR significantly mitigates the degradation of shockable rhythms over time, strengthening the need to improve bystander CPR rates around the world.

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

Resuscitation: 25 Jul 2021; epub ahead of print
Cournoyer A, Chauny JM, Paquet J, Potter B, ... Castonguay V, Daoust R
Resuscitation: 25 Jul 2021; epub ahead of print | PMID: 34324890
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Impact:
Abstract

Survival to hospital discharge is equivalent to 30-day survival as a primary survival outcome for out-of-hospital cardiac arrest studies.

Majewski D, Ball S, Bailey P, Mckenzie N, ... Morgan A, Finn J
Aim
The 2015 Utstein guidelines stated that 30-day survival could be used as an alternative to survival to hospital discharge (STHD) as the primary survival outcome in out-of-hospital cardiac arrest (OHCA) studies. We sought to ascertain the equivalence (concordance) of these two survival outcome measures.
Methods
We conducted a population-based retrospective cohort study of OHCA patients who were attended by St John Western Australia (SJ-WA) paramedics in Perth, WA between 1999 and 2018. OHCA patients were included if they received either an attempted resuscitation by SJ-WA or bystander defibrillation; were a resident of WA; and were transported to a hospital emergency department (ED). STHD was determined through hospital record review and 30-day survival via the WA Death Registry and cemetery registration data.
Results
The study cohort comprised a total of 7953 OHCA patients, predominantly male (70%), with a median (IQR) age of 63 (46-77 years), a presumed cardiac arrest aetiology (78.9%), and the majority occurred in a private residence (66.8%). Survival rates were identical for STHD and 30-day survival, with both being (13.78%, 95% CI: 13.02-14.54%) (p = 0.99). The overall concordance between the two survival rates was 99.6%. There were only 30 (0.4%) discordant cases in total: 15 cases with STHD-yes but 30-day survival-no; and 15 cases with STHD-no but 30-day survival-yes.
Conclusion
We found that STHD and 30-day survival were equivalent survival metrics in our OHCA Registry. However, given potential differences in health systems, we suggest that 30-day survival is likely to enable more reliable comparisons across jurisdictions.

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

Resuscitation: 23 Jul 2021; 166:43-48
Majewski D, Ball S, Bailey P, Mckenzie N, ... Morgan A, Finn J
Resuscitation: 23 Jul 2021; 166:43-48 | PMID: 34314779
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Impact:
Abstract

Combined use of venoarterial extracorporeal membrane oxygenation and intra-aortic balloon pump after cardiac arrest.

Kuroki N, Nagao K, Otsuka T, Kuwabara M, ... Yamamoto T, Takayama M
Objectives
We investigated whether intra-aortic balloon pump (IABP) combined with venoarterial extracorporeal membrane oxygenation (VA-ECMO) was associated with favourable neurological outcomes for patients after the return of spontaneous circulation (ROSC). Moreover, we evaluated the aetiology of cardiac arrest on the effectiveness of this therapy in a sub-study.
Background
There is insufficient research on the optimal combination of machines for patients after ROSC is not established.
Methods
This is a large-scale, multicentre, 30-day cohort study. Among 80,716 patients who delivered to the emergency room, 935 patients treated with VA-ECMO after ROSC were included using the data from the Tokyo Cardiovascular Care Unit Network Registry between 2010 and 2017. The study patients were stratified according to the use of IABP [the ECMO + IABP group (n = 762) vs. the ECMO-alone group (n = 173)]. We also evaluated the cause of cardiac arrest [acute coronary syndrome (ACS) and non-ACS] in the sub-study. To adjust the patients\' backgrounds, we used the propensity score matching for additional analyses. The endpoint was 30-day favourable neurological outcome.
Results
The ECMO + IABP group showed significantly better neurological outcomes than the ECMO-alone group (crude; 35% vs. 25%; log-lank P < 0.001). In the ACS subgroup, the ECMO + IABP group showed significantly better neurological outcome (crude; 34% vs. 18%; log-lank P < 0.001), but not in the non-ACS subgroup (crude; 38% vs. 32%; log-lank P = 0.11). These results are similar after adjustments to their backgrounds using propensity matching.
Conclusions
Compared to VA-ECMO alone, the combined use of VA-ECMO and IABP is associated with better neurological outcomes after ROSC, especially in complicated ACS.

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

Resuscitation: 23 Jul 2021; epub ahead of print
Kuroki N, Nagao K, Otsuka T, Kuwabara M, ... Yamamoto T, Takayama M
Resuscitation: 23 Jul 2021; epub ahead of print | PMID: 34314778
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Impact:
Abstract

Treatments costs associated with inpatient clinical deterioration.

Curtis K, Sivabalan P, Bedford DS, Considine J, ... Shaban RZ, Fry M
Aims
This study aimed to quantify the health economic treatment costs of clinical deterioration of patients within 72 h of admission via the emergency department.
Methods
This study was conducted between March 2018 and February 2019 in two hospitals in regional New South Wales, Australia. All patients admitted via the emergency department were screened for clinical deterioration (defined as initiation of a medical emergency team call, cardiac arrest or unplanned admission to Intensive Care Unit) within 72 h through the site clinical deterioration databases. Patient characteristics, including pre-existing conditions, diagnosis and administrative data were collected.
Results
1600 patients clinically deteriorated within 72 h of hospital admission. Linked treatment cost data were available for 929 (58%) of these patients across 352 Australian Refined Diagnosis Related Groups. The average (standard deviation) treatment costs for patients who deteriorated within 72 h was $26,778 ($34,007) compared to $7727 ($12,547). The average hospital length of stay of the deterioration group was nearly 8 days longer than patients without deterioration. When controlling for length of stay and Australian Refined Diagnosis Related Group codes, the incremental cost per episode of deterioration was $14,134.
Conclusion
Clinical deterioration within 72 h of admission is associated with increased treatment costs irrespective of diagnosis, hospital length of stay and age. Implementation of interventions known to prevent patient deterioration require evaluation.

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

Resuscitation: 23 Jul 2021; 166:49-54
Curtis K, Sivabalan P, Bedford DS, Considine J, ... Shaban RZ, Fry M
Resuscitation: 23 Jul 2021; 166:49-54 | PMID: 34314776
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Impact:
Abstract

Performance of OHCA, NULL-PLEASE and CAHP scores to predict survival in Out-of-Hospital Cardiac Arrest due to acute coronary syndrome.

Pham V, Laghlam D, Varenne O, Dumas F, Cariou A, Picard F
Aim
Out-of-hospital Cardiac Arrest (OHCA) carries a poor prognostic with high mortality rates and multiple scoring systems have been developed to assess its prognostic. This study sought to evaluate the performance of three prognostic scores to predict survival in OHCA patients due to acute coronary syndrome (ACS).
Methods and results
This is an observational, monocentric study including 386 consecutive patients treated for OHCA due to ACS, treated by percutaneous coronary intervention, between 2007 and 2019. The OHCA, NULL-PLEASE and CAHP scores were calculated respectively for 370 patients (95.9%), 371 patients (96.1%) and 350 patients (90.7%). A C-statistic analysis was performed to determine score performance. The areas under the curve for the OHCA, NULL-PLEASE and CAHP scores were 0.861 (95% CI, 0.823-0.898), 0.789 (95% CI, 0.744-0.834) and 0.830 (95% CI, 0.788-0.872) respectively demonstrating good performance. The OHCA score performed better than the NULL-PLEASE score (p = 0.001), and there was no difference between the CAHP and the NULL-PLEASE score (p = 0.062) nor between the OHCA and the CAHP score (p = 0.105).
Conclusion
The OHCA score, the NULL-PLEASE score and the CAHP score performed well in predicting in-hospital death in patients presenting OHCA secondary to ACS. The NULL-PLEASE score is the easiest to use but performed less accurately than the OHCA score.

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

Resuscitation: 21 Jul 2021; 166:31-37
Pham V, Laghlam D, Varenne O, Dumas F, Cariou A, Picard F
Resuscitation: 21 Jul 2021; 166:31-37 | PMID: 34302930
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Impact:
Abstract

Implications for cardiac arrest coverage using straight-line versus route distance to nearest automated external defibrillator.

Karlsson L, Sun CLF, Torp-Pedersen C, Wodschow K, ... Chan TCY, Folke F
Aim
Quantifying the ratio describing the difference between \"true route\" and \"straight-line\" distances from out-of-hospital cardiac arrests (OHCAs) to the closest accessible automated external defibrillator (AED) can help correct likely overestimations in AED coverage. Furthermore, we aimed to examine to what extent the closest AED based on true route distance differed from the closest AED using \"straight-line\".
Methods
OHCAs (1994-2016) and AEDs (2016) in Copenhagen, Denmark and in Toronto, Canada (2007-2015 and 2015, respectively) were identified. Three distances were calculated between OHCA and target AED: 1) the straight-line distance (\"straight-line\") to the closest AED, 2) the corresponding true route distance to the same AED (\"true route\"), and 3) the closest AED based only on true route distance (\"shortest true route\"). The ratio between \"true route\" and \"straight-line\" distance was calculated and differences in AED coverage (an OHCA ≤ 100 m of an accessible AED) were examined.
Results
The \"straight-line\" AED coverage of 100 m was 24.2% (n = 2008/8295) in Copenhagen and 6.9% (n = 964/13916) in Toronto. The corresponding \"true route\" distance reduced coverage to 9.5% (n = 786) and 3.8% (n = 529), respectively. The median ratio between \"true route\" and \"straight-line\" distance was 1.6 in Copenhagen and 1.4 in Toronto. In 26.1% (n = 2167) and 22.9% (n = 3181) of all Copenhagen and Toronto OHCAs respectively, the closest AED in \"shortest true route\" was different than the closest AED initially found by \"straight-line\".
Conclusions
Straight-line distance is not an accurate measure of distance and overestimates the actual AED coverage compared to a more realistic true route distance by a factor 1.4-1.6.

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

Resuscitation: 21 Jul 2021; epub ahead of print
Karlsson L, Sun CLF, Torp-Pedersen C, Wodschow K, ... Chan TCY, Folke F
Resuscitation: 21 Jul 2021; epub ahead of print | PMID: 34302928
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Impact:
Abstract

Comparison of volume-controlled, pressure-controlled, and chest compression-induced ventilation during cardiopulmonary resuscitation with an automated mechanical chest compression device: A randomized clinical pilot study.

Fuest K, Dorfhuber F, Lorenz M, von Dincklage F, ... Blobner M, Schaller SJ
Aim of the study
Automated mechanical chest compression devices (AMCCDs) can help performing high-quality cardiopulmonary resuscitation (CPR). Guidelines for CPR are lacking information about the optimal ventilation mode during CPR using AMCCDs. Aim of this pilot study was to compare three common ventilation modes during CPR using AMCCD.
Methods
In this randomized controlled trial, we included patients with an out-of-hospital cardiac arrest arriving at the resuscitation room receiving chest compressions via AMCCD with an expected continuation of at least 15 min. Patients were randomly assigned to three groups: biphasic positive airway pressure with assisted spontaneous ventilation (BIPAP) with assisted spontaneous breathing, continuous positive airway pressure (CPAP) and volume-controlled ventilation (VCV). Outcomes were tidal volume, respiratory minute volume, and end-tidal CO2 during the study period. Groups were compared using generalized linear models. Data is given as median and interquartile ranges.
Results
Of 53 screened patients, 30 were randomized. The tidal volume was significantly (p < 0.05) lower in patients of the CPAP group (68 [64-83] ml) compared with those of the BIPAP (349 [137-500] ml), while the respiratory minute volume differed between the CPAP group (6.2 [5.3-8.1] l/min) and both the BIPAP (7.1 [6.7-10.2] l/min) and VCV group (7.2 [3.7-8.4] l/min).
Conclusions
All ventilation modes achieved an adequate respiratory minute volume during CPR with an AMCCD. However, BIPAP seems to be superior due to the higher tidal volume. Therefore, we recommend starting mechanical ventilation when using AMCCD with BIPAP ventilation to avoid risks related to dead space ventilation.

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

Resuscitation: 21 Jul 2021; 166:85-92
Fuest K, Dorfhuber F, Lorenz M, von Dincklage F, ... Blobner M, Schaller SJ
Resuscitation: 21 Jul 2021; 166:85-92 | PMID: 34302927
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Impact:
Abstract

Long-term outcomes after out-of-hospital cardiac arrest in relation to socioeconomic status.

Møller S, Wissenberg M, Søndergaard K, Kragholm K, ... Gerds TA, Torp-Pedersen C
Aims
This study aimed to examine whether socioeconomic differences exist in long-term outcomes after out-of-hospital cardiac arrest (OHCA).
Methods
We included 2309 30-day OHCA survivors ≥ 30 years of age from the Danish Cardiac Arrest Registry, 2001-2014, divided in tertiles of household income (low, medium, high). Absolute probabilities were estimated using logistic regression for 1-year outcomes and cause-specific Cox regression for 5-year outcomes. Differences between income-groups were standardized with respect to age, sex, education and comorbidities.
Results
High-income compared to low-income patients had highest 1-year (96.4% vs. 84.2%) and 5-year (87.6% vs. 64.1%) survival, and lowest 1-year (11.3% vs. 7.4%) and 5-year (13.7% vs. 8.6%) risk of anoxic brain damage/nursing home admission. The corresponding standardized probability differences were 8.2% (95%CI 4.7-11.6%) and 13.9% (95%CI 8.2-19.7%) for 1- and 5-year survival, respectively; and -4.5% (95%CI -8.2 to -1.2%) and -5.1% (95%CI -9.3 to -0.9%) for 1- and 5-year risk of anoxic brain damage/nursing home admission, respectively. Among 831 patients < 66 years working prior to OHCA, 72.1% returned to work within 1 year and 80.8% within 5 years. High-income compared to low-income patients had the highest chance of 1-year (76.4% vs. 58.8%) and 5-year (85.3% vs. 70.6%) return to work with the corresponding absolute probability difference of 18.0% (95%CI 3.8-32.7%) for 1-year and 9.4% (95%CI -3.4 to 22.3%) for 5-year.
Conclusion
Patients of high socioeconomic status had higher probability of long-term survival and return to work, and lower risk of anoxic brain damage/nursing home admission after OHCA compared to patients of low socioeconomic status.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 21 Jul 2021; epub ahead of print
Møller S, Wissenberg M, Søndergaard K, Kragholm K, ... Gerds TA, Torp-Pedersen C
Resuscitation: 21 Jul 2021; epub ahead of print | PMID: 34302925
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Impact:
Abstract

A multi-centre randomised controlled trial of respiratory function monitoring during stabilisation of very preterm infants at birth.

van Zanten HA, Kuypers KLAM, van Zwet EW, van Vonderen JJ, ... Davis PG, Te Pas AB
Aim
To determine whether the use of a respiratory function monitor (RFM) during PPV of extremely preterm infants at birth, compared with no RFM, leads to an increase in percentage of inflations with an expiratory tidal volume (Vte) within a predefined target range.
Methods
Unmasked, randomised clinical trial conducted October 2013 - May 2019 in 7 neonatal intensive care units in 6 countries. Very preterm infants (24-27 weeks of gestation) receiving PPV at birth were randomised to have a RFM screen visible or not. The primary outcome was the median proportion of inflations during manual PPV (face mask or intubated) within the target range (Vte 4-8 mL/kg). There were 42 other prespecified monitor measurements and clinical outcomes.
Results
Among 288 infants randomised (median (IQR) gestational age 26+2 (25+3-27+1) weeks), a total number of 51,352 inflations were analysed. The median (IQR) percentage of inflations within the target range in the RFM visible group was 30.0 (18.0-42.2)% vs 30.2 (14.8-43.1)% in the RFM non-visible group (p = 0.721). There were no differences in other respiratory function measurements, oxygen saturation, heart rate or FiO2. There were no differences in clinical outcomes, except for the incidence of intraventricular haemorrhage (all grades) and/or cystic periventricular leukomalacia (visible RFM: 26.7% vs non-visible RFM: 39.0%; RR 0.71 (0.68-0.97); p = 0.028).
Conclusion
In very preterm infants receiving PPV at birth, the use of a RFM, compared to no RFM as guidance for tidal volume delivery, did not increase the percentage of inflations in a predefined target range.
Trial registration
Dutch Trial Register NTR4104, clinicaltrials.gov NCT03256578.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 21 Jul 2021; epub ahead of print
van Zanten HA, Kuypers KLAM, van Zwet EW, van Vonderen JJ, ... Davis PG, Te Pas AB
Resuscitation: 21 Jul 2021; epub ahead of print | PMID: 34302924
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Impact:
Abstract

Socioeconomically equitable public defibrillator placement using mathematical optimization.

Leung KHB, Brooks SC, Clegg GR, Chan TCY
Background
Mathematical optimization can be used to place automated external defibrillators (AEDs) in locations that maximize coverage of out-of-hospital cardiac arrests (OHCAs). We sought to determine whether optimization can improve alignment between AED locations and OHCA counts across levels of socioeconomic deprivation.
Methods
All suspected OHCAs and registered AEDs in Scotland between Jan. 2011 and Sept. 2017 were included and mapped to a corresponding socioeconomic deprivation level using the Scottish Index of Multiple Deprivation (SIMD). We used mathematical optimization to determine optimal locations for placing 10%, 25%, 50%, and 100% additional AEDs, as well as locations for relocating existing AEDs. For each AED placement policy, we examined the impact on AED distribution and OHCA \"coverage\" (suspected OHCA occurring within 100 m of AED) with respect to SIMD quintiles.
Results
We identified 49,432 suspected OHCAs and 1532 AEDs. The distribution of existing AED locations across SIMD quintiles significantly differed from the distribution of suspected OHCAs (P < 0.001). Optimization-guided AED placement increased coverage of suspected OHCAs compared to existing AED locations (all P < 0.001). Optimization resulted in more AED placements and increased OHCA coverage in areas of greater socioeconomic deprivation, such that resulting distributions across SIMD quintiles matched the shape of the OHCA count distribution. Optimally relocating existing AEDs achieved similar OHCA coverage levels to that of doubling the number of total AEDs.
Conclusions
Mathematical optimization results in AED locations and suspected OHCA coverage that more closely resembles the suspected OHCA distribution and results in more equitable coverage across levels of socioeconomic deprivation.

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

Resuscitation: 13 Jul 2021; 166:14-20
Leung KHB, Brooks SC, Clegg GR, Chan TCY
Resuscitation: 13 Jul 2021; 166:14-20 | PMID: 34271132
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Impact:
Abstract

Repolarization and ventricular arrhythmia during targeted temperature management post cardiac arrest.

Thomsen JH, Hassager C, Erlinge D, Nielsen N, ... Køber LV, Kjaergaard J
Background
Targeted temperature management (TTM) following out-of-hospital cardiac arrest (OHCA) prolongs the QT-interval but our knowledge of different temperatures and risk of arrhythmia is incomplete.
Objective
To assess whether the QTc, QT-peak (QTp) and T-peak to T-end interval (TpTe) may be useful markers of ventricular arrhythmia in contemporary post cardiac arrest treatment.
Methods
An ECG-substudy of the TTM-trial (TTM at 33 °C vs. 36 °C) with serial ECGs from 680 (94%) patients. Bazett\'s (B) and Fridericia\'s (F) formula were used for heart rate correction of the QT, QTp and TpTe. Ventricular arrhythmia (VT/VF) were registered during the first three days of post cardiac arrest care.
Results
The QT, QTc and QTp intervals were prolonged more at 33 °C compared to 36 °C and restored to similar and lower levels after rewarming. The TpTe-interval remained between 92-100 ms throughout TTM in both groups. The QTc intervals were associated with ventricular arrhythmia, but not after adjustment for cardiac arrest characteristics. The QTp-interval was not associated with risk of ventricular arrhythmia. Heart rate corrected TpTe-intervals were associated with higher risk of arrhythmia (Odds ratio (OR): TpTe(B): 1.12 (1.02-1.23, p = 0.01 TpTe(F): 1.12 (1.02-1.23, p = 0.02) per 20 ms). Further a prolonged TpTe-interval ≥ 90 ms was consistently associated with higher risk (ORadjusted: TpTe(B): 2.05 (1.25-3.37), p < 0.01, TpTe(F): 2.14 (1.32-3.49), p < 0.01).
Conclusions
TTM prolongs the QT-interval by prolongation of the QTp-interval without association to increased risk. The TpTe-interval is not significantly affected by core temperature, but heart rate corrected TpTe intervals are robustly associated with risk of ventricular arrhythmia.
Trial registration
The TTM-trial is registered and accessible at ClinicalTrials.gov (Identifier: NCT01020916).

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

Resuscitation: 13 Jul 2021; 166:74-82
Thomsen JH, Hassager C, Erlinge D, Nielsen N, ... Køber LV, Kjaergaard J
Resuscitation: 13 Jul 2021; 166:74-82 | PMID: 34271131
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Impact:
Abstract

Discrimination between the presence and absence of spontaneous circulation using smartphone seismocardiography: A preliminary investigation.

Lee HY, Jung YH, Jeung KW, Lee DH, ... Mamadjonov N, Heo T
Background
Seismocardiography measures the vibrations produced by the beating heart using an accelerometer sensor placed on the chest. We evaluated the ability of smartphone seismocardiography to distinguish between the presence and absence of spontaneous circulation.
Methods
Seismocardiography signals were obtained using a smartphone placed on the sternum in a convenience sample of 60 adult patients (30 comatose patients with spontaneous circulation and 30 deceased patients). The maximum, minimum, and standard deviation (SD) of acceleration values for head-to-foot, right-to-left, and dorsoventral axes and the three axis-root mean square (RMS) of the acceleration signals were calculated. Blinded observers (n = 156) were each asked to determine the presence or absence of spontaneous circulation based on seismocardiography video clips for each of the 60 patients.
Results
The seismocardiography revealed periodic large positive peaks in the patients with spontaneous circulation, which were absent in the patients without spontaneous circulation. For each of the four output measurements (three independent axes plus the three-axis RMS), the acceleration maxima and SD were significantly higher and the minima significantly lower in the patients with spontaneous circulation than in those without spontaneous circulation (all P < 0.001 except the minimum of three axis-RMS results [P = 0.009]). The observers accurately identified the seismocardiography signals from patients without spontaneous circulation, with a sensitivity of 97.6% (95% confidence interval, 97.0%-98.2%) and a specificity of 98.4% (95% confidence interval, 97.8%-99.0%).
Conclusions
In conclusion, blinded observers accurately distinguished between seismocardiography signals from patients with and without spontaneous circulation.

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

Resuscitation: 13 Jul 2021; 166:66-73
Lee HY, Jung YH, Jeung KW, Lee DH, ... Mamadjonov N, Heo T
Resuscitation: 13 Jul 2021; 166:66-73 | PMID: 34271129
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Impact:
Abstract

Fewer tracheal intubation attempts are associated with improved neurologically intact survival following out-of-hospital cardiac arrest.

Murphy DL, Bulger NE, Harrington BM, Skerchak JA, ... Rea TD, Sayre MR
Background
International guidelines emphasize advanced airway management during out-of-hospital cardiac arrest (OHCA). We hypothesized that increasing endotracheal intubation attempts during OHCA were associated with a lower likelihood of favorable neurologic survival at discharge.
Methods
This retrospective, observational cohort evaluated the relationship between number of intubation attempts and favorable neurologic survival among non-traumatic OHCA patients receiving cardiopulmonary resuscitation (CPR) from January 1, 2015-June 30, 2019 in a large urban emergency medical services (EMS) system. Favorable neurologic status at hospital discharge was defined as a Cerebral Performance Category score of 1 or 2. Multivariable logistic regression, adjusted for age, sex, witness status, bystander CPR, initial rhythm, and time of EMS arrival, was performed using the number of attempts as a continuous variable.
Results
Over 54 months, 1205 patients were included. Intubation attempts per case were 1 = 757(63%), 2 = 279(23%), 3 = 116(10%), ≥4 = 49(4%), and missing/unknown in 4(<1%). The mean (SD) time interval from paramedic arrival to intubation increased with the number of attempts: 1 = 4.9(2.4) min, 2 = 8.0(2.9) min, 3 = 10.9(3.3) min, and ≥4 = 15.5(4.4) min. Final advanced airway techniques employed were endotracheal intubation (97%), supraglottic devices (3%), and cricothyrotomy (<1%). Favorable neurologic outcome declined with each additional attempt: 11% with 1 attempt, 4% with 2 attempts, 3% with 3 attempts, and 2% with 4 or more attempts (AOR = 0.41, 95% CI 0.25-0.68).
Conclusions
Increasing number of intubation attempts during OHCA resuscitation was associated with lower likelihood of favorable neurologic outcome.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 13 Jul 2021; epub ahead of print
Murphy DL, Bulger NE, Harrington BM, Skerchak JA, ... Rea TD, Sayre MR
Resuscitation: 13 Jul 2021; epub ahead of print | PMID: 34271128
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Impact:
Abstract

Long-term survival and health-related quality of life after in-hospital cardiac arrest.

Schluep M, Hoeks SE, Blans M, van den Bogaard B, ... Robert Jan Stolker RJ, Rik Endeman H
Introduction
In-hospital cardiac arrest (IHCA) is an adverse event associated with high mortality. Because of the impact of IHCA more data is needed on incidence, outcomes and associated factors that are present prior to cardiac arrest. The aim was to assess one-year survival, patient-centred outcomes after IHCA and their associated pre-arrest factors.
Methods
A multicentre prospective cohort study in 25 hospitals between January 1st 2017 and May 31st 2018. Patients ≥ 18 years receiving cardiopulmonary resuscitation (CPR) for IHCA were included. Data were collected using Utstein and COSCA-criteria, supplemented by pre-arrest Modified Rankin Scale (MRS, functional status) and morbidity through the Charlson Comorbidity Index (CCI). Main outcomes were survival, health-related quality of life (HRQoL, EuroQoL) and functional status (MRS) after one-year.
Results
A total of 713 patients were included, 64.5% was male, median age was 63 years (IQR 52-72) and 72.8% had a non-shockable rhythm, 394 (55.3%) achieved ROSC, 231 (32.4%) survived to hospital discharge and 198 (27.8%) survived one year after cardiac arrest. Higher pre-arrest MRS, age and CCI were associated with mortality. At one year, patients rated HRQoL 72/100 points on the EQ-VAS and 69.7% was functionally independent.
Conclusion
One-year survival after IHCA in this study is 27.8%, which is relatively high compared to previous studies. Survival is associated with a patient\'s pre-arrest functional status and morbidity. HRQoL appears acceptable, however functional rehabilitation warrants attention. These findings provide a comprehensive insight in in-hospital cardiac arrest prognosis.

Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 13 Jul 2021; epub ahead of print
Schluep M, Hoeks SE, Blans M, van den Bogaard B, ... Robert Jan Stolker RJ, Rik Endeman H
Resuscitation: 13 Jul 2021; epub ahead of print | PMID: 34271127
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Impact:
Abstract

Premenopausal-aged females have no neurological outcome advantage after out-of-hospital cardiac arrest: A multilevel analysis of North American populations.

Awad EM, Humphries KH, Grunau BE, Christenson JM
Aim
We investigated the impact of premenopausal age on neurological function at hospital discharge in patients with out-of-hospital cardiac arrest (OHCA). We hypothesized that premenopausal-aged females (18-47 years of age) with OHCA would have a higher probability of survival with favourable neurological function at hospital discharge compared with males of the same age group, older males, and older females (>53 years of age).
Methods
Retrospective analyses of data from the Resuscitation Outcomes Consortium multi-center randomized controlled trial (June 2011-May 2015). We included adults with non-traumatic OHCA treated by emergency medical service. We stratified the cohort into four groups by age and sex: premenopausal-aged females (18-47 years of age), older females (≥53 years old), younger males (18-47 years of age), and older male. We used multilevel logistic regression to examine the association between age-sex and favourable neurological outcomes (modified Rankin Scale ≤ 3).
Results
In total, 23,725 patients were included: 1050 (4.5%) premenopausal females; 1930 (8.1%) younger males; 7569 (31.9%) older females; and 13,176 (55.5%) older males. The multilevel analysis showed no difference in neurological outcome between younger males and younger females (OR 0.95, 95% CI 0.69-1.32, p = 0.75). Both older females (OR 0.36, 95% CI 0. 0.26-0.48, p < 0.001) and older males (OR 0.52, 95% CI 0.39-0.69, p < 0.001) had a significantly lower odds of favourable neurological outcome than younger females. Among all groups, older females had the worst outcomes.
Conclusions
We did not detect an association between premenopausal age and survival with good neurological outcome, suggesting females sex hormones do not impact OHCA outcomes. Our findings are not in line with results from other studies. Studies that rigorously evaluate menopausal status are required to definitively assess the impact of female sex hormones on outcomes.

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

Resuscitation: 13 Jul 2021; 166:58-65
Awad EM, Humphries KH, Grunau BE, Christenson JM
Resuscitation: 13 Jul 2021; 166:58-65 | PMID: 34271125
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Impact:
Abstract

Out-of-hospital cardiac arrest outcomes in emergency departments.

Kempster K, Howell S, Bernard S, Smith K, ... Morley P, Bray J
Background
The emergency department (ED) plays an important role in out-hospital-cardiac arrest (OHCA) management. However, ED outcomes are not widely reported. This study aimed to (1) describe OHCA ED outcomes and reasons for ED deaths, and (2) whether these differed between hospitals.
Methods
Data were obtained from the Victorian Ambulance Cardiac Arrest Registry and 12 hospitals for adult, non-traumatic OHCA cases transported to ED between 2014 and 2016. Multivariable logistic regression was used to examine the association of level of cardiac arrest centre on ED survival in a subset of cases (non-paramedic witnessed OHCA who were unconscious on ED arrival with ROSC).
Results
Of 1547 eligible OHCA cases, 81% (N = 1254) survived ED, varying between 57% to 88% between EDs. Among non-survivors, the majority had either: cessation of resuscitation after presenting with CPR in progress (27%); withdrawal of life-sustaining treatment for non-neurological (n = 65, 22%) or neurological (16%) reasons; or a unsuccessful resuscitation following a rearrested in ED (20%). These causes of ED deaths varied between the different levels of cardiac arrest centres, and in our subset of interest (n = 952) ED survival was associated with transportation to centres with high annual OHCA volumes and with 24-hour cardiac intervention capabilities (AOR = 3.43, 95% CI 1.89-6.21).
Conclusion
Our study found wide variation in survival between EDs, which was associated with hospital characteristics. Such data suggests the need for a detailed review of ED deaths, particularly in non-cardiac arrest centres, and potentially the need for monitoring ED survival as a measure of quality.

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

Resuscitation: 13 Jul 2021; 166:21-30
Kempster K, Howell S, Bernard S, Smith K, ... Morley P, Bray J
Resuscitation: 13 Jul 2021; 166:21-30 | PMID: 34271123
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Impact:
Abstract

An exploratory assessment of serum biomarkers of post-cardiac arrest syndrome in children.

Kernan KF, Berger RP, Clark RSB, Scott Watson R, ... Fink EL, Simon DW
Aim
We hypothesized that serum biomarkers of inflammation including chemokine, cytokine, pituitary hormones, and growth factors following cardiac arrest in children would independently associate with 6-month neurologic outcome.
Methods
In this prospective observational single center study of children with in-hospital and out-of-hospital cardiac arrest surviving to intensive care unit admission, serum was obtained twice per 24 h period between 0 h and 96 h and once at approximately 196 h post-cardiac arrest. Inflammatory mediators, hormones, and growth factors were analyzed by Luminex Multiplex Bead Immunoassay. We recorded demographics, resuscitation characteristics, and Pediatric Cerebral Performance Category (PCPC) at 6 months. We analyzed the association and area under the curve (AUC) of biomarker levels with favorable (PCPC 1-3) or unfavorable (PCPC 4-6, or >1 increase from baseline) outcome.
Results
Forty-two children (50% female; median age of 2.5 [IQR: 0.4-10.2]) were enrolled and 18 (42%) died prior to 6-month follow up. Receiver operator curves for initial levels of ciliary neurotrophic factor (CNTF, AUC 0.84, 95% CI 0.73-0.96, p < 0.001) and interleukin (IL-17, AUC 0.84, 95% CI 0.73-0.97, p < 0.001) best classified favorable versus unfavorable 6-month outcome. In multivariable analysis, initial levels of CNTF and IL-17 remained associated with 6-month PCPC. Peak levels of interferon-γ-inducible protein 10 (IP-10), CNTF, and hepatocyte growth factor (HGF) were also independently associated with outcome.
Conclusion
Increased serum concentrations of CNTF and IL-17 associated with unfavorable 6-month neurologic outcome of children surviving cardiac arrest. Further investigation of the prognostic utility and roles of CNTF and IL-17 in the pathophysiology of post-cardiac arrest syndrome are warranted. This project is registered with clinicaltrials.gov (NCT00797680) as \"Duration of Hypothermia for Neuroprotection after Pediatric Cardiac Arrest: A Randomized, Controlled Trial\".

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 13 Jul 2021; epub ahead of print
Kernan KF, Berger RP, Clark RSB, Scott Watson R, ... Fink EL, Simon DW
Resuscitation: 13 Jul 2021; epub ahead of print | PMID: 34271122
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Impact:
Abstract

Impact of intraosseous versus intravenous resuscitation during in-hospital cardiac arrest: A retrospective study.

Schwalbach KT, Yong SS, Chad Wade R, Barney J
Aim
To compare outcomes between Intraosseous (IO) and peripheral intravenous (PIV) injection during in-hospital cardiac arrest (IHCA) and examine its utility in individuals with obesity.
Methods
We performed a retrospective cohort analysis of adult, atraumatic IHCA at a single tertiary care center. Subjects were classified as either IO or PIV resuscitation. The primary outcome of interest was survival to hospital discharge. The secondary outcomes of interest were survival with favourable neurologic status, rates-of-ROSC (ROR) and time-to-ROSC (TTR). Subgroup analysis among patients with BMI ≥ 30 kg/m2 was performed.
Results
Complete data were available for 1852 subjects, 1039 of whom met eligibility criteria. A total of 832 were resuscitated via PIV route and 207 via IO route. Use of IO compared to PIV was associated with lower overall survival to hospital discharge (20.8% vs 28.4% p = 0.03), lower rates of survival with favourable neurologic status (18.4% vs 25.2% p = 0.04), lower ROR (72.2% vs 80.7%) and longer TTR (12:38 min vs 9:01 min). After multivariate adjustment there was no significant differences between IO and PIV in rates of survival to discharge (OR 0.71, 95% CI 0.47-1.06, p = 0.09) or rates of survival with favourable neurologic status (OR 0.74, 95% CI 0.49-1.13, p = 0.16). The ROR and TTR remained significantly worse in the IO group. Subgroup analysis of patients with BMI ≥ 30 kg/m2 identified no benefit or harm with use of IO compared to PIV.
Conclusion
Intraosseous medication delivery is associated with inferior rates-of-ROSC and longer times-to-ROSC compared to PIV, but no differences in overall survival to hospital discharge or survival with favourable neurologic status during IHCA.

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

Resuscitation: 13 Jul 2021; 166:7-13
Schwalbach KT, Yong SS, Chad Wade R, Barney J
Resuscitation: 13 Jul 2021; 166:7-13 | PMID: 34273470
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Impact:
Abstract

Association between previous health condition and outcome after cardiac arrest.

Dumas F, Paoli A, Paul M, Savary G, ... Bougouin W, Cariou A
Introduction
Overall survival of patients with out-of-hospital cardiac arrest (OHCA) remains low, even in those with return of spontaneous circulation (ROSC). In addition to usual prognostic characteristics, patients\' medical history may also influence their outcome. This study aimed to investigate the role of pre-arrest comorbidities on hospital survival, neurological outcome and mode of death in OHCA patients with successful ROSC.
Methods
From Jan 2012 to Sep 2017, all consecutive non-traumatic OHCA adults, admitted with a stable ROSC were included. Utstein characteristics, circumstances of arrest and interventions were prospectively recorded. Prior comorbidities were measured using the Charlson Comorbidity Index (CCI), and the population was divided into 3 groups (CCI 0, CCI 1-3 and CCI ≥ 4). The association of CCI with early and long-term mortality was assessed using logistic regression and association with withdrawal-of-life sustaining treatments (WLST) or another cause of death using multinomial regression.
Results
During the study period, 777 patients were analyzed and 483 (62%) died before hospital discharge, with death rate of 49%, 60% and 70% in CCI 0, CCI 1-3 and CCI ≥ 4 respectively. After adjustment, an increase CCI was significantly associated with in-hospital mortality (OR = 2.47 [1.35-4.52], p = 0.001 for CCI 1-3; OR = 2.82 [1.49-5.33], p = 0.003 for CCI ≥ 4; ref = CCI 0). Other independent predictors were non-shockable rhythm (OR = 3.23 [2.08-5]), lack of bystander CPR (OR = 1.96 [1.22-3.13]), epinephrine dose ≥ 2 mg (OR = 5.56 [3.70-8.33]), CA to CPR ≥ 5 min (OR = 1.96 [1.28-3.03]) and CPR to ROSC ≥ 20 min (OR = 2.13 [1.39-3.23]). Using multinomial regression, an increase in CCI was associated with all modes of in-hospital death, particularly with WLST-related death (RRadj = 2.48 [1.26-4.90], p = 0.01 for CCI = 1-3 and 3.75 [1.85-8.7.58], p < 0.001 for CCI ≥ 4, reference CCI = 0).
Conclusion
Alteration of chronic health status, as assessed by an elevated CCI, was associated with a higher mortality and a worse neurological outcome in OHCA patients. Presence and burden of comorbidities should be considered in the evaluation of the prognosis in patients admitted in hospital after cardiac arrest.

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

Resuscitation: 06 Jul 2021; epub ahead of print
Dumas F, Paoli A, Paul M, Savary G, ... Bougouin W, Cariou A
Resuscitation: 06 Jul 2021; epub ahead of print | PMID: 34245838
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Impact:
Abstract

The second year of a second chance: Long-term psychosocial outcomes of cardiac arrest survivors and their family.

Case R, Stub D, Mazzagatti E, Pryor H, ... Bray JE, Smith K
Aim
Cardiac arrest (CA) survival has diverse psychosocial outcomes for both survivors and their close family, with little known regarding long-term adjustment and recovery experiences. We explored the psychological adjustment and experiential perspectives of survivors and families in the second year after out-of-hospital cardiac arrest (OHCA).
Methods
A prospective, mixed-methods study of adult OHCA survivors in Victoria, Australia was conducted. Eighteen survivors and 12 family members completed semi-structured interviews 14-19 months post-arrest. Survivors\' cognition, anxiety, depression and post-traumatic stress symptoms were measured using a battery of psychological assessments. A thematic content analysis approach was applied to qualitative interview data by two independent investigators, with data coded and categorised into themes and sub-themes.
Results
Survivors\' cognition, depression, anxiety and post-traumatic stress symptoms were not clinically elevated in the second year post-arrest. Subjective cognitive failures were associated with increased anxiety but not with mental state. Depression was significantly correlated with post-traumatic symptoms. Six primary themes emerged from survivors\' recovery stories, focused on: awakening and realisation, barriers to adjustment, psychosocial difficulties, integration, protective factors and unmet needs. Family perspectives revealed four primary themes focused on trauma exposure, survivor adjustment problems, family impact, and areas for service improvement.
Conclusion
Survivors and their family members describe complex recovery journeys characterised by a range of psychosocial adjustment challenges, which are not adequately captured by common psychological measures. Post-arrest care systems are perceived by survivors and their families as inadequate due to a lack of accurate information regarding post-arrest sequalae, limited follow-up and inconsistent access to allied health care.

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

Resuscitation: 05 Jul 2021; epub ahead of print
Case R, Stub D, Mazzagatti E, Pryor H, ... Bray JE, Smith K
Resuscitation: 05 Jul 2021; epub ahead of print | PMID: 34242735
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Impact:
Abstract

Bystander CPR occurrences in out of hospital cardiac arrest between sexes.

Souers A, Zuver C, Rodriguez A, Van Dillen C, Hunter C, Papa L
Background
Bystander CPR (B-CPR) is known to be a critical action in treating out-of-hospital cardiac arrest (OHCA). Immediate CPR may double a patient\'s chance of survival. Only 40% of OHCA patients receive B-CPR (Cardiac Arrest Registry to Enhance Survival1). Civilians may be more comfortable performing CPR on male than female victims based on stereotyped training and the culture of cardiac disease treatment.
Objective
We hypothesize that of OHCA patients receiving B-CPR, there is a gender disparity favoring males.
Methods
This is a retrospective analysis of the National Emergency Medical Services Information System (NEMSIS) dataset. 149,734 cases were included in this analysis. Primary outcome was frequency of B-CPR between genders. Secondary analysis included gender disparity in AED pad placement, and subsets divided by type of bystander.
Results
Among 149,734 OHCA, 78,738 received B-CPR. 28,485 of 55,215 females (51.59%) received B-CPR, compared to 50,253 of 94,519 males (53.17%, p < 0.001). Of OHCA with bystander AED pad placement, 22.9% of females had AED pads applied, compared to 24.6% of males (p < 0.001). In OHCA witnessed by family member, 57.80% of females versus 61.70% of males received B-CPR (p < 0.001). In OHCA witnessed by layperson, 62.50% of females versus 69.00% of males received B-CPR (p < 0.001).
Conclusion
There was a significantly lower rate of B-CPR in women experiencing OCHA in the population sample analyzed. Continued education and research are needed on the topic to address gender-specific differences in OHCA.

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

Resuscitation: 04 Jul 2021; 166:1-6
Souers A, Zuver C, Rodriguez A, Van Dillen C, Hunter C, Papa L
Resuscitation: 04 Jul 2021; 166:1-6 | PMID: 34237358
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Impact:
Abstract

Prehospital Tibial Intraosseous Drug Administration is Associated with Reduced Survival Following Out of Hospital Cardiac Arrest: A study for the CARES Surveillance Group.

Hamam MS, Klausner HA, France J, Tang A, ... Reddi S, Miller JB
Background
Recent reports have questioned the efficacy of intraosseous (IO) drug administration for out-of-hospital cardiac arrest (OHCA) resuscitation. Our aim was to determine whether prehospital administration of resuscitative medications via the IO route was associated with lower rates of return of spontaneous circulation (ROSC) and survival to hospital discharge than peripheral intravenous (IV) infusion in the setting of OHCA.
Methods
We obtained data on all OHCA patients receiving prehospital IV or IO drug administration from the three most populous counties in Michigan over three years. Data was from the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) database. The association between route of drug administration and outcomes was tested using a matched propensity score analysis.
Results
From a total of 10,626 OHCA patients, 6869 received parenteral drugs during their prehospital resuscitation (37.8% by IO) and were included in analysis. Unadjusted outcomes were lower in patients with IO vs. IV access: 18.3% vs. 23.8% for ROSC (p < 0.001), 3.2% vs. 7.6% for survival to hospital discharge (p < 0.001), and 2.0% vs. 5.8% for favorable neurological function (p < 0.001). After adjustment, IO route remained associated with lower odds of sustained ROSC (OR 0.72, 95% CI 0.63-0.81, p < 0.001), hospital survival (OR 0.48, 95% CI 0.37-0.62, p < 0.001), and favorable neurological outcomes (OR 0.42, 95% CI 0.30-0.57, p < 0.001).
Conclusion
In this cohort of OHCA patients, the use of prehospital IO drug administration was associated with unfavorable clinical outcomes.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 04 Jul 2021; epub ahead of print
Hamam MS, Klausner HA, France J, Tang A, ... Reddi S, Miller JB
Resuscitation: 04 Jul 2021; epub ahead of print | PMID: 34237357
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Impact:
Abstract

Multimodal monitoring including early EEG improves stratification of brain injury severity after pediatric cardiac arrest.

Topjian AA, Zhang B, Xiao R, Fung FW, ... Graham K, Abend NS
Aims
Assessment of brain injury severity early after cardiac arrest (CA) may guide therapeutic interventions and help clinicians counsel families regarding neurologic prognosis. We aimed to determine whether adding EEG features to predictive models including clinical variables and examination signs increased the accuracy of short-term neurobehavioral outcome prediction.
Methods
This was a prospective, observational, single-center study of consecutive infants and children resuscitated from CA. Standardized EEG scoring was performed by an electroencephalographer for the initial EEG timepoint after return of spontaneous circulation (ROSC) and each 12-h segment from the time of ROSC up to 48 h. EEG
Background:
Category was scored as: (1) normal; (2) slow-disorganized; (3) discontinuous or burst-suppression; or (4) attenuated-featureless. The primary outcome was neurobehavioral outcome at discharge from the Pediatric Intensive Care Unit. To develop the final predictive model, we compared areas under the receiver operating characteristic curves (AUROC) from models with varying combinations of Demographic/Arrest Variables, Examination Signs, and EEG Features.
Results
We evaluated 89 infants and children. Initial EEG
Background:
Category was normal in 9 subjects (10%), slow-disorganized in 44 (49%), discontinuous or burst suppression in 22 (25%), and attenuated-featureless in 14 (16%). The final model included Demographic/Arrest Variables (witnessed status, doses of epinephrine, initial lactate after ROSC) and EEG
Background:
Category which achieved AUROC of 0.9 for unfavorable neurobehavioral outcome and 0.83 for mortality.
Conclusions
The addition of standardized EEG
Background:
Categories to readily available CA variables significantly improved early stratification of brain injury severity after pediatric CA.

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

Resuscitation: 04 Jul 2021; epub ahead of print
Topjian AA, Zhang B, Xiao R, Fung FW, ... Graham K, Abend NS
Resuscitation: 04 Jul 2021; epub ahead of print | PMID: 34237356
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Impact:
Abstract

Expired carbon dioxide during newborn resuscitation as predictor of outcome.

Holte K, Ersdal H, Klingenberg C, Eilevstjønn J, ... Kidanto H, Størdal K
Aim
To explore and compare expired CO2 (ECO2) and heart rate (HR), during newborn resuscitation with bag-mask ventilation, as predictors of 24-h outcome.
Methods
Observational study from March 2013 to June 2017 in a rural Tanzanian hospital. Side-stream measures of ECO2, ventilation parameters, HR, clinical information, and 24-h outcome were recorded in live born bag-mask ventilated newborns with initial HR < 120 bpm. We analysed the data using logistic regression models and compared areas under the receiver operating curves (AUC) for ECO2 and HR within three selected time intervals after onset of ventilation (0-30 s, 30.1-60 s and 60.1-300 s).
Results
Among 434 included newborns (median birth weight 3100 g), 378 were alive at 24 h, 56 had died. Both ECO2 and HR were independently significant predictors of 24-h outcome, with no differences in AUCs. In the first 60 s of ventilation, ECO2 added extra predictive information compared to HR alone. After 60 s, ECO2 lost significance when adjusted for HR. In 70% of newborns with initial ECO2 <2% and HR < 100 bpm, ECO2 reached ≥2% before HR ≥ 100 bpm. Survival at 24 h was reduced by 17% per minute before ECO2 reached ≥2% and 44% per minute before HR reached ≥100 bpm.
Conclusions
Higher levels and a faster rise in ECO2 and HR during newborn resuscitation were independently associated with improved survival compared to persisting low values. ECO2 increased before HR and may serve as an earlier predictor of survival.

Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.

Resuscitation: 21 Jun 2021; epub ahead of print
Holte K, Ersdal H, Klingenberg C, Eilevstjønn J, ... Kidanto H, Størdal K
Resuscitation: 21 Jun 2021; epub ahead of print | PMID: 34098031
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Impact:
Abstract

Cerebral perfusion and metabolism with mean arterial pressure 90 vs. 60 mmHg in a porcine post cardiac arrest model with and without targeted temperature management.

Skåre C, Karlsen H, Strand-Amundsen RJ, Eriksen M, ... Tønnessen TI, Olasveengen TM
Aim
To determine whether targeting a mean arterial pressure of 90 mmHg (MAP90) would yield improved cerebral blood flow and less ischaemia compared to MAP 60 mmHg (MAP60) with and without targeted temperature management at 33 °C (TTM33) in a porcine post-cardiac arrest model.
Methods
After 10 min of cardiac arrest, 41 swine of either sex were resuscitated until return of spontaneous circulation (ROSC). They were randomised to TTM33 or no-TTM, and MAP60 or MAP90; yielding four groups. Temperatures were managed with intravasal cooling and blood pressure targets with noradrenaline, vasopressin and nitroprusside, as appropriate. After 30 min of stabilisation, animals were observed for two hours. Cerebral perfusion pressure (CPP), cerebral blood flow (CBF), pressure reactivity index (PRx), brain tissue pCO2 (PbtCO2) and tissue intermediary metabolites were measured continuously and compared using mixed models.
Results
Animals randomised to MAP90 had higher CPP (p < 0.001 for both no-TTM and TTM33) and CBF (no-TTM, p < 0.03; TH, p < 0.001) compared to MAP60 during the 150 min observational period post-ROSC. We also observed higher lactate and pyruvate in MAP60 irrespective of temperature, but no significant differences in PbtCO2 and lactate/pyruvate-ratio. We found lower PRx (indicating more intact autoregulation) in MAP90 vs. MAP60 (no-TTM, p = 0.04; TTM33, p = 0.03).
Conclusion
In this porcine cardiac arrest model, targeting MAP90 led to better cerebral perfusion and more intact autoregulation, but without clear differences in ischaemic markers, compared to MAP60.
Institutional protocol number
FOTS, id 8442.

Copyright © 2021. Published by Elsevier B.V.

Resuscitation: 20 Jun 2021; epub ahead of print
Skåre C, Karlsen H, Strand-Amundsen RJ, Eriksen M, ... Tønnessen TI, Olasveengen TM
Resuscitation: 20 Jun 2021; epub ahead of print | PMID: 34166747
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Abstract

Prognostic association of frailty with post-arrest outcomes following cardiac arrest: A systematic review and meta-analysis.

Mowbray FI, Manlongat D, Correia RH, Strum RP, ... Couban R, Foroutan F
Objective
To synthesize the current evidence examining the association between frailty and a series of post-arrest outcomes following the provision of cardiopulmonary resuscitation (CPR).
Data sources
We searched MEDLINE, PubMed (exclusive of MEDLINE), EMBASE, CINAHL, and Web of Science from inception to August 2020 for observational studies that examined an association between frailty and post-arrest health outcomes, including in-hospital and post-discharge mortality. We conducted citation tracking for all eligible studies.
Study selection
Our search yielded 20,480 citations after removing duplicate records. We screened titles, abstracts and full-texts independently and in duplicate.
Data extraction
The prognosis research strategy group (PROGRESS) and the critical appraisal and data extraction for systematic review of prediction modelling studies (CHARMS) guidelines were followed. Study and outcome-specific risk of bias were assessed using the Quality in Prognosis Studies (QUIPS) instrument. We rated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) recommendations for prognostic factor research.
Data synthesis
Four studies were included in this review and three were eligible for statistical pooling. Our sample comprised 1,134 persons who experienced in-hospital cardiac arrest (IHCA). The mean age of the sample was 71 years. The study results were pooled according to the specific frailty instrument. Three studies used the Clinical Frailty Scale (CFS) and adjusted age (our minimum confounder); the presence of frailty was associated with an approximate three-fold increase in the odds of dying in-hospital after IHCA (aOR = 2.93; 95% CI = 2.43-3.53, high certainty). Frailty was also associated with decreased incidence of ROSC (return of spontaneous circulation) and discharge home following IHCA. One study with high risk of bias used the Hospital Frailty Risk Score and reported a 43% decrease in the odds of discharge home for patients with frailty following IHCA.
Conclusion
High certainty evidence was found for an association between frailty and in-hospital mortality following IHCA. Frailty is a robust prognostic factor that contributes valuable information and can inform shared-decision making and policies surrounding advance care directives. Registration: PROSPERO Registration # CRD42020212922.

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

Resuscitation: 20 Jun 2021; epub ahead of print
Mowbray FI, Manlongat D, Correia RH, Strum RP, ... Couban R, Foroutan F
Resuscitation: 20 Jun 2021; epub ahead of print | PMID: 34166743
Go to: DOI | PubMed | PDF | Google Scholar |
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This program is still in alpha version.